Description: CONTENTS ABSTRACT i EDITORIAL 6 PREFACE 8 1. INTRODUCTION 11 2. What is the purpose of this report? 12 2.1. What is remote high dose rate brachytherapy? 13 3. Current Clinical Use of HDR brachytherapy 15 4. Infrastructure and Components of the Remote Afterloading HDR suite 16 4.1. HDR Suite 17 4.2. HDR Unit 18 4.2.1. HDR source 18 4.2.2. Afterloader device (treatment unit) 19 4.2.3. Control console 20 4.3. Applicators 20 4.4. Treatment Planning System 21 4.4.1. Preplanning 22 4.4.2. Individualised planning 22 4.5. Associated safety devices 22 4.6. Building 23 4.6.1. Infrastructure required for applicator/catheter placement (procedure room) 23 4.6.2. Infrastructure required for localisation radiographs 23 4.6.3. Infrastructure required for the treatment planning room 24 4.6.4. Infrastructure required for the treatment room 24 4.7. Imaging 24 4.8. Equipment for radiation safety and source handling 25 5. Personnel Requirements and Training 26 5.1. Personnel requirements 26 5.1.1. Radiation oncologist 26 5.1.2. Medical physicist 27 5.1.3. Technician / Brachytherapy technologist 28 5.1.4. Nurse 28 5.2. Is there need for special training for HDR procedures? 29 5.2.1. Radiation oncologist training 29 5.2.2. Physicist training 29 5.2.3. Technician and nurse training 30 5.2.4. Emergency procedures 30 6. QUALITY ASSURANCE (QA) 31 6.1. Clinical QA 31 6.2. Physical quality assurance 31 6.3. Organisational quality assurance 32 6.4. Specific QA related to HDR units 32 6.5. Special requirements for interstitial brachytherapy 32 7. EXPOSURES, EVENTS, AND ACCIDENTS 33 7.1. Events related to packing and transport 33 7.2. Exposures to personnel and public 34 7.3. Events during operation 34 7.3.1. Reported mechanical and computer events 34 7.3.2. Reported human errors 35 8. Examples of reported events 37 8.1. The most severe case 37 8.2. Transport and package 37 8.2.1. Source placed outside the transport safe and not secured 37 8.2.2. Returned source not inserted in safe: failure to survey 38 8.2.3. Damage in transit 38 8.3. Exposure to personnel and public 39 8.3.1. Inadequate shielding of bunker 39 8.3.2. Faulty connection from transport container to HDR safe 39 8.4. Mechanical events 39 8.4.1. Source cable separated from drive unit 39 8.4.2. Source stuck (unknown reason) 40 8.4.3. Undersized transfer cable diameter 40 8.4.4. Treatment planning software error / or human error 41 8.4.5. Kink in the applicator (needle) 42 8.4.6. Failure of retraction system 43 8.4.7. Loss of connection between control panel and HDR unit 43 8.4.8. Optical interlock 43 8.4.9. Open-ended source carrier 44 8.5. Human errors 44 8.5.1. Wrong patient: Identification problem 44 8.5.2. Reverse order of entry of dwell positions 44 8.5.3. Inadequate default position for start of dwell sites 45 8.5.4. Kink in catheter 46 8.5.5. Dwell position error 46 8.5.6. Wrong catheter 47 8.5.7. Wrong length catheter 47 8.5.8. Wrong orifice 47 8.5.9. Wrong transfer tube 48 8.5.10. Failure to recalibrate 48 8.5.11. Dislodged applicator 49 9. Recommendations 50 9.1. General 50 9.2. Specific 50 APPENDIX A. CLINICAL INDICATIONS 53 A.1. Cervical cancer 53 A.1.1. Carcinoma of the endometrium 54 A.2. Oesophageal cancer 54 A.3. Head and neck cancer 55 A.3.1. Nasopharynx 55 A.4. Other interstitial or mould applications 55 A.5. Lung cancer 55 A.6. Breast 56 A.7. Prostate 56 A.8. Soft tissue sarcomas 57 A.8.1. Soft tissue sarcomas in children 58 A.9. Other sites 59 A.10. Intraoperative use of HDR brachytherapy 59 10. REFERENCES 60

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