Isodose patterns in patients with inadequate prostate brachytherapy coverage

Purpose: The development of a practical, real-time dosimetry system should result in improved implant dose distributions and higher prostate cancer control rates. Our purpose here is to demonstrate that intraoperative isodose reconstruction in relation to the seed distribution, even without accurate registration with the prostatic volume, can likely identify an inadequate implant intraoperatively and guide corrective seed placement. Methods and Materials: A total of 102 Pd-103 implants performed by standard techniques, using a modified peripheral loading pattern, were studied. A postimplant computed tomography (CT) scan was obtained 2-4 It after the implant. The contoured images and sources were entered into a Varian Variseed 7.0 treatment planning system. Dosimetric parameters analyzed included the percent of the postimplant prostate or rectal volume covered by the prescription dose (V100), and the dose that covers 90% of the postimplant prostate volume (D90). Isodose patterns were analyzed at midprostate, and for the entire prostate. Adverse isodose patterns were defined as gaps, holes, islands. Isodose gaps are subprescription intervals between the prostatic margin and the prescription isodose. Isodose holes are regions of subprescription dose within the prostate. Isodose islands are isolated regions greater than or equal toprescription dose inside the prostatic margins. Results: Characteristic isodose patterns were predictive for V100 values. Midprostatic isodose holes were seen in 55% of patients with a V100 < 80%, 5% of patients with a V100 of 80-90%, and only 1% of patients with a V100 > 90%. When analyzing the entire prostate, isodose holes were seen in 55% of patients with a V100 < 80%, 18% of patients with a V100 of 80-90%, and 9% of patients with a V100 > 90%. Midprostatic isodose islands were seen in 55% of patients with a V100 < 80%, 5% of patients with a V100 of 80-90%, and no patient with a V100 > 90%. When analyzing the entire prostate, isodose islands were seen in all patients with V100 < 80%, 36% of patients with a V100 of 80-90%, and only 1% of patients with a V100 > 90%. The likelihood of a V100 less than 80% was best predicted by the presence of isodose holes or islands at midprostate. Patients with either finding had an 86% chance of having a V100 < 80%. Conclusion: These semiquantitative findings can provide practical guidelines for intraoperative dosimetry, to provide a more rational guide to intraoperative postimplant assessment and modification. If isodose holes or islands are seen within the implanted volume, additional seeds are added to the affected region to obtain a V100 > 80%. (C) 2003 Elsevier Inc.