Brachytherapy

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How entrepreneurial are you?

This guy apparently travels all over the country to drop seeds in prostates in outpatient clinics and from what I can tell that's all he does. I would imagine he does quite well.

Prostate Cancer Institute of America

Prostate Cancer Institute of America was founded in 2022 by Dr. Ajay Bhatnagar and is the only practice in the United States exclusively dedicated to providing LDR-B services.
prostatecancerusa.com prostatecancerusa.com
 
Personally, I have the impression that prostate brachytherapy is a field that is shrinking and will continue to shrink.

Two main drivers:

1. Adoption of Active Surveillance for patients with low-risk prostate cancer. Adding to this, in the future, we can expect more tests (Prolaris, Artera AI, ...) to actually allow more patients to undergo surveillance.

2. EBRT is no longer the EBRT it used to be. The 7-8 week treatments are gone (and where they are not gone yet, will disappear at some point), with 5 (or even less?) - fraction SBRT becoming s.o.c. within the next 5 years for intermediate risk cancer. What are the potential benefits of LDR/HDR-brachytherapy compared to SBRT delivered within a week or so?
 
Palex80 said:
Personally, I have the impression that prostate brachytherapy is a field that is shrinking and will continue to shrink.

Two main drivers:

1. Adoption of Active Surveillance for patients with low-risk prostate cancer. Adding to this, in the future, we can expect more tests (Prolaris, Artera AI, ...) to actually allow more patients to undergo surveillance.

2. EBRT is no longer the EBRT it used to be. The 7-8 week treatments are gone (and where they are not gone yet, will disappear at some point), with 5 (or even less?) - fraction SBRT becoming s.o.c. within the next 5 years for intermediate risk cancer. What are the potential benefits of LDR/HDR-brachytherapy compared to SBRT delivered within a week or so?
Click to expand...

It is true brachy monotherapy will decrease with AS, as it is only indicated in FIR disease

Brachy boost, however, is alive and well. Perhaps it will decrease with increased use of FLAME type protocols, but i've never seen a rad-onc in my neck of the woods boost intraprostatic tumor.

Focal Brachy is another area that is ripe for expansion, though still needs more data.

Agree that the model that works best both financially and clinically is for high volume brachy therapists that cover a broad geographic area, putting in seeds and having clinics 1-2 days a month in a specific area and moving on.

Anecdotally I've been happier with brachy outcomes both oncologically and symptomatically compared to SBRT
 
Palex80 said:
2. EBRT is no longer the EBRT it used to be. The 7-8 week treatments are gone (and where they are not gone yet, will disappear at some point), with 5 (or even less?) - fraction SBRT becoming s.o.c. within the next 5 years for intermediate risk cancer.
Click to expand...

Strongly disagree. Denying patients the option of conventional fractionation with integrated boost is borderline malpractice. I have pretty much stopped giving 70/28 to the whole gland without spacer as virtually all of my patients with late rectal bleeding received this regimen.
 
DoctwoB said:
Brachy boost, however, is alive and well. Perhaps it will decrease with increased use of FLAME type protocols, but i've never seen a rad-onc in my neck of the woods boost intraprostatic tumor.
Click to expand...
Well, "brachy boost" means you will need a source that will send you these patients for the brachy boost.
The OP was asking if it's possible to build a practice doing only (or mostly) brachytherapy.

So, I would be dependent on another radiation oncologist that would deliver his 5 weeks of EBRT, prior to him sending me the patient for the brachy boost.

And what happens, when that radiation oncologist decides to quit or decides to go for a FLAME-like schedule?
 
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alwaysbeIMRTing said:
Strongly disagree. Denying patients the option of conventional fractionation with integrated boost is borderline malpractice. I have pretty much stopped giving 70/28 to the whole gland without spacer as virtually all of my patients with late rectal bleeding received this regimen.
Click to expand...
1. I presume, you are aware of the DELINEATE trial?
It's basically FLAME, but given in 4 weeks. We do it all the time, much more convenient.

2. Calling "not giving FLAME" a "borderline malpractice" is absurd.
There is a clear benefit in terms of bPFS with FLAME, but that's about it. No impact on MFS or OS. In terms of evidence, FLAME is inferior to POP-RT (which did show a MFS-benefit, which again is a proven surrogate for OS). So, unless you are doing WPRT to every high-risk patient of yours, one could argue that you are malpracticing. Are you giving WPRT to your high-risk patients?

3. Look at the data from PACE-B. I see very little room for improvement in intermediate risk PCA, both in terms of toxicity and in terms of bPFS.
 
medgator said:
Chicago prostate guy. Dattoli in FL. Georgia prostacision (?) place.

A few have done it. I think it's getting harder outside of a hospital setting these days though
Click to expand...
Did Dattoli beat those charges? Can't find any follow up.
 
Palex80 said:
1. I presume, you are aware of the DELINEATE trial?
It's basically FLAME, but given in 4 weeks. We do it all the time, much more convenient.

2. Calling "not giving FLAME" a "borderline malpractice" is absurd.
There is a clear benefit in terms of bPFS with FLAME, but that's about it. No impact on MFS or OS. In terms of evidence, FLAME is inferior to POP-RT (which did show a MFS-benefit, which again is a proven surrogate for OS). So, unless you are doing WPRT to every high-risk patient of yours, one could argue that you are malpracticing. Are you giving WPRT to your high-risk patients?

3. Look at the data from PACE-B. I see very little room for improvement in intermediate risk PCA, both in terms of toxicity and in terms of bPFS.
Click to expand...

Are any of these trials powered to detect a real difference in MFS, PCSM or OS?

Less familiar with your data, but look at ASCENDE-RT. roughly 50% reduction in biochemical failure (p<0.001). 50% reduction in prostate cancer deaths, but only 9 vs. 6 events so p = .5.

Absence of evidence != evidence of absence. To truly be powered for survival outcomes any prostate cancer trial needs to be absolutely massive, not to mention extremely long follow up.
 
Palex80 said:
1. I presume, you are aware of the DELINEATE trial?
It's basically FLAME, but given in 4 weeks. We do it all the time, much more convenient.

2. Calling "not giving FLAME" a "borderline malpractice" is absurd.
There is a clear benefit in terms of bPFS with FLAME, but that's about it. No impact on MFS or OS. In terms of evidence, FLAME is inferior to POP-RT (which did show a MFS-benefit, which again is a proven surrogate for OS). So, unless you are doing WPRT to every high-risk patient of yours, one could argue that you are malpracticing. Are you giving WPRT to your high-risk patients?

3. Look at the data from PACE-B. I see very little room for improvement in intermediate risk PCA, both in terms of toxicity and in terms of bPFS.
Click to expand...

Yes, and when I use moderate hypofractionation I prefer the 20 fraction regimen as well. What is absurd is mandating X number of fractions and denying patients a certain regimen that works very well with minimal toxicity simply because it takes longer. I am not sure about the mental twisting you are doing with regards to comparing across POP-RT and FLAME trials and saying pick one. When I treat high risk, I treat the pelvis, prostate, and boost the gross disease while respecting bladder, rectum, and urethra constraints.
 
DoctwoB said:
Are any of these trials powered to detect a real difference in MFS, PCSM or OS?

Less familiar with your data, but look at ASCENDE-RT. roughly 50% reduction in biochemical failure (p<0.001). 50% reduction in prostate cancer deaths, but only 9 vs. 6 events so p = .5.

Absence of evidence != evidence of absence. To truly be powered for survival outcomes any prostate cancer trial needs to be absolutely massive, not to mention extremely long follow up.
Click to expand...
I fully agree with you, that ASCENDE-RT showed a clear benefit in terms of bPFS, but a FLAME-/DELINEATE-like approach may have also produced the same effect. The comparator arm of ASCENDE-RT was normofractionated RT to 78 Gy.
 
alwaysbeIMRTing said:
Yes, and when I use moderate hypofractionation I prefer the 20 fraction regimen as well. What is absurd is mandating X number of fractions and denying patients a certain regimen that works very well with minimal toxicity simply because it takes longer. I am not sure about the mental twisting you are doing with regards to comparing across POP-RT and FLAME trials and saying pick one. When I treat high risk, I treat the pelvis, prostate, and boost the gross disease while respecting bladder, rectum, and urethra constraints.
Click to expand...
Wonderful, that soulds like a good plan.
 
DrProtonX said:
Is it possible to build a practice doing only (or mostly) brachytherapy?
Click to expand...

Would be hard to do a private practice in this model.

In an academic setting you could certainly be a Rad Onc who does most/exclusively brachytherapy procedures. Many a Rad Onc would prefer to never touch a patient or do a hands-on procedure again, and tons of places where the person doing brachy is just the newest person to join the institution....

alwaysbeIMRTing said:
How entrepreneurial are you?

This guy apparently travels all over the country to drop seeds in prostates in outpatient clinics and from what I can tell that's all he does. I would imagine he does quite well.

Prostate Cancer Institute of America

Prostate Cancer Institute of America was founded in 2022 by Dr. Ajay Bhatnagar and is the only practice in the United States exclusively dedicated to providing LDR-B services.
prostatecancerusa.com prostatecancerusa.com
Click to expand...

Interesting business model. Not sure how Bobby Koneru (the LDRT guy) loops into this. Manuj Agarwal seems to have his toes in all sorts of things... remember this: About - Blue Wellth - Longevity & Cancer Recovery

Maybe just PP Rad Oncs being business oriented...

But - Focal brachytherapy being done in any scenario that is NOT on-protocol for newly diagnosed localized prostate cancer w/o h/o EBRT is just as shady and non-EBM as focal therapies from Urologists being done off-protocol.

DoctwoB said:
It is true brachy monotherapy will decrease with AS, as it is only indicated in FIR disease

Brachy boost, however, is alive and well. Perhaps it will decrease with increased use of FLAME type protocols, but i've never seen a rad-onc in my neck of the woods boost intraprostatic tumor.

Focal Brachy is another area that is ripe for expansion, though still needs more data.

Agree that the model that works best both financially and clinically is for high volume brachy therapists that cover a broad geographic area, putting in seeds and having clinics 1-2 days a month in a specific area and moving on.

Anecdotally I've been happier with brachy outcomes both oncologically and symptomatically compared to SBRT
Click to expand...

Per RTOG 0232, Brachy monotherapy is very reasonable for UIR patients that would have been enrolled on that trial.

Brachy boost is intriguing but is not a 'slam dunk' because improving bPFS at sake of toxicity is not the right answer for all prostate patients. FLAME style is easier for most, although I wouldn't knock someone for pushing brachy boost over FLAME boost.

LDR prostate as a boost doesn't make sense when HDR prostate can do the same thing in one treatment (as opposed to monotherapy which requires 2 separate treatments).

It's strange - the people I see who most frequently want LDR brachy mono (a small fraction of the total prostate population) are some of the worst candidates for it - VHR disease, AUA 20+ at basleine, 100cc+ gland.... the people who are perfect candidates - FIR w/ 60cc gland w/ AUA of 2 always end up picking mod hypo or SBRT or something else....
 
DrProtonX said:
Is it possible to build a practice doing only (or mostly) brachytherapy?
Click to expand...
Brachy is a big part of what I do. I’m an ardent believer who thinks we don’t do enough. I think your question as posed is probably ill advised. Brachy utilization keeps going down and I think building a practice around Brachy carries more risk than it’s worth in most markets/situations.

that’s not to say you can’t mostly do Brachy. Big practices usually have 1-2 folks do most of the Brachy. Granted, the way you phrased the question, I don’t think that’s what you were asking about.
 
evilbooyaa said:
Would be hard to do a private practice in this model.

In an academic setting you could certainly be a Rad Onc who does most/exclusively brachytherapy procedures. Many a Rad Onc would prefer to never touch a patient or do a hands-on procedure again, and tons of places where the person doing brachy is just the newest person to join the institution....



Interesting business model. Not sure how Bobby Koneru (the LDRT guy) loops into this. Manuj Agarwal seems to have his toes in all sorts of things... remember this: About - Blue Wellth - Longevity & Cancer Recovery

Maybe just PP Rad Oncs being business oriented...

But - Focal brachytherapy being done in any scenario that is NOT on-protocol for newly diagnosed localized prostate cancer w/o h/o EBRT is just as shady and non-EBM as focal therapies from Urologists being done off-protocol.



Per RTOG 0232, Brachy monotherapy is very reasonable for UIR patients that would have been enrolled on that trial.

Brachy boost is intriguing but is not a 'slam dunk' because improving bPFS at sake of toxicity is not the right answer for all prostate patients. FLAME style is easier for most, although I wouldn't knock someone for pushing brachy boost over FLAME boost.

LDR prostate as a boost doesn't make sense when HDR prostate can do the same thing in one treatment (as opposed to monotherapy which requires 2 separate treatments).

It's strange - the people I see who most frequently want LDR brachy mono (a small fraction of the total prostate population) are some of the worst candidates for it - VHR disease, AUA 20+ at basleine, 100cc+ gland.... the people who are perfect candidates - FIR w/ 60cc gland w/ AUA of 2 always end up picking mod hypo or SBRT or something else....
Click to expand...

Interesting what to make of RTOG 0232 vs. ASCENDE-RT, as they are trials in different patient populations with some overlap in the intermediate risk area.

0232 has a much lower risk population, mostly GG2, mostly PSA <10, though the sub-analysis of GG3 did not show a benefit to the brachy boost.

ASCENDE-RT showed significant benefit in both the intermediate risk and high risk arms.

How do you reconcile those findings?
 
DoctwoB said:
Interesting what to make of RTOG 0232 vs. ASCENDE-RT, as they are trials in different patient populations with some overlap in the intermediate risk area.

0232 has a much lower risk population, mostly GG2, mostly PSA <10, though the sub-analysis of GG3 did not show a benefit to the brachy boost.

ASCENDE-RT showed significant benefit in both the intermediate risk and high risk arms.

How do you reconcile those findings?
Click to expand...
These are different questions. ASCEND asked if using a brachytherapy boost instead of EBRT boost after whole pelvic radiation was useful in higher risk patients. It delivers a higher BED and there was reason to think it could improve in gland control with the hope that would translate to better oncologic outcomes.

0232 looks more similar than it was. It asked if adding EBRT to the prostate and SVs (not whole pelvis) improved efficacy in, as you pointed out, lower risk patients. Outcomes in this group with BT alone were always very good, and if you look at the dose comparisons of what was given, the EBRT Didn’t end up being much of a boost.

In short, I don’t have trouble reconciling the results at all.
 
Aphtalyfe said:
Just wanted to reiterate this and also that NCCN has brachytherapy monotherapy as an option for UIR patients.
Click to expand...
True, though AUA/Astro guidelines disagree

  1. In patients with unfavorable intermediate- or high-risk prostate cancer electing radiation therapy, clinicians should offer dose-escalated hypofractionated EBRT or combined EBRT + brachytherapy (LDR, HDR) along with a risk-appropriate course of ADT. (Strong Recommendation; Evidence Level: Grade A/B)
 
Palex80 said:
3. Look at the data from PACE-B. I see very little room for improvement in intermediate risk PCA, both in terms of toxicity and in terms of bPFS.
Click to expand...

PACE- B is complete BS. EVERY bad outcome I’ve seen in the last 5 years has been from SBRT. There have been quite a few and not just my patients. The ones with really bad toxicity won’t come back to your clinic which is why it’s underreported. It’s FAR more than the 2% reported.
 
thesauce said:
PACE- B is complete BS. EVERY bad outcome I’ve seen in the last 5 years has been from SBRT. There have been quite a few and not just my patients. The ones with really bad toxicity won’t come back to your clinic which is why it’s underreported. It’s FAR more than the 2% reported.
Click to expand...

I think you should consider that your clinic should stop doing prostate SBRT, yes.
 
thesauce said:
PACE- B is complete BS. EVERY bad outcome I’ve seen in the last 5 years has been from SBRT. There have been quite a few and not just my patients. The ones with really bad toxicity won’t come back to your clinic which is why it’s underreported. It’s FAR more than the 2% reported.
Click to expand...
This is not my impression. And I've been following up my patients.
 
thesauce said:
PACE- B is complete BS. EVERY bad outcome I’ve seen in the last 5 years has been from SBRT. There have been quite a few and not just my patients. The ones with really bad toxicity won’t come back to your clinic which is why it’s underreported. It’s FAR more than the 2% reported.
Click to expand...
 
medgator said:
Click to expand...


82 Gy with hydrogel:
pubmed.ncbi.nlm.nih.gov

Dose-escalated radiotherapy to 82 Gy for prostate cancer following insertion of a peri-rectal hydrogel spacer: 3-year outcomes from a phase II trial - PubMed

Dose-escalation to 82 Gy, facilitated by use of a hydrogel spacer, is safe and feasible, with minimal toxicity up to 37.5 months post-treatment when compared to rates of rectal toxicity in previous dose-escalation trials up to 80 Gy. Trials with longer follow-up of oncological and functional...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Grade 3 GI and GU adverse events was 0% and 2.9%, respectively.

No late RTOG-defined grade ≥ 2 GI toxicity was observed, with no GI toxicity observed in any patient at 37.5 months post-treatment

Shocking that there might actually be something to this radiobiology thing!
 
BobbyHeenan said:
Conclusion “similar rates of toxicity.”

Hmmm.

I mean I like prostate sbrt and use it for some but that conclusion is not what the results say.
Click to expand...

It’s called subjective minimizing language. This is how they get trainees to buy into this s***.

It is also why all these medonc drugs get excitement behind them - they do the same thing there even when DEATH is a side effect.
 
Acute toxicity is worsened with SBRT, no doubt. By my interpretation of the data and my own experience, long-term toxicity is not. Pretty easy to explain this to patients, show them the acute toxicity numbers, etc.
 
thesauce said:
It’s called subjective minimizing language. This is how they get trainees to buy into this s***.
Click to expand...
Glad someone else gets it.

It took me a few years of independent practice to detox myself from the prostate hypofrac dogma hammered into trainees and realize that the obsession (and it really is an obsession) of shaming and hating on conventional prostate radiation in the community is anathema for completely disingenuous reasons in academic circles (these are the EXACT same people who will take cash pay for 8 weeks of protons to a prostate).

I absolutely see increased late toxicity namely rectal bleeding with the hypofrac regimens. When given the choice of 5 or 20-28 fx with spacer and informing of acute toxicity, vast majority choose 45 fractions without spacer and are glad they did. I am too. It is a real shame if patients are never even offered a high level evidence-based treatment that works very well with very low toxicity, and even a bigger shame if the rad onc political bullies get it pulled from guidelines.
 
DoctwoB said:
Interesting what to make of RTOG 0232 vs. ASCENDE-RT, as they are trials in different patient populations with some overlap in the intermediate risk area.

0232 has a much lower risk population, mostly GG2, mostly PSA <10, though the sub-analysis of GG3 did not show a benefit to the brachy boost.

ASCENDE-RT showed significant benefit in both the intermediate risk and high risk arms.

How do you reconcile those findings?
Click to expand...
0232 is a trial of brachy +/- EBRT boost.

ASCENDE-RT is a trial of EBRT +/- brachytherapy boost.

The trial is asking two separate questions. I see that others have gone further into it.

DoctwoB said:
True, though AUA/Astro guidelines disagree

  1. In patients with unfavorable intermediate- or high-risk prostate cancer electing radiation therapy, clinicians should offer dose-escalated hypofractionated EBRT or combined EBRT + brachytherapy (LDR, HDR) along with a risk-appropriate course of ADT. (Strong Recommendation; Evidence Level: Grade A/B)
Click to expand...
The most recent AUA/ASTRO guideline is from 2022. RTOG 0232 was published in 2023: Effect of Brachytherapy With External Beam Radiation Therapy Versus Brachytherapy Alone for Intermediate-Risk Prostate Cancer: NRG Oncology RTOG 0232 Randomized Clinical Trial - PubMed
The abstract published in 2016 (https://www.redjournal.org/article/S0360-3016(16)30352-2/fulltext) did not have sufficiently granular evidence, in my opinion, to allow monotherapy to be a recommendation for UIR.
 
alwaysbeIMRTing said:
How entrepreneurial are you?

This guy apparently travels all over the country to drop seeds in prostates in outpatient clinics and from what I can tell that's all he does. I would imagine he does quite well.

Prostate Cancer Institute of America

Prostate Cancer Institute of America was founded in 2022 by Dr. Ajay Bhatnagar and is the only practice in the United States exclusively dedicated to providing LDR-B services.
prostatecancerusa.com prostatecancerusa.com
Click to expand...
How does something like this work? Don’t you need some way to receive/store ldr sources? A place to do post implant scans/dosimetry? Surely this has to be more than just a van by the river with a rectal ultrasound/stepper off the back?
 
medgator said:
Dattoli in FL.
Click to expand...

  • This position is part-time/per-diem and requires Board Certification as a Radiation Oncologist.
  • Fair-market daily rate (less than locum agency rates).
  • Flexible Scheduling.
  • Supportive and collegial environment.
  • Advanced technology and highly-specialized prostate cancer care.
  • Ideal for physicians in the Sarasota region seeking supplemental or semi-retirement income.
  • - NO AGENCIES and NO CALLS
Yeah. Because those locum agency rates in Florida are sky high and you need to have realistic expectations. Basically if you're bored to tears playing golf every day, come treat prostates at an RTT hourly rate. Who signs up for this?
 
alwaysbeIMRTing said:
  • This position is part-time/per-diem and requires Board Certification as a Radiation Oncologist.
  • Fair-market daily rate (less than locum agency rates).
  • Flexible Scheduling.
  • Supportive and collegial environment.
  • Advanced technology and highly-specialized prostate cancer care.
  • Ideal for physicians in the Sarasota region seeking supplemental or semi-retirement income.
  • - NO AGENCIES and NO CALLS
Yeah. Because those locum agency rates in Florida are sky high and you need to have realistic expectations. Basically if you're bored to tears playing golf every day, come treat prostates at an RTT hourly rate. Who signs up for this?
Click to expand...
Is that right about locums in FL? I don’t see much solicitation from locum agencies for FL. I’d suspect the opposite - lotsa retired docs
 
A_DeMichele said:
Is that right about locums in FL? I don’t see much solicitation from locum agencies for FL. I’d suspect the opposite - lotsa retired docs
Click to expand...
The joke is that locums rates are abysmal in FL due to the glut of retired rad oncs.
And these guys are openly stating in their ad that they pay less than locums agencies, who already offer rad oncs stupidly low rates due to their vig.
This might be the worst job ad I have ever seen. They should just hire a resident on a "research" rotation.
 
Neuronix said:
These practices get retired docs in Florida to cover for around $1000/day.
Click to expand...
And that is the inflection point where you can actually do (much) better sitting at home doing rad onc (for an insurance company) than you can leaving home and doing rad onc on real patients.
 
After 1099 SE tax, retired doctor lifestyle marginal income tax rates, gas/travel, lunch, malpractice costs, etc. these guys are probably netting about what it costs to play a round of golf at the country club the next day. While the practice bills out and collects probably 4k in pro fees in their name.

Again, who are the 75 year olds doing this? What went wrong in their life? I must meet these people.
 
alwaysbeIMRTing said:
After 1099 SE tax, retired doctor lifestyle marginal income tax rates, gas/travel, lunch, malpractice costs, etc. these guys are probably netting about what it costs to play a round of golf at the country club the next day. While the practice bills out and collects probably 4k in pro fees in their name.

Again, who are the 75 year olds doing this? What went wrong in their life? I must meet these people.
Click to expand...
Nothing went wrong, my former Chair is doing that on Gulf coast (mid-70s, yes). He's put in his time
 
TheWallnerus said:
And that is the inflection point where you can actually do (much) better sitting at home doing rad onc (for an insurance company) than you can leaving home and doing rad onc on real patients.
Click to expand...

The insurance companies are pickier, believe it or not. The former chair types or retirees mentioned in the other posts probably know little about modern rad onc and don't care to learn. If you're just babysitting linacs, dealing with side effects, etc, you don't need to know all that much about modern rad onc.
 
A_DeMichele said:
Nothing went wrong, my former Chair is doing that on Gulf coast (mid-70s, yes). He's put in his time
Click to expand...

A mid 70s chair who lived through the high reimbursing early IMRT years and had a decade or more a chair salary followed by the stock market earning nearly 15% a year for over a decade. Now wants to spend his golden years babysitting a linac for a few hundred bucks? Something went wrong.

Sometimes I wonder if these guys do this as a way to tell their old man stories to other old men because the coffee shop isn't open all day.
We all have those prostate OTVs where nothing is wrong but the guy wants to talk about his car or wife or cows or something for 30 minutes. I don't have time for that, but when the older locums come and cover for me it drives my staff nuts because apparently he does stay in there and shoot the breeze for half an hour and now there are 10 patients backed up.
 
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