University of Ghana  http://ugspace.ug.edu.gh
COLLEGE OF BASIC AND APPLIED SCIENCES 
 
 
 
 
 
 
ASSESSMENT OF DOSE VARIATION TO CRITICAL POINTS IN LOW DOSE 
RATE INTRACAVITARY BRACHYTHERAPY OF CERVICAL CANCER AT 
KOMFO ANOKYE TEACHING HOSPITAL 
 
 
 
BY  
 
 
JOSEPH ADOM 
(10551170)  
 
 
 
THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN 
PARTIAL FULFILLMENT FOR THE AWARD OF MPHIL MEDICAL PHYSICS 
DEGREE 
 
 
JULY, 2017  
University of Ghana  http://ugspace.ug.edu.gh
 
DECLARATION 
This thesis is the result of research work carried out by Joseph Adom in the Department of 
Medical Physics, School of Nuclear and Allied Sciences, University of Ghana, under the 
supervision of Dr. Francis Hasford, Prof John Humphrey Amuasi and Mr. Eric Kotei 
Addison.  
I hereby affirm that, no part of this work has been presented in part or whole to any other 
University or institution for the award of a diploma, or degree at any level. Accordingly 
other works and/or researches done by other researchers cited in this work have been 
acknowledged under references.  
 
…………………………     …………………………  
JOSEPH ADOM      DR. FRANCIS HASFORD             
(STUDENT)                  (PRINCIPAL SUPERVISOR)  
Date………………………               Date………………………  
 
……………………………     .……………………………  
PROF. JOHN H. AMUASI                MR. ERIC K.T ADDISON 
(CO-SUPERVISOR)       (CO-SUPERVISOR)  
Date……………………      Date.……....………………… 
 
i 
 
University of Ghana  http://ugspace.ug.edu.gh
 
ABSTRACT 
For LDR brachytherapy, the time taken to deliver the dose to a patient is very long which 
makes the patient be on the machine for a very long period of time. Due to this long 
treatment time, soaking of vaginal packing and patient movement can change the 
applicators position. The aim of this work is to assess the dose variation to point ‘A’ and 
point ‘B’ as well as critical organs (i.e. bladder and rectum) for low dose rate (LDR) 
brachytherapy at Komfo Anokye Teaching Hospital. Forty (40) patients with invasive 
cervical cancer were treated with LDR brachytherapy with 30 – 35Gy prescription to point 
‘A’. Two pairs of orthogonal X-ray images were taken: one prior to treatment and the other 
after treatment. Pre- and post- treatment doses were calculated and analyzed to determine 
the variation in the doses to points ‘A’ and ‘B’, as well as, the critical organs. The disparity 
in dose to point ‘A’ was found to be 1.16% which is very laudable as compared to other 
studies that established dose variations of 2, 35, 8 and 20%. Variation in dose at point B in 
this work was 0.75%. In this study, average variations of 2.32 and 0.30% were found for 
the bladder and rectum, respectively. For quality assurance purposes the variation found 
between prescribed and deposited dose was 2.11%. The geometric variations between the 
Intracavitary Brachytherapy Treatment (ICBT) applicators and the critical organs vary 
during the treatment procedure and thus result in dose alterations. Since the variation is 
within the recommended standard levels, it can be concluded that, the practice at KATH 
meets the international standard. 
 
 
 
 
 
ii 
 
University of Ghana  http://ugspace.ug.edu.gh
 
DEDICATION 
This work is dedicated to my brother Solomon Adom (of blessed memory), my wife 
Miriam Owusu Sekyere and my wonderful children Othniel Adom Agyapong, Ilona 
Kissiwaah Adom and Kennice Nyarko Adom. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
iii 
 
University of Ghana  http://ugspace.ug.edu.gh
 
ACKNOWLEDGEMENT 
I want to first and foremost thank and appreciate the Almighty God for providing me with 
the wisdom, knowledge, understanding, good health and also providing all my needs for  
this work according to his riches in glory. All praise, glory and honour be unto His Holy 
Name. 
With a grateful heart, I want to acknowledge and appreciate my supervisors Dr. Francis 
Hasford, Prof John Humphrey Amuasi and Mr. Eric Kotei Addison for working 
unstintingly, meticulously going through my write up and guiding me through my data 
collection. Their constructive criticisms, corrections, encouragement and pieces of advice 
they gave me have added massively to the quality of this thesis work.  
To my colleague physicists at Komfo Anokye Teaching Hospital, I want to say a very big 
thank you for your support. My heartfelt gratitude goes to all the nurses at Komfo Anokye 
Hospital Oncology Directorate and also my right hand men Mr. Linus Owusu-Agyapong 
and Kingsley Akosah for their relentless support throughout this work. Finally, l want to 
say a very big thank you to my parents, siblings my in-laws for their support and 
encouragement during my schooling. Also I want to thank my friends (especially Olivia 
Adu-Poku and Ms Mary Emelia Otsedzen) who stood by me in sickness during the course 
of my studies and also for their immense support and encouragements. My sincere 
appreciation goes to my wife Miriam Owusu Sekyere for her love, support and backing 
throughout this study period. I appreciate you all. 
 
iv 
 
University of Ghana  http://ugspace.ug.edu.gh
 
TABLE OF CONTENTS 
 
DECLARATION ................................................................................................................. i 
ABSTRACT ........................................................................................................................ ii 
DEDICATION ................................................................................................................... iii 
ACKNOWLEDGEMENT ................................................................................................. iv 
TABLE OF CONTENTS .................................................................................................... v 
LIST OF FIGURES .......................................................................................................... vii 
LIST OF TABLES ............................................................................................................. ix 
ABBREVIATIONS ............................................................................................................ x 
CHAPTER ONE ................................................................................................................. 1 
1 INTRODUCTION ..................................................................................................... 1 
1.1 Background ................................................................................................... 1 
1.2 Statement of the problem .............................................................................. 3 
1.3 Objectives ..................................................................................................... 4 
1.4 Relevance And justification .......................................................................... 5 
1.5 Scope and limitation ..................................................................................... 5 
1.6 Structure of the thesis ................................................................................... 5 
CHAPTER TWO ................................................................................................................ 7 
2 LITERATURE REVIEW .......................................................................................... 7 
2.1 Background ................................................................................................... 7 
2.2 Principles of Radiation Therapy ................................................................... 8 
2.3 Radiation Therapy Techniques ..................................................................... 9 
2.3.1 Fractionation. ......................................................................................... 9 
2.3.2 External Beam Radiation Therapy (EBRT) ......................................... 10 
2.3.3 Brachytherapy ...................................................................................... 11 
2.3.4 Definition of Organs at Risk ................................................................ 14 
2.4 Brachytherapy Systems ............................................................................... 15 
2.4.1 ICRU System ....................................................................................... 15 
2.4.2 Manchester System .............................................................................. 15 
2.5 Magnitude of displacements of applicators ................................................ 16 
2.5.1 Dose variations due to change in applicator position .......................... 17 
CHAPTER THREE .......................................................................................................... 19 
v 
 
University of Ghana  http://ugspace.ug.edu.gh
 
3 METHODOLOGY .................................................................................................. 19 
3.1 Materials ..................................................................................................... 19 
3.1.1 Fletcher Type Brachytherapy Applicators ........................................... 19 
3.1.2 Prowess Panther Treatment Planning System ..................................... 21 
3.1.3 Cs-137 LDR Brachytherapy System ................................................... 22 
3.2 Method ........................................................................................................ 23 
3.2.1 Patient Imaging .................................................................................... 23 
3.2.2 Patient Treatment ................................................................................. 24 
3.2.3 Brachytherapy Treatment Planning ..................................................... 25 
3.2.4 Analysis ............................................................................................... 29 
CHAPTER FOUR ............................................................................................................. 30 
4 RESULTS AND DISCUSSION .............................................................................. 30 
4.1 Dose Variations ........................................................................................... 30 
4.1.1 Dose Variations at Point ‘A’ ............................................................... 30 
4.1.2 Dose Variations at Point ‘B’ ................................................................ 36 
4.1.3 Variation of Doses at the Critical Organs ............................................ 38 
CHAPTER FIVE .............................................................................................................. 43 
5 CONCLUSION AND RECOMMENDATION ...................................................... 43 
5.1 Conclusion .................................................................................................. 43 
5.2 Recommendation ........................................................................................ 44 
REFERENCES ................................................................................................................. 45 
APPENDIX ....................................................................................................................... 49 
 
 
 
 
 
 
 
 
vi 
 
University of Ghana  http://ugspace.ug.edu.gh
 
LIST OF FIGURES 
Figure 3.1 Fletcher type brachytherapy applicators. ......................................................... 20 
Figure 3.2 Varian Acuity Simulator .................................................................................. 21 
Figure 3.3 Interface of Prowess® Panther TPS ................................................................. 22 
Figure 3.4 Cs-137 LDR Brachytherapy System ............................................................... 23 
Figure 3.5 (a) AP image of the pelvis of a patient (b) LAT image of the pelvis of a patient
........................................................................................................................................... 24 
Figure 3.6 A schematic diagram of channel arrangement in AMRA-Curietron intracavitary 
brachytherapy system........................................................................................................ 25 
Figure 4.1 A bar chart of dose rate variation to point 'A' for pre & post treatment for first 
10 patients ......................................................................................................................... 31 
Figure 4.2 A bar chart of dose rate variation to point 'A' for pre & post treatment for next 
set of 12 patients ............................................................................................................... 31 
Figure 4.3 A bar chart of dose rate variation to point 'A' for pre & post treatment for last 
12 patients ......................................................................................................................... 32 
Figure 4.4 A bar chart of dose rate variation to point 'A' for pre & post treatment for 6 
hysterectomy patients........................................................................................................ 33 
Figure 4.5 A bar chart of dose prescribed and received for the first 20 patients .............. 35 
Figure 4.6 A bar chart of dose prescribed and received for the last 20 patients ............... 35 
Figure 4.7 A bar chart of dose rate variation to point 'B' for pre & post treatment for first 
10 patients ......................................................................................................................... 36 
Figure 4.8 A bar chart of dose rate variation to point 'B' for pre & post treatment for next 
set of 12 patients ............................................................................................................... 37 
vii 
 
University of Ghana  http://ugspace.ug.edu.gh
 
Figure 4.9 A plot of dose rate variation to point 'B' for pre & post treatment for last 12 
patients .............................................................................................................................. 37 
Figure 4.10 A bar chart of total dose received to bladder for pre- & post treatment 
calculation for first 20 patients ......................................................................................... 38 
Figure 4.11 A bar chart of total dose received to bladder for pre- & post-treatment 
calculation for last 20 patients .......................................................................................... 39 
Figure 4.12 A bar chart of total dose received to rectum for pre- and post-treatment 
calculation for first 20 patients ......................................................................................... 40 
Figure 4.13 A plot of total dose received to rectum for pre- and post-treatment calculation 
for last 20 patients ............................................................................................................. 41 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
viii 
 
University of Ghana  http://ugspace.ug.edu.gh
 
LIST OF TABLES 
Table 2.1 Examples of cancers treated with radiation therapy. .......................................... 9 
Table 2.2 Various types of Brachytherapy Implant .......................................................... 12 
Table 2.5 Brachytherapy Treatments Classified With Respect To Dose Rate ................. 12 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ix 
 
University of Ghana  http://ugspace.ug.edu.gh
 
ABBREVIATIONS 
2D   Two-Dimensional  
3D   Three-Dimensional  
3DCRT  Three-Dimensional Conformal Radiotherapy 
ABS   American Brachytherapy Society  
AP   Anterior-posterior 
CFRMI The French Committee on Ionizing Radiation Measurements 
CT   Computer Tomography 
CTV   Clinical Target Volume 
DNA   Deoxyribonucleic Acid 
EBRT   External Beam Radiation Therapy 
GTV   Gross Tumor Volume 
GTVLN  Lymph Nodes Gross Tumor Volume 
HDR   High Dose Rate 
ICBT   Intracavitary Brachytherapy Treatment 
ICRU   International Commission on Radiation Units and Measurements 
IGRT    Image-Guided Radiation Therapy  
IMRT   Intensity Modulated Radiation Therapy  
x 
 
University of Ghana  http://ugspace.ug.edu.gh
 
IORT   Intra-Operative Radiotherapy 
LAT   Lateral  
KATH                         Komfo Anokye Teaching Hospital 
LDR   Low Dose Rate 
MDR   Medium Dose Rate 
MRI   Magnetic Resonance Imaging 
NCRP   National Council on Radiation Protection and Measurements 
pCTV   primary Clinical Target Volume 
QUANTEC   Quantitative Analysis of Normal Tissue Effect in the Clinics 
rCTV    regional Clinical Target Volume 
RT   Radiotherapy 
SBRT   Stereotactic Body Radiation Therapy  
TBI   Total Body Irradiation TBI 
TPS   Treatment Planning System  
VMAT  Volumetric Modulated Arc Therapy  
WHO   World Health Organization
xi 
 
University of Ghana  http://ugspace.ug.edu.gh
 
CHAPTER ONE 
1 INTRODUCTION 
1.1 BACKGROUND 
Cervical cancer is the fourth most occurring cancer affecting women in the world, after 
breast, colorectal, and lung cancers, with 528 000 new cases every year; it is most common 
in the lower resource countries of sub-Saharan Africa (WHO 2012). Cancer of the cervix 
is responsible for the death of an estimated 231000 women annually, with over 80% of 
these deaths occurring in developing countries (Domfeh et al. 2008). The second most 
prominent female malignancy in sub-Saharan Africa is cervical cancer (Parkin et al. 2003). 
Southern and Eastern Africa with respectively 43 per 100000 women and 37 per 100000 
women reported the maximum incidence rates in the world (WHO, 2008). The 
corresponding mortality rates are 34 per 100000 women and 23 per 100000 women. For 
instance, the incidence rate for all races is 8.2 per 100000 women in the United States 
(Leaver and Labonte, 2010), while Makin and Kamanu (2010) note that reported mortality 
rates in resource rich countries seldom exceed 5 per 100,000 women. This difference 
between Africa and the advanced world is enormous, and the success in the latter, is 
attributed largely to wide spread comprehensive cervical cancer screening control 
programs (WHO, 2008; Adewole et al., 2005). In Africa, with a total number of 267.9 
million women aged 15 years or greater, estimates are that 78897 women are diagnosed 
with cervical cancer annually and 61671 (78%) die from the disease (Denny, 2010). In sub-
Saharan Africa, among the highest worldwide with the available age-standardized rates 
ranging from 19.9 per 100000 in Ibadan, Nigeria, (Parkin et al. 2003) through 35.7 per 
100000 in Bamako, Mali, to 41.7 per 100000 in Kyadondo, Ugandais the cervical cancer 
1 
 
University of Ghana  http://ugspace.ug.edu.gh
 
incidence (Parkin et al. 2002). The occurrence of cervical human papilloma virus (HPV) 
infection differs significantly worldwide. Population-based HPV prevalence surveys have 
revealed a 13-fold disparity in women who are sexually-active from ages between 15 and 
65 years, with the range of  2.0% in Hanoi, North Vietnam (Anh et al. 2003), 3.0% in 
Barcelona, Spain (de Sanjose et al. 2003), 14.8% in Bogota, Columbia (Molano et al. 
2002), through 17.7% in Concordia, Argentina (Matos et al. 2003) to the highest of 26.3% 
in Ibadan, Nigeria, a West African neighbor of Ghana (Thomas et al. 2004).  
Radiotherapy, in the form of External Beam Radiotherapy (EBRT), brachytherapy or both, 
constitutes an essential aspect of treating carcinomas. Cancers such as those of the breast, 
prostate, cervical and skin are usually treated by combining both EBRT and brachytherapy. 
In Ghana, brachytherapy is usually used to manage cervical cancers and sometimes prostate 
cancers. Intracavitary brachytherapy (ICBT) was first performed by Margaret Cleaves in 
1903 which involves placement of uterine tandem and vaginal ovoids (Koushik et al. 2010). 
Due to technological advancements, three types of brachytherapy have been developed; 
high dose rate (HDR), medium dose rate (MDR) and low dose rate (LDR) brachytherapy, 
with LDR and HDR commonly used. The development of after loading along with different 
applicators which make use of newer radioisotopes with a range of specific 
activities(resulting in varied dose rates), has increased flexibility in brachytherapy for the 
modern radiation oncologist (Datta et al. 2001). Furthermore, the readiness of modern 
imaging devices for better tumor localization and newer treatment planning systems has 
provided options for altering patient treatment (Datta et al. 2001). Again, technological 
advancements in dosimetry, treatment planning, treatment delivery-units and tumor 
imaging have aided the radiation oncologist and physicist to individualize treatment. 
2 
 
University of Ghana  http://ugspace.ug.edu.gh
 
Unlike brachytherapy, this has been accepted and put into practicing teletherapy. In Ghana, 
both HDR and LDR are used in the two national radiotherapy facilities. For a better and 
effective treatment delivery and reduction in the risk of complications, the proper insertion 
of the intracavitary applicator is paramount to the success of the treatment. Thus, a higher 
dose will be delivered to the main tumor while sparing surrounding healthy tissues. In 
treating cervical cancer with brachytherapy, a high dose rate (HDR) or low dose rate (LDR) 
therapy machine may be deployed depending on its availability to the radiotherapy 
department. In using continuous LDR brachytherapy, the displacement and motion of the 
applicator as a result of prolonged treatment time and unavailability of rigid applicator 
fixation is one of the most major problems (Ljunggren et al, 1987). Other authors have 
found that there is a significant inter-fraction motion of the reference points as the 
International Commission on Radiation Units and Measurements, ICRU Report 38 (ICRU, 
1985) defined with regards to the bony pelvis between the first and second intracavitary 
applications. This movement causes a variation in the dose to the prescription point from 
233 to 135% (Grigsby et al. 1993). 
 
1.2 STATEMENT OF THE PROBLEM 
The clinical decision to determine the radiation amount given to a patient undergoing LDR 
intracavitary brachytherapy is determined by the radiation dose the critical organs (i.e. the 
rectum and the bladder) receive. The position of the applicators (i.e. the vaginal ovoids and 
the uterine tandem) are very crucial in the delivery of radiation dose to the diseased area. 
In some cases, only two ovoids are used, that is, when the patient has undergone total or 
partial hysterectomy. For LDR brachytherapy, the time taken to deliver the dose to a patient 
3 
 
University of Ghana  http://ugspace.ug.edu.gh
 
is very long which makes the patient be on the machine for a very long period of time. Low 
dose rate intracavitary brachytherapy involves delivery of radiation at a continuous rate of 
0.4-2 Gy/hr and this means, delivering 30 to 35 Gy will take around 30 to 50 hours. Due to 
this long treatment time, soakage of vaginal packing and patient movement can change the 
applicators position. These changes go a long way to defeat the intent of the oncologist and 
makes most of the patients have some complications such as fistula after treatment. In view 
of this, there is the need to evaluate the dose variation to the rectum and bladder as a result 
of the patient delay on the machine. 
 
1.3 OBJECTIVES 
The principal objective of this work was to determine the variation of dose to the critical 
organs (i.e. rectum and bladder) resulting from prolonged treatment periods for cervical 
cancer patients undergoing brachytherapy. This objective was to be achieved by: 
 Evaluating the geometric movement of the fixed reference points in LDR 
brachytherapy patients. 
 Determining the actual dose difference, in turn to critical structures and the clinical 
outcome. 
The specific objectives are to: 
 Evaluate rectal and bladder doses in pre-treatment planning. 
 Evaluate rectal and bladder doses in post-treatment planning. 
 Assess dose variations between pre- and post-treatment plans. 
 
4 
 
University of Ghana  http://ugspace.ug.edu.gh
 
1.4 RELEVANCE AND JUSTIFICATION 
LDR brachytherapy takes a very long time to deliver a specific dose to a target during a 
brachytherapy procedure. Dose variation assessment is, therefore, required before and after 
treatment to evaluate the dose delivered to the target as a result of patient movement due 
to the longer stay on the machine. It also helps the radiation oncologist to make an informed 
decision on whether to fractionate or give full dose. Dose variation assessments in LDR 
brachytherapy treatments have the potential to ensuring accurate and precise treatment in 
radiotherapy centres.  
 
1.5 SCOPE AND LIMITATION 
The research study covers the steps below: 
 Acquisition of orthogonal X-ray images of patients reporting for cervical 
brachytherapy procedures. The radiographs obtained on the patients are digitized into 
a treatment planning system and planned to determine the absorbed doses and dose to 
the rectum and blabber. 
 Acquisition of orthogonal X-ray images of patients after undergoing cervical 
brachytherapy to determine absorbed doses and dose to rectum and bladder.  
 Comparison between the forecasted and delivered doses is made to measure the effect 
of movements and changes in applicator positions on the treatment delivered.  
1.6 STRUCTURE OF THE THESIS 
This thesis is presented in five main chapters: 
5 
 
University of Ghana  http://ugspace.ug.edu.gh
 
 Chapter one gives an introduction to the research topic, explains the purpose of this 
study, as well as, its importance; and the importance for checking the dose variation in 
LDR intracavitary brachytherapy treatment technique; 
 Chapter two provides an overview of the literature associated to the study, what other 
researchers have done, theoretical approaches used in the past and how they are applied 
in practice;  
 Chapter three explains materials used for the study and the techniques applied in all the 
needed calculations;  
 Chapter four presents the results generated and the successive discussions, giving an 
understanding of the outcomes and their inference; and 
 Chapter five is the conclusion of the work, providing a general summary of the 
thesis, lessons learned and recommendations based on the results available. 
 
 
 
 
 
 
 
6 
 
University of Ghana  http://ugspace.ug.edu.gh
 
CHAPTER TWO 
2 LITERATURE REVIEW 
2.1 BACKGROUND 
Cancer is a disease that occurs at the cellular deoxyribonucleic acid (DNA) level. It is an 
uncontrolled growth of human cells, making them able to spread to surrounding and remote 
tissues. Cancer has the potential to invade other body parts through the hematopoietic 
and/or lymphatic systems. There are over one hundred types of cancers and are mostly 
named by the organ or kind of cell they attack (cancer that begins in melanocytes of the 
skin is melanoma). Cervical cancer begins in cells lining of the cervix. The squamous cells 
and glandular cells are the two main forms of cells covering the cervix. The meeting place 
of these types of cell is known as the transformation zone. Early detection of the tumor 
makes its treatment quite easier and effective. If there is an uncontrolled cell growth, it will 
end up in death of the individual (Chaffer et al., 2011). The past years have observed a 
great development towards the treatment and understanding of the previous proposed 
cancer hallmarks (Hanahan and Weinberg, 2000) and with improvements in early detection 
and in the different treatment modalities, many cancers have become curable (Pollack et 
al., 2009). In treating cancers (depending on the stage and grade), surgery, chemotherapy 
or radiation therapy are considered. Radiotherapy involves the use of high energy 
radiations (i.e. photons and particles) to treat illness (usually cancers). After Wilhelm 
Röntgen had discovered X-rays in 1895, its clinical usefulness, by way of cancer treatment 
was first appreciated. Furthermore, about half of all cancer patients will undergo 
radiotherapy in their course of illness 
7 
 
University of Ghana  http://ugspace.ug.edu.gh
 
 (Delaney et al., 2005; Begg et al., 2011) with an estimation that radiotherapy contributes 
to around 40% towards curative treatment (Barnett et al., 2009). 
 
2.2 PRINCIPLES OF RADIATION THERAPY 
Radiation is the emission of energy as electromagnetic waves or as moving subatomic 
particles, especially high energy particles which cause ionization. In radiotherapy, the 
radiations used to kill the cancer cells are known as ionizing radiation. These ionizing 
radiations form ions and deposit energy in the tissue cells they pass through. This energy 
deposited can cause genetic changes resulting in cancer cell death. The DNA is damaged 
by a high energy radiation and the cell loses its ability to divide and proliferate further 
(Jackson and Bartek, 2009).Even though radiation causes damage to both normal cells as 
well as cancer cells, the therapeutic goal is to cause lethal damage to cancer cells and 
minimize radiation dose to normal cells. Table 2.1 shows a list of common cancers treated 
with radiotherapy. Radiation can be delivered in two ways, which are external beam 
radiation where radiation is delivered from outside the body by aiming high-energy rays to 
the location of the tumor; and brachytherapy, where the source is placed directly into the 
tumor. 
 
 
 
 
 
8 
 
University of Ghana  http://ugspace.ug.edu.gh
 
Table 2.1 Examples of cancers treated with radiation therapy. 
Early cancers curable with radiation Cancers curable with radiation therapy 
therapy alone in combination with other modalities 
Skin cancers (Squamous and Basel cell) Breast carcinomas 
Prostate carcinomas Rectal and anal carcinomas 
Lung carcinomas (non-small cell) Locally advanced cervix carcinomas 
Cervix carcinomas Locally advanced head and neck 
carcinomas 
  
Lymphomas (Hodgkin’s and low grade Locally advanced lung carcinomas 
Non-Hodgkin’s) 
  
Head and neck carcinomas Advanced lymphomas 
 Bladder carcinomas 
 Endometrial carcinomas 
 CNS tumors 
 Soft tissue sarcomas 
 Pediatric tumors 
 
 
2.3 RADIATION THERAPY TECHNIQUES 
2.3.1 Fractionation. 
Radiotherapy administered in a fractionated regime is dependent on the different 
radiobiological properties of both cancer and various normal tissues. In general, these 
regimes increase the survival advantage of normal tissues over malignant cells, mostly 
based on the fact that, normal cells have a better sub lethal damage repair of radiation 
9 
 
University of Ghana  http://ugspace.ug.edu.gh
 
damage than cancer cells. Normal cells have more time to repair damage before replication 
than the cancer cells. In the 1920s, initial effects of fractionated radiotherapy finally led to 
the development of regimes comparing various treatment schedules based on overall dose, 
number of fractions and total treatment time (Bernier et al., 2004). Current regimes are 
based on the linear-quadratic formula which takes care of the time-dose factors for 
individual tumor types and normal tissues (Ellis, 1969). A typical radiation therapy regime 
now includes daily fractions of 1.5 to 3Gydelivered over several weeks. 
 
2.3.2 External Beam Radiation Therapy (EBRT) 
This is the most commonly used form of radiation therapy, and most often uses photon 
beams. The radiation originates from an external source and is focused on the tumor. High 
energy X-rays and/or gamma rays are used to deposit radiation doses to the tumor to 
damage the cancerous cells and, with careful treatment planning, healthy cells are spared. 
During EBRT sessions, patients are made to lie on a treatment couch in one position for 
every fraction of treatment. For every fraction, more than one radiation beams from several 
gantry angles are focused on the patient. A cobalt-60 therapy machine or linear accelerator 
(LINAC) is usually used for EBRT. Before the start of radiotherapy treatment procedure, 
a treatment plan is designed and is done by arranging beams at angles to deliver dose at the 
site of the tumor(s). This is done by taking a CT scan to get a 3-dimensional image of the 
body of the patient. Treatment Planning Systems (TPSs) are used to generate beam shapes 
and dose distributions with the intent to maximize tumor control and minimize normal 
tissue complications. Ideally, EBRT would destroy a cancerous cell/tissue every time if a 
big enough dose could be given to the cancer. The therapeutic goal is to deliver a very high 
10 
 
University of Ghana  http://ugspace.ug.edu.gh
 
dose to the cancer cells whiles minimizing radiation to the normal cells. But in reality, this 
is not possible therefore there is a compromise between sparing healthy tissues from 
damage and killing the cancerous ones, and therefore, radiotherapy techniques need to be 
improved. 
Several techniques of EBRT exist and these are employed depending on several factors 
like availability of technology and the treatment option. These techniques include three-
dimensional conformal radiotherapy (3DCRT), intensity modulated radiation therapy 
(IMRT), volumetric modulated arc therapy (VMAT), image guided radiotherapy (IGRT), 
stereotactic body radiation therapy (SBRT), radiosurgery, proton therapy, adaptive 
radiotherapy, intra-operative radiotherapy (IORT), molecular radiotherapy, and total body 
irradiation (TBI). 
 
2.3.3 Brachytherapy 
This is a term which describes the short distance treatment of cancer with radiation from 
small, encapsulated radionuclide sources. These sources are directly placed into or near the 
tumor. The dose can be delivered either by temporal or permanent implants. Photon 
emitting sources are commonly used in brachytherapy; however, there are few specialized 
cases where beta or neutron emitting sources are used. Brachytherapy treatment is divided 
into two main types; 
 Intracavitary, where sources are placed in body cavities close to the tumor volume; 
 Interstitial, where sources are implanted within the tumor volume. 
There are other common forms of brachytherapy treatments which include surface plaque, 
intraoperative, intravascular and intraluminal source applications, where either gamma or 
11 
 
University of Ghana  http://ugspace.ug.edu.gh
 
beta emitting sources are used. The advantage of brachytherapy treatments over external 
beam radiotherapy is its ability to localize the delivered dose to the target volume. 
(Suntharalingam et al., 2005). The disadvantage is that brachytherapy can only be used in 
cases where the tumor is well localized and relatively small. In a typical radiotherapy 
department about 10–20% of all radiotherapy patients undergo brachytherapy 
(Suntharalingam et al., 2005). Several factors must be considered when delivering 
brachytherapy, especially, how the sources are positioned relative to the volume to be 
treated. Tables 2.2–2.5 summarize brachytherapy treatment techniques with regard to the 
type of implant, duration of implant, method of source loading and dose rate according to 
the ICRU (ICRU, 1985).. 
Table 2.2 Various types of brachytherapy implant 
Type of implant Description 
Intracavitary Sources are placed into body cavities close to the tumor volume 
Interstitial  Sources are implanted surgically within the tumor volume 
Surface (mould)  Sources are placed over the tissue to be treated 
Intraluminal  Sources are placed in a lumen 
Intraoperative  Sources are implanted into the target tissue during surgery 
Intravascular  A single source is placed into small or large arteries 
 
 
 
Table 2.3 Brachytherapy treatments classified with respect to dose rate 
Dose rate  Numerical value of the dose rate at the dose 
specification point(s) 
12 
 
University of Ghana  http://ugspace.ug.edu.gh
 
Low dose rate (LDR) 0.4–2 Gy/h 
Medium dose rate (MDR) 2–12 Gy/h 
High dose rate (HDR) >12 Gy/h 
 
 
2.3.3.1 Brachytherapy Applicators 
Several applicators used in brachytherapy are accessible for gynecologic applications; 
nevertheless, the supremacy of one over another cannot be promoted. A model 
gynecological brachytherapy applicator should have the following features: Simple, 
comfortable for patient, high tensile strength, economical, robust, nontoxic, ease of 
sterilization, and adaptability. Apart from its physical features, an applicator should be 
easily “image-able” using different modalities, comprising CT and MRI, with marginal 
image artefact (Suntharalingam et al., 2005). 
 
2.3.3.2 Applicator Fixation and Immobilization 
Patient immobilization and organ fixation are renowned as critical to the radiation therapy 
outcome. In brachytherapy, the outcome also could be determined by the maintenance of 
the relative position of the applicator to the target and organs of concern. Vaginal packing 
and simple waistbands are mutual efforts at fixation. During LDR brachytherapy an initial 
and final check should be carried out in order to assess changes in the applicator positions 
(Suntharalingam et al., 2005).  
13 
 
University of Ghana  http://ugspace.ug.edu.gh
 
2.3.3.3 Cs-137 Brachytherapy Source 
Caesium-137 was used to substitute radium-226 for short-term interstitial/intracavitary low 
dose rate brachytherapy due to its stable daughter product and improved radiation 
protection features. It is 'readily' acquired from fission of uranium-235 in a nuclear reactor. 
The half-life of 137Cs is 30.1 years. The radioactive material is then doubly encapsulated in 
stainless steel, with each layer soldered closed. 
 
2.3.4 Definition of Organs at Risk 
The description of healthy tissue volumes at risk is set on the basis of the MRI outcomes. 
Imaging is done with the patient in the treatment position, with all other treatment settings 
replicated as meticulously as possible. In cases where patients lie in supine with the knees 
slightly raised, patient imaging is done in the exact position. In the imaging process, an 
MRI-compatible treatment applicator is placed, along with a Foley catheter in the bladder. 
A rectal marker, if used, must be MRI compatible. Imaging of the bladder is duplicated as 
closely as possible for the treatment conditions. The anterior and superior walls of the 
bladder move away from the treatment applicator when the bladder is filled, thereby 
minimizing the dose. Under some conditions, filling of the bladder may push the posterior 
and inferior walls closer to the applicator, thereby increasing the dose to these areas (Nag 
et al., 2004).  
Just like the bladder, filling of the rectum during the time of imaging and treatment should 
be the same. Sometimes, some late complications emanate as a result of dose to the small 
bowel after many years of treatment. 
14 
 
University of Ghana  http://ugspace.ug.edu.gh
 
2.4 BRACHYTHERAPY SYSTEMS 
Brachytherapy systems are specific systems containing radioisotope(s) that have spatial 
distribution in an applicator to deliver a specific dose to a designated region. Specification 
of treatment in terms of dose, timing, and administration is very crucial within every system 
in order to make prescriptions in a reproducible manner. In the treatment of the cervix, 
various systems have been developed for dose specification but the two systems mostly 
used are the Manchester and the ICRU systems. Others include Stockholm and the 
historical Paris system.  
.  
 
2.4.1 ICRU System 
The system recommended by the ICRU relates the dose distribution to the target volume 
rather than to a specific point (ICRU, 1985).  
 
2.4.2 Manchester System 
This system was formerly developed as a practical system for interstitial, mould, and 
intracavitary radiotherapy using radium. It gives rules that state how the radium is to be 
distributed, and tables which allow either the amount of radium required, or the treatment 
time to be calculated. The system has also successfully been used with other radionuclides. 
The source strength of those radionuclides with a long half-life and a short half-life is 
specified conveniently by the radium equivalent mass and the initial activity, respectively. 
A numerical factor, determined by the exposure rate constant, the actual total treatment 
time and the half-life, is used to estimate the equivalent radium milligram hours. 
15 
 
University of Ghana  http://ugspace.ug.edu.gh
 
Mass, equivalent mass, and activity are all acceptable statements of the source content and, 
therefore, of source strength. Alternatively, the strength of a source may be specified in the 
form of the radiation emission. The use of exposure rate at a specified distance was 
recommended by the National Council on Radiation Protection and Measurement and has 
been discussed in papers by Wambersie et al (1973), and Dutreix and Wambersie (1975). 
Since then, exposure and exposure rate have been substituted in modern radiation 
dosimetry by air kerma and air kerma rate. The French Committee on Ionising Radiation 
Measurements proposed, and the British Committee on Radiation Units and Measurements 
formally recommended that brachytherapy source strength should be identified in terms of 
air kerma rate at 1 m and that the unit used should be the microgray per hour (µGyh-1) 
(Massey et al., 1985). The Manchester system is characterized by doses to four points: ‘A’, 
‘B’, bladder and rectum (ICRU, 1985). Point ‘A’, which is located 2 cm superior to the 
cervical orifice and 2 cm lateral to the cervical canal determines the duration of implant. 
Point ‘B’ is 3 cm laterally to point ‘A’ only when there is displacement in central canal, 
otherwise it remains fixed at 5 cm from the midlines. A radiation survey is then performed 
in areas within and around the patient’s room after the implantation of the sources in the 
patient. Radiation levels are measured and recorded in order to assist in maintaining 
minimum exposure of hospital staff and visitors. 
 
2.5 MAGNITUDE OF DISPLACEMENTS OF APPLICATORS 
Corn in the 1980s first estimated the magnitude of variation of applicators, showing several 
dislocation of applicators in the lateral direction on an average of 3 mm (Corn et al., 1993). 
Other oncologists, such as, Pham et al. (1998) and Bahena et al. (1998) also found that the 
16 
 
University of Ghana  http://ugspace.ug.edu.gh
 
displacements were not only in lateral, but also in antero-posterior and superio-inferior 
directions. In the study of Koushik et al. (2010), the normal dislocations in the lateral and 
antero-posterior directions were 3 and 1 mm, respectively. It kowtows to the above cited 
studies. Glenn et al.(1993) have assessed the geometric movement of the fixed 
brachytherapy reference points comparative to the bony pelvis, all through the time interval 
of the first and the second gynecologic intracavitary implants. Using a Fletcher-Suit-
Delclos applicator in 40 successive patients, they detected movement of the absolute 
position of ICRU report 38 reference points between the first and the second applications, 
leading to substantial variances in the absolute dose rates to these reference points in two 
insertions. Kim et al. (1997) studied the major geometric disparities between multiple HDR 
applications of brachytherapy in 17 consecutive patients of carcinoma cervix treated with 
Gammamed (Isotopen Technik, Hann, Germany) or the Nucletron (Nucletron 
International, Veenendaal, The Netherlands) HDR systems. The geometric disparities 
studied involved an assessment of axis, length and slippage in the tandem placement and 
separation, vaginal packing and slippage in colpostat placement. Major disparities between 
applications were detected more commonly in the colpostat placement than in the tandem 
placement. For tandems, the rates of disparity stated by them were: 5.7% in axis, 4.3% in 
length, and 1.4% in slippage. For colpostat, the rates of variations were: 7.1% in separation, 
25.7% in vaginal packing, and 7.1% in slippages.  
 
2.5.1 Dose Variations Due to Change in Applicator Position 
The variation of dose to point ‘A’ has been studied by many researchers such as Corn et 
al. (1993) and Hoskin et al. (1996). These studies revealed different levels of dose 
17 
 
University of Ghana  http://ugspace.ug.edu.gh
 
variations such as 2, 35, 8 and 20%. These variations are widely ranged for the fact that 
some of the studies were done using radium source and several with iridium and cesium 
sources. According to the study of Koushik et al. (2010), they found an average variation 
of 14% which is well within the results shown in the above mentioned studies. They also 
assessed the variation in dose at point ‘B’ and point ‘P’ in order to make out the differences 
at the lymph node areas. In the study they found variations of 2 and 1% at point ‘B’ and 
point ‘P’, respectively. Corn et al. (1993) also observed this variation to be 1.7 and 0.9%, 
respectively. As per the guidelines, researchers usually use only one rectal point, but in 
Koushik et al’ (2010) tried to include two rectal points in order to assess rectal morbidity. 
Studies done by Corn et al. and Pham et al. have shown certain dissimilarity of 3 and 10%, 
respectively (Corn et al., 1993; Pham et al., 1998). Koushik et al found 3.5% variation in 
the dose to rectum. For bladder dose variation, Koushik et al, presented on an average 
estimate of 9.3% (Koushik et al.,2010) and the results of other studies by Corn et al. and 
Pham et al. were 1.9% and18% respectively (Corn et al., 1993; Pham et al., 1998).  
 
 
 
    
18 
 
University of Ghana  http://ugspace.ug.edu.gh
 
CHAPTER THREE 
3 METHODOLOGY 
3.1 MATERIALS 
In this study, materials used for patient set up and absorbed dose calculations include 
Fletcher type brachytherapy applicators, Varian Acuity simulator, Prowess Panther 
treatment planning system (TPS) and Cs-137 LDR brachytherapy system. 
 
3.1.1 Fletcher Type Brachytherapy Applicators 
The Fletcher type brachytherapy applicators employed in this work comprise of a tandem 
and two vaginal ovoids. The diameter are 0.6 and 2 cm for the tandem and ovoids, 
respectively, with an active source length of 1.72 cm. The applicators are simple to use, 
comfortable for patients and have a high tensile strength. It is also economical, robust, non-
toxic and easier to sterilize. The tandem and ovoids are made from titanium. The Fletcher 
type brachytherapy applicators are shown in Figure 3.1. 
19 
 
University of Ghana  http://ugspace.ug.edu.gh
 
 
Figure 3.1 Fletcher type brachytherapy applicators. 
 
3.1.2 Varian Acuity Simulator 
The Acuity simulator is a highly valued verification and simulation system and is designed 
to work alongside CT simulators. This system can also be used to plan and simulate 
brachytherapy patients. This allows the whole process to be done in a single room without 
having to utilize multiple rooms within the department. The stable gantry gives Acuity the 
maximum isocentric accuracy specification in its field. It supports both two-dimensional 
(2D) and three-dimensional (3D) imaging. Figure 3.2 shows a Varian Acuity simulator. 
20 
 
University of Ghana  http://ugspace.ug.edu.gh
 
 
Figure 3.2 Varian Acuity Simulator 
 
3.1.2 Prowess Panther Treatment Planning System 
Prowess® has a competitive advantage by offering Panther 3D conformal therapy on the 
familiar and most user-friendly Windows® platform. Users can generate treatment plans 
quickly due to the familiar Windows®. The version used in this work is v.4.31. Figure 3.3 
shows an interface of the Prowess® Panther TPS at Komfo Anokye Teaching Hospital.  
21 
 
University of Ghana  http://ugspace.ug.edu.gh
 
 
Figure 3.3 Interface of Prowess® Panther TPS 
 
3.1.3 Cs-137 LDR Brachytherapy System 
The treatment machine used in the study is AMRA-Curietron with model number CA: 
9610, which is a LDR brachytherapy machine and manufactured by Cis-Bio International 
(Germany). The maximum activity of the source was 259 GBq. The system has five 
channels and is a remote afterloader as shown in Figure 3.4. In the Curietron treatment 
machine, the ovoids are marked with the letter "V" which represents channels 1 and 5, 
respectively. For the tandem, there are three channels which are marked by the letter "U." 
In this instance, there are three channels for "U"; these are channels 2, 3, and 4. 
22 
 
University of Ghana  http://ugspace.ug.edu.gh
 
 
Figure 3.4 Cs-137 LDR Brachytherapy System 
 
3.2 METHOD 
3.2.1 Patient Imaging 
The age group of adult patients for the study was between 25 and 60 years all being females 
with the tumor stages I-IV at KATH. Orthogonal images of anterior-posterior (AP) and 
lateral (LAT) were taken for every patient. In each case, two sets of orthogonal images 
(before and after treatment) were considered to decide on various parameters relating to 
the applicator geometry and its spatial relation to the bony pelvis as described in Figures 
3.5(a) and 3.5(b). In order to see the bladder and rectum, Urografin (radio-opaque 
substance) was passed through a catheter into the organs. Gauze was packed into the vagina 
in order to stabilize the applicators. Reference planes (x, y, z) were also defined for each 
set of images by using the patient’s bone landmarks to evaluate changes in positioning of 
23 
 
University of Ghana  http://ugspace.ug.edu.gh
 
applicators relative to fixed bony landmarks of the patient. To ensure the same patient 
positioning for the post treatment images, marks were made on the patients. 
 
a                                                                 b 
Figure 3.5 (a) AP image of the pelvis of a patient (b) LAT image of the pelvis of a patient 
 
3.2.2 Patient Treatment 
The Curietron LDR brachytherapy treatment machine has five channels to which the 
ovoids (marked ‘V’) and tandem (marked ‘U’) connect. During treatment, only one channel 
of the "U" was selected and used depending upon the measured length of the tandem that 
protruded. It has been found clinically that if the measured length (L) of the protruded 
tandem is ≤ 4 cm, then channel 2 is required to be used. Alternatively, if the measured 
length of the protruded tandem is between 4 and 5 cm, then channel 3 is required to be 
24 
 
University of Ghana  http://ugspace.ug.edu.gh
 
used. If the measured length of the protruded tandem is found to be >5 cm, then channel 4 
is required to be used.  
In this study, four source arrangements or channel combinations were used, namely 1-2-5, 
1-3-5, 1-4-5, and 1-5. The channel 1-5 combination was used when the patient had 
undergone total or partial hysterectomy. After the various combinations, the Cs-137 
radioactive sources in the brachytherapy system were called in (moved into treatment 
positions) from their respective storage locations. The time at which the sources were 
called was noted. Figure 3.6 shows a schematic diagram of the source arrangement. 
 
Figure 3.6 A schematic diagram of channel arrangement in AMRA-Curietron intracavitary 
brachytherapy system. 
 
3.2.3 Brachytherapy Treatment Planning 
3.2.3.1 Planning Process 
The treatment was planned using the AP and LAT images obtained. Outline shape of the 
ovoid (on the lateral image) was obtained and the centre was located. The new diameters 
of ovoid and tandem on the image were measured (I), with the original diameter of 20 mm 
25 
 
University of Ghana  http://ugspace.ug.edu.gh
 
and 6 mm for the ovoid and tandem, respectively. Equation 3.1 was used to estimate the 
magnification of the images (given tandem dtandem = 6 mm, dovoid 20 mm). 
𝐼𝑚𝑎𝑔𝑒 𝑠𝑖𝑧𝑒
𝑀𝑎𝑔𝑛𝑖𝑓𝑖𝑐𝑎𝑡𝑖𝑜𝑛 (𝑀) =    3.1, 
𝑂𝑏𝑗𝑒𝑐𝑡 𝑠𝑖𝑧𝑒
 
𝐼 𝐼
𝑀𝑡𝑎𝑛𝑑𝑒𝑚 =   𝑀𝑜𝑣𝑜𝑖𝑑 =                3.2, 6 20
The average of the magnifications of ovoid and tandem was then estimated and taken as 
the magnification factor of the lateral image 𝑀𝑙𝑎𝑡.  
𝑀
𝑀 = 𝑡𝑎𝑛𝑑𝑒𝑚
+ 𝑀𝑜𝑣𝑜𝑖𝑑
𝑙𝑎𝑡               3.3, 2
The active source length (17.2 mm) was then multiplied by the image magnification, to 
obtain the active source length which was used for the treatment planning.  
𝑠𝑜𝑢𝑟𝑐𝑒 𝑙𝑒𝑛𝑔𝑡ℎ𝑎𝑝𝑝𝑎𝑟𝑒𝑛𝑡 = 𝑀𝑙𝑎𝑡  𝑥 17.2 𝑚𝑚  3.4, 
The centre of the tandem was identified and the sources were allocated on it using a pair 
of vernier callipers including the interval between sources (given actual interval 3.1 mm).  
𝑖𝑛𝑡𝑒𝑟𝑣𝑎𝑙𝑎𝑝𝑝𝑎𝑟𝑒𝑛𝑡 = 𝑀𝑙𝑎𝑡  𝑥 3.1 𝑚𝑚   3.5. 
A perpendicular line was drawn through the last point of the line source. One active source 
length (𝑠𝑜𝑢𝑟𝑐𝑒 𝑙𝑒𝑛𝑔𝑡ℎ𝑎𝑝𝑝𝑎𝑟𝑒𝑛𝑡) was subtracted from ovoid length (apparent), then the 
average was found. A vernier callipers was used to demarcate the points from both ends of 
ovoid. The centre between two sources was noted and a perpendicular line drawn through, 
which was parallel to the perpendicular line drawn through the last point source. Point ‘A’ 
was located 2 cm above the intersection of the ovoid and the perpendicular line passing 
through the centre of the source located in ovoid and traced adjacent to the tandem. Point 
‘B’ was located 3 cm away from point A lateral to the tandem on the AP image. Both points 
‘A’ and ‘B’ were located on the image as multiples of the image magnification. 
26 
 
University of Ghana  http://ugspace.ug.edu.gh
 
 
Figure 3.7. The position of dosage points A and B. 
 
 
3.2.3.2 Digitization and Dose Computations 
The LAT and AP X-ray images were digitized to generate a plan for treatment delivery. 
Beginning with the lateral, then to the AP, the points on the images were transferred unto 
the TPS. Data were input into the treatment planning computer, optimized, and dwell times 
and dose distribution calculated. The data were entered into the computer, based on 
information from the prescription by the physician who did the insertion and localization 
films. Figure 3.7 shows the planning, digitizing and dose computation phases in the study.  
27 
 
University of Ghana  http://ugspace.ug.edu.gh
 
 
Figure 3.7a                                                         b 
 
 
c 
Figure 3.7a. Brachytherapy planning 
Figure 3.7b. Digitizing the brachytherapy plan onto the TPS 
Figure 3.7c.  Dose calculation of the brachytherapy procedure. 
 
 
 
 
28 
 
University of Ghana  http://ugspace.ug.edu.gh
 
Then absorbed dose to tissue/medium is given by, 
𝜇 𝑚𝑒𝑑
𝐷 𝑒𝑛𝑚𝑒𝑑 = 𝐷𝑎𝑖𝑟 ( )    3.6 𝜌 𝑎𝑖𝑟
 
𝑊 𝜇 𝑚𝑒𝑑
𝐷 = 𝑋 ( 𝑎𝑖𝑟) ( 𝑒𝑛𝑚𝑒𝑑 )    3.7 𝑒 𝜌 𝑎𝑖𝑟
𝑊𝑎𝑖𝑟 33.97𝐽 𝜇Where, ( ) =  ;( 𝑒𝑛) is the mass energy absorption coefficient, and X been 
𝑒 𝐶 𝜌
exposure rate in the air. The mathematical equation for the treatment time is given as; 
 
𝐷
𝑡 =       3.8 
?̇?
 
where  D = Prescribed dose, 
?̇?   = Dose rate of cesium-137 
Dmed =absorbed dose to tissue/medium, 
Dair = absorbed dose in air, 
𝜇𝑒𝑛 = energy absorption coefficient, 
𝜌 = density of the medium, 
 
3.2.4 Analysis 
Calculations made in this study were done using Microsoft Excel which forms part of the 
Microsoft Office 2013 Suite. The variation in doses to point “A” and point “B” as well as 
the critical organs were determined by the use of the software. Tables and graphs for data 
analysis were also done using the same software. 
 
 
29 
 
University of Ghana  http://ugspace.ug.edu.gh
 
CHAPTER FOUR 
4 RESULTS AND DISCUSSION 
4.1 DOSE VARIATIONS 
Variability in doses to points ‘A’, ‘B’, bladder and rectum resulting from change or 
movement of applicators has been studied for forty (40) patients. Thirty-four (34) of the 
patients had their cervix present whiles six (6) patients had undergone hysterectomy. The 
variations were studied in terms of: (a) difference in pre and post treatment calculated doses 
and; (b) difference in prescribed and delivered doses, as shown in appendices C-F. 
 
4.1.1 Dose Variations at Point ‘A’ 
The geometrical point ‘A’ often occurs in a high gradient region of the pear-shaped volume 
of isodose distribution, based on the anatomy of the patient’s pelvic region in the 
geometrical arrangement of the radioactive source.  The slightest change in position can 
result in large differences in delivered dose. The dose variations at point ‘A’ for 34 patients 
with their cervix present is shown in Figures 4.1, 4.2 and 4.3 and in tabular form in 
Appendix A1. 
30 
 
University of Ghana  http://ugspace.ug.edu.gh
 
DOSE RATE VARIATION TO POINT A FOR PRE & POST
Dose Rate Variation to Point A
(Pre)
250 Dose Rate Variation to Point A
(Post)
200
150
100
50
0
1 2 3 4 5 6 7 8 9 10
PATIENT NUMBER  
Figure 4.1A bar chart of dose rate variation to point 'A' for pre & post treatment for first 
10 patients 
 
DOSE RATE VARIATION TO POINT A FOR PRE & POST
120
Dose Rate Variation to Point A (Pre)
Dose Rate Variation to Point A (Post)
100
80
60
40
20
0
11 12 13 14 15 16 17 18 19 20 21 22
PATIENT NUMBER  
Figure 4.2 A bar chart of dose rate variation to point 'A' for pre & post treatment for next 
set of 12 patients 
31 
 
DOSE RATE TO POINT A (PRE & POST) (Gy/hr) DOSE RATE TO POINT A (Gy/hr)
University of Ghana  http://ugspace.ug.edu.gh
 
DOSE RATE VARIATION TO POINT A FOR PRE & POST
120
Dose Rate Variation to Point A (Pre)
Dose Rate Variation to Point A (Post)
100
80
60
40
20
0
23 24 25 26 27 28 29 30 31 32 33 34
PATIENT NUMBER  
Figure 4.3 A bar chart of dose rate variation to point 'A' for pre & post treatment for last 
12 patients 
 
From Figures 4.1, 4.2 and 4.3 above, it was observed that there was minimum deviation 
between most of the pre-treatment calculated dose and post-treatment calculated dose. 
Patients 2, 4, 7, 8, 15, 21, 29 and 34 showed large deviations of 125, 13, 11, 15, 13, 12, 16 
and 23%, respectively. The deviations occurred due to loose packing of the applicators, 
transport of patient from simulator room to brachytherapy room and instability of patients 
during the treatment. Patient 2 in Figure 4.1 showed an outrageous deviation, with more 
than 100% dose increment. It was observed that the tandem turned to the opposite direction 
making it move closer to the point ‘A’, thereby doubling the dose received. Patient 19 also 
showed a sharp decline in both pre- and post-treatment calculated dose (from Figure 4.2). 
This was as a result of a short tandem used which had only 2 source allocations, thereby 
reducing the dose rate to point ‘A’. 
32 
 
DOSE RATE VARIATION TO POINT A (PRE 
& POST (Gy/hr)
University of Ghana  http://ugspace.ug.edu.gh
 
Figure 4.4 and Appendix A2 show the dose variation at point A for 6 patients who had 
undergone hysterectomy. 
DOSE RATE VARIATION TO POINT A FOR PRE & POST
Dose Rate to Point A (Pre)
180 Dose Rate to Point A (Post)
160
140
120
100
80
60
40
20
0
35 36 37 38 39 40
PATIENT NUMBER  
Figure 4.4 A bar chart of dose rate variation to point 'A' for pre & post treatment for 6 
hysterectomy patients 
 
The dose rates to point ‘A’ for pre- and post-treatment calculated doses do not differ much 
(since the time taken for treatment is shorter) for the patients who had undergone total or 
partial hysterectomy. For hysterectomy patients, point ‘A’ is located in the middle of the 
vaginal ovoids which are within the source. Therefore as the dose increases the time also 
becomes shorter resulting in less movement of the patient during treatment. Two patients 
(i.e. Patients 39 and 40) showed a 10% deviation which was the highest for the 
hysterectomy patients.   
33 
 
DOSE RATE TO POINT A (PRE & POST) 
(Gy/hr)
University of Ghana  http://ugspace.ug.edu.gh
 
4.1.1.1 Difference in Prescribed Dose and Delivered Dose 
In brachytherapy, doses are prescribed to point ‘A’ by clinicians since it is usually located 
within the tumor. Doses prescribed to point ‘A’ are usually 30 or 35Gy. Variation in doses 
prescribed and delivered is shown in Figures 4.5 and 4.6 and in tabular form in Appendix 
B. High variation between doses prescribed and delivered to point ‘A’ is not of much 
concern (i.e. when it does not lead to under dose of the tumor) since it is delivered to the 
tumor itself other than the organs at risk.  
From Figures 4.5, it was observed that patients 2showed a delivered dose twice as much as 
the prescribed dose. This was not of much concern since further investigations of the same 
patient showed no alarming increase of the doses to the organs at risk. Even though the 
dose to point ‘A’ doubled, but, was within the tumor. The total bladder dose for the same 
patient after treatment was 65.05 Gy whiles that of rectum was 69.55 Gy. QUANTEC dose 
limit for LDR BT for bladder is 80 Gy, whiles that of rectum is 75 Gy. Some patients also 
showed lesser delivered doses than prescribed which was also not of concern since it did 
not lead to under dosing of the tumor. 
 
34 
 
University of Ghana  http://ugspace.ug.edu.gh
 
DOSE PRESCRIBED AND DOSE RECEIVED
80
70 Dose Prescribed
Dose Received
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
PATIENT NUMBER  
Figure 4.5A bar chart of dose prescribed and received for the first 20 patients 
 
DOSE PRESCRIBED AND DOSE RECEIVED
45 Dose Prescribed
40 Dose Received
35
30
25
20
15
10
5
0
21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
PATIENT NUMBER  
Figure 4.6 A bar chart of dose prescribed and received for the last 20 patients 
35 
 
DOSE PRESCRIBED AND RECEIVED (Gy) DOSE PRSECRIBED & RECEIVED (Gy)
University of Ghana  http://ugspace.ug.edu.gh
 
4.1.2 Dose Variations at Point ‘B’ 
Point ‘B’ is 5cm lateral from the midline at the same level as point ‘A’. The dose variations 
at point ‘B’ for 34 patients with their cervix present is shown in Figures 4.7, 4.8 and 4.9 
and in tabular form in Appendix G1.  
The point ‘B’ does not rotate hence very small deviation is observed between the pre and 
post-treatment calculated doses. The dose rate to this point was very low compared with 
that of the critical organs. This was assessed to find out the difference at the lymph node 
area. From Figures 4.7, 4.8 and 4.9, Patients 15 and 18 showed very high deviations (12% 
and 21% respectively). This deviation is attributed to movement of the applicators due to 
loose packing. 
DOSE VARIATION TO POINT B (PRE & POST)
30
25
20
DOSE VARIATION
TO POINT B (PRE)
15
DOSE VARIATION
10 TO POINT B (POST)
5
0
1 2 3 4 5 6 7 8 9 10
PATIENT NUMBER  
Figure 4.7 A bar chart of dose rate variation to point 'B' for pre & post treatment for first 
10 patients 
36 
 
DOSE VARIATION TO POINT B (Gy/hr) 
University of Ghana  http://ugspace.ug.edu.gh
 
DOSE VARIATION TO POINT B (PRE & POST)
35
Dose Rate to Point B (Pre)
30
Dose Rate to Point B (Post)
25
20
15
10
5
0
11 12 13 14 15 16 17 18 19 20 21 22
PATIENT NUMBER  
Figure 4.8 A bar chart of dose rate variation to point 'B' for pre & post treatment for next 
set of 12 patients 
 
DOSE RATE VARIATION TO POINT B FOR PRE & POST
30 Dose Rate to Pt 'B' (Pre)
Dose Rate to Pt 'B' (Post)
25
20
15
10
5
0
23 24 25 26 27 28 29 30 31 32 33 34
PATIENT NUMBER
 
Figure 4.9 A plot of dose rate variation to point 'B' for pre & post treatment for last 12 
patients 
 
37 
 
DOSE RATE TO POINT B (PRE & DOSE RATE TO POINT B (Gy/hr)
POST) (Gy/hr)
University of Ghana  http://ugspace.ug.edu.gh
 
4.1.3 Variation of Doses at the Critical Organs 
The bladder and rectum are the organs of interest during a cervical brachytherapy 
procedure. Particular interest is given to these organs to ensure that they do not exceed the 
acceptable limits of radiation exposure which is based on the volume of that organ 
receiving a particular dose. The American Brachytherapy Society (ABS) has given 
recommendations on the acceptable levels of radiation exposure to these organs at risk 
(Nag et al., 2002).  
4.1.3.1 Dose Variation at the Bladder 
The quantitative analysis of normal tissue effect in the clinics (QUANTEC) has set 80Gy 
as the bladder tolerance dose for the purpose of LDR brachytherapy (Viswanathan et al., 
2009). The dose variation to the bladder is shown in Figures 4.10 and 4.11 and in Appendix 
H1 in tabular form. 
DOSE VARIATION TO BLADDER FOR PRE AND POST
250
Dose Rate to Bladder (Pre)
Dose Rate to Bladder (Post)
200
150
100
50
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
PATIENT NUMBER
 
Figure 4.10 A bar chart of total dose received to bladder for pre- &post treatment 
calculation for first 20 patients 
38 
 
DOSE RATE TO BLADDER (Gy/hr)
University of Ghana  http://ugspace.ug.edu.gh
 
DOSE VARIATION TO BLADDER FOR PRE AND POST
140 Dose Rate to Bladder (Pre)
Dose Rate to Bladder (Post)
120
100
80
60
40
20
0
21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
PATIENT NUMBER  
Figure 4.11 A bar chart of total dose received to bladder for pre- & post-treatment 
calculation for last 20 patients 
 
From Figures 4.10 and 4.11 above, Patients 11 and 21 have their doses calculated for both 
pre- and post-treatment exceeding the bladder dose limit set by QUANTEC. According to 
Sheybani et al. (2013), the filling of the bladder, packing with gauze and the anatomy of 
the patient can lead to increase doses to the bladder. This may explain why Patients 11 and 
21 had both pre and post doses being high. Patients 7, 16 and 26 also had their pre-treatment 
calculated doses above the tolerance level, but their post-treatment calculated doses 
showed a reduction of the doses (lower than the tolerance level). Comparing the pre and 
post-treatment images of the patients showed that the bladder had moved further away from 
the applicators which in effect reduced the dose to the bladder. On the contrary, Patients 
17 and 23 had their pre-treatment calculated doses below the tolerance level, but their post-
treatment calculated doses showed an increase in the doses (higher than the tolerance 
level). Comparing the pre and post-treatment images of the patients showed that the bladder 
39 
 
DOSE RATE TO BLADDER (Gy/hr)
University of Ghana  http://ugspace.ug.edu.gh
 
had moved closer to the applicators which in effect increased the dose to the bladder. 
Average doses of 69.26Gy and 71.09Gy were obtained for the pre- and post-treatment with 
an average deviation of 2.32%. 
 
4.1.3.2 Dose Variation at the Rectum 
The quantitative analysis of normal tissue effect in the clinics (QUANTEC) has set 75Gy 
as the rectum tolerance dose for the purpose of LDR brachytherapy (Viswanathan et al., 
2009). The dose variation to the rectum is shown in Figures 4.12 and 4.13 and in Appendix 
H2 in tabular form. 
DOSE VARIATION TO RECTUM FOR PRE AND POST
100 Dose Rate to Rectum (Pre)
Dose Rate to Rectum (Pre)
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
PATIENT NUMBER  
Figure 4.12 A bar chart of total dose received to rectum for pre- and post-treatment 
calculation for first 20 patients 
 
40 
 
DOSE RATE TO RECTUM (Gy/hr)
University of Ghana  http://ugspace.ug.edu.gh
 
 
DOSE VARIATION TO RECTUM FOR PRE AND POST
120
Dose Rate to Rectum (Pre)
Dose Rate to Rectum (Post)
100
80
60
40
20
0
21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
PATIENT NUMBER
Figure 4.13 A plot of total dose received to rectum for pre- and post-treatment calculation 
for last 20 patients 
 
From Figures 4.12 and 4.13 above, Patient 31 had the dose calculated for both pre and post-
treatment exceeding the rectum dose limit set by QUANTEC. According to Sheybani et al. 
(2013) the filling of the rectum with gauze and the anatomy of the patient can lead to 
increased doses to the rectum, and this may explain why Patient 31 had both pre and post 
doses been high. Patients 7, 14, 20, 27 and 33 also had their pre-treatment calculated doses 
above the tolerance level, but their post-treatment calculated doses showed a reduction of 
the doses (lower than the tolerance level). Comparing the pre- and post-treatment images 
of the patients showed that the rectum had moved further away from the applicators, which 
in effect reduced the dose to the rectum. On the contrary, Patients 8, 18, 19 and 20 had their 
41 
 
DOSE RATE  TO RECTUM (Gy/hr)
University of Ghana  http://ugspace.ug.edu.gh
 
pre-treatment calculated doses below the tolerance level, but their post treatment calculated 
doses showed an increase in the doses (higher than the tolerance level). Comparing the pre 
and post- treatment images of the patients showed that the rectum had moved closer to the 
applicators which in effect increased the dose to the rectum. An average dose of 67.02 Gy 
and 66.64 Gy were obtained for the pre- and post-treatment with an average deviation of 
0.30%. 
 
 
 
 
 
 
 
 
 
 
 
 
 
42 
 
University of Ghana  http://ugspace.ug.edu.gh
 
CHAPTER FIVE 
5 CONCLUSION AND RECOMMENDATION 
5.1 CONCLUSION 
Applicator displacement, such as the tandem and ovoids, can have a substantial influence 
on patient dosimetry. The geometric relationships between intracavitary brachytherapy 
applicators and the critical structures differ significantly during the course of LDR BT. 
Source movement results in considerable dose alterations to the critical organs which can 
generate an increased rate of complications that can influence the cure rates. The disparity 
in dose to point ‘A’ was found to be 1.16 % which is very laudable as compared to other 
studies that established dose variations of 2, 35, 8 and 20% (Corn et al., 1993). This wide 
range is due to the fact that the studies were performed with radium, iridium, and cesium 
sources. Variation in dose at point ‘B’ in this work was 0.75%; while (Corn et al., 1993) 
showed this variation to be 1.7%. As per the guidelines there was only one rectal point 
chosen by most researchers, but in this study three rectal and bladder points were 
respectively used in order to assess rectal and bladder mobility. Studies done by Corn and 
Pham have found dose dissimilarities in the rectum and bladder of 3 and 10%, respectively 
(Corn et al., 1993; Pham et al., 1998). In this study, an average variations of 2.32 and 0.30% 
were found for the bladder and rectum respectively. For quality assurance purposes, the 
variation found between prescribed and deposited dose was 2.11% 
From the results obtained and the observations made from this work, it can be concluded 
that most of the findings agreed with literature and works done by other researchers. Since 
43 
 
University of Ghana  http://ugspace.ug.edu.gh
 
the variation is within the established dose variation, it can be concluded that, the practice 
at KATH meets the international standard. 
 
5.2 RECOMMENDATION 
The recommendations made to the various stakeholders in cancer management at the 
KATH Radiotherapy Department as well as the research community as a whole are as 
follows: 
HDR brachytherapy be considered as a viable option for a short treatment time. Apart from 
the fact that HDR BT has the short treatment time, it has several advantages over the LDR 
BT such as:  
 Outpatient treatment,  
 Short administration time,  
 Standard source strength,  
 Source easily available, 
  Intravenous conscious sedation feasible, 
  Possibility to reassess tumor size after multiple fractions, 
  Dose optimization of normal tissues, 
  Minimal staff exposure and applicator stabilized by board during treatment.  
It is also recommended that further studies are carried out for patients who have undergone 
hysterectomy in order to assess the veracity of the dose deviations observed in this study. 
 
44 
 
University of Ghana  http://ugspace.ug.edu.gh
 
REFERENCES 
Adewole, I.F., Benedet, J.L., Crain, B.T. & Follen, M.2005. Evolving a strategic approach 
to cervical cancer control in Africa. Gynecologic Oncology 99, S209-S212. 
Anh P.T., Hieu N.T., Herrero R., Vaccarella S.,Smith J.S.,Thuy N.T., Nga N.H., Duc N.B., 
Ashley R., Snijders P.J., Meijer C.J., Munoz N., Parkin D.M., Franceschi S. Human 
papillomavirus infection among women in South and North Vietnam. Int J Cancer 
2003; 104: 213–220. 
BahenaJ. H., Martinez A., Yan D, Mele E., Edmunson G., Brown D., Hardy M., Brabbins 
D., Gustafson G. (1998) Spatial Reproducibility of The Ring and Tandem High-
Dose Rate Cervix Applicator. Int. J. Radiation Oncology Biol. Phys., Vol. 41, No. 
1, pp. 13–19 
Barnett G. C., West C. M., Dunning A. M., Elliott R. M., Coles C. E.,Pharoah P. D., Burnet 
N. G.Normal tissue reactions to radiotherapy: towards tailoring treatment dose by 
genotype. National RevCancer 2009; 9: 134-142. 
Begg A. C., Stewart F. A., Vens C. (2011) Strategies to improve radiotherapy with targeted 
drugs. Nat Rev Cancer; 11: 239-253. 
Bernier J., Hall E. J., Giaccia A. (2004) Radiation oncology: a century ofachievements. 
Nature 2004; 4: 737-747. 
Chaffer C. L., Weinberg R. A. (2011): A perspective on cancer cell metastasis. Science; 
331: 1559-1564. 
Corn W, Galvin D, Soffen M et al. Positional stability ofsources during LDR brachytherapy 
for cervical carcinoma.Int J RadiatOncolBiolPhys1993; 26: 513-518. 
DattaN. R., Basu R., Das K. J. M., RajasekarD., Pandey C. M., Singh U., AyyagariS. 
(2001) Variations of intracavitary applicator geometry during multiple HDR 
brachytherapy insertions in carcinoma cervix and its influence on reporting as per 
ICRU report 38. Radiotherapy and Oncology 60 pp15–24 
de Sanjose S., Almirall R., Lloveras B., Font R.,Diaz M., Munoz N., Catala I., Meijer C.J., 
Snijders 
P.J., Herrero R., Bosch F.X. Cervical humanpapillomavirus infection in the female 
populationin Barcelona, Spain. Sex Transm Dis 2003; 30:788–793 
Delaney G, Jacob S, Featherstone C., Barton M. (2005) The role of radiotherapy in cancer 
treatment: estimating optimal utilizationfrom a review of evidence-based clinical 
guidelines. Cancer; 104: 1129-1137. 
45 
 
University of Ghana  http://ugspace.ug.edu.gh
 
Denny, L. 2010. Cervical cancer in South Africa: An overview of current status and 
prevention 
strategies. CME Feb. 28(2):70-73. 
Domfeh A. B., WireduE. K., AdjeiA. A., Ayeh-KumiP. F. K., AdikuT. K., TetteyY., Gyasi 
R. K. and ArmahH. B. 2008 Cervical Human Papillomavirus Infection in Accra, 
Ghana. Ghana Medical JournalVolume 42, Number 2, pp 72 – 78 
Dutreix, A., &Wambersie, A. (1975). Specification of gamma-ray brachytherapy sources. 
The British journal of radiology, 48(576), 1034-1035. 
Ellis F, (1969) Dose, time and fractionation: a clinical hypothesis. Clinical Radiology; 20: 
1-7. 
Glenn, P. G., Bourland, J.D., Grigsby, P.W., Meli, J.A. & Weaver, K.A. 1993. A Report 
of AAPM Task Group No. 41. Remote afterloading technology. American 
Association of Physicists in Medicine(AAPM). Publisher: American Institute of 
Physics 
Grigsby PW, Georgiou A, Williamson JW, Perez CA. (1993) Anatomicvariation of 
gynecologic brachytherapy prescription points. International Journal of Radiation 
Oncology Biology Physics;27:725–729 
Hanahan D., Weinberg R. (2001)The hallmarks of cancer. Cell ;100: 57-70. 
Hoskin PJ, Cook M, Bouscale D, et al. Changes in applicatorposition with fractionated 
high dose rate gynaecologicalbrachytherapy. RadiotherOncol1996; 40:59–62. 
ICRU. Dose and volume specification for reporting intracavitary therapy in gynecology. 
ICRU report no. 38. InternationalCommission on Radiation Units and 
Measurements, Bethesda 1985. 
Jackson S. P., Bartek J. (2009) The DNA-damage response in humanbiology and disease. 
Nature; 461: 1071-1078. 
Kim RY, Caranto JF, Pareek PN et al. Dynamics of pear shapeddimensions and volume of 
intracavitary brachytherapy in cancer of the cervix: a desirable pear shape in the era 
of 3Dimensional treatment planning. Int J RadiatOncolBiolPhys1997; 37:1193-
1199 
Koushik K., Bilimagga R., Rao N., JanakiM.G., Ponni A., RajeevA.G. (2010) Positional 
variation of applicators during low doserate intracavitary brachytherapy for 
cervical cancer:a prospective study. Journal Contemporary Brachytherapy 2010; 2, 
3: 93-97 DOI: 10.5114/jcb.2010.16919 
46 
 
University of Ghana  http://ugspace.ug.edu.gh
 
Leaver, D. &Labonte, G. 2010. HPV and cervical cancer. Radiation therapist, 19(1):27-44 
Leedy, P. D. &Ormrod, J. E. 2005. Practical research planning & design, 8th ed. 
New Jersey:Pearson. 
Ljunggren A, Swyman D, Herby L et al. (1987)An assessment of calculated doses in 
intracavitary gynecological radiotherapy. MedDosim; 12: 15-17 
Makin, M.S. &Kamanu, C.I. 2010. Prevention and treatment of cervical cancer in Africa 
II Surgery in Africa-Monthly Review.  
Massey, J. B., Pointon, R. S., & Wilkinson, J. M. (1985). The Manchester System and the 
BCRU recommendations for brachytherapy source specification. The British 
journal of radiology, 58(693), 911-913. 
Matos E., Loria D., Amestoy G., Herrera L.,Prince M.A., Moreno J., Krunfly C., van den 
BruleA.J., Meijer C.J., Munoz N., Herrero R., Proyecto Concordia Collaborative 
Group. Prevalence of human papillomavirus (HPV) infection among women in 
Concordia, Argentina: a population-based study. Sex Transm Dis 2003; 30: 593–
599. 
Molano M., Posso H., Weiderpass E., van denBrule A.J., Ronderos M., Franceschi S., 
Meijer C.J., Arslan A., Munoz N. Prevalence and determinants of HPV infection 
among Colombian 
women with normal cytology. Br J Cancer 2002;87: 324–333. 
Nag, S., Cardenes, H., Chang, S., Das, I. J., Erickson, B., Ibbott, G. S., Varia, M. (2004). 
Proposed guidelines for image-based intracavitary brachytherapy for cervical 
carcinoma: report from Image-Guided Brachytherapy Working Group. 
International Journal of Radiation Oncology Biology Physics, 60(4), 1160-1172. 
ParkinD.M., Ferlay J., Hamdi-Cherif M., Sitas F.,Thomas J.O., Wabinga H. and Whelan 
S.L. Cancerin Africa: Epidemiology and Prevention. 4.3 Cervix Cancer. IARC 
Scientific Publications 2003;No 153: Lyon: IARC Press, pp 268–276. 
Parkin D.M., Whelan S.L., Ferlay J., Thomas D.B.,Teppo L. Cancer Incidence in Five 
Continents. IARC Scientific Publications 2002; No 155: Lyon:IARC Press. 
Pham T, Chen Y, Rouby E et al. Changes in HDR tandem and ovoid applicator positions 
during treatment in an unfixed brachytherapy system. Radiology 1998; 206: 525-
531. 
Pollack LA, Rowland JH, Crammer C, Stefanek M: Introduction: charting the landscape 
of cancer survivors' health-related outcomes and care. Cancer 2009; 115: 4265-
4269. 
47 
 
University of Ghana  http://ugspace.ug.edu.gh
 
Sheybani A., Tennapel M. J., Sun W., Kim Y., Rockey W. M. (2013) Dose-Volume Effect 
of Bladder and Rectal Filling during Intracavitary High-Dose-Rate Brachytherapy. 
Brachytherapy 12: S11-S77 
Suntharalingam, N., Podgorsak E. B, Tölli H. (2005) "Brachytherapy: physical and clinical 
aspects." Podgorsak EB. Radiation Oncology Physics: a handbook for teachers and 
students. Vienna: International Atomic Energy Agency: 451-84. 
Thomas J.O., Herrero R., Omigbodun A.A., Ojemakinde K., Ajayi I.O., Fawole A., 
Oladepo O., Smith J.S., Arslan A., Munoz N., Snijders P.J.F., Meijer C.J.L.M., 
Franceschi S. Prevalence ofpapillomavirus infection in women in Ibadan, Nigeria: 
a population based study. Br J Cancer 2004;90: 638-645 
Viswanathan, A.N. &Thomadsen, B. Undated. (2009)American Brachythterapy Society 
(ABS) cervicalcancer task group. Reviewed by: Erickson, B. Gaffney, D. Small, 
W. & Hsu, I. 
Wambersie, A., Dutreix, J., &Duplan, J. F. (1973). Effects of fractionation in radiotherapy. 
Repopulation of normal tissues during treatment. Univ., Louvain, Belgium. 
WHO (World Health Organization). 2012. “Prevention of Cervical Cancer through 
Screening and Using Visual Inspection with Acetic Acid (VIA) and Treatment with 
Cryotherapy.” WHO, Geneva. 
WHO. 2008. World cancer report 2008. Geneva: Published by the International Agency 
for 
Research on Cancer. World Health Organization (WHO). Available:  
http://www.iarc.fr/en/publications/pdfs-online/wrc/2008/index.pdf. [4/05/2010] 
 
 
 
 
 
48 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX 
APPENDIX A Data measurements for Pre and Post Treatment doses to Point 
A  
APPENDIX A1 Patients with cervix intact  
Dose Rate to 
Dose Rate to 
 Patient Point Mean Dose Treatment Deviation 
Point ‘A’ 
Number ‘A’(Pre) Rate (Gy/hr) time (hr) (%) 
(Post) (Gy/hr) 
(Gy/hr) 
1 95.47 90.04 92.75 36.66 0.06 
2 90.84 204.45 147.64 33.027 -1.25 
3 92.66 87.55 90.10 32.378 0.06 
4 88.18 76.42 82.30 34.023 0.13 
5 93.37 91.10 92.23 32.132 0.02 
6 91.10 88.37 89.73 38.421 0.03 
7 72.95 80.76 76.85 41.127 -0.11 
8 62.26 71.40 66.83 56..216 -0.15 
9 89.78 89.03 89.40 33.417 0.01 
10 88.32 81.38 84.85 33.969 0.08 
11 85.57 92.27 88.92 40.90 -0.08 
12 91.98 90.10 91.04 32.62 0.02 
13 90.26 91.98 91.12 38.78 -0.02 
14 82.84 84.94 83.89 42.25 -0.03 
15 86.10 96.93 91.52 34.84 -0.13 
16 94.75 88.66 91.70 31.66 0.06 
17 84.71 85.01 84.86 35.42 -0.004 
18 90.25 94.08 92.16 33.42 -0.04 
19 62.46 59.68 61.07 56.04 0.05 
20 86.74 85.86 86.30 40.35 0.01 
21 85.03 95.57 90.30 41.16 -0.12 
22 83.73 82.34 83.03 35.83 0.02 
49 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX A1 Continued 
Dose Rate to Dose Rate to 
 Patient Point Point ‘A’ Mean Dose Treatment Deviation 
Number ‘A’(Pre) (Post) Rate (Gy/hr) time (hr) (%) 
(Gy/hr) (Gy/hr) 
23 85.07 88.67 86.87 35.27 -0.04 
24 83.09 79.68 81.38 36.02 0.04 
25 92.26 89.85 91.05 32.52 0.03 
26 97.59 92.43 95.01 30.74 0.05 
27 90.87 82.27 86.57 33.02 0.10 
28 90.74 81.41 86.08 33.06 0.10 
29 103.27 86.61 94.94 29.05 0.16 
30 87.14 86.37 86.75 40.17 0.01 
31 93.87 87.80 90.83 31.95 0.07 
32 87.80 92.86 90.33 34.17 -0.06 
33 83.64 87.79 85.71 41.85 -0.05 
34 89.35 68.98 79.17 39.17 0.23 
 
 
APPENDIX A2 Patients who have undergone Hysterectomy 
Dose Rate to Dose Rate to 
 Patient Mean Dose Rate Treatment Deviation 
Point ‘A’(Pre) Point ‘A’ 
Number (Gy/hr) time (hr) (%) 
(Gy/hr) (Post) (Gy/hr) 
35 134.36 124.06 129.21 26.04 0.08 
36 133.72 138.07 135.90 26.17 -0.03 
37 158.02 147.22 152.62 22.15 0.07 
38 137.71 143.36 140.53 25.42 -0.04 
39 168.43 152.47 160.45 20.78 0.10 
40 165.26 149.38 157.32 21.18 0.10 
 
50 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX B Prescribed and Received doses  
APPENDIX B1 Patients with Cervix intact 
Dose           
Patient Dose Received Prescribed Mean (Gy) Deviation (%) 
Number (Gy) (Gy) 
1 35 33.00 34.00 0.06 
2 30 67.52 48.76 -1.25 
3 30 28.34 29.17 0.06 
4 30 25.99 28.00 0.13 
5 30 29.27 29.64 0.02 
6 35 33.95 34.48 0.03 
7 30 33.21 31.61 -0.11 
8 35 40.13 37.57 -0.15 
9 30 29.75 29.88 0.01 
10 30 27.64 28.82 0.08 
11 35 37.73 36.37 -0.08 
12 30 29.38 29.69 0.02 
13 35 35.66 35.33 -0.02 
14 35 35.88 35.44 -0.03 
15 30 33.77 31.89 -0.13 
16 30 28.06 29.03 0.07 
17 30 30.10 30.05 -0.003 
18 30 31.27 30.64 -0.04 
19 35 33.43 34.22 0.05 
20 35 34.69 34.85 0.01 
21 35 39.34 37.17 -0.12 
22 30 29.50 29.75 0.02 
 
 
51 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX B1 Continued 
Patient Dose           Dose Received (Gy) Mean (Gy) Deviation (%) 
Number Prescribed (Gy) 
23 30 31.26 30.63 -0.04 
24 30 28.70 29.35 0.04 
25 30 29.21 29.61 0.03 
26 30 29.41 29.71 0.02 
27 30 24.68 27.34 0.18 
28 30 26.91 28.46 0.10 
29 30 25.16 27.58 0.16 
30 35 34.69 34.85 0.01 
31 30 28.05 29.02 0.07 
32 30 31.73 30.87 -0.06 
33 35 36.73 35.87 -0.05 
34 35 27.02 31.01 0.23 
 
 
APPENDIX B2 Patients who have undergone Hysterectomy  
Patient Dose           Dose Received Mean (Gy) Deviation (%) 
Number Prescribed (Gy) (Gy) 
35 35 32.30 33.65 0.08 
36 35 36.13 35.57 -0.03 
37 35 32.60 33.80 0.09 
38 35 36.43 35.72 -0.04 
39 35 31.68 33.34 0.10 
40 35 31.63 33.32 0.10 
 
52 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX C  Data measurements for Pre and Post Treatment doses to 
Bladder 
APPENDIX C1  Patients with cervix intact   
Dose to Dose to 
Patient Deviation TDR TDR 
Bladder Bladder Mean(Gy) 
Number (%) (Pre)(Gy) (Post)(Gy) 
(Pre) (Gy) (Post) (Gy) 
1 16.59 29.33 22.96 -0.77 66.59 79.33 
2 15.05 19.55 17.30 -0.30 65.05 69.55 
3 6.34 11.39 8.87 -0.80 62.34 67.39 
4 19.47 13.05 16.26 0.33 65.47 59.05 
5 9.07 13.66 11.37 -0.51 59.07 63.66 
6 20.34 24.48 22.41 -0.20 70.34 74.48 
7 63.15 32.78 47.97 0.48 109.15 78.78 
8 11.23 13.39 12.31 -0.19 57.23 59.39 
9 18.76 20.41 19.59 -0.09 68.76 70.41 
10 13.27 17.35 15.31 -0.31 59.27 63.35 
11 78.24 78.97 78.61 -0.01 128.24 128.97 
12 24.15 16.36 20.26 0.32 74.15 66.36 
13 26.58 37.52 32.05 -0.41 76.58 87.52 
14 14.00 31.40 22.70 -1.24 60.00 77.4 
15 8.47 14.81 11.64 -0.75 58.47 64.81 
16 28.40 16.22 22.31 0.43 84.40 72.22 
17 18.74 34.56 26.65 -0.84 64.74 80.56 
18 29.50 20.21 24.86 0.32 79.50 70.21 
19 14.83 21.47 18.15 -0.45 60.83 67.47 
20 33.00 36.55 34.78 -0.11 79.00 82.55 
21 39.53 49.21 44.37 -0.25 85.53 95.21 
22 32.14 20.71 26.43 0.36 78.14 66.71 
 
53 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX C1 Continued 
Dose to Dose to 
Patient Deviation TDR TDR 
Bladder Bladder Mean(Gy) 
Number (%) (Pre)(Gy) (Post)(Gy) 
(Pre) (Gy) (Post) (Gy) 
23 17.57 34.17 25.87 -0.95 63.57 80.17 
24 6.74 12.61 9.68 -0.87 56.74 62.61 
25 21.18 26.49 23.84 -0.25 71.18 76.49 
26 30.14 13.53 21.84 0.55 86.14 69.53 
27 16.63 24.87 20.75 -0.50 66.63 74.87 
28 11.00 7.35 9.18 0.33 61.00 57.35 
29 15.44 20.14 17.79 -0.30 65.44 70.14 
30 19.03 22.22 20.63 -0.17 65.03 68.22 
31 18.33 17.32 17.83 0.06 78.33 77.32 
32 16.50 12.95 14.73 0.22 66.50 62.95 
33 20.16 22.78 21.47 -0.13 71.76 74.38 
34 14.71 19.11 16.91 -0.30 66.71 71.11 
 
 
APPENDIX C2  Patients who have undergone Hysterectomy 
Dose to Dose to 
Patient Deviation TDR TDR 
Bladder Bladder Mean(Gy) 
Number (%) (Pre)(Gy) (Post)(Gy) 
(Pre) (Gy) (Post) (Gy) 
35 9.89 12.75 11.32 -0.29 61.89 64.75 
36 3.23 9.72 6.48 -2.01 53.23 59.72 
37 7.25 9.7 8.48 -0.34 53.25 55.70 
38 5.32 6.97 6.15 -0.31 56.32 57.97 
39 5.42 7.78 6.60 -0.44 57.02 59.38 
40 6.70 5.67 6.19 0.15 56.70 55.67 
       
 
54 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX D  Data measurements for Pre and Post Treatment Doses to 
Rectum 
APPENDIX D1  Patients with cervix intact 
Dose to Dose to 
Patient Deviation TDR TDR 
Rectum Rectum Mean(Gy) 
Number (%) (Pre)(Gy) (Post)(Gy) 
(Pre) (Gy) (Post) (Gy) 
1 28.95 21.84 25.40 0.25 78.95 71.84 
2 11.58 9.79 10.69 0.16 61.58 59.79 
3 20.32 18.87 19.60 0.07 76.32 74.87 
4 15.34 12.92 14.13 0.16 61.34 58.92 
5 20.98 9.16 15.07 0.56 70.98 59.16 
6 12.67 16.35 14.51 -0.29 62.67 66.35 
7 35.03 25.94 30.49 0.26 81.03 71.94 
8 11.10 43.93 27.52 -2.96 57.1 89.93 
9 15.50 21.48 18.49 -0.39 65.5 71.48 
10 15.21 20.85 18.03 -0.37 61.21 66.85 
11 15.51 12.49 14.00 0.20 65.51 62.49 
12 12.40 15.98 14.19 -0.29 62.40 65.98 
13 13.30 18.00 15.65 -0.35 63.30 68.00 
14 31.40 20.56 25.98 0.35 77.40 66.56 
15 10.67 14.95 12.81 -0.40 60.67 64.95 
16 16.78 16.92 16.85 -0.01 72.78 72.92 
17 18.59 12.53 15.56 0.33 64.59 58.53 
18 23.92 27.24 25.58 -0.134 73.92 77.24 
19 20.76 31.52 26.14 -0.52 66.76 77.52 
20 36.71 37.40 37.06 -0.02 82.71 83.40 
21 22.49 12.80 17.65 0.43 68.49 58.80 
22 15.09 16.12 15.61 -0.07 61.09 62.12 
 
 
55 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX D1 Continued 
23 6.76 26.22 16.49 -2.88 52.76 72.22 
24 17.99 14.22 16.11 0.21 67.99 64.22 
25 9.09 7.69 8.39 0.15 59.09 57.69 
26 13.75 12.77 13.26 0.07 69.75 68.77 
27 31.48 8.03 19.76 0.75 81.48 58.03 
28 18.84 15.98 17.41 0.15 68.84 65.98 
29 9.51 6.76 8.14 0.29 59.51 56.76 
30 22.67 19.01 20.84 0.16 68.67 65.01 
31 21.67 17.38 19.53 0.20 81.67 77.38 
32 14.56 12.84 13.70 0.12 64.56 62.84 
33 28.29 22.60 25.45 0.20 79.89 74.2 
34 20.58 16.24 18.41 0.21 72.58 68.24 
 
 
APPENDIX D2  Patients who have undergone Hysterectomy  
Dose to Dose to 
Patient Deviation TDR TDR 
Rectum Rectum Mean(Gy) 
Number (%) (Pre)(Gy) (Post)(Gy) 
(Pre) (Gy) (Post) (Gy) 
35 9.37 10.47 9.92 -0.12 61.37 62.47 
36 7.06 7.54 7.30 -0.07 57.06 57.54 
37 12.76 12.55 12.66 0.02 58.76 58.55 
38 12.35 13.23 12.79 -0.07 63.35 64.24 
39 8.74 9.13 8.94 -0.05 60.34 60.73 
40 7.15 10.97 9.06 -0.53 57.15 60.97 
 
 
 
 
 
56 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX E Data measurements for Pre and Post Treatment Dose Rate to 
Bladder 
APPENDIX E1  Patients with cervix intact 
Dose Rate to Dose Rate to 
Patient 
Bladder (Pre) Bladder (Post) Mean(Gy/hr) Deviation (%) 
Number 
(Gy/hr) (Gy/hr) 
1 45.27 80.02 62.65 -0.77 
2 45.57 59.21 52.39 -0.30 
3 19.59 35.19 27.39 -0.80 
4 57.25 38.37 47.81 0.33 
5 28.25 42.53 35.39 -0.51 
6 52.95 63.74 58.34 -0.20 
7 153.56 79.71 116.64 0.48 
8 19.98 32.49 26.24 -0.63 
9 56.14 61.10 58.62 -0.09 
10 39.07 51.09 45.08 -0.31 
11 191.30 193.08 192.20 -0.01 
12 74.05 50.16 62.11 0.32 
13 68.55 96.76 82.66 -0.41 
14 33.16 74.33 53.74 -1.24 
15 24.33 42.53 33.43 -0.75 
16 89.71 51.24 70.48 0.43 
17 52.94 97.59 75.27 -0.84 
18 88.77 60.82 74.80 0.32 
19 26.47 38.33 32.40 -0.45 
20 81.79 90.59 86.19 -0.11 
21 96.04 119.57 107.80 -0.25 
22 89.71 57.81 73.76 0.36 
 
 
57 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENIX E1 Continued 
23 49.83 96.91 73.37 -0.95 
24 29.82 35.01 32.42 -0.17 
25 65.16 81.49 73.32 -0.25 
26 39.50 44.04 41.77 -0.12 
27 50.37 75.35 62.86 -0.50 
28 33.27 22.23 27.75 0.33 
29 53.15 69.36 61.26 -0.31 
30 47.38 55.33 51.36 -0.17 
31 57.38 54.23 55.81 0.06 
32 48.29 37.92 43.11 0.22 
33 48.18 54.45 51.32 -0.13 
34 37.57 52.84 45.20 -0.41 
 
 
APPENDIX E2  Patients who have undergone Hysterectomy 
Dose Rate to Dose Rate to 
Patient 
Bladder (Pre) Bladder (Post) Mean(Gy/hr) Deviation (%) 
Number 
(Gy/hr) (Gy/hr) 
35 37.98 48.97 43.48 -0.29 
36 12.36 37.18 24.77 -2.01 
37 32.74 43.80 38.27 -0.34 
38 20.97 27.46 24.22 -0.31 
39 26.13 37.49 31.81 -0.44 
40 31.65 26.82 29.24 0.15 
 
 
 
58 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX F  Data measurements for Pre and Post Treatment Dose Rate to 
Rectum 
APPENDIX F1  Patients with cervix intact 
Dose Rate to Dose Rate to 
Patient 
Rectum (Pre) Rectum (Post) Mean(Gy/hr) Deviation (%) 
Number 
(Gy/hr) (Gy/hr) 
1 78.97 59.58 69.28 0.25 
2 35.07 29.66 32.37 0.15 
3 62.79 58.30 60.54 0.07 
4 45.10 37.98 41.54 0.16 
5 65.31 28.51 46.91 0.56 
6 32.99 42.56 37.78 -0.29 
7 85.20 63.08 74.14 0.26 
8 19.75 77.80 48.77 -2.94 
9 46.39 64.29 55.34 -0.39 
10 44.79 61.38 53.09 -0.37 
11 37.92 30.55 34.23 0.19 
12 38.02 49.02 43.52 -0.29 
13 34.31 46.43 40.37 -0.35 
14 74.32 48.66 61.49 0.35 
15 30.64 42.92 36.78 -0.40 
16 53.02 53.47 53.25 -0.01 
17 52.52 35.40 43.96 0.33 
18 71.98 81.97 76.98 -0.14 
19 37.06 56.25 46.66 -0.52 
20 90.98 92.70 91.84 -0.02 
21 54.65 31.11 42.88 0.43 
22 42.11 45.00 43.56 -0.07 
 
 
 
59 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX F1 Continued 
23 19.19 74.36 46.77 -2.88 
24 49.95 39.5 44.72 0.21 
25 27.96 23.66 25.81 0.15 
26 44.75 41.57 43.16 0.07 
27 95.37 24.32 59.85 0.75 
28 57.01 48.36 52.68 0.15 
29 32.75 23.28 28.02 0.29 
30 56.45 47.35 51.90 0.16 
31 67.84 54.42 61.13 0.20 
32 42.63 37.59 40.11 0.12 
33 67.62 54.01 60.82 0.20 
34 52.56 41.48 47.02 0.21 
 
 
APPENDIX F2  Patients who have undergone Hysterectomy 
Dose Rate to Dose Rate to 
Patient 
Rectum (Pre) Rectum (Post) Mean(Gy/hr) Deviation (%) 
Number 
(Gy/hr) (Gy/hr) 
1 35.99 40.24 38.12 -0.12 
2 26.99 28.83 27.91 -0.07 
3 57.64 56.67 57.16 0.02 
4 48.62 52.08 50.35 -0.07 
5 42.10 43.94 43.02 -0.04 
6 33.77 51.82 42.80 -0.54 
 
 
 
 
 
60 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX G  Data measurements for Pre and Post Treatments Dose Rate to 
Point ‘B’ 
APPENDIX G1  Patients with cervix intact 
Patient Dose Rate to Point Dose Rate to Point 
Mean(Gy/hr) Deviation (%) 
Number ‘B’(Pre) (Gy/hr) ‘B’ (Post) (Gy/hr) 
1 24.91 23.57 24.24 0.05 
2 23.35 21.67 22.51 0.07 
3 24.15 24.71 24.43 -0.02 
4 19.64 23.86 21.75 -0.22 
5 24.76 24.79 24.77 -0.001 
6 23.95 22.42 23.18 0.06 
7 21.72 21.85 21.78 -0.01 
8 19.2 20.14 19.67 -0.05 
9 23.99 22.68 23.33 0.06 
10 22.65 21.23 21.94 0.06 
11 22.87 23.55 23.21 -0.03 
12 24.01 24.21 24.11 -0.01 
13 23.68 23.15 23.41 0.02 
14 23.34 22.28 22.81 0.05 
15 22.91 25.62 24.27 -0.12 
16 23.87 23.36 23.62 0.02 
17 22.89 22.14 22.52 0.03 
18 31.55 24.97 28.26 0.21 
19 18.40 19.22 18.81 -0.05 
20 22.48 23.78 23.13 -0.06 
21 24.47 24.53 24.50 -0.003 
22 22.88 23.60 23.24 -0.03 
 
 
 
61 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX G1 Continued 
23 21.78 22.09 21.93 -0.02 
24 22.87 22.39 22.63 0.02 
25 22.92 23.27 23.09 -0.02 
26 24.15 23.71 23.93 0.02 
27 23.24 21.96 22.60 0.06 
28 24.73 22.59 23.66 0.09 
29 23.32 21.41 22.36 0.08 
30 21.43 21.62 21.52 -0.01 
31 26.14 25.45 25.79 0.03 
32 22.91 23.66 23.28 -0.03 
33 23.95 24.88 24.42 -0.04 
34 23.65 22.49 23.07 0.05 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
62 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX H Variation of doses to Critical Organs 
APPENDIX H1 Bladder 
Patient Total Bladder Total Bladder 
Deviation 
Number Dose (Pre) Dose (Post) % Deviation 
(Gy) 
(Gy) (Gy) 
1 66.59 79.33 -0.1606 -16.06 
2 65.05 69.55 -0.0647 -6.47 
3 62.34 67.39 -0.0749 -7.49 
4 65.47 59.05 0.1087 10.87 
5 59.07 63.66 -0.0721 -7.21 
6 70.34 74.48 -0.0556 -5.56 
7 109.15 78.78 0.3855 38.55 
8 57.23 59.39 -0.0364 -3.64 
9 68.76 70.41 -0.0234 -2.34 
10 59.27 63.35 -0.0644 -6.44 
11 128.24 128.97 -0.0057 -0.57 
12 74.15 66.36 0.1174 11.74 
13 76.58 87.52 -0.1250 -12.50 
14 60 77.4 -0.2248 -22.48 
15 58.47 64.81 -0.0978 -9.78 
16 84.4 72.22 0.1687 16.87 
17 64.74 80.56 -0.1964 -19.64 
18 79.5 70.21 0.1323 13.23 
19 60.83 67.47 -0.0984 -9.84 
20 79 82.55 -0.0430 -4.30 
21 85.53 95.21 -0.1017 -10.17 
22 78.14 66.71 0.1713 17.13 
23 63.57 80.17 -0.2071 -20.71 
24 56.74 62.61 -0.0938 -9.38 
25 71.18 76.49 -0.0694 -6.94 
26 86.14 69.53 0.2389 23.89 
27 66.63 74.87 -0.1101 -11.01 
28 61 57.35 0.0636 6.36 
29 65.44 70.14 -0.0670 -6.70 
30 65.03 68.22 -0.0468 -4.68 
31 78.33 77.32 0.0131 1.31 
32 66.5 62.95 0.0564 5.64 
33 71.76 74.38 -0.0352 -3.52 
34 66.71 71.11 -0.0619 -6.19 
 
63 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX H1 Continued 
35 61.89 64.75 -0.0442 -4.42 
36 53.23 59.72 -0.1087 -10.87 
37 53.25 55.7 -0.0440 -4.40 
38 56.32 57.97 -0.0285 -2.85 
39 57.02 59.38 -0.0397 -3.97 
40 56.7 55.67 0.0185 1.85 
Average 69.26 71.09 -0.0232 -2.32 
 
 
APPENDIX H2 
Patient Total Bladder 
Total Bladder Deviation 
Number Dose (Post) % Deviation 
Dose (Pre) (Gy) (Gy) 
(Gy) 
1 78.95 71.84 0.09 9.01 
2 61.58 59.79 0.03 2.91 
3 76.32 74.87 0.02 1.90 
4 61.34 58.92 0.04 3.95 
5 70.98 59.16 0.17 16.65 
6 62.67 66.35 -0.06 -5.87 
7 81.03 71.94 0.11 11.22 
8 57.10 89.93 -0.58 -57.50 
9 65.50 71.48 -0.09 -9.13 
10 61.21 66.85 -0.09 -9.21 
11 65.51 62.49 0.05 4.61 
12 62.40 65.98 -0.06 -5.74 
13 63.30 68.00 -0.07 -7.43 
14 77.40 66.56 0.14 14.01 
15 60.67 64.95 -0.07 -7.06 
16 72.78 72.92 -0.001 -0.19 
17 64.59 58.53 0.09 9.38 
18 73.92 77.24 -0.05 -4.49 
19 66.76 77.52 -0.16 -16.12 
20 82.71 83.40 -0.01 -0.83 
21 68.49 58.80 0.14 14.15 
22 61.09 62.12 -0.02 -1.69 
23 52.76 72.22 -0.37 -36.88 
24 67.99 64.22 0.06 5.55 
25 59.09 57.69 0.02 2.37 
26 69.75 68.77 0.01 1.41 
64 
 
University of Ghana  http://ugspace.ug.edu.gh
 
APPENDIX H2 Continued 
27 81.48 58.03 0.29 28.78 
28 68.84 65.98 0.04 4.16 
29 59.51 56.76 0.05 4.62 
30 68.67 65.01 0.05 5.33 
31 81.67 77.38 0.05 5.25 
32 64.56 62.84 0.03 2.66 
33 79.89 74.20 0.07 7.12 
34 72.58 68.24 0.06 5.98 
35 61.37 62.47 -0.02 -1.79 
36 57.06 57.54 -0.01 -0.84 
37 58.76 58.55 0.003 0.36 
38 63.35 64.24 -0.01 -1.41 
39 60.34 60.73 -0.01 -0.65 
40 57.15 60.97 -0.07 -6.68 
Average 67.03 66.64 0.003 -0.30 
 
 
 
65