Quality indicators and technique for analyzing permanent I-125 prostate seed implants: Seven years postimplant dosimetry evaluation

Department of Medical Physics, Royal Adelaide Hospital, SA 5000, Australia. loredana@
Medical Physics (Impact Factor: 2.64). 07/2012; 39(7):4123-31. DOI: 10.1118/1.4725173
Source: PubMed


The roles of postimplant dosimetry (PID) after permanent I-125 implant are to identify and rectify inadequate implants, assess the dosimetric quality indicators, and evaluate dose to the organs at risk. The aim of the current work was to assess the progress of prostate implant quality via postimplant dosimetry over seven years.
The following factors were investigated to assess the PID results obtained over seven years: the improvement in implant technique, the computed tomography (CT) delineation-based PID versus ultrasound-CT (US-CT) fusion-based PID, and the evolution of parameters such as D90 and NDR (natural dose ratio). The correlation between dosimetric parameters and clinical outcomes were also evaluated.
The seven years PID learning curve shows clear changes in dosimetric trend for the 265 patients studied. Manual target contouring on CT was shown to overestimate the prostate volume when compared to ultrasound data, translating to CT-based D90 values being lower than US-CT D90. It was found that NDR does not contribute with additional dosimetric information to postimplant dosimetry evaluation. Patient follow-up data show that 4.7% patients have relapsed, and urinary retention was reported in 2.7% of the patients.
CT-based PID was found less reliable than US-CT fusion-based PID due to target volume overestimation. This result shows the biased interpretation of low D90 values based on CT-based targeting, providing unreliable correlations between D90 and relapse probability. The low urinary retention statistics are in accordance with the PID data for the organ, as only 5.2% of patients had their PID D10 > 218 Gy, i.e., above the recommended GEC-ESTRO guidelines. Besides the "learning" component, the PID D90 curve is influenced by the PID technique.

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    • "In our centre, post implant dosimetry is completed based on US-CT image co-registration, with the pelvic CT scan taken on day 0 or 1 after the implant. Details on post implant dosimetry technique and results have been recently published [6]. According to the latest ABS guidelines [7] the post implant dosimetry (PID) is considered to be a mandatory component of the implant’s quality assurance and should be undertaken within 60 days of the implant. "
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    ABSTRACT: Background Low risk prostate cancers are commonly treated with low dose rate (LDR) brachytherapy involving I-125 seeds. The implementation of a ‘live-planning’ technique at the Royal Adelaide Hospital (RAH) in 2007 enabled the completion of the whole procedure (i.e. scanning, planning and implant) in one sitting. ‘Live-planning’ has the advantage of a more reliable delivery of the planned treatment compared to the ‘traditional pre-plan’ technique (where patient is scanned and planned in the weeks prior to implant). During live planning, the actual implanted needle positions are updated real-time on the treatment planning system and the dosimetry is automatically recalculated. The aim of this investigation was to assess the differences and clinical relevance between the planned dosimetry and the updated real-time implant dosimetry. Methods A number of 162 patients were included in this dosimetric study. A paired t-test was performed on the D90, V100, V150 and V200 target parameters and the differences between the planned and implanted dose distributions were analysed. Similarly, dosimetric differences for the organs at risk (OAR) were also evaluated. Results Small differences between the primary dosimetric parameters for the target were found. Still, the incidence of hotspots was increased with approximately 20% for V200. Statistically significant increases were observed in the doses delivered to the OAR between the planned and implanted data; however, these increases were consistently below 3% thus probably without clinical consequences. Conclusions The current study assessed the accuracy of prostate implants with I-125 seeds when compared to initial plans. The results confirmed the precision of the implant technique which RAH has in place. Nevertheless, geographical misses, anatomical restrictions and needle displacements during implant can have repercussions for centres without live-planning option if dosimetric changes are not taken into consideration.
    Full-text · Article · Nov 2012 · Radiation Oncology
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    • "For our study group, it was difficult to assess changes in PID figures between week 4 and immediate post implant scanning due to numerous other changes in our PID technique that took place at around the same time (such as switching from CT-based PID to CT-US fusion PID for example). Analysis of PID statistics for our study group is available in a separate publication [4]. All patients within the study group were asked to strain urine and monitor ejaculate for detection and capture of loose seeds for safe disposal. "
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    ABSTRACT: Low dose rate prostate brachytherapy treatments began at the Royal Adelaide Hospital (RAH), Australia, in September 2004. This paper will focus on the evolution of treatment technique since then showing how procedural improvements have enabled timely diagnosis of under-dose and scheduling of top-up treatments for sub-optimum implants, and how significant time savings have been achieved for staff and patients. In addition, implant dosimetry trends over this period have been investigated and results are presented. Iodine-125 seeds (Oncura model 6711) have been used since LDR prostate treatments began, with an aim to deliver a prostate dose of 145 Gy. Three key changes in implant technique took place during the period Sept 2004 to Sept 2011. The live implant dosimetry trends of the prostate D90, urethra V150, and rectum D0.1cc and D2.0cc, were assessed to see if the change in technique had an impact on the treatment planning and seed deployment. The switch from manual loading of seeds to pre-loaded needles and the change from a two-step pre-planning procedure to live planning have realized the greatest time savings with approximately 1.0 FTE physicist day saved per 2 patient implant day and 2 patient visits saved per treatment. Dosimetric parameters also improved with mean implant D90s rising from 166 Gy to 180 Gy. The average Urethra D10 also increased over the study group, rising from 186 Gy to 199 Gy while the rectum dose remained unchanged. Both rectum and urethra dose remained below GEC-ESTRO guidelines despite the observed rise in urethral dose.
    Full-text · Article · Sep 2012 · Physica Medica
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    ABSTRACT: Objective: Brachytherapy employing iodine-125 seeds is an established treatment for low-risk prostate cancers. Post-implant dosimetry (PID) is an important tool for identifying suboptimal implants. The aim of this work was to improve suboptimal implants by a subsequent iodine-125 seed top-up (reimplantation), based on the PID results. Methods: Of 255 patients treated between 2009 and 2012, 6 were identified as having received suboptimal implants and were scheduled for seed top-up. Needle configurations and the number of top-up seeds were determined based on post-implant CT images as well as a reimplantation treatment plan. An average of 14 seeds per patient were implanted during each top-up. Dosimetric outcome was assessed via target parameters and doses received by organs at risk. Results: All six patients had a successful top-up, with a 67% increase in the mean dose delivered to 90% of the prostate volume and a 40% increase in the volume that receives 100% of the prescribed dose. However, the final dosimetric assessment was based on the same seed activity, as the planning system does not account for the decay of the initially implanted seeds. Although physical dosimetry is not influenced by different seed activities (doses are calculated to infinity), the radiobiological implications might be slightly different from the situation when optimal implantation is achieved with one treatment only. Conclusion: Seed reimplantation in suboptimal prostate implants is feasible and leads to successful clinical outcomes. Advances in knowledge: Suboptimal prostate implants can occur for various reasons. This work shows that seed reimplantation as salvage therapy can lead to an optimal dosimetric outcome with manageable normal tissue effects.
    Full-text · Article · Mar 2013 · The British journal of radiology
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