Abstract:
Breast cancer patients are treated intraoperatively with radiation shortly after excision of a tumor. Pathology of the tissue is determined with a nearly instantaneous method, further excision is performed if needed, and the patient, still anesthetized and preferably unmoved, is then treated with radiation therapy. In a preferred embodiment an applicator is inserted into the excision cavity, the cavity is three-dimensionally mapped using radiation sources and a sensor, a radiation treatment plan is developed using a radiation prescription and the determined shape and location of the cavity, and the treatment plan is executed, all while the patient remains under anesthesia.

Description:
BACKGROUND OF THE INVENTION  
         [0001]    This invention concerns the treatment of breast cancer or otherwise-sited cancer, and especially an efficient procedure for radiation treatment following surgical tumor excision, including pathology of the excised tissue, without waking or moving the patient or using external imaging techniques.  
           [0002]    In treating cancer of the breast, as well as cancer found in other areas of the human body, with the patient under anesthesia, the tumor is surgically excised (with some surrounding tissue) and then typically, the surgical wound is closed, the patient is sent home pending determination of pathology of the excised tumor margin, a radiation treatment plan is developed, and the patient in a series of later visits is subjected to radiation treatment in the volume of tissue surrounding the excised tumor. This can often involve re-opening of the surgical cavity for insertion of an applicator for use with ionizing radiation sources, i.e. radioactive isotopes. The forming of a radiation treatment plan under these circumstances is usually a several-hour process that can require imaging of the excision cavity, to determine its shape and location in the body, using external devices such as magnetic resonance imaging or CT scanning equipment. Transfer of data is then needed between the imaging equipment and the treatment planning software for preparing a plan of irradiation, with the need to verify transferred data values to check for errors.  
           [0003]    These several steps involve considerable time and associated costs and makes intraoperative radiation treatment logistically difficult if not impossible. In the case of breast tumors, moving of the patient for imaging is a problem in itself, because the breast is flexible and the excision cavity may move. There is a need for a methodology which would allow intraoperative radiation treatment of breast cancer and other cancers, without moving the patient, without requiring external imaging devices and without waking the patient from anesthesia.  
           [0004]    There is also a need for increased precision in delivering radiation to a volume of tissue following surgery, to closely follow a physician&#39;s prescription. For example, more versatility and accuracy are needed in avoiding damage to skin in irradiation of breast tissue, and avoiding damage to the heart, lungs and bones, while still delivering prescribed dosage where needed. Over-radiation of any tissue areas is to be avoided as much as possible.  
           [0005]    Recent advances have occurred in determining pathology of a tumor, or of the surrounding tissue, almost instantaneously. See, for example, “Twenty Watts of Terahertz”, Eric J. Lerner,  The Industrial Physicist,  page 9, April/May 2003. See also “Development of Novel Technologies for In Vivo Imaging”, PAR-01-102, May 29, 2001, nih.gov website; “In Vivo Endoscopic Optical Biopsy with Optical Coherence Tomography”, Tearney, Brezinski, et al.,  Science,  Vol. 276, Jun. 27, 1997, pp 2037-2039; “Oesophageal Histology Without a Biopsy”, Tudor Toma,  The Scientist,  Feb. 7, 2001, biomedcentral.com website; “Determination of Spatial Location and Pathology of Breast Lesions using Proton MRS”, imrr.org website; “Multiphoton Excitation Microscopy of Human Skin in Vivo: Early Development of an Optical Biopsy”, Barry R. Masters and Peter T. C. So, optics.sgu.ru website.  
           [0006]    Determination of pathology of tissue at the excision site is information the physician uses to determine whether further excision of tissue is required, or if the next step is radiation. The determination of a treatment plan depends on obtaining information on the shape and location of the excision cavity and the need to avoid damage to other areas of tissue (such as the skin, the chest wall, lungs and heart). Intraoperative radiation treatment has generally not been possible or practical for several reasons: the need to move the patient to the location of imaging equipment, to obtain the imaging data and transfer that data to a form useable in applicator equipment for performing the irradiation; and the need to obtain data on pathology of the excised tissue or the remaining tissue in the excision cavity, prior to executing a treatment plan. Obtaining these needed data requires considerable time; in general a patient following tumor excision should be ready for radiation treatment within about ½ hour, certainly less than 1 hour, and this is not possible with current procedures and equipment.  
           [0007]    Proxima Therapeutics has developed a program for radiation treatment following tumor excision. In this procedure a breast tumor is excised, then an applicator is inserted into the excision cavity (often through a new incision at the time of tumor excision or up to several weeks later). The applicator is expanded and the incision is closed except for a pigtail or spigot extending out of the breast for later use. At a later date, following determination of pathology, if no further excision is indicated, the patient returns for radiation treatment via the applicator. The Proxima applicator is spherical and not capable of changing shape to accommodate irregularly-shaped cavities. The applicator comprises a balloon which can be filled to the appropriate size for the particular cavity, but beyond this size variation adjustment is not possible. The surgeon needs to cut as near-spherical an excision as possible to enable the proper use of the device. With the applicator in the excision cavity and filled, the patient&#39;s breast is imaged by exterior imaging equipment. This imaging not only determines the size of the inflated applicator within the breast excision cavity, but also enables the physician to look at any gaps between the applicator and the tissue at the boundaries of the excision cavity. Seroma from the wound may lie between the applicator and the cavity walls. 90% to 95% contact between the applicator and the excision cavity is required to ensure proper radiation delivery. If the applicator/tissue contact is sufficient, the physician uses a table to look up the needed dwell time for the diameter of the applicator and for the particular activity of the radio isotope source, which is known. The ionizing radiation source, i.e. an iridium ( 192 Ir) wire on the end of a stainless steel guide wire, is inserted into the middle of the applicator for the prescribed duration.  
           [0008]    The Proxima procedure is based on a known geometry, i.e. a spherical shape of the applicator and cavity. The equipment is not adaptable to an irregularly-shaped excision cavity. Moreover, the applicator and procedure are not useful for smaller-sized tumors, because of unacceptable surface-to-depth ratio of radiation dosage at near ranges of the radiation source.  
           [0009]    The following patents and applications have some relevance to the present invention: European Patent Application EP1050321.  
         SUMMARY OF THE INVENTION  
         [0010]    By the procedure of the present invention, intraoperative radiation treatment, in a practical sense, is enabled. Primarily this is achieved by (a) providing near-real-time data on pathology following the excision; and (b) immediate, on-site mapping of the shape and location of the excision cavity, all without waking or moving the patient. If pathology determination indicates to the physician that further excision is needed, this is done prior to the on-site mapping. A treatment plan is calculated from the three dimensional mapping data in a very short time, and the treatment plan is executed using the same applicator, the same applicator position and the same ionizing radiation sources as are used in the mapping. In a sense, the mapping step of the inventive procedure comprises a “trial treatment”, providing accurate, useful data, with verification of the effects of each of a plurality of radiation sources in the applicator, including effects where radiation is not wanted, enabling accurate subsequent execution of the treatment plan.  
           [0011]    The intraoperative procedure of the invention not only greatly improves accuracy in radiation treatment, but also subjects the patient to far less discomfort and trauma as compared to typical procedures. By the disclosed procedure the patient, while anesthetized in the operating room, is operated on to remove the tumor, the tumor is investigated as to pathology, by a very rapid process, decision is made as to any need for further excision (which is done if needed), the physician prescribes radiation dosage for a volume of tissue surrounding the excision cavity, the shape of the cavity is mapped and recorded by internal measurements, calculations of radiation to be delivered at various sites in the cavity are made by use of the mapping data to thus prepare a treatment plan, and the treatment plan is carried out, all without waking or moving the patient, and all within a reasonable time.  
           [0012]    In a preferred form of the invention, the procedure is applied to treatment of breast cancer. The tumor is excised from the breast, producing an excision cavity. While the patient remains under anesthesia, pathology is determined, further excision is made in the breast cavity if needed, and then the excision cavity is mapped using radiation sources, either isotopes or switchable x-ray sources. This is done using an expandable applicator, e.g. a balloon having a series of guides, the radiation sources being inserted into peripheral guides. A radiation sensor is placed into a central guide. The applicator is expanded to substantially fill the excision cavity, so that the peripheral guides are placed at walls of the cavity adjacent to a volume of breast tissue to be treated with radiation, such volume having been adjacent to the removed tumor. The excision cavity of the breast is mapped by moving the sources and sensor through the guides and determining dosage at the sensor for each of the sources in turn at a plurality of locations along such movement, those locations being sufficient to substantially define the shape of the walls of the cavity. Dosage received at the sensor for each source at each location is calculated into a distance from the source to the sensor, thus enabling a three dimensional wire-frame type map or model to be generated.  
           [0013]    In a preferred embodiment sensors are also located outside the breast volume to be treated, on the breast surface and at the chest cavity wall (by needle), and these are monitored during mapping so as to locate the cavity within the breast.  
           [0014]    The physician prescribes radiation treatment for the breast volume which surrounded the excised tumor, and from this prescription and from the derived three-dimensional map of the excision cavity, a radiation treatment plan is calculated for a volume to be treated immediately surrounding the excision cavity. The location of the cavity is important and the location data is used to avoid damaging radiation at the skin and at the chest wall. Computer software determines the treatment plan based on all this geometry.  
           [0015]    Next, with the applicator remaining in position in the cavity and expanded as in the mapping step, the radiation treatment plan is carried out via movement and repositioning of the ionizing radiation sources within the applicator guides. Appropriate dwell times are used for the various locations, such that the prescribed dosage of radiation is received in essentially all regions of the volume to be treated, without damaging sensitive areas such as the skin and chest wall. The sensors outside the breast can be used to monitor radiation actually received during the procedure at those sites, and/or as feedback to stop the procedure if excess dosage is received or is predicted to exceed the prescribed dose.  
           [0016]    In one preferred procedure, the ionizing radiation sources comprise switchable x-ray sources, variable as to voltage and current, as well as being switchable on/off during treatment, allowing the treatment plan to more accurately treat the prescribed volume without damage to sensitive areas. The sensors outside the breast volume to be treated are monitored to verify the accuracy of the procedure, and as noted above can actively feed back information to the processor controlling the treatment. With the controllable x-ray sources this feedback can be used to reduce depth of penetration of radiation from appropriate ones of the x-ray sources when needed.  
           [0017]    It is therefore among the objects of the invention to improve radiation treatment of breast cancer and other malignant tumors, primarily by performing the radiation treatment intraoperatively, without moving or waking the patient, through the use of in situ three dimensional mapping of an excision cavity following surgery, using ionizing radiation sources and at least one sensor, and by using a method of instant pathology determination. Related objects are nearly the mapping procedure itself, and the treatment itself, using controllable x-ray sources, preferably with real time monitoring with extra-cavity sensors. These and other objects, advantages and features of the invention will be apparent from the following description, considered along with the accompanying drawings. 
       
    
    
     DESCRIPTION OF THE DRAWINGS  
       [0018]    [0018]FIG. 1 is a flow diagram showing typical prior practice in exclusion of a tumor, determining pathology, as subsequent radiation.  
         [0019]    [0019]FIG. 2 is a flow diagram outlining a procedure in accordance with the invention.  
         [0020]    [0020]FIG. 3 is a flow diagram in greater detail, representing a preferred embodiment, including a three-dimensional mapping procedure.  
         [0021]    [0021]FIG. 4 is a schematic view indicating a step for calibrating radiation sources prior to mapping and prior to treatment.  
         [0022]    [0022]FIG. 5 is a schematic view in sectional elevation indicating several possible locations of excision cavities in a breast, surrounded by a volume to be treated and indicating depth of prescribed radiation in the volume to be treated, and the intersection of the prescription radiation volume with the skin and chest wall, and also indicating use of sensors on the breast and elsewhere outside the cavity for locating the cavity and for feedback.  
         [0023]    [0023]FIG. 5A is a schematic view showing a portion of FIG. 5 and showing limitation of radiation at the skin according to prior practice.  
         [0024]    [0024]FIG. 5B is a view similar to FIG. 5A showing limitation of radiation penetration achievable with the invention.  
         [0025]    [0025]FIG. 6 is a graph showing radiation dose vs. distance from source.  
         [0026]    [0026]FIGS. 7, 7A and  7 B are a graph, a schematic view and a table indicating relationship of distance to time required to receive a preselected dose, as well the relationship of simply distance to dose.  
         [0027]    [0027]FIG. 8 is a schematic view in perspective, showing a wire-frame model of an excision cavity.  
         [0028]    [0028]FIG. 9 is a schematic perspective view of a breast indicating an excision cavity in the form of a wire-frame map or model as in FIG. 8.  
     
    
     DESCRIPTION OF PREFERRED EMBODIMENTS  
       [0029]    [0029]FIG. 1 shows typical current practice, prior to the present invention, for excising a tumor, particularly from the breast of a patient, and the post-operative procedure. The patient is anesthetized as indicated at  10 , and the tumor is excised as indicated at  12  in the drawing. Following excision, the surgical wound is closed as noted at  14 , and the patient recovers as shown in the block  16  and is sent home.  
         [0030]    Meanwhile, the excised tissue is sent to pathology as shown at  18 , and the pathology of the tissue is determined as to whether there is a clean margin, as indicated at  20 . As explained above, this takes some time. Different surgeons apply different standards as to whether a margin is sufficiently clean such that radiation treatment is judged to be sufficient to remove all remaining microfoci disease which might remain. If the physician decides the pathology of the tissue does not indicate a clean margin, as at  21 , then further excision is deemed to be necessary. Thus, in this case, the post-recovery patient is again anesthetized at  22 , additional tissue is excised, through the same or a different surgical wound, as at  24 , and the excised tissue is again sent to pathology, as indicated by return to the block  18 . The surgical wound is closed (block  26 ), and the patient again recovers from the surgery, indicated at  28 , and is again sent home.  
         [0031]    If, at the decision block  20 , the surgeon decides the excised tissue exhibits a clean margin ( 30 ), then a radiation treatment plan is prescribed and calculated, as noted in the block  32 . Then the patient, after recovery (at  16  or  28 ) is treated with radiation according to the treatment plan, as indicated at  34 . At  36  completion of the procedure is indicated.  
         [0032]    In this traditional practice, the radiation treatment plan is derived from (a) a prescription which typically involves a standard dosage of radiation at a standard prescribed depth in the tissue surrounding the excision cavity in the patient, (b) imaging of the excision cavity, by external imaging devices such as x-ray, ultrasound or CT scanning equipment, to determine the size and shape of the cavity and its location within the breast, and (c) use of the imaging data in the treatment planning software, which depends on accurate transfer of data between the imaging equipment and the software. Accuracy can be difficult, as explained above in the case of breast surgery, since the patient must be moved to the imaging facility and the breast comprises flexible tissue and may move, causing the location of the excision cavity to move and change in shape.  
         [0033]    [0033]FIG. 2 is a flow chart showing the main elements of a procedure according to the invention for intraoperative radiation treatment associated with excision of a tumor. The patient is anesthetized at  40  and the tumor is excised at  42 , as in the prior procedure. The excised tissue is taken to pathology (block  44 ), and as noted in the decision box  46 , it is determined through pathology whether the tissue exhibits a clean margin. This is accomplished with a near-real-time method of pathology, as discussed above, without waking and preferably without moving the patient. Such methods are discussed above.  
         [0034]    If it is determined from the near-instantaneous method of pathology that the excised tissue (or the wall of the excision cavity) does not exhibit a clean margin, then the surgeon proceeds to excise additional tissue, indicated at  48 . This may be through the same or a different surgical incision. With this completed, the tissue is again examined by a near-instantaneous method of pathology, and the results are used to determine whether the tissue exhibits a clean margin.  
         [0035]    If a clean margin is determined, the process proceeds to IORT, intraoperative radiation therapy, shown at  50 , according to a calculated treatment plan. After the radiation treatment, the wound is closed ( 52 ), the patient is allowed to recover, indicated at  54 , and the procedure is complete (block  56 ).  
         [0036]    [0036]FIG. 3 is a more detailed flow chart, showing additional steps in a preferred procedure for intraoperative radiation therapy according to the invention.  
         [0037]    Steps  40 ,  42 ,  44 ,  46  and  48  are the same as described above with respect to FIG. 2. Once a clean margin is determined, which might be after additional excision of tissue while the patient remains anesthetized as described above, an applicator is placed into the excision cavity, as noted at  60 . The applicator may be a balloon type device or other expandable applicator having guides for receiving x-ray sources and, in this case, a guide for receiving an x-ray sensor placed generally centrally. Once the applicator has been placed in the excision cavity, in a preferred embodiment x-ray sources are inserted into guides which will ultimately be expanded against the walls of the cavity, and a sensor is placed in the central guide, as indicated in the box  62 . Then the sources are calibrated (as at  64 ), with the applicator collapsed and with the sources closely adjacent to the central sensor. This is shown schematically in FIG. 4, the guides containing the sources being shown at  65  and the central guide with the sensor being at  66 . The later expanded positions of the guides  66  are shown at  65   a,  against the wall  67  of the excision cavity.  
         [0038]    With this calibration data taken in the collapsed state as to the radiation emanating from each of the sources as read at the adjacent sensor, differences in the sources and relative values can be determined such that once the applicator is expanded, dosages read at the central sensor from each source can be used accurately to calculate distance.  
         [0039]    With the sources calibrated, the applicator is expanded as indicated at  68  in the flow chart and at  65   a  in FIG. 4.  
         [0040]    The expansion of the applicator locates the x-ray source guides directly against the walls of the excision cavity (FIG. 4), with the sensor guide remaining in a generally central location ( 66  in FIG. 4). Preferably, additional sensors have been placed at other strategic locations as discussed above: in the case of the breast, on the exterior surface of the breast, and preferably also at the chest wall, via a needle. These sensors are used to locate the excision cavity during the mapping step to be described below, as well as providing a means for quality control, and possibly emergency shutoff, during the radiation treatment. FIG. 5 shows schematically, in the case of a breast B, sensors s located on the exterior surface of the breast, preferably arrayed laterally as well as in vertical separation as shown, and sensors s′ inserted via needle at the chest wall. This is discussed further below.  
         [0041]    With the applicator expanded and the sensor or sensors in place, the three dimensional mapping begins as indicated at  69  in FIG. 3. The patient remains in the same position and anesthetized, and x-ray sources, which may be switchable, e.g. small x-ray tubes, or an isotope source, are placed in the guides of the applicator. With the x-ray sensor located in the generally central guide, the sources and sensor in the guides are pulled back in a series of steps from the distal end of the excision cavity to the proximal end, in approximately five to ten different longitudinal positions of the cavity (i.e. positions along the length of the applicator guides). In the case of switchable x-ray sources, each source may be switched on for a set, short period of time, and the dosage read at the central sensor. Alternatively each source may be switched on at maximum voltage for maximum penetration, and switched off automatically when a preselected dosage of x-rays is detected at the sensor. The duration of time is then used to calculate distance, as discussed below in reference to FIGS. 6 and 7. In either event this is done in succession for the plurality of sources placed around the walls of the cavity, e.g. about two to ten sources (different numbers can be used). In this way, a unique reading is obtained for each source position, and this is repeated at the plurality of longitudinal positions in the cavity as noted above. Each dosage value (or time duration) is translatable into a distance, and thus a three dimensional map of the incision cavity&#39;s interior is obtainable.  
         [0042]    In the case of isotopes, only a single isotope is generally used at one time, placed first in one guide, where all readings are taken in succession, then in the next guide, and so on. Different isotopes can be used but preferably not inserted simultaneously.  
         [0043]    [0043]FIGS. 6, 7,  7 A and  7 B demonstrate calculation of the shape of the cavity wall by the method described above. In FIG. 6, dose is indicated as a function of distance from the sensor. The vertical or y axis is a logarithmic scale. As indicated, dose falls off very rapidly with distance, not only due to the inverse square law (1/r 2 ) but also taking in the effects of attenuation of radiation passing through tissue absorption. For example, FIG. 6 shows that doubling the distance from the sensor, from about 0.5 cm to 1.0 cm, drops the dose approximately by a factor of nine, and from 1 cm to 2 cm, by an approximate factor of ten. The chart in FIG. 6 represents the dose from an x-ray source operating at 45 kV p .  
         [0044]    [0044]FIG. 7A schematically shows a possible location of six different x-ray sources D 1  through D 6 , in positions against the wall (not shown) of an excision cavity. A sensor s is shown in a generally central position. As schematically indicated, each of the sources is a different difference from the sensor s. FIG. 7B shows an example of dose versus distance for the six sources D 1  through D 6 . The information under “distance” and “dose” is as taken from the graph of FIG. 6. However, the right column in FIG. 7B corresponds to FIG. 7, which is the time duration to receive a specified dose, e.g. 0.1 Gy (as is well known 1 Gy=100 rad). FIG. 7 is a graph showing this form of distance mapping, with milliseconds on the vertical axis and distance on the horizontal axis. As discussed above, minimal radiation of the patient during mapping can be achieved by turning the switchable radiation sources to a high voltage setting and maintaining that setting for each source position, shutting off the source whenever a preselected dose is reached, such as 0.1 Gy. Note that 0.1 Gy, which is 10 rad, is a more than adequate level of radiation for detection by the central sensor and also sensors located outside the breast, as in FIG. 5. The graph of FIG. 7 illustrates how distance is determined, by an algorithm.  
         [0045]    Returning to FIG. 5, the sensors s and s′ are located on the surfaces of the breast and at the chest wall, to monitor radiation and also to locate the three dimensional cavity map relative to these locations. The surface mounted sensors s, as shown in FIG. 5, may fall within the prescribed volume to be treated. This is the case with the upper cavity c 1 ; the lower cavity c 2  has the chest wall sensor s′ located within its prescription dose volume. During the mapping procedure, these sensors determine that the skin or chest wall is within the prescription dose region, and that the skin or the chest wall may receive a dose exceeding that desired by the physician. Excessive doses at these structures can lead to damage—in the case of the skin, poor cosmesis outcome, and in the case of the chest wall, possible damage to lungs, heart, great arteries and bone. Thus, the decision is made, either by the physician or the radiation oncologist, or by the computer program, as to whether the prescription dose should be maintained or whether the issue of damage to these other structures should dominate the treatment plan. With the switchable x-ray sources which are preferred according to this invention, this issue is much more easily and more accurately handled. The x-ray sources can be switched on and off, and/or their voltage can be varied when nearing the surface, to lessen penetration. Moreover, the sensors s, s′ can be used to monitor the treatment plan&#39;s accuracy and effectiveness, by measuring dose actually received at those structures during treatment. As noted above, voltage can be varied in real time during the treatment, in accordance with such detection.  
         [0046]    In addition, and importantly, the sensors s and s′ can be used to verify the total dose received in all regions, by calculation in the software which accurately extrapolates the total dose received at all locations. Is it not necessary that a sensor be located directly in the prescription volume as FIG. 5.  
         [0047]    [0047]FIGS. 5A and 5B demonstrate that use of switchable and variable sources, e.g. switchable x-ray tubes, enables far greater flexibility in treating a very specific prescription volume. Using the example of the breast, FIG. 5A again shows, as in FIG. 5, the situation where a prescription volume to be treated intersects with the exterior breast surface B. As explained, this is objectionable and often unacceptable with the potential to do severe damage to the skin. The dashed line V 1  defining this volume to be treated is an isodose curve, basically a three dimensional surface. A treatment plan must integrate the doses received from each of the many sources at all of the dwell points, optimizing the dose at every point within the volume to be treated and eliminating potentially damaging radiation at boundaries such as the breast surface. This is a complex algorithm but is typically accomplished, as best possible, for isotopes having a fixed TG-43 profile. The algorithm takes into account angles relative to each source, and the fall-off of dose with depth and with angle. In FIG. 5A the modified curve V 2  is an optimized isodose curve based on the best that can be accomplished using merely the limitation of dwell time in the treatment plan. This shows approximately how the isodose curve would change if the dose at the skin were limited so as not to exceed the prescription dose. As shown in the schematic approximation of FIG. 5A, the skin boundary is not overlapped with the prescription dose by the curve V 2 , but at the same time, other areas within the prescribed volume are not given the prescription dose, i.e. these regions are underdosed.  
         [0048]    [0048]FIG. 5B, a schematical view similar to FIG. 5A, shows approximately what can be achieved using the invention and the preferred switchable, variable x-ray sources. Again, the isodose curve V, intersects with and overlaps the breast surface B. Here, however, the x-ray sources are switchable and variable as to at least voltage and preferably also current. The treatment plan algorithm takes this into account and optimizes, for all regions of the volume V to be treated, the dose that will be received, with the sources varied as to voltage for varying depth of penetration, and also as to either current or dwell time (current and dwell time are equivalent). The dwell time is varied by switching these sources on/off, while reduction of current is another way to reduce dose. The modified curve V 3  in FIG. 5B approaches very closely the skin, as is desired, through virtually the entire range of the volume V to be treated inside the breast. This is achieved by a complex algorithm that calculates the treatment plan, with the ability to vary both dwell time (or current) and voltage (depth of penetration).  
         [0049]    As noted above, an algorithm to achieve this complex prescription isodose surface must involve the integration of the effects of all sources at all positions. Every dwell point of a source affects every point within the volume to be treated and surrounding points. If, for example, six sources (i.e. guides) are used in the applicator, and ten different dwell points are used in each guide, this produces sixty different dwell points, the effects of each of which must be integrated to the treatment plan as to the effect at every point reached by the radiation. This is a difficult problem but can be solved, with the appropriate algorithm, and the ability to achieve the desired treatment plan is made possible by the use of sources which are variable as to voltage, i.e. depth of dose.  
         [0050]    The treatment described could be accomplished with continuous movement of the sources and sensor, with such movement taken into account in the algorithm and rate (or varying rates) of movement being a part of the treatment plan. It is also possible to perform three-dimensional mapping using moving sources, but this may be undesirable if the sources are continuously emitting radiation, since this can lead to excessive doses of radiation during mapping, or when mapping radiation is accumulated with treatment radiation. Development of more sensitive sensors could make moving mapping more desirable, with less radiation emitted. In the claims, references to moving the sources and sensor to a plurality or positions or locations, or references to taking readings at various locations should be understood to include continuous movement as well as a series of stops.  
         [0051]    It should also be understood that the calculation of a radiation treatment plan can take into account radiation already received during mapping in the volume to be treated. Once the cavity shape and location are determined, the radiation dose at each location, received during mapping, can be calculated. If mapping radiation is limited so that the mapping dose is comparatively extremely small, this dose can generally be ignored.  
         [0052]    [0052]FIG. 8 shows an example of a wire-frame type three dimensional map  70  that can be obtained using the mapping procedure of the invention. Outer longitudinal lines  72 ,  74 ,  76 ,  78 , etc. of the wire frame model or three dimensional map represent the approximate positions of the guides in the cavity. Nodes  80  on each of the lines  72 ,  74 ,  76 , etc. are at the locations of the guides where readings were taken from the sources there positioned, i.e. dwell points. The series of location points for the sensor are indicated at  82 ,  84 ,  86 ,  88 ,  90  and  92 . The dwell points or nodes  80  are all in the same plane with one of the sensor location points  82 ,  84 ,  86 , etc. All measurements are taken one plane at a time, with the central measurement sensor and the x-ray sources within that same plane during that measurement. As noted earlier, in the case of isotopes typically only one isotope is used, positioned successively in each of the guides, so that each planar dwell point is within the same plane after all readings are taken for that plane. In other words, in each plane of measurement, the sources are advanced to the same point, such that they all lie in the same plane with the sensor. Readings are taken sequentially rather than simultaneously, and for isotopes this involves repositioning to each of the different dwell points within each plane (although the order of the dwell points need not be to complete one plane before undertaking the next). For switchable sources, the series of sources preferably are simultaneously in place, but are sequentially turned on. It should be understood, however, that for switchable sources a single source could be used if desired, and for isotopes multiple sources could be used, although preferably not inserted into the excision cavity at the same time.  
         [0053]    Each of the sensor points  82 ,  84 ,  86 , etc. is roughly near the center of a plane, of which six such planes  82   a,    84   a,    86   a,    88   a,  etc. are shown in FIG. 8, one for each reading location. It can be appreciated that merely having the data of the distance from the center or sensor point of each such wire plane to each of the plurality of surrounding points (six in the illustrated embodiment) will provide the dimensions of the plane, but will not locate that plane relative to the next and succeeding planes. One plane may be laterally displaced from the other planes, i.e., the sensor points  82 ,  84 ,  86 , etc. may not be in a single line and perhaps not on a single smooth curve. Further, some of the planes could be rotated about the sensor point  82  or  84  or  86 , etc. relative to other such planes, if the guides follow slightly tortuous paths. The additional data needed to locate these planes precisely relative to one another can be provided in one of two ways: by use of an applicator with a relatively rigid and linear central guide, and with peripheral guides that expand in a manner such that each particular curving guide lies in a single plane; or using data from the additional sensors placed outside the cavity, e.g. at the breast surface and along the chest wall, as described above. These additional sensors will provide distance data that will locate the planes relative to one another, and also locate the excision cavity itself (i.e. the wire frame model  70 ) within the breast or other patient tissue.  
         [0054]    In FIG. 3 the three dimensional mapping is indicated as completed in the block  96 . These data, along with a radiation prescription ( 98 ), i.e. desired dosage and depth for the patient tissue surrounding the excision cavity, are used to calculate a radiation treatment plan  100 . The calculation of the treatment plan takes into account the distance to the surface-located sensors and to the chest wall, in the case of a breast to be treated, since radiation must be limited at the skin to prevent damage, and also at the chest wall. The calculation will take this into account, lessening the depth of penetration of the total radiation in the regions of these locations. This is achieved far more easily using switchable x-ray sources, and preferably sources which are not only switchable on/off but also with voltage control and current control.  
         [0055]    With the treatment plan calculated, it is executed using the same sources and sensors, as indicated in the block  102 . At this point the exterior sensors, outside the excision cavity, can be used to monitor radiation dosage actually received. This can be used for emergency shutoff, or simply for quality control of the procedure, verifying the actual treatment was according to plan.  
         [0056]    [0056]FIG. 9 is similar to FIG. 8 but shows a three dimensional wire frame model as it might be located within a breast  100 . The wire frame model is shown at  70   a,  oriented within the breast tissue. As in FIG. 5, the sensors can be located at the exterior of the breast and at the chest wall, not shown in FIG. 9.  
         [0057]    The above described preferred embodiments are intended to illustrate the principles of the invention, but not to limit its scope. Other embodiments and variations to this preferred embodiment will be apparent to those skilled in the art and may be made without departing from the spirit and scope of the invention as defined in the following claims.