Before simulation, the internal leader of the catheters is removed and replaced with markers called “dummy ribbons,” which help to identify the potential source positions. The implant catheters should be individually numbered for correct identification during source loading. The position of the catheter at the

skin should also be marked for future reference during treatment delivery to ensure that the catheter depth has not changed between treatments. CT simulation is the current standard for BT dosimetry of sarcomas. GSK-3 cancer It allows for three-dimensional dosimetry of the implant. The radio-opaque markers or clips placed at the time of surgery help the physician contour the CTV. Presentation of axial isodose curves, dose–volume histogram (DVH) data, and virtual images facilitates understanding of the target doses and permits placement of dose constraints on normal tissue (Fig. 3). In BT, the CTV and planning treatment volumes are ideally congruous. The quality of the implant can be measured in terms of D90 (dose to 90% of the CTV), V100 (percent of the CTV that receives the 100% isodose), V150 (percent of the CTV that receives the 150%

isodose), or similar measures. Normal tissue dose constraints are typically derived RG7422 mw from the DVH data, which are represented as doses to various volumes, such as D0.1cc, D1cc, and D2cc. An attempt should be made to limit the dose to the surgical incision to less than 100% isodose unless it is considered at high risk for tumor involvement. The dose to the Clomifene skin should be measured, and ideally should be no more than two-thirds

of the prescribed dose. In addition, source loading should be no closer than 0.5 cm from the skin surface to minimize skin toxicity. There are limited data in the literature to equate DVH parameters with LC or toxicity outcomes. Once dosimetry is completed, the prescription dose can be delivered to the CTV. Treatment can be administered as an inpatient with LDR manual loaded sources (most commonly iridium-192 [192Ir] seeds embedded in ribbons). Radiation safety precautions related to time of exposure, distance, and shielding are needed on the wards, where the patients are confined for the duration of the implant. Alternatively, HDR remote afterloading may be selected. It has the advantage of avoiding radiation exposure to personnel, and for many sarcomas, the treatment can be given as an outpatient. In LDR dosimetry, the median peripheral dose rate, defined as the lowest continuous isodose rate line that covers the CTV (usually ∼0.45 Gy/h), is identified. This is generally 5 mm from the plane of the implant. The dosimetry for CT-based HDR is optimally volume based as described, or it can also be calculated at a point 5 mm from the catheters. Pulsed dose rate (PDR), a hybrid source delivery method that involves remote afterloading in short bursts at hourly doses at rates, is thought to be radiobiologically comparable to LDR.