Technology in Cancer Research & Treatment

ISSN 1533-0346
Volume 3, Number 3, June (2004)
©Adenine Press (2004)

HDR Brachytherapy with Surface Applicators: Albert M. Sabbas, Ph.D.*

Technical Considerations and Dosimetry Fridon G. Kulidzhanov, Ph.D.
Joseph Presser, M.Sc.
www.tcrt.org
Mary K. Hayes, M.D.
HDR surface molds offer an alternative radiotherapy modality to electrons for the treatment Dattatreyudu Nori, M.D.
of skin lesions. Treatment planning and dosimetry are discussed for two types of surface
molds used in our clinic. Standard rectangular applicators are used on a variety of sites
Department of Radiation Oncology
where surface curvature is minimal. In these cases an idealized planar geometry is used
for treatment planning dose calculations. The calculations yield treatment dose uniformity New York Presbyterian Hospital
at the prescription depth in tissue as well as skin dose, as a percentage of the treatment Weill Cornell Medical College
dose, and its dose uniformity. The availability of optimization techniques results in superior
525 East 68th Street
dose uniformity at depth but the dose at the skin has to be carefully evaluated. We have
studied the dependence of these dosimetric parameters on the size of the surface mold and New York, NY 10021
the type of optimization procedure used in the dosimetry calculations. The second type of
surface applicator involves the use of a customized silicone rubber mold attached to a ther-
moplastic mask of the patient. We have used them to treat lesions of the face where sur-
face curvatures are appreciable and reproducibility of setup is more critical. In these cases
a CT data set is used for reconstruction of the catheters, activation of relevant dwell posi-
tions and dosimetry, including optimization. Towards establishing effective methods for
quality assurance of the optimized HDR surface mold planning calculations, we have com-
pared their dosimetry to both a classical brachytherapy system and to one based on an ana-
lytical model of the applicator. The classical system yields an independent verification of the
integrated activity used in the planning calculations, whereas the analytical model is used
to evaluate depth dose dependence on mold size and optimization.

Key words: High dose rate brachytherapy; Surface molds; Skin lesions; Dose optimization.

Introduction

Surface mold therapy was introduced in the beginning of the 20th century to treat
skin lesions following the discovery of radium (1). Radioactive molds became
one of the established radiation modalities to treat skin cancer along with super-
ficial and orthovoltage X-rays. The surface mold applicators were typically
loaded with gamma emitters such as Ra-226, Rn-222, Au-198, Co-60 or Cs-137
and they were widely used for the treatment of skin lesions of the extremities.
This technique was described in a report by Ashby et al. in 1989 (2) where they
used radon sources in wax and paraffin molds.

With the introduction of linear accelerators and the availability of high-energy

electron beams, brachytherapy mold therapy became less popular. Lovett et al.
(3) reported on the treatment of skin carcinomas with external beam radiothera-
py. Electrons in particular, became the preferred way of treating superficial skin * Corresponding Author:
lesions due to the wider availability of linacs and the radiation hazards associat- Albert M. Sabbas, Ph.D.
ed with the construction and use of the brachytherapy surface molds. Email: asabbas@nyp.org

259
260
The development of afterloading techniques and in particu-
lar the HDR remote afterloader overcame the issues associ-
ated with personnel radiation protection. HDR surface mold
therapy was first introduced by Joslin (4, 5). As HDR
brachytherapy units became more widely used there has
been a revived interest in surface molds. Radiation safety
hazards associated with LDR molds were no longer present
and the treatment could be delivered safely over a short time
as an outpatient procedure. Various authors have reported on
the use of HDR brachytherapy for the treatment of superfi-
cial tumors as an alternative to electron beam therapy (6-12).
Svoboda et al. (13) used soft silicone rubber applicators that
allow treatment of any flat areas by a single mold up to a 24
cm square. Cuix et al. (14) demonstrated the clinical effica-
cy of custom-made surface molds to treat irregular or curved
surfaces with the HDR afterloader. They placed the molds on
top of individually-constructed patients’ masks made out of
plaster. HDR surface molds have also been used to treat
tumors of sites other than skin. Jolly and Nag (15) reported
on the use of dental molds for the treatment of head & neck
cancers. Harrison (16) used specially-made flexible applica-
tors for intraoperative radiation therapy (IORT).
In this paper we describe our experience in using two types
of surface molds for the treatment of skin lesions with par-
ticular emphasis being given on treatment planning and
dosimetry aspects. We have treated close to 80 cases since
1995, when we first introduced this technique in our depart-
ment as an alternative to electron beam therapy, including
lesions of the septum of the nose and the oral cavity. The
types of cutaneous lesions that we have treated are primary
and secondary skin cancers, Kaposis’s sarcoma, mycosis
fungoides and cutaneous lymphomas. Depending on the his-
tology, patients were treated with a dose 300-500 cGy per
fraction twice a week, for a total dose ranging from 1600-
5000 cGy (4-13 fractions). A more detailed list of the types
of cases we have treated along with clinical results will be
presented in a separate manuscript.
We have used standard commercially available applicators
when treating surfaces with minimal curvature. In these
cases we base the dosimetry on an idealized flat planar
geometry. For these applicators we present the dependence
of the treatment dose and skin dose uniformity on method of
optimization and size of treatment area. We have also used
customized surface molds rigidly attached to the patient’s
thermoplastic mask for facial sites where surface curvature is
more pronounced. In these cases catheter reconstruction and
dosimetry are all CT-based and image driven. Finally, the
dosimetry of the HDR stepping source configuration is com-
pared to a classical table-based dosimetry system as well as
an analytical model of the surface mold, the latter two serv-
ing as QA tools of the HDR computerized dose calculations.
Technology in Cancer Research & Treatment, Volume 3, Number 3, June 2004
Sabbas et al.
Materials and Methods
Standard Rectangular Applicators
We have been using commercially available (Mick Radio-
Nuclear Instruments, Inc.) flexible applicators made out of
a flexible silicone rubber material for treatment sites
where curvature is minimal such as skin lesions of the
extremities. The thickness of the applicator is 8 mm and
the distance between the catheter plane and patient skin is
5 mm. They come with predrilled holes every 1 cm for
embedding the HDR catheters These applicators were ini-
tially developed for intra-operative work and are known as
the HAM applicators (Harrison-Anderson-Mick) (16).
Figure 1 shows the two types of HAM applicators used in
our clinic. The 6 catheter applicator is used to treat small
areas up to 6 cm × 6 cm2. The 12 catheter applicator can
be used to treat larger areas, such as skin lesions at the
torso and legs, up to an area of 21 cm × 11 cm2.
By activating certain combinations of catheters and dwell
positions a variety of areas of different sizes and shapes can
be treated. With an overall thickness of less than 1 cm,
they conform well and easily to the treatment surfaces. A
spacing of 5 mm between the skin and the source plane is a
good compromise between maintaining an acceptable dose
uniformity at the skin while at the same time maximizing
the dose fall-off with depth.
We place a solder wire over the marked outline of the lesion
plus margin on the skin prior to acquiring a single en-face
film. The applicator is positioned so that its distal edge is
aligned to the distal edge of the lesion. By adjusting the ori-
entation of the applicator the curvature of the treatment sur-
face, if any, is set in a direction perpendicular to direction of
the catheters and exposure to the surrounding patient’s
anatomy while the source is in transit from the afterloader
to the applicator is kept at a minimum. We do not use the
en face film for reconstructing the source dwell positions in
space. Rather we use it for documentation of the treatment
area and deciding which catheters and dwell positions to
activate (Fig. 2). We also mark two corners of the applica-
tor on the patient’s skin for reproducible placement of the
mold prior to each radiation fraction (Fig. 3).
For treatment planning purposes we assume an idealized
flat planar geometry of the surface mold. Figure 4
shows the coordinate system we use to input source
dwell positions into the dose planning system. An atlas
of plans corresponding to various combinations of
catheters and dwell positions can be thus calculated in
advance and the appropriate one chosen based on the
desired number of catheters and dwell positions needed
to cover the treatment area.
HDR Brachytherapy with Surface Applicators
We use optimization techniques for the calculation of dwell
times in order to meet certain prescription and dose unifor-
mity criteria. The optimization process can be thought of as
a computerized application of the Paterson-Parker rules (17)
to achieve dose uniformity and homogeneity within the
implant, albeit quite more flexible. The dose prescription/
optimization points are arranged at a depth of 5 mm (some-
times 3 mm) within the skin or 1 cm from the source plane.
We have used two types of optimization methods for these
planar molds. An optimization on dose points uses the sin-
gular value decomposition algorithm (18) to minimize the
sum of the squares of the differences between calculated and
desired dose to the points. This results in uneven dwell times
with larger dwell times at the periphery of the implant. A
geometric optimization (19) method calculates the dwell
times according to the relative positioning of the dwell posi-
tions to achieve the desired dose homogeneity within the
implant. The merits of each of these two optimization meth-
ods, as they relate to the dosimetry of these planar surface
molds, will be presented in the next section.
Customized Surface Molds
To provide even better conformality and reproducibility
when treating curved surfaces, particularly with lesions of
the face near the nose, we have customized the construc-
tion of the surface mold to the particular patient. A mask
made out of thermoplastic material, 3 mm in thickness, is
made to conform to the patient’s face. If the lesion is close
to the eyes the mask has provisions for attaching securely
two 6 mm thick eye Pb shields (2 HVL’s) for all the treat-
ment fractions. A highly flexible 4 mm thick Silicone
Rubber applicator is then attached over the mask to cover
the area to be treated. The catheters are embedded within
the applicator at midplane thus providing a total distance
of 5 mm between the source plane and the skin. These sur-
face molds can be cut to various rectangular sizes accord-
ing to the area to be treated. They have two sets of holes
spaced every 1 cm, one set of holes for inserting the HDR
catheters and the other set on the front plane for attaching
them to the thermoplastic mask with plastic screws.
Figure 5 shows the customized face mask with the appli-
cator attached over it.
Treatment planning and dosimetry are based on a volumet-
ric CT data set acquired with the mask and applicator in
place. The slice thickness of the CT axial cuts is 3 mm or
less. The reconstruction of the catheters in space is done by
tracking them on various consecutive CT images and the
activation of relevant dwell positions and choice of pre-
scription depth are entirely image-based. Isodose shaping
optimization software are used to conform the dose to the
individual anatomy and target volumes without the use of
explicit optimization dose points.
Technology in Cancer Research & Treatment, Volume 3, Number 3, June 2004
261
Results
CT-based Planning
Figure 6 depicts the dosimetry of a CT-based plan using a 4
mm silicone rubber mold securely attached to the patient’s
thermoplastic mask. The setup is customized to the particu-
lar patient for ease of placement, which also results in a repro-
ducible treatment geometry. For the particular case described
here, four catheters were embedded within the silicone mold
with the catheter plane being at a distance of 5 mm from the
skin. The treatment site was the right nasal side wall with the
lesion (squamous cell carcinoma of the skin) measuring
approximately 3 × 3 cm2. To provide adequate coverage the
dwell positions enabled per catheter varied with the most
medial having 7 positions enabled, the two central catheters
each with 8 active positions and the most lateral having 3
active positions. The spacing between successive dwell posi-
tions was 5 mm. The dwell positions for the most lateral
catheter were activated with an offset of about 2.5 cm from
the tip of the catheter to avoid proximity to the right orbit.
This particular patient had undergone Moh’s surgery prior to
radiation treatment and the pathology results were positive
up to the bone. Therefore, the facial bone, also shown in the
3D view, served as the landmark for prescribing the dose at
depth. The optimization of the dwell times was done by
directly shaping the isodoses to conform to the CT anatomy.
Image-based brachytherapy is fast becoming the standard
and as this example illustrates, a single CT data set can be
used for catheter reconstruction, deciding on which dwell
positions to activate, displaying of the isodoses in 2D or 3D
as well as dwell time optimization. In the case described
above, TLD’s were placed by the right inner canthus and
under the right eye within the treatment field. These meas-
ured doses agreed to within a few percent with the calculat-
ed doses by the treatment plan. The measured doses at the
two eye lids under the lead shields also agreed well with the
calculated doses after the latter were multiplied by 0.25 to
account for the two HVL’s of Pb present during treatment.
Dosimetry of Flat Planar Applicators
Figure 7 shows the isodose distributions from a 6 × 6 cm2
surface mold on planes perpendicular and parallel to the
brachytherapy catheters. The parallel plane is at a distance
of 10 mm from the catheters which corresponds to a depth of
5 mm in tissue. The effects on the shape of the isodoses with
no optimization, dose point optimization and geometric opti-
mization are shown in Figures 7a, b and c respectively.
Plans with no optimization or equal dwell times for all dwell
positions yield the widest variation of dose across the treat-
ment plane. The maximum doses occur at the center of the
implant, while the periphery of the implant is underdosed.
262 Sabbas et al.

Figure 4: Schematic of the surface applicator and the coordinate system

used for treatment planning. Most of the times a flat planar geometry is
used for the dose calculations.
Figure 1: Two types of commercially available HAM applicators made out
of a silicone rubber material. These applicators are used to treat different
types of lesions through the activation of the appropriate number of
catheters and dwell positions. A. 12 channel mold. B. 6 channel mold.

Figure 5: A flexible silicone rubber applicator with 4 HDR catheters

embedded is shown attached to the patient’s thermoplastic face mask. The
extent of the lesion is outlined in blue ink. The Pb shields for the two eyes
are attached to the underside of the mask.

Variations of the prescription dose among the optimization

Figure 2: En face simulation film with the lesion delineated with solder
wire. The decision of which dwell positions to enable is based on this film.
points, placed opposite the source positions at 10 mm, can be
as high as 25 to 35% of the prescription dose.

Dose point optimization yields the most uniform dose across

the treatment plane with dose variations of only 2 to 4% among
the optimization points. Optimization results in unequal dwell
times with the highest dwell times occurring at the periphery of
the implant. As a result, dose homogeneity at distances from
the catheters closer than 10 mm worsens. The plan based on
geometric optimization is a compromise between dose unifor-
mity across the treatment plane and dose homogeneity at short-
er distances and is in-between the no optimization and dose
point optimization plans. The dose variations among the opti-

Figure 3: Applicator placed on the patient’s skin is attached to the HDR

afterloader prior to treatment delivery.

Technology in Cancer Research & Treatment, Volume 3, Number 3, June 2004

HDR Brachytherapy with Surface Applicators
mization points are within the 15-20% range relative to the pre-
scription dose with a standard deviation of about 10%.
Of significant clinical importance when treating surface
lesions is the dose to the skin. In Figure 8 we plot the skin
dose as a function of treatment area for a number of rectan-
gular planar surface molds. The skin dose is expressed as a
percentage of the prescription dose and both the average and
maximum dose to the selected skin points are shown. The
skin points are positioned opposite to the source dwell posi-
tions at a distance of 5 mm. Most of the calculations are
based on the geometric optimization, which is what is used
mostly in the clinic. For the 5 × 5 and 9 × 9 molds we also
show the calculated skin doses based on the dose point opti-
mization which results in larger dose inhomogeneities and
maximum doses compared to the geometric optimization,
240% versus 175%, at the skin for the 5 × 5 mold.
In general, the skin dose decreases with size of the surface
area treated since the dose fall-off is less with larger surface
molds. This decrease is more pronounced when no opti-
mization is used and is least noticeable when the dose point
optimization is used, since the optimization compensates for
the finite surface area by increasing the peripheral dwell
times. For no optimization the maximum skin dose occurs
near the center of the treatment area. The dose variation at
the skin for dose-point optimized plans is the largest. The
center dose is close to the minimum and the maximum
occurs at the edge of the treatment area where the optimized
dwell times are the largest. We have observed skin reactions
at the treatment edges for patients treated with plans opti-
mized on dose points and this is a clinical confirmation of
the substantial surface hot spot at the periphery. The least
variation in the skin dose and the smallest hot spots are
exhibited by plans calculated using geometric optimization.
Comparison with a Classical Brachytherapy System
The optimization methods achieve a dose uniformity at the pre-
scription dose plane by yielding a set of unequal dwell times.
This is in close analogy to the Paterson Parker rules of the
Manchester LDR brachytherapy system (17), which is a set of
rules for arranging Radium or other types of low activity
sources in order to achieve uniform dose to a plane or volume.
The total activity multiplied by the duration of the implant ∫Adt,
is a good indicator of the dose delivered by such an implant.
The Manchester tables (20) for planar implants list the
mg·hr to deliver 10 Gy to tissue for different surface areas
and treatment distances from the source plane (RA). We
have used these tables to independently verify ∫Adt for com-
puterized HDR plans. Specifically, we calculate ∫Adt using
RA, the prescription dose D and a conversion factor of
6.3734 (Ci·s/mg·hr). The RA is based on a surface area
Technology in Cancer Research & Treatment, Volume 3, Number 3, June 2004
263
We then compare ∫Adt to the one derived based on the activ-
ity of the HDR source multiplied by the sum of all the dwell
times of the HDR plan.
In Figure 9 we plot the ratio of the ∫Adt as derived from the
HDR brachytherapy calculations and that based on the inde-
pendent dosimetry verification, as outlined above, for various
sizes of planar surface molds. Each surface mold is desig-
nated by its size in terms of number of catheters times num-
ber of positions (C × P) with 1 cm spacing between dwell
positions. The prescription distance for all the molds was set
to 1 cm (5 mm depth in tissue) except for the 11 × 9 mold
where the distance was set at 0.8 cm (3 mm depth in tissue).
For plans based on the dose point optimization algorithm the
agreement is within 3%. For plans based on the geometric
optimization algorithm the agreement is acceptable, mostly
within 8%, though not as good as the dose point optimization
plans that seem to replicate the Paterson Parker rules better.
Comparison with Analytical Model
We studied the exact dependence of the depth dose from an
HDR surface mold on the treatment area by considering an
analytical model of the surface mold. For 192Ir the radial
dose function g(d) exhibits less than 1% variation over the
first 5 cm distance from the source (21). The variation of
dose with distance d along the central axis of the mold is
therefore mainly due to the geometry factor G(d).
Considering a circular mold of radius R, total activity A and
uniform activity density α, the geometry factor can be cal-
culated by integrating over the area of the applicator.
[ ( )]
2π R ρdρdθ 2
α∫ α∫ 2 2
0 ρ + d 1 R
G (d ) = 0
= ln 1 + . [1]
A R2 d
For treatment distances much greater than the lateral extent of
the applicator, R<<d, G(d)=1/d2 which is the familiar inverse
square dependence of the depth dose from a point source. In
Figure 10 we plot the dose fall-off, as predicted from Eq. [1] for
surface molds of uniform activity of radii 2, 3, 4, and 5 cm. For
comparison the 1/d2 curve of a point source and 1/d curve from
an infinitely long linear source are also plotted. The curves are
normalized to a distance of 1 cm from the source plane or to a
depth of 0.5 cm in tissue. As seen from Figure 10 the surface
dose varies from 176% for the smallest 4 cm diameter applica-
tor to142% for the largest 10 cm diameter applicator. The depth
dose is also steeper for the smaller size applicators.
In Figure 11 we compare the depth dose of the analytical
model and the computerized HDR brachytherapy calcula-
tions for a 6x6 cm2 mold (R=3.4 cm). Both the unoptimized
(equal dwell times) and the dose-point optimized calculations
are plotted. All three curves are normalized to a depth of 0.5
264 Sabbas et al.

Figure 6: CT-based dosimetry for the applicator

shown in Figure 5. A. Axial cut. B. Reconstructed
coronal view. C. Reconstructed sagittal view. D.
3D view with the 400 cGy/Fx dose cloud shown
together with the outlined anatomy.

Figure 7: Dosimetry of a flat 6 × 6 applicator on a

plane perpendicular to the catheters and a plane par-
allel to the catheters at a distance of 1 cm form the
plane of the catheters. A. No optimization. B. Dose
point optimization. C. Geometric optimization.

Technology in Cancer Research & Treatment, Volume 3, Number 3, June 2004

HDR Brachytherapy with Surface Applicators
Figure 8: Skin dose expressed as a percentage of the treatment dose as a
function of the applicator size (# of catheters x # of dwell positions). There
is a 0.5 cm bolus between the plane of the catheters and the skin and the
dose is prescribed to a depth of 0.5 cm in tissue. Both the average and max-
imum skin doses are plotted for the geometric optimization (all sizes) and
for the dose point optimization (two sizes).
Figure 9: Agreement between the HDR contact therapy calculation and
the Paterson Parker tables of the integrated activity for various surface
applicator sizes.
Figure 10: Depth dose calculations for various radii of surface applicators
based on the analytical model of the applicator. For comparison the inverse
square dose fall-off from a point source and the inverse distance dose fall-
off from an infinitely long linear source are also shown. The dose is nor-
malized to a depth of 0.5 cm in tissue.
Technology in Cancer Research & Treatment, Volume 3, Number 3, June 2004
265
Figure 11: Depth doses from a 6 × 6 surface applicator based on the ana-
lytical model (continuous curve) and the HDR stepping source non-opti-
mized and optimized dose calculations.
Figure 12: Comparison of the depth doses for different modalities: Co-60
80 SSD, 6 MeV electrons 100 SSD, 100kVp superficial X-rays 15 SSD and
a 6 × 6 surface mold with a 0.5 cm bolus between the skin and the plane of
the catheters. The HDR calculations are optimized. The dose is normalized
to 100% at the skin for the superficial and HDR modalities and dmax for the
Co-60 and the electrons.
Figure 13: Comparison of the dosimetry on a curved surface from A. 6 ×
6 HDR surface applicator with 0.5 cm bolus and B. 6MeV electron beam
with a 6 × 6 cone and 1 cm bolus.
266
cm in tissue. The analytical model predicts well, to within a
few percent, the depth dose from the stepping source unopti-
mized plan. Upon optimization the depth dose becomes less
rapid by as much as 7% compared to the unoptimized plan
since peripheral dwell positions are weighted heavier.
Discussion
In Figure 12 we plot the percent depth dose for three external
beam modalities along with that from an optimized 6 × 6 cm2
HDR surface mold used clinically. The high dose region for 6
MeV electrons ( > 80% of the maximum dose) extends over
1.8 cm from the surface and is then followed by a precipitous
drop in the radiation dose. In contrast the depth doses of the
HDR 192Ir and superficial X-rays do not exhibit any skin spar-
ing and fall off exponentially with depth. For the HDR mold
the dose is already down to 67% and 52% of the skin dose at
depths of 5 mm and 1 cm respectively. HDR contact therapy
treats more superficially than electrons. HDR contact therapy
also exhibits faster dose fall-off than the superficial beam.
The HDR mold, due to its flexibility, is able to conform well
to the skin area and the dose can be delivered uniformly at
depth when treating curved surfaces as well. The electron
cones on the other hand are rigid and as a result there can be
appreciable variations in the treatment SSD across the treat-
ment area. Obliquity effects for electrons (22) when incident
on curved surfaces can further contribute to the dose inho-
mogeneity at depth. We plot in Figure 13 the isodose distri-
butions on a curved surface (5 cm radius of curvature) from
a standard 6cm × 6cm HDR surface applicator and from a 6
MeV electron beam, 6 × 6 cone, 100 SSD and 1 cm bolus.
The thickness of the bolus used with electrons was chosen so
that the prescription level of 100% occurs at approximately
7 mm from the surface at the center of the treatment area for
both modalities. For the HDR mold, the prescription dose is
delivered uniformly at depth across the whole width of the
treatment area. For electrons, on the other hand, the extent
of the prescription dose falls short of the intended treatment
width by as much as 2 cm.
As mentioned earlier, a flat planar geometry is almost always
assumed during dosimetry calculations when we use stan-
dard rectangular applicators to treat skin lesions of the
extremities and the torso. The dwell times for the 6cm × 6
cm mold used to treat the curved surface shown in Figure
13a were calculated based on a flat surface geometry to
deliver 400 cGy at a treatment depth of 0.5 cm in the skin.
As seen from this figure, the curvature of the treatment area
causes the prescription isodose to appear deeper than 5 mm
by 1.7 mm on the concave side. Therefore, assuming a flat
geometry results in isodoses being shifted no deeper than 2
mm as long as the treatment surface curvature is not exces-
sive (more than 5 cm in radius).
Technology in Cancer Research & Treatment, Volume 3, Number 3, June 2004
Sabbas et al.
In conclusion, some of the key features of HDR contact ther-
apy are summarized below:
(I) Surface molds can conform easily to the curva-
ture of the treatment surface. On the other hand,
there are uneven air gaps between the tip of the
electron cone and the patient’s surface, especial-
ly when treating curved surfaces, which con-
tribute to the dose inhomogeneity at depth with
electron beam therapy.
(II) Optimization algorithms are routinely incorporated
in the HDR brachytherapy calculations and con-
tribute further to the dose homogeneity at depth.
(III) Through adjustment of dwell positions and dwell
times manually or as part of the optimization
process the radiation field can be customized in
terms of its shape and intensity profile. No custom
cutouts are needed to shape the radiation field.
(IV) The dose fall-off is faster than Superficial
Therapy and is thus better suited for the treatment
of more superficial lesions.
(V) It is easy to shield selected areas of the treatment
field using Pb sheets. The HVL for Ir-192 is 3
mm of lead.
(VI) HDR contact therapy can be used to treat struc-
tures with excessive curvature like the septum of
the nose. It can be also used to treat cavities not
easily accessible by electron applicators like the
buccal mucosa.
(VII) Radiation safety issues are minimal for the HDR
remote afterloader since there is no radiation
exposure to personnel.
(VIII) The treatment times are of the order of a few min-
utes. Hence the dose is delivered quickly and
effectively as an out-patient procedure.
(IX) Scheduling of HDR contact treatments does not
impact on the busy schedule of the linac. In addi-
tion, the HDR dose fractionation calls for fewer
fractions or patient visits.
HDR Brachytherapy with Surface Applicators
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