Since the last edition of this textbook, interventional radiation therapy (brachytherapy) has undergone significant developments.
The incorporation of advanced image-guiding procedures and the establishment of new applicators allow for the highly accurate implantation of complex implants. 3D-guided real-time adaptive brachytherapy is becoming the newest clinical standard. We now find ourselves in an exciting "new era" of brachytherapy.
The current edition of this textbook has been updated to include all these new developments in brachytherapy, including the results of recent clinical trials and updates to the brachytherapy guidelines by the European Brachytherapy Group within ESTRO (GEC-ESTRO).
A number of highly experienced authors and skilled colleagues from all over Europe have contributed to this edition to educate and inspire all members of the radiation oncology team to utilise the full potential of brachytherapy to the benefit of their patients.

1. Introduction 21
2. History of brachytherapy 22
3. Physical aspects - sources, dosimetry and dose specification 28
3.1. Sources 28
3.1.1. Radionuclides in brachytherapy 28
3.1.1.1. Gamma and characteristic X-ray radiation 28
3.1.1.2. Beta-emitters 29
3.1.2. Characterisation of source strength 29
3.2. Dosimetry 29
3.2.1. Control of reference air kerma rate 29
3.2.1.1. Measurement with well-type ionisation chambers 29
3.2.1.2. Measurement in compact chambers in solid body phantoms 29
3.2.2. Checking the source position 30
3.2.3. Calculation of dose distributions 30
3.2.3.1. Dose distributions of single sources 30
3.2.3.2. Applicator reconstruction 31
3.2.4. Optimisation and visualisation of dose distributions 33
4. Quality assurance 38
4.1. Quality assurance for afterloading devices and procedures in case of emergency for a
remote afterloader 38
4.2. Quality assurance in brachytherapy treatment planning systems 41
4.3. Special methods 41
5. Dosimetrical aspects - dose specifications, dose-volume definitions,
EQD2 concept 46
5.1. Dose specification in general 46
5.2. Dose specification in intraluminal and intracavitary therapy 47
5.2.1. Source positions along one straight line (e.g. vaginal cylinder, oesophageal/bronchial
applicators, vessels) 47
5.2.2. Advanced cervical carcinoma 48
5.2.3. Endometrial carcinoma not treated surgically 48
5.3. Dose specification in interstitial brachytherapy 48
5.3.1. Point based systems 48
5.3.2. Dose and volume relations, Dose-volume histograms (DVH) and quality parameters (indices) 50
5.3.2.1. Relevant dose values and volumes 50
5.3.2.2. Quality parameters - QI indices 51
5.4. Dose fractionation, combination with external beam and the EQD2 concept 53
6. Clinical treatment planning and imaging 56
6.1. Clinical treatment planning 56
6.1.1. Indication 56
6.1.1.1. Definitive treatment 56
6.1.1.2. Adjuvant therapy 56
6.1.2. Gross Target Volume (GTV) and Clinical Target Volume (CTV) 56
6.1.3. Selection of technique, preliminary and definitive treatment plan 57
6.1.3.1. Interstitial brachytherapy 57
6.1.3.2. Intracavitary brachytherapy 60
6.1.3.3. Intraluminal brachytherapy 60
6.1.4. Dose, dose fractionation, dose rate 60
6.1.5. Infrastructure and personnel planning 61
6.2. Modern imaging techniques in brachytherapy 62
6.2.1. Basics of image-guided brachytherapy 62
6.2.2. Image-guided preliminary treatment planning 64
6.2.3. Image-guided application 64
6.2.4. Image-guided definitive treatment planning 65
6.2.5. Imaging techniques in brachytherapy 66
6.2.5.1. CT imaging 66
6.2.5.2. MR imaging 67
6.2.5.3. US imaging 67
7. Instruments and equipment 69
7.1. Instruments for interstitial brachytherapy 69
7.1.1. Temporary implants 69
7.1.1.1. Needles, catheters 69
7.1.1.2. Templates 71
7.1.1.3. Auxiliary instruments 73
7.1.2. Permanent implants 74
7.2. Instruments for intracavitary brachytherapy 75
7.2.1. Uterovaginal applicators 75
7.2.2. Vaginal applicators 76
7.2.3. Endometrial applicators 77
7.2.4. Intraluminal applicators for tumours in the oesophagus, bronchus, trachea, common bile duct
and nasopharynx and for intravascular brachytherapy 77
7.2.5. Moulds for cancers of the paranasal sinuses or orbit 78
7.3. Surface applicators 78
7.3.1. Skin applicators 78
7.3.2. Eye applicators 79
7.4. Afterloading devices 79
7.4.1. The irradiation device 80
7.4.2. The control unit 81
7.4.3. Important requirements for radiation protection 81
8. Intra- and perioperative brachytherapy 82
8.1. Introduction 82
8.2. Indications and patient selection criteria 83
8.2.1. Intraoperative brachytherapy 83
8.2.2. Perioperative brachytherapy 84
8.3. Practical execution and technique, practical tips 85
8.4. Treatment planning 87
8.4.1. Target volumes, dose specification and dose, QA 87
8.5. Results 88
8.6. Side effects 89
8.6.1. Short-term toxicity 89
8.6.2. Long-term toxicity 89
8.7. Summary 90
9. Interstitial hyperthermia 91
9.1. Techniques of interstitial hyperthermia 91
9.2. Planning, performance and documentation of interstitial hyperthermia 91
9.3. Quality and effectiveness of hyperthermia 92
9.4. Treatment results in interstitial brachytherapy and hyperthermia 92
9.4.1. Glioblastoma 92
9.4.2. Local and locoregional recurrences of head and neck cancer 93
9.4.3. Breast cancer 94
9.4.4. Tumours of the small pelvis 94
9.4.5. Prostate cancer 94
9.6. Summary 95
10. Pre- and postoperative supportive care in brachytherapy 97
10.1. Patient preparation 97
10.2. Anaesthesia and patient positioning 97
10.3. Pain management 98
10.4. Anti-infective therapy 98
10.5. Prophylaxis of thrombosis 99
10.6. Pre- and postoperative supportive care by specific tumour sites 99
10.6.1. Head and neck cancer 99
10.6.2. Breast cancer 100
10.6.3. Prostate cancer 100
10.6.4. Gynaecological tumours 101
10.7. Follow-up 102
11. Cervical cancer 103
11.1. Indications 103
11.2. Brachytherapy pre-planning 103
11.2.1. Brachytherapy target volumes 103
11.2.2. Organs at risk 105
11.2.3. Dose optimisation 105
11.2.4. Dose, dose rate, fractionation 112
11.3. Technique of applicator insertion 112
11.4. Results 113
11.4.1. Concomitant chemoradiotherapy 113
11.5. Side effects 114
11.6. Summary 114
12. Endometrial carcinoma 117
12.1. Indications, patient selection criteria 117
12.1.1. Current Indications for adjuvant radiotherapy, including Brachytherapy 117
12.1.1.1. Low risk endometrial cancer 117
12.1.1.2. Intermediate risk endometrial cancer 117
12.1.1.3. High to intermediate risk endometrial cancer 118
12.1.1.4. High risk endometrial cancer 118
12.1.1.5. Adjuvant intravaginal brachytherapy 119
12.1.2. Brachytherapy in primary endometrial carcinoma 119
12.1.3. Intracavitary and interstitial brachytherapy for recurrences 119
12.2. Treatment planning 120
12.2.1. Target volumes 120
12.2.1.1. Adjuvant intracavitary brachytherapy 120
12.2.1.2. Primary brachytherapy 121
12.2.1.3. Interstitial brachytherapy in recurrent disease 122
12.2.2. Dose specification 122
12.2.2.1. Adjuvant brachytherapy 122
12.2.2.2. Primary brachytherapy 123
12.2.2.3. Interstitial brachytherapy 123
12.2.3. Dose, dose rate, fractionation 123
12.3. Practical execution and technique 124
12.3.1. Adjuvant brachytherapy 124
12.3.2. Primary brachytherapy 124
12.3.3. Interstitial brachytherapy 124
12.4. Results 125
12.5. Side effects 125
12.6. Summary 126
13. Primary vaginal carcinoma 128
13.1. Indications 128
13.2. Brachytherapy pre-planning 128
13.2.1. Target volume 128
13.2.2. Organs at risk 130
13.2.3. Dose planning 130
13.2.4. Dose, dose rate and fractionation 131
13.2.4.1. Planning aims for the target volumes 131
13.2.4.2. Dose constraints for the organs at risk 132
13.3. Practical execution and technique 132
13.4. Results 133
13.5. Side effects 133
13.6. Summary 134
14. Vulvar carcinoma 135
14.1. Indications, patient selection criteria 136
14.2. Treatment planning 136
14.2.1. Target volumes 136
14.2.2. Dose specification 137
14.2.3. Dose, dose rate, fractionation 138
14.3. Practical execution and technique 138
14.4. Results 140
14.5. Side effects 140
14.6. Summary 141
15. Carcinoma of the female urethra 142
15.1. Indications, patient selection criteria 142
15.2. Treatment planning 142
15.2.1. Target volumes 142
15.2.2. Dose specification 142
15.2.3. Dose, dose rate, fractionation 143
15.3. Practical execution and technique 143
15.4. Results 144
15.5. Side effects 144
15.6. Summary 145
16. Carcinoma of the prostate 146
16.1. Indications, patient selection criteria 147
16.1.1. Permanent brachytherapy with J-125 seeds 147
16.1.2. Temporary brachytherapy with Ir-192 147
16.1.3. Contraindications to brachytherapy 147
16.2. Treatment planning 147
16.2.1. Target volumes and organs at risk 147
16.2.2. Isotope, dose specification and fractionation 148
16.2.2.1. Permanent brachytherapy with J-125 , Pd-103 148
16.2.2.2. Temporary brachytherapy with Ir-192 148
16.3. Practical execution and technique 149
16.3.1. Permanent brachytherapy (seeds) 150
16.3.2. Temporary brachytherapy 151
16.4. Results 154
16.4.1. Permanent brachytherapy (seeds) 154
16.4.2. Temporary brachytherapy (HDR) 154
16.4.3. Salvage brachytherapy as re-irradiation 155
16.5. Side effects 155
16.5.1. Permanent brachytherapy (seeds) 155
16.5.2. Temporary brachytherapy (HDR) 155
16.6. Summary 156
17. Carcinoma of the penis 159
17.1. Indications, patient selection criteria 159
17.2. Treatment planning 159
17.3. Practical execution and technique 159
17.3.1. Surface mould brachytherapy 159
17.3.2. Interstitial brachytherapy 160
17.4. Results 163
17.5. Side effects 163
17.5.1. Early side effects 163
17.5.2. Late side effects 163
17.6. Summary 164
18. Bladder cancer 165
18.1. Indications 165
18.2. Treatment planning 165
18.3. Dose specification 166
18.4. Dose, dose rate and fractionation 167
18.5. Practical execution and technique 167
18.6. Results 167
18.7. Side effects 168
18.8. Summary 168
19. Head and neck tumours 170
19.1. Carcinoma of the lip 170
19.1.1. Indications, patient selection criteria 170
19.1.2. Treatment planning 170
19.1.2.1. Target volumes 170
19.1.2.2. Dose specification 170
19.1.2.3. Dose, dose rate, fractionation 172
19.1.3. Practical execution, technique 172
19.1.4. Results 172
19.1.5. Side effects 172
19.2. Oral cavity: carcinoma of the floor of the mouth, carcinoma of the mobile tongue 172
19.2.1. Indications, patient selection criteria 172
19.2.2. Treatment planning 174
19.2.2.1. Target volumes 174
19.2.2.2. Dose specification 175
19.2.2.3. Dose, dose rate, fractionation 175
19.2.3. Practical execution, technique 175
19.2.4. Results 177
19.2.5. Side effects 178
19.3. Oropharynx 178
19.3.1. Indications, patient selection criteria 178
19.3.2. Treatment planning 178
19.3.2.1. Target volumes 178
19.3.2.2. Dose specification 178
19.3.2.3. Dose, dose rate, fractionation 178
19.3.3. Practical execution, technique 179
19.3.4. Results 182
19.3.5. Complications 182
19.4. Buccal mucosa 182
19.4.1. Indications, patient selection criteria 182
19.4.2. Treatment planning 182
19.4.2.1. Target volumes 182
19.4.2.2. Dose specification 182
19.4.2.3. Dose, dose rate, fractionation 182
19.4.3. Practical execution and technique 183
19.4.4. Results 183
19.4.5. Side effects 183
19.5. Nasopharynx 183
19.5.1. Indications, patient selection criteria 183
19.5.2. Treatment planning 183
19.5.2.1. Target volumes 183
19.5.2.2. Dose specification 183
19.5.2.3. Dose, dose rate, fractionation 183
19.5.3. Practical execution, technique 184
19.5.4. Results 184
19.5.5. Side effects 186
19.6. Nasal cancer 186
19.6.1. Indications, patient selection criteria 186
19.6.2. Treatment planning 186
19.6.2.1. Target volumes 186
19.6.2.2. Dose specification 186
19.6.2.3. Dose, dose rate, fractionation 186
19.6.3. Practical execution, technique 186
19.6.4. Results 188
19.6.5. Side effects 188
19.7. Summary 188
20. Breast cancer 191
20.1. Indications, patient selection criteria 191
20.1.1. Interstitial brachytherapy as boost 191
20.1.2. Partial breast irradiation with interstitial multicatheter brachytherapy alone 191
20.1.3. Postoperative surface/interstitial brachytherapy of the chest wall after chest wall recurrence in
patients who have previously had radiotherapy 193
20.2. Treatment planning 193
20.2.1. Target volumes 193
20.2.1.1. Interstitial brachytherapy 193
20.2.1.2. Target volume in surface brachytherapy 199
20.2.1.3. Target volume in interstitial brachytherapy for the chest wall 199
20.2.2. Dose specification 199
20.2.2.1. Interstitial brachytherapy 199
20.2.2.2. Surface brachytherapy 200
20.2.2.3. Interstitial brachytherapy chest wall 200
20.2.3. Dose, dose rate, fractionation 200
20.3. Practical execution and technique 201
20.3.1. Interstitial brachytherapy 201
20.3.2. Mould (surface brachytherapy) 204
20.3.3. Interstitial brachytherapy of the chest wall 204
20.4. Results 204
20.4.1. Boost 204
20.4.2. Interstitial brachytherapy alone 205
20.4.3. Surface radiotherapy of the chest wall as re-irradiation 205
20.5. Side effects 205
20.5.1. Boost 206
20.5.2. Interstitial brachytherapy alone as APBI 206
20.5.3. Surface salvage-brachytherapy as re-irradiation 206
20.6. Summary 206
21. Lung cancer 210
21.1. Indications, patient selection criteria 210
21.1.1. Curative endobronchial brachytherapy 210
21.1.2. Palliative endobronchial brachytherapy 211
21.1.3. Curative endobronchial brachytherapy combined with external beam radiotherapy 211
21.1.4. Palliative endobronchial brachytherapy in combination with external beam radiotherapy 211
21.2. Treatment planning 212
21.2.1. Target volumes 212
21.2.1.1. The target volume for a curative intention 212
21.2.1.2. The target volume for a palliative intention 212
21.2.2. Dose specification 212
21.2.2.1. The dose specification for a curative intention 212
21.2.2.2. The dose specification for a palliative intention 213
21.2.3. Dose, dose rate, fractionation 213
21.3. Practical execution and technique 214
21.4. Results 215
21.4.1. Results of endobronchial HDR or LDR brachytherapy alone in curative intention 215
21.4.2. Results of combined external beam and endobronchial radiotherapy in curative intention 215
21.4.3. Results of endobronchial HDR or LDR brachytherapy alone in palliative intention 215
21.4.4. Results of combined external beam and endobronchial radiotherapy in palliative intention 216
21.5. Side effects 216
21.6. Interstitial and intraoperative brachytherapy - indication, technique, results 218
21.7. Summary 219
22. Oesophageal carcinoma 222
22.1. Indications, patient selection 222
22.2. Treatment planning 222
22.2.1. Target volumes 222
22.2.2. Dose specification 224
22.2.3. Dose, dose rate, fractionation 225
22.3. Practical execution and technique 225
22.4. Results 226
22.5. Side effects 227
22.6. Summary 228
23. Carcinoma of the anal canal 230
23.1. Indications, patient selection criteria 230
23.2. Treatment planning 230
23.2.1. Target volumes 231
23.2.2. Dose specification 231
23.2.3. Dose, dose rate, fractionation 231
23.3. Practical execution and technique 232
23.4. Results and side effects 233
23.5. Side effects 234
23.6. Summary 235
24. Skin tumours 237
24.1. Indications, patient selection criteria 237
24.2. Treatment planning 237
24.2.1. Target volumes 238
24.2.2. Dose specification 238
24.2.3. Dose, dose rate, fractionation 238
24.3. Practical execution and technique 238
24.4. Results 241
24.5. Side effects 242
24.6. Summary 242
25. Uveal choroidal melanomas 244
25.1. Indications, patient selection criteria 244
25.2. Treatment planning 244
25.2.1. Target volumes 244
25.2.2. Eye plaques 245
25.2.2.1. Ruthenium-106 eye plaques 245
25.2.2.2. Iodine-125 eye plaques 245
25.2.3. Dose specification and dosimetry 246
25.2.3.1. Ruthenium-106 eye plaques 246
25.2.3.2. Iodine-125 eye plaques 247
25.3. Practical execution and technique 247
25.4. Results 249
25.5. Side effects 251
25.6. Summary 251
26. Paediatric malignancies 253
26.1. Indications 253
26.2. Treatment planning 253
26.2.1. Target volumes 253
26.2.2. Dose specification 253
26.2.3. Dose, dose rate, fractionation 253
26.3. Practical execution and technique 253
26.4. Results 255
26.5. Side effects 256
26.6. Summary 256
27. Primary and secondary liver malignancies 257
27.1. Indication, patient selection criteria 257
27.2. Practical execution and technique 257
27.3. Treatment planning 259
27.4. Results 262
27.5. Summary 263
28. Soft tissue sarcomas 266
28.1. Indications, patient selection criteria 266
28.2. Treatment planning 266
28.2.1. Target volumes 266
28.2.2. Dose specification 266
28.2.3. Dose, dose rate, fractionation 266
28.3. Practical execution and technique 266
28.4. Results 267
28.5. Side effects 269
28.6. Summary 269
29. Keloids and pterygia 275
29.1. Indications, patient selection criteria 275
29.2. Treatment planning 275
29.2.1. Target volumes 275
29.2.2. Dose specification 275
29.2.3. Dose, dose rate, fractionation 275
29.3. Practical execution and technique 276
29.4. Results 278
29.5. Side effects 278
29.6. Summary 279
30. Perspectives in brachytherapy 281
30.1. Summary 283
Index 284