Optimum timing for image-based dose evaluation of 125I and 103PD prostate seed implants.

Abstract Purpose/Objective: Image-based dose evaluation of permanent brachytherapy implants for prostate cancer is important for optimal patient management after implantation. Because of edema caused by the surgical procedure in the implantation, if the dose evaluation is based on the images obtained too early after implantation, dose coverage will usually be underestimated. Conversely, if the images are obtained too late, the dose coverage will be overestimated. This study uses a biomathematical model to simulate edema and its resolution on 29 patients, so that the optimum time to obtain image scans and perform dose evaluation can be investigated and estimated. Methods and Materials: Edema of a prostate and its resolution has been shown to follow an exponential function V(t) = V(0)(1 + ΔV[e −0.693t/Te − 1]) where ΔV is the initial relative increase in the prostate volume due to edema (and is related to edema magnitude), and T e (edema half-life) is the time for the edema to decrease by half in volume. In this study, edema was simulated by increasing the volume of preimplant prostate (obtained from ultrasound volume study) to a given magnitude of edema. Similarly, the locations of planned seeds were changed to their corresponding locations in the edematous prostate proportionally. The edema was then allowed to resolve according to the exponential function. The correct dose distribution was calculated by taking into account the dynamic variations of the prostate volume, seed locations, and source strengths with respect to time. Dose volume histograms (DVHs) were then generated from this dose distribution. The conventional postimplant DVHs, which assume the prostate volume and seed locations are as in the image scans and constant in time, were also calculated based on the simulated image scans for various days postimplantation. The conventional DVHs of prostate on various days after implantation were compared to the DVH calculated assuming dynamic conditions. The optimum timing for conventional postimplant dose evaluation was identified as the time at which a minimum difference between the conventional DVH and the dynamic model DVH was achieved. The analysis was done on 29 prostate seed implant patients for both 125 I and 103 Pd. The edema magnitude was assumed to be 30%, 40%, 50%, 75%, and 100% of original prostate volume, and the half-life of edema was assumed to be 4, 7, 10, 15, 20, and 25 days. In this study, the original volume of prostate varied from 17 cm 3 to 91 cm 3 , and number of seeds in the implants varied from 57 to 119. Results: The optimum timing was mainly dependent on the half-lives of edema and radionuclides, and varied slightly with edema magnitude, prostate volume, and number of seeds. It can be expressed as a function of edema half-life in the form of C 0 + C 1 exp(−C 2 T e ) . However, if the dose evaluation was performed based on the image scans taken too early or too late, the error became larger, as the edema magnitude was larger. By averaging all 29 patients and various edemas, it was found that for 125 I seed implants, if the postimplant dose evaluation is performed based on image scans taken between 5 and 9 weeks, the average error will be less than 5%, with a maximum possible error less than 10% in 80% coverage dose; for 103 Pd seed implants, if the postimplant dose evaluation is performed based on image scans taken between 2 and 4 weeks, the average error will be less than 5%, with a maximum error less than 15% in 80% coverage dose. Because of edema, a conventional preimplant plan also overestimates dose coverage of prostate. On the average, a standard preimplant planning overestimates dose coverage by about 6% for 125 I implants and 14% for 103 Pd implants in our study. Conclusion: Based on the dynamic model, the optimum timing of image scans for postimplant dose evaluation of prostate seed implantation is 7 weeks postimplantation for 125 I implants and about 3 weeks for 103 Pd implants. The time-window for reasonable accuracy (± 5%) is ± 2 weeks for 125 I and ± 1 week for 103 Pd around the optimum timing. During preimplant procedure, the minimum prescribed coverage dose should be increased by an amount of about 6% for 125 I implants and about 14% for 103 Pd implants to compensate for the effect of edema.