Radiol Oncol 2002; 36(3): 245-8. 

European Project BRAPHYQS 

Janez Burger 

Department of Brachytherapy, Institute of Oncology Ljubljana, Slovenia 

Background. Quality assurance in radiotherapy and brachytherapy is extremely important because errors 
that may occur during treatment process can be fatal for the patient. European Society for Therapeutic 
Radiology and Oncology has therefore founded BRAPHYQS, a special group that is responsible for the revision 
of quality assurance procedures of treatment performed in brachytherapy centers and for outlining 
common standards of work in European countries. 
Conclusions. The project BRAPHYQS has the following aims: (1) to publish European recommendations 
for implementing QA/QC in European brachytherapy centers; (2) to set up a central dosimetry audit in 
European brachytherapy centers (this task will be delegated to ESTRO-EQUAL laboratory at the Institute 
Gustave Roussy in Paris); (3) to set up a central audit for the geometrical reconstruction of source positions 
with a special test phantom that will be available to each brachytherapy center. Hence, a series of »Baltas 
phantoms« will be elaborated and distributed to the brachytherapy centers in Europe; (4) to prepare a draft 
of booklet of QA/QC recommendations for testing the brachytherapy equipment and therapy planning systems. 


Key words: quality assurance, health care; radiotherapy; brachytherapy; Europe 

Introduction 

Quality Assurance (QA) in radiotherapy ensures 
accurate dose prescription and application 
of radiation doses for each individual localization 
of tumor growth in cancer patients. 
The higher is the accuracy of radiotherapy, 
the greater are the chances of cure. QA in radiotherapy 
requires regular control of irradia-

Received 22 April 2002 
Accepted 6 May 2002-04-22 

Correspondence to; Janez Burger, B.Sc., M.Sc., 
Department of Brachyradiotherapy, Institute of 
Oncology, Zaloška 7, 1000 Ljubljana; Phone: 00 386 1 
522 4426; E-mail: jburger@onko-i.si 

tion equipment as well as continuous upgrading 
of skills of the personnel in charge of QA. 
Dosimetric and electromechanic properties of 
the irradiadition devices and all related 
equipment should be regularly checked. QA 
in radiotherapy and brachytherapy is of utmost 
importance because any failure in the 
treatment procedure may be fatal for the patient. 


Brachytherapy physics quality assurance 
system (BRAPHYQS) 

In January 2001, the European Society for 
Therapeutic Radiology and Oncology (ES



Burger J / BRAPHYQS 

TRO) submitted an extensive and valuable 
project, entitled ESQUIRE (Education 
Science and Quality Assurance in 
Radiotherapy in Europe), to European 
Commission for financing (ESTRO 2001). The 
project was accepted. This is a great step forward 
in the endeavors for quality assurance 
in radiotherapy in Europe. Mr. Hans 
Svensson (Sweden) was appointed Chief of 
the Project. Professional and cost-wise, radiotherapy 
is considered to be the prevalent 
treatment modality of cancer patients, despite 
extremely high investments in the purchase 
of equipment. ESQUIRE project will 
take charge of quality control (QC) of the 
therapy as well as of upgrading the knowledge 
and skills of the personnel in the training 
programs prepared by different committees 
under the patronage of ESTRO. These 
are: 
-monitoring of radiation dose application 
-registration and data managing of radiation 

side-effects 
-transfer of technology experiences and 

skills to other radiotherapy centers in 

Europe 
-control over complete radiotherapy proce


dure and research 
-quality assurance in Intensity Modulated 

Radiotherapy (IMRT) 
-quality improvement in brahytherapy 

(BRAPHYQS) 

The BRAPHYQS group will undertake the 
revision of QA procedures in brachytherapy 
centers in Europe and suggest common standards 
to be respected in European countries. 
The revisions will involve the accuracy of 
dosimetry and geometric reconstruction of radioactive 
sources implanted by different 
brachytherapy methods. The team is also in 
charge to publish a booklet containing a set of 
descriptions of QA/QC procedures in 
brachytherapy. In radiotherapy, the general 
tendency is to apply the doses to target tissue 
using the procedures that can avoid the exposure 
of the healthy surrounding tissue.1,2 

Brachytherapy is a treatment modality that allows 
irradiation of smaller volumes with lower 
doses to the surrounding tissue than those 
usually emitted in radiotherapy with external 
beam.3 At the same time, there is also a 
greater probability of committing errors in 
dosimetry, which urgently requires setting up 
uniform European QA standards in 
brachytherapy. Brachytherapy will continue 
to be the principal treatment modality of cancer 
patients, particularly as an additional 
boost in combination with external beams 
during teletherapy. Brachytherapy has a significant 
role in clinical studies, e.g. in the famous 
EORTC 22881/10882 study which compared 
two treatment modalities of breast cancer, 
one with the boost and the other without 
it. The study confirmed that local control in 
younger patients was improved if these patients 
received a boost with brachytherapy to 
the tumor.4 In the brachytherapy of the 
prostate, manual insertion of low-energy 
sources, such as J-125 and Pd-103, is still 
practiced,5 though at present radioactive 
sources are usually inserted by afterload devices, 
which certainly improved the protection 
of the medical staff against ionizing radiation. 
Today, we generally use the isotopes 
Cs-137 and Ir-192. The progress in 
brachytherapy undoubtedly requires a constant 
checking of mechanized and computerized 
treatment procedures. These procedures 
have been extensively described in various articles 
and brochures published by different 
national and international organizations. 
Though numerous, they lack uniform and 
common QA standards of work that could be 
directly followed by other brachytherapy centers. 
In addition to language barriers that 
arise from national protocols, there are also 
problems that are due to the differences in 
the definitions of QA/QC procedures regarding 
the frequencies and tolerances specified 
in these procedures. The principal task of 
BRAPHYQS is to analyze the currently valid 
protocols and to set up methodology together 

Radiol Oncol 2002; 36(3): 245-8. 


Burger J / BRAPHYQS 

with the recommendations for work in 
European medical physics as well as elsewhere. 
New protocols would be a supplement 
to the existing QA/QC database. European 
brachytherapy centers should therefore get 
together and jointly work on the compilation 
and unification of the procedures in 
brachytherapy radiophysics and to collect 
them in a booklet that will be formally published 
by ESTRO. This kind of international 
cooperation is planned to go on for two years 
and is expected to be concluded by the end of 
2002. Slovenia also takes part in this joint 
European project which is certainly most advantageous 
for better flow of information into 
the country. 

In 1999, the Institute of Physics and 
Engineering in Medicine in United Kingdom 
published recommendations for QA in radiotherapy 
that also involve protection against 
irradiation and calibration of brachytherapy 
sources. In the Netherlands, such recommendations 
concerning low dose-rate (LDR) were 
published already in 1989, whereas the recommendations 
for handling the high dose-
rate facilities (HDR) were appeared as late as 
1994. A particular emphasis was placed to the 
dosimetry of HDR sources. The last report of 
the year 2000 contains minimal requirements 
for QA/QC in brachytherapy as regards the 
frequencies and tolerances to be respected in 
testing brachytherapy equipment.6 In 
Germany, the dosimetry in brachytherapy 
was fixed in 1993 in accordance with the 
German standard DIN 6809-2, whereas in 
France, the appropriate standards are CFMRI 
dated from 1983 and NFC 74-210 from 1992. 
In Spain, TG 43 formulism,7 published in 
1995 in American Association of Physicists in 
Medicine (AAPM), served as a base. From 
then onwards, formulism is applied to many 
planning systems and is more and more likely 
to develop into the standard for dose calculation. 
AAPM also published ‘Code of 
Practice for brachytherapy physics’ and ‘High 
dose rate brachytherapy treatment deliv


ery’. 8.9 This report covers all aspects of HDR, 
including dose prescription, safety, planning 
and dose calculation, and protection against 
ionizing irradiation. Intravascular brachytherapy 
in America is covered by ‘Intravascular 
Brachytherapy Physics’.10 

International Atomic Eneregy Agency 
(IAEA) has dealt with brachytherapy in several 
publications. In 1996, IAEA founded the 
Department for Calibration of LDR Cs-137 
Sources, and in 1999, the Agency published 
TECDOC-1079 »Calibration of brachytherapy 
sources«.11 Guidelines to Secondary 
Standard Dosimetry Laboratories and medical 
physicists on standardized methods for 
calibration of brachytherapy sources’. In 
2000, the IAEA report No. 17 ‘Lessons 
Learned from Accidental Exposures in 
Radiotherapy’ appeared.12 The report comprises 
descriptions of 92 unfortunate cases of 
patients having received miscalculated doses. 
Of these, 32 were treated with brachytherapy 
with sealed sources. The failures were mainly 
due to inaccurate assessment of source activity, 
inaccurate dose calculation and entering 
of incorrect parameters into the planning system. 
The failures were also due to inadequately 
inserted sources or unprofessionally 
removed sources by the patients themselves. 
The most serious failure that resulted in the 
death of a patient was caused by the malfunction 
of afterload device. 

The above cases are truly requiring an outline 
of a well-conceived program for QA in 
brachytherapy. 

Conclusions 

The BRAPHYQS Projects has the following 
aims: 

1.To publish European recommendations for 
implementing QA/QC in European 
brachytherapy centers; 
2.To 
set up a central dosimetry audit in 
European brachytherapy centers (this task 
Radiol Oncol 2002; 36(3): 245-8. 


Burger J / BRAPHYQS 

will be delegated to ESTRO-EQUAL laboratory 
at the Institute Gustave Roussy in 
Paris); 

3.To set up a central audit for the geometrical 
reconstruction of source positions with a 
special test phantom that will be available 
to each brachytherapy center. Hence, a series 
of »Baltas phantoms« will be elaborated 
and distributed to the brachytherapy centers 
in Europe; 
4.To prepare a draft of booklet QA/QC recommendations 
for testing the brachytherapy 
equipment and therapy planning systems. 
References 

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Horiot JC, Collete L, Fourquet A, Jager JJ, Peterse 
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