Dosimetric effect of source centering and residual plaque for beta-emitting catheter based intravascular brachytherapy sources

Conundrums of coronary brachytherapy

PURPOSE

In the 1998-2005 heyday of intravascular coronary brachytherapy, a variety of delivery devices were developed and marketed. As the industry shrank, only one device, the Novoste Beta-Cath 3.5F System (Best Vascular, Norcross, GA) remained in commercial production. The 2008 instruction manual, the only official source of technical guidance, lacks recommendations for various common scenarios.

METHODS AND MATERIALS

The clinical conundrums described here were encountered during regular use of the Novoste system in 81 patients treated from January to December of 2020 in the course of using the Novoste device in accordance with the 2008 manufacturer's instruction manual. Our experience and strategies are reported and critiqued.

RESULTS

Ambiguous patient selection factors include vein grafts, multiple affected vessels, large vessels, retreatment, multiple overlapping stents and prior radiation. Procedural ambiguities include vessel size determination, proper prescription dose, very long lesions and eccentric source positioning. Potential procedural mishaps include stuck sources and the risk of contamination.

CONCLUSIONS

The Novoste intravascular coronary brachytherapy system is the only commercially available brachytherapy delivery catheter, and may remain so for some time. The issues detailed here provide insight and guidance for current users and may prompt research into areas lacking adequate information.

Evaluation of a Proposed Biodegradable 188Re Source for Brachytherapy Application: A Review of Dosimetric Parameters

This study aimed to evaluate dosimetric characteristics based on Monte Carlo (MC) simulations for a proposed beta emitter bioglass 188Re seed for internal radiotherapy applications. The bioactive glass seed has been developed using the sol-gel technique. The simulations were performed for the seed using MC radiation transport code to investigate the dosimetric factors recommended by the AAPM Task Group 60 (TG-60). Dose distributions due to the beta and photon radiation were predicted at different radial distances surrounding the source. The dose rate in water at the reference point was calculated to be 7.43 ± 0.5 cGy/h/μCi. The dosimetric factors consisting of the reference point dose rate, D(r0,θ0), the radial dose function, g(r), the 2-dimensional anisotropy function, F(r,θ), the 1-dimensional anisotropy function, φan(r), and the R90 quantity were estimated and compared with several available beta-emitting sources. The element 188Re incorporated in bioactive glasses produced by the sol-gel technique provides a suitable solution for producing new materials for seed implants applied to brachytherapy applications in prostate and liver cancers treatment. Dose distribution of 188Re seed was greater isotropic than other commercially attainable encapsulated seeds, since it has no end weld to attenuate radiation. The beta radiation-emitting 188Re source provides high doses of local radiation to the tumor tissue and the short range of the beta particles limit damage to the adjacent normal tissue.

Comparison of a centered 32P source wire system with a noncentered 90Sr/Y brachytherapy system for intracoronary β-radiation following PCI of diffuse in-stent restenosis

BACKGROUND

We investigated the potential impact of differences in effective radiation dose between the centered Guidant 32P source wire system and the noncentered Novoste 90Sr/Y BetaCath system on clinical and angiographic outcomes of intracoronary brachytherapy for the prevention of in-stent restenosis.

METHODS

From 10/00 to 05/04, a total of 400 patients underwent percutaneous coronary intervention (PCI) with brachytherapy for diffuse in-stent restenosis at our institution. Following balloon dilatation, patient Group A (n=200) was treated with the centered 32P Galileo source wire system, patient Group B (n=200) was treated with the noncentered 90Sr/Y BetaCath radiation system. In Group A, the prescribed dose of 20 Gy was applied in 1-mm depth of the vessel wall. In Group B, the prescribed dose of 18.4 Gy was applied for visual reference vessel sizes >2.7 and <3.35 mm, 23 Gy for >3.36 and <4.00 mm, and 25.3 Gy for >4.00 mm, each calculated at a distance of 2 mm from the center line of the radiation source. Patients received aspirin and clopidogrel over 12 months. Primary endpoint was target lesion revascularization (TLR) at 6 months. Secondary endpoints were the binary restenosis rate and major adverse cardiac event (MACE) at 30 days and 6 months.

RESULTS

At 30 days, one patient of each group underwent PCI at a nontarget lesion (0.5%). At 6 months, MACEs were equally distributed in both groups. Target lesion revascularization at 6 months was 5.9% in Group A and 9.2% in Group B (P=.08). Binary angiographic restenosis rate at 6 months was 5.5% in Group A and 11.2% in Group B (P=.014).

CONCLUSION

Intracoronary beta-radiation using the centered 32P source wire system yielded a significant reduction of recurrence rate compared to the noncentered 90S/Y BetaCath system after PCI of diffuse in-stent restenosis. There was a nonsignificant trend toward reduction of TLR among patients treated with the centered 32P source wire system.

Improving patient-specific dosimetry for intravascular brachytherapy

PURPOSE

Accurate patient-specific dosimetry in intravascular brachytherapy (IVBT) is generally difficult due to the extremely high-dose gradient, complexity of treatment device, and patient-specific geometry (e.g., calcification, stent, curvature, movement of target). The purpose of this study is to analyze quantitatively and systematically the dose effects of calcification, stent, guidewire, and source curvature on clinical dosimetry in an IVBT procedure, and propose a method that can be used to assess these effects in routine clinical practice.

METHODS AND MATERIALS

Monte Carlo techniques were used to calculate 3-D dose distribution in both homogeneous and inhomogeneous media for three most commonly used IVBT sources: (90)Sr beta (Novoste), (192)Ir gamma (Cordis/Best), and (32)P beta (Guidant). Dosimetric perturbations in the presence of metallic stents, calcified plaques, metallic guide wires, and source curvature were studied for situations commonly encountered in the clinic. The importance of each of these perturbations and their practical influence on patient-specific dosimetry were analyzed. Factors (plaque, stent, guidewire, and curvature) that may be used to correct/reduce these perturbations were introduced to prevent dosimetric cold spots during IVBT. Practical methods of using these correction factors are proposed.

RESULTS

Dose perturbations are significant due to the presence of source curvature, metallic stents, calcified plaques, and metallic guide wires, especially for beta sources. These perturbations can be as high as 30% under normal clinical conditions, although they can be much higher in extreme situations. Empirical relationships of plaque factor with the thickness of calcified plaque, stent factor with stent metallic surface area, guidewire with guidewire thickness, and curvature factor with the bending angle are derived. These relationships are found to be useful in improving clinical dose accuracy in IVBT treatment planning or dose evaluation after treatment.

CONCLUSIONS

Significant dose perturbations due to the presence of source curvature, metallic stents, calcified plaques, and guide wires have been found in IVBT for in-stent restenosis. Because it has been reported that, with the current prescriptions for IVBT, higher doses consistently improve treatment outcomes, the empirical method derived from this work can be used to assess cold spots dosimetrically, thus improving patient-specific dosimetry for IVBT.

Monte Carlo parametric study of stent impact on dose for catheter-based intravascular brachytherapy with 90Sr/90Y

The radiation treatment of catheter-based beta-emitter sources is being used to prevent restenosis following interventional coronary procedures. We present the results of a Monte Carlo calculation study to assess the dosimetric impact in the vessel tissue due to the presence of the stent. A catheter-based beta-emitter system is modeled using the Monte-Carlo code MCNP4B. Dose distributions are calculated in annular voxels (0.050 x 0.025 mm2 section) along the axis of a 40 mm. 90Sr/90Y source with and without the stent (at a distance of 1.5-3.0 mm from the longitudinal axis of the source). The main results include: (a) a clear difference between the local perturbation just behind the strut and a more general perturbation seen deeper into the vessel tissue; (b) the local perturbations disappears at a depth of 300-400 microm while the more general perturbation affects the tissue in its full thickness including the prescription point; (c) in the local perturbation the maximum impact is determined mainly by the material and the thickness of the strut while the spatial attenuation of this impact is defined mainly by the strut width; (d) in the general perturbation, the most important magnitude is the free-area ratio for the path of the electrons, being the material characteristics and strut thickness of secondary importance; (e) analytical expressions are presented to estimate the magnitude of this perturbation according to the complete characteristics of the expanded strut, i.e., thickness, free-area ratio, and material; and (f) a simple algorithm is presented for estimating the free-area ratio when this information is not available.

Use of water-equivalent plastic scintillator for intravascular brachytherapy dosimetry

Beta irradiation has recently been investigated as a possible technique for the prevention of restenosis in intravascular brachytherapy after balloon dilatation or stent implantation. Present methods of beta radiation dosimetry are primarily conducted using radiochromic film. These film dosimeters exhibit limited sensitivity and their characteristics differ from those of tissue, therefore the dose measurement readings require correction factors to be applied. In this work a novel, mini-size (2 mm diameter by 5 mm long) dosimeter element fabricated from Organic Plastic Scintillator (OPS) material was employed. Scintillation photon detection is accomplished using a precision photodiode and innovative signal amplification and processing techniques, rather than traditional photomultiplier tube methods. A significant improvement in signal to noise ratio, dynamic range and stability is achieved using this set-up. In addition, use of the non-saturating organic plastic scintillator material as the detector enables the dosimeter to measure beta radiation at very close distances to the source. In this work the plastic scintillators have been used to measure beta radiation dose at distances of less than 1 mm from an Sr-90 cardiovascular brachytherapy source having an activity of about 2.1 GBq beta radiation levels for both depth-distance and longitudinal profile of the source pellet chain, both in air and in liquid water, are measured using this system. The data obtained is compared with results from Monte Carlo simulation technique (MCNP 4B). Plastic scintillator dosimeter elements, when used in conjunction with photodiode detectors may prove to be useful dosimeters for cardiovascular brachytherapy beta sources, or other applications where precise near-source field dosimetry is required. The system described is particularly useful where measurement of actual dose rate in real time, a high level of stability and repeatability, portability, and immediate access to results are prime requirements.

Dosimetry characterization of 32P intravascular brachytherapy source wires using Monte Carlo codesPENELOPEandGEANT4

Monte Carlo calculations using the codes PENELOPE and GEANT4 have been performed to characterize the dosimetric parameters of the new 20 mm long catheter-based 32P beta source manufactured by the Guidant Corporation. The dose distribution along the transverse axis and the two-dimensional dose rate table have been calculated. Also, the dose rate at the reference point, the radial dose function, and the anisotropy function were evaluated according to the adapted TG-60 formalism for cylindrical sources. PENELOPE and GEANT4 codes were first verified against previous results corresponding to the old 27 mm Guidant 32P beta source. The dose rate at the reference point for the unsheathed 27 mm source in water was calculated to be 0.215 +/- 0.001 cGy s(-1) mCi(-1), for PENELOPE, and 0.2312 +/- 0.0008 cGy s(-1) mCi(-1), for GEANT4. For the unsheathed 20 mm source, these values were 0.2908 +/- 0.0009 cGy s(-1) mCi(-1) and 0.311 0.001 cGy s(-1) mCi(-1), respectively. Also, a comparison with the limited data available on this new source is shown. We found non-negligible differences between the results obtained with PENELOPE and GEANT4.

Effects of vessel geometry and catheter position on dose delivery in intracoronary brachytherapy

In-stent restenosis is commonly observed in coronary arteries after intervention. Intravascular brachytherapy has been found effective in reducing the recurrence of restenosis after stent placement. Conventional dosing models for brachytherapy with beta (beta) radiation neglect vessel geometry as well as the position of the delivery catheter. This paper demonstrates in computer simulations on phantoms and on in vivo patient data that the estimated dose distribution varies substantially in curved vessels. In simulated phantoms of 50-mm length with a shape corresponding to a 60 degrees - 180 degrees segment of a respectively sized torus, the average dose in 2-mm depth was decreased by 2.70%-7.48% at the outer curvature and increased by 2.95%-9.70% at the inner curvature as compared with a straight phantom. In vivo data were represented in a geometrically correct three-dimensional model that was derived by fusion of intravascular ultrasound (IVUS) and biplane angiography. These data were compared with a simplified tubular model reflecting common assumptions of conventional dosing schemes. The simplified model yielded significantly lower estimates of the delivered radiation and the dose variability as compared with a geometrically correct model (p < 0.001). The estimated dose in ten vessel segments of eight patients was on average 8.76% lower at the lumen/plaque and 6.52% lower at the media/adventitia interfaces (simplified tubular model relative to geometrically correct model). The differences in dose estimates between the two models were significantly higher in the right coronary artery as compared with the left coronary artery (p < 0.001).

Electron capture radioactive sources for intravascular brachytherapy: a feasibility study

The feasibility of electron capture (EC) radionuclides as an alternative to the beta and high-energy gamma emitters presently in use for intravascular brachytherapy is investigated. A potential advantage of the low-energy x-ray radiation from EC isotopes may be an enhanced biological effectiveness with respect to the presently applied beta nuclides, but at the same time avoiding the shielding problems induced by the large penetrability of high-energy gamma rays. A survey considering the most important practical aspects such as dose delivery to the vessel walls in reasonable time spans, absorption properties, possible production of sources with the required specific activities and radiation safety reveals 71Ge as the most promising candidate.

Wire or coated balloon? Searching for an optimal source for intravascular brachytherapy with beta emitters using (32)P as an example

This study identifies basic dosimetric differences between two designs for intravascular brachytherapy (IVBT) in current clinical practice and ongoing trials and their clinical implications within beta emitting systems using P-32 as an example. The two designs are (i) the wire-type source, where the radioactive source material is confined to a wirelike structure within the vessel lumen, and (ii) the balloon-surface source, where the radioactive source material is distributed over a surface area (balloon-wall) which is brought in close proximity with the vessel wall. Using Monte Carlo simulations with the EGS4 code, the target coverage, the influence of centering errors, and the perturbation of the dose distribution caused by metallic stents have been compared. The radial dose fall-off in the target region was found to be steeper for balloon surface systems compared with wire systems. The inner lumen wall dose for a balloon surface source was 25% higher than that for a wirelike source (2.5 mm vessel diameter). However, the comparably shallower fall-off from wire-type systems is very sensitive to centering uncertainties. A 0.5 mm displacement, for example, will cause the dose to change by a factor of 2 at the inner vessel wall and by a factor of 1.8 at the prescription point. It is shown that the interference from metallic stents is more significant for wire-type systems than it is for balloon-surface-type systems, where double the dose variation beyond the stent at the radial prescription distance may occur. Centering uncertainties dominate the dose perturbation effects for wire-type systems. Balloon-surface-type designs show a more predictable dose distribution that features, however, a higher inner vessel surface dose. Since a direct clinical comparison of systems of both types is not likely, these findings should be considered when interpreting clinical results from treatments with either type of source and, possibly, for future source design.

Normalized conceptus doses for abdominal radiographic examinations calculated using a Monte Carlo technique

The aim of the present study was to develop a reliable method for estimating conceptus radiation doses resulting from abdominal radiographic examinations for all trimesters of pregnancy. The method is based on normalized conceptus doses estimated using Monte Carlo modeling. The Monte Carlo N-Particle (MCNP) radiation transport code was employed in the current study. The validity of the MCNP computational approach was verified by comparison with dose data obtained in anthropomorphic phantoms simulating pregnancy at the three trimesters of gestation using thermoluminescence dosimetry (TLD). The results consist of radiation doses normalized to air kerma so that conceptus dose from any technique and x-ray unit used for abdominal radiography can be easily calculated. Normalized conceptus doses are presented for the first, second, and third trimesters of gestation for various kVp and total beam filtration values. Data apply to radiographic systems equipped with high frequency or 3 phase 12 pulse generators. A very good agreement was observed between the normalized conceptus doses estimated by TLD measurements and the MCNP simulation for all periods of gestation (maximum difference 8.1%). The results of MCNP procedures were compared to published data obtained by TLD measurements. Normalized conceptus dose values agree well, with most differences being lower than 10%. The normalized doses obtained in the current study are dependent on field size. However, for small changes in the size of the x-ray field, the change in normalized doses is not considerable. Accurate estimation of conceptus doses due to abdominal conventional x-ray examinations can be made using the dose data provided in the current study.

Application of imaging-derived parameters to dosimetry of intravascular brachytherapy sources: perturbation effects of residual plaque burden

The dosimetric effect of geometric and material heterogeneities on intravascular brachytherapy dose delivery has been studied recently. Residual plaque within the coronary vessel appears to have an impact on the uniform delivery of radiation dose to the arterial tissue. In this study, we have examined the effect of residual plaque burden and post-PCI (percutaneous coronary intervention) plaque configuration on the dose to the arterial wall from clinical intravascular brachytherapy beta-emitting sources containing 32P and 90Sr/90Y. Monte Carlo simulations using the MCNP4B code were performed for these catheter-based sources with residual plaque burden ranging between 25% and 50%. The residual plaque burden values were derived from post-PCI data provided in several recent clinical studies. Dose calculations were performed for three different values of plaque density (1.45 g cm(-3), 2.20 g cm(-3), and 3.1 g cm(-3)) and three different plaque morphologies for the same residual plaque burden. The dose perturbation factor (DPF), defined as the ratio of dose at 2 mm radial distance for a given case to the dose at the same radial distance in homogeneous water medium, was determined for each of the three different plaque densities. The range of DPF values was 0.81-1.01, 0.62-0.99, and 0.41-0.97 for different plaque densities for the 32P source. Corresponding DPF values for the 90Sr/90Y source were 0.90-1.01, 0.84-1.01, and 0.62-1.01. The results indicate the need for accurate assessment of post-PCI clinical measurements such as minimal lumen diameter and residual plaque burden and incorporation of these values into dose calculations.

Dosimetric effects of source-offset in intravascular brachytherapy

In intravascular brachytherapy (IVBT), radioactive sources can be displaced (offset) laterally from the center of the lumen and/or longitudinally from the desired location due to the cardiac motion and/or the absence of a source-centering device. The purpose of this work is to study the dosimetric impact of such a source offset. Dose effects of both lateral and longitudinal source offsets with or without the presence of a calcified plaque or a metallic stent are calculated for the three most commonly used sources (32P, 90Sr/90Y, and 192Ir). The MCNP Monte Carlo code is used in the calculation. Static and random source offsets are considered. The major results include that (a) dose can be changed significantly (by a factor of up to 4) due to a static lateral source offset; (b) this dose variation is reduced if the lateral source offset is considered as random moving within the vessel (the dose at the 2 mm reference radial distance is increased by 5-15% for the three sources in the case of the 2D random offset studied); (c) the presence of a calcified plaque and/or a metallic stent worsens the dosimetric effects; (d) the longitudinal random source offset results in a reduction (15-18%) in the effective treatment length; (e) the dose effects of source offsets for the beta source are higher than those for the gamma source. The data presented in this paper may be used for IVBT treatment planning or for dosimetric analysis of treatment outcome. The dose change due to the source offset should be considered in dose prescription. The reduction of effective treatment length should be taken into account in selection of a proper source length to ensure an adequate coverage of the treatment target.