Description High dose rate (HDR) brachytherapy is a rapidly growing technique replacing low dose rate (LDR) procedures over the last few years in
both industrialised and developing countries. It is estimated that about 1/2 million procedures (administrations of treatment) are performed
by HDR units annually. LDR equipment has been discontinued by many manufacturers over the last few years leaving HDR as the major alternative
for brachytherapy.HDR brachytherapy techniques deliver a very high dose, in the order of 1.6-5 Gy per minute, so mistakes can lead to
under- or over-dosage with the potential for clinical adverse effects. More than 500 HDR accidents (including one death) have been reported
along the entire chain of procedures from source packing to delivery of dose. Human error has been the prime cause of radiation events.
In the present report, the International Commission on Radiological Protection concludes that many accidents could have been prevented
if staff had had functional monitoring equipment and paid attention to the results.Since iridium has a relatively short half-life, the
HDR sources need to be replaced about every 4 months. Over 10,000 HDR sources are transported annually with the resultant potential for
accidents, and the appropriate procedures and regulations must be observed. A number of specific recommendations on procedures and equipment
are given in this report. The need for an emergency plan, and for practising emergency procedures, is stressed. The possibility of loss
or theft of sources must be kept in mind. A collaborating team of specifically trained personnel following quality assurance (QA) procedures
is necessary to prevent accidents. Maintenance is an indispensable component of QA; external audits of procedures reinforce good and
safe practice and identify potential causes of accidents. QA should include peer review of cases. Accidents and incidents should be reported
and the lessons learned should be shared with other users to prevent similar mistakes.
Contents 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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