Potential role of various dosimetric quality indicators in prostate brachytherapy

Purpose: Postoperative CT-based dosimetric analysis provides detailed information regarding the coverage and uniformity of an implant, but the assessment of implant quality remains an unanswered and controversial issue. There is no disagreement that a good implant should cover the target volume with an adequate dose, but there is no consensus as to what represents an adequate dose. Materials and Methods: The American Brachytherapy Society has recently proposed that prostate brachytherapy quality be measured in terms of the following parameters: D90, V100, and V150 where D90 is defined as the minimal dose covering 90% of the prostate volume and V100 and V150 are defined as the percent volume of the prostate receiving at least 100% or 150% of the prescribed minimal peripheral dose (mPD), respectively. We report detailed day 0 dosimetric evaluation for 60 consecutive prostate brachytherapy patients implanted via a standard transperineal ultrasound guided approach in terms of D90, D100, V90, V100, and V150 and also the maximal and average rectal and urethral dose. Results: Dosimetric evaluation resulted in a V100 greater than 80% of the prostate volume and a D90 greater than 90% of the mPD in the entire patient population. There was a statistically significant difference between the quality scores of 125I implants and 103Pd implants with the 125I mean V100 and D90 at 95.3% volume and 109.9% mPD, respectively, vs. 103Pd at 91.8% volume and 103.7% mPD. Likewise, the rectal and urethral doses as a fraction of mPD were significantly lower in 103Pd than in 125I implants. This occurred despite the fact that palladium implants were typically preplanned with significantly better coverage and hotter V150 than iodine implants. We consider V150 to be an important parameter for determining dose homogeneity although the clinical utility of dose homogeneity remains unknown. The mean V150 was 45.6 ± 9.6% volume. There was no additional dosimetric utility from a determination of V90 while D100 was found to be overly sensitive to steep dose gradients at the periphery of the prostate. Conclusions: This report represents the first detailed postimplant day 0 dosimetric evaluation comparing ABS recommended quality parameters used to evaluate prostate brachytherapy. At the present time, no long-term clinical outcomes are available because of short follow-up. As PSA based follow-up data becomes available, however, this report may help define what represents an adequate implant.