Systematic review
Review of intraoperative imaging and planning techniques in permanent seed prostate brachytherapy

https://doi.org/10.1016/j.radonc.2009.12.012Get rights and content

Abstract

Techniques for permanent low dose rate seed brachytherapy for prostate cancer have evolved in the recent years with increasing use of interactive planning in the operating room (OR) during seed placement. This overcomes one of the main sources of error in the original two-stage technique in which a planning study performed at a time distant from the implant is used to define seed positions and then an attempt to reproduce this at the time of implant is required. This review addresses the various ways in which real-time dosimetry may be used. Three basic approaches are described; intraoperative planning when a plan is produced as a separate stage prior to the implant during a single OR procedure, interactive planning which incorporates stepwise modification of the treatment plan based on feedback from real-time tracking of the actual needle positions and dynamic dose calculation in which there is a continuous updating of the dosimetry using continuous feedback of the seed positions as they are implanted. The impact of these changes on dosimetric and biochemical outcome endpoints is considered demonstrating the superior results which can be obtained by closer integration of the planning processes with actual implantation and seed deposition.

Section snippets

Material and methods

The evidence was selected and reviewed initially by one member of the PROBATE Group (AP) and was subsequently reviewed by the other members of the group in a series of meetings for incremental systematization of the information found. Members of the PROBATE Group have disclosed potential conflict of interest information.

A systematic literature search was carried out using the PubMed database. Medical subject headings included ‘brachytherapy’, ‘prostatic neoplasms’, and ‘radiotherapy planning,

Intraoperative pre-planning

In accord with the American Brachytherapy Society (ABS), intraoperative pre-planning refers to the creation of a plan in the operating room (OR) just before the implant procedure, with immediate execution of this plan [14]. Intraoperative pre-planning eliminates the conventional pre-planning patient visit (a few days or weeks prior to the implant) by bringing the planning system into the OR. Because there is no pre-plan on which to base seed ordering, the approximate number of seeds to be

Interactive planning

Following the terminology of the American Brachytherapy Society (ABS), interactive planning refers to an intraoperative stepwise refinement of the treatment plan using computerized dose calculations derived from image-based needle position feedback [14]. In this approach, the process of seed ordering, image acquisition, target definition, and organ contouring is similar to the intraoperative pre-planning method. An optimized treatment plan is then performed in the operating room, the DVH is

Dynamic dose calculation

Dynamic dose calculation represents a paradigm shift in dose prescription and specification and source delivery for permanent seed implantation. It will mirror the image-guided radiation therapy (IGRT) paradigm in EBRT in that an intended prescription dose is adaptively “painted” to a changing 3D target volume. This process of dose-painting may result in alteration of a previously accepted isodose distribution and total implanted activity at any time, until the end of the procedure when a

MRI-based intraoperative planning

Magnetic resonance imaging has an established role in the preoperative assessment of prostate cancer and has been used for biopsy guidance [45], [46], staging [47], [48], [49] and treatment planning for EBRT ([50]) and brachytherapy [51], [52].

The TRUS-based approach for permanent seed implantation has limitations as it is based on needle positions rather than direct seed capture, causes variable deformation of the patient’s anatomy and is affected by reduced image quality due to poor mucosal

Robotics for permanent seed implantation

Robotics is playing an increasing role in urologic surgery since the introduction of the da Vincï system [71]. Robotic assistance in prostate brachytherapy has been an active research field in the recent years. Several robotic system designs have been proposed, including 3DTRUS-based robots [72], [73], [74] and MRI-based robots [75], [53].

There are several advantages to the use of robotic-assisted devices. First, the elimination of the template offers a larger implantation space that can

Conclusion

The two-step TRUS-based transperineal prostate implant technique revolutionized brachytherapy for prostate cancer and has stood the test of time. There is no doubt that in experienced hands with good quality control systems in place it can deliver highly effective treatment for prostate cancer. However imaging technology and planning software continue to evolve and this review has demonstrated that there are now many ways in which interactive planning in the operating room delivering additional

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