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Variseed

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VariSeed is an automated brachytherapy seed implantation system designed to assist with the delivery of radioactive seeds for the treatment of prostate cancer. The system is designed to facilitate the accurate placement of radioactive seeds within the prostate gland during the brachytherapy procedure.

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10 protocols using variseed

1

Seed Position Verification in Radiotherapy

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Seed position and geometric verification during surgery and follow-up in living animals were major issues in this study. For example, if the seeds are spaced irregularly, this may cause significant dose modifications that, in turn, may lead to under-detection or over-dosing, with the foreseeable consequences of inefficient treatment and the risks of complications. A preliminary analysis with an Advantage Workstation (GE, version 4.4, USA) was carried out in order to check the positioning of the plates and any seed migration. Then, the mesh coordinates were determined between the centroid of the plate and the bone anatomical landmarks to have the same mark on the two CT scans at D+15 (CT1) and D+180 (CT3) (Figure 4). The tolerance of a shift was set at 10 mm in all directions (X, Y, Z).
Finally, a dosimetric analysis was performed on VariSeedTM (Treatment Planning System, v8.0.2, Varian Medical Systems, Inc., Palo Alto, CA, USA) between CT1, CT2, and CT3. Seeds were detected automatically on each CT scan. Seed activity was fixed arbitrarily at 1 U (= 1 uGy.m2/h) or 0.787 mCi, to have a 160 Gy dose line around the mesh volume and 5 mm from the center of each seed (Figure 5).
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2

Prostate Brachytherapy Dose Protocol

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The prescription for the prostatic V100 (volume of the prostate receiving 100% dose [=145 Gy]) was ≥95%. The D90 (minimal dose received by 90% of the prostate) was ≥145 Gy. In the UMCU images were imported in the Sonographic Planning of Oncology Treatment planning software (SPOT, Nucletron BV, Veenendaal, the Netherlands). The planning system in the RISO consisted of subsequent versions of Variseed TM (Varian Medical Systems, Palo Alto, CA). Loose and stranded seeds were both used in this cohort.
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3

Prostate Brachytherapy Dose Protocol

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The prescription for the prostatic V100 (volume of the prostate receiving 100% dose [=145 Gy]) was ≥95%. The D90 (minimal dose received by 90% of the prostate) was ≥145 Gy. In the UMCU images were imported in the Sonographic Planning of Oncology Treatment planning software (SPOT, Nucletron BV, Veenendaal, the Netherlands). The planning system in the RISO consisted of subsequent versions of Variseed TM (Varian Medical Systems, Palo Alto, CA). Loose and stranded seeds were both used in this cohort.
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4

Prostate Brachytherapy Pretreatment Planning

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One month before the procedure, computed tomography (CT) and magnetic resonance imaging (MRI) of the pelvis were performed as a pre-plan to simulate implantation. An order was placed for the number of seeds used in the pre-plan, plus a few extra seeds. Treatment was planned using a peripheral approach. The prescribed doses were 145 Gy and 114 Gy for monotherapy and combined therapy, respectively. VariSeed (Varian Medical Systems, Palo Alto, CA, USA) was used both in calculating the preoperative prostate volume and in planning seed placement. Extraprostatic seed placement was not planned.
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5

Brachytherapy for Recurrent Prostate Cancer

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Briefly, our implant technique was adapted from the American Brachytherapy Society (ABS) [7 (link)] with slight modifications to the technique used for intact prostate to accommodate the perirectal location of the local recurrences, as was described previously [6 (link)]. Patients were positioned in exaggerated dorsal lithotomy, the rectum was irrigated, and a transrectal ultrasound probe visualized the nodule was inserted. The brachytherapy plan was generated using VariSeed (v7.1, Varian Medical Systems, Palo Alto, CA, USA) with a prescribed dose of 144 Gy. The prescription target was the nodule with a small 3-5 mm margin. Seeds were implanted into the nodule. Except for perirectal sources, all sources were stranded or linked (Oncura RAPID Strand [Oncura Inc., Arlington Heights, IL, USA] or CR Bard RediLink (Bard Inc., Medical Division, Covington, GA, USA), respectively. Activity ranged between 0.38-0.48 U/source. The rectal volume receiving 100% (rV100) of the prescribed dose was kept < 1 cm [4 (link)]. Source needle insertion was performed in a manner similar to a typical prostate implantation.
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6

Low-Dose-Rate Brachytherapy for Prostate Cancer

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The LDR-BT procedure was performed at our institution using 125I seeds (Onco-Seed®, Nihon Medi-physics, Kobe, Japan). The target volume of the implant was the prostate gland and the implantation was based on intraoperative planning with real-time dynamic dose calculation using commercial software (VariSeed®, Varian Medical Systems, Palo Alto CA, USA). Implantation was performed under general anesthesia using real-time transrectal ultrasound (TRUS) and a standard template, and the seeds were individually deposited using a Mick applicator. The LDR-BT constraints are shown in Table 2. All patients underwent chest and pelvic radiography just after the implantation to assess seed distribution in the prostate and to detect seed migration.
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7

SEED-BT Dosimetric Analysis for Prostate Cancer

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Some patients receiving SEED-BT at institution A in 2006 were treated using preplanning methods. Most other patients at the 3 institutions were treated using an intraoperative planning method with modified peripheral loading techniques using a Mick applicator12 (link),13 (link). The therapeutic planning and post-implant dosimetric evaluation were performed using the Interplant planning system (CMS, St. Louis, MO) or Variseed (Varian, Palo Alto, CA). 125I was used for all patients. Either Oncoseed 6711 (GE Healthcare, Arlington Heights, IL) or STM 1251 (BD, Tempe, AZ) was used for SEED-BT. The doses were defined using the TG-43 criteria14 (link). At 1 month after treatment with SEED-BT alone, a computed tomography-based dosimetric analysis was performed to calculate the D90, V100, and V150 results. Prostate D90 is the minimum dose to 90% of the prostate gland at 1 month. Prostate V100 and V150 are the percentages of the prostate gland volume respectively receiving 100% and 150% of the prescribed dose at 1 month. These treatment protocols were used at each institution:
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8

Cesium-131 Brachytherapy for Surgical Tumor Bed

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In patients who underwent resection, 131Cs brachytherapy seeds were implanted at 0.5-1 cm distance, making sure that the tumor bed was covered by 80 Gy at 0.5 cm using a nomogram created in Variseed (Varian Medical System, Palo Alto, CA, USA) [27 (link)]. Median seed activity was 2.4 U (0.5 mCi/s). Median seed air kerma strength was 2.4 U (3.77 mCi apparent activity). Post implant dosimetry was analyzed using BrachyVision software (Varian Medical Systems, Palo Alto, CA, USA). The dosimetry and exposure rate have been previously reported by our institution in a prior study, with excellent dosimetric coverage and acceptable exposure rate to treating physicians and staff [23 (link)].
Briefly, after the resection of the tumor that needs to be implanted, the tumor bed (Clinical Target Volume-CTV) is identified and a 131Cs plaque (Figure 1) is placed on the tumor bed (planer implant). The implant is placed so that it covers the entire tumor bed and an additional 0.5 cm around the tumor bed. This means that V100 (volume of CTV receiving 100% prescribed dose) is at 100%. In addition, D90 (dose going to 90% clinical target volume) is also at least 100% of the prescription dose in all implants. As mentioned previously, our prescription dose was 80 Gy. This technique of 131Cs implant was performed as an open surgical procedure.
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9

Prostate Brachytherapy Implant Procedure

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Our implant procedure has previously been described in detail [14 ]. We implanted 125I sources using a modified peripheral-loading pattern for seed placement, using a treatment planning system (Variseed; Varian Medical Systems, Palo Alto, CA, USA). A pre-plan for the implant was generated from a transrectal ultrasound volume study. A transrectal ultrasound–guided transperineal technique under general and spinal anesthesia was used to deliver the sources. The prescribed dose for an implant was 144 Gy when performed as monotherapy, and 110 Gy when performed before external beam radiotherapy. The prescribed dose of the external beam radiotherapy was 45 Gy, with a daily fraction of 1.8 Gy. External beam radiotherapy was combined in patients with a high risk or a part of intermediate risk. Hormone therapy was indicated in patients with a prostate volume of >40 cm3 and in patients at high risk. A post-implant dosimetric analysis was performed using a computed tomography (CT) scan performed 30 days post-implant. Thereafter, we calculated dose–volume histograms, including prostate D90 (dose to 90% of the gland). Prostate D90 is expressed as a percentage of the prescribed dose. PSA measurements after BT were performed every 3 months for the first 3 years, and every 6 months thereafter.
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10

Urethral Dose Metrics and Urinary Toxicity

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IPSS scores were collected prior to therapy and at routine clinical follow up (at 1 month, 6 months, 12 months post-treatment and then annually thereafter). The primary clinical outcome measured was serial IPSS scores at baseline, 1 month, 6 months, 12 months and 2 years, specifically focusing on clinically significant change comparing baseline versus 6- and 12-month scores. The prostatic urethra was manually segmented on post-implant non-contrast CT imaging as part of routine standard of care post-implant quality assurance procedures. Delivered urethral dose measurements were calculated using the brachytherapy treatment planning and evaluation software (VariSeed©, Varian Medical Systems, Palo Alto, CA). The relative volume (in percent) of the urethra receiving 75%, 100%, 125%, 150%, and 200% of the prescribed dose (U75%, U100%, U125%, U150%, and U200%, respectively) were recorded. Because the data regarding urethral dose-volume parameters and their potential association with urinary toxicity are extremely sparse, these factors were determined a priori as reasonable, practical metrics that can be easily assessable on a planning dose-volume histogram. Other clinical outcomes recorded were presence of hematuria, dysuria, development of acute urinary retention, and ultimate development of urinary stricture at any point in follow-up.
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