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Afterloading – Internal Radiation Therapy for Cancer

Afterloading is a form of internal radiation therapy in which a radioactive source is precisely placed inside or near a tumor to destroy cancer cells from within.

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Things worth knowing about "Afterloading"

Afterloading is a form of internal radiation therapy in which a radioactive source is precisely placed inside or near a tumor to destroy cancer cells from within.

What is Afterloading?

Afterloading (also known as brachytherapy afterloading) is a radiation therapy technique in which a radioactive source is guided directly into the body with high precision to irradiate a tumor from the inside. Unlike external beam radiation therapy, where radiation is delivered from outside the body, afterloading allows highly targeted irradiation of tumor tissue while sparing the surrounding healthy tissue.

How Does the Afterloading Procedure Work?

In afterloading, an applicator (a hollow catheter or probe) is first positioned in or near the tumor site, typically under imaging guidance such as ultrasound, CT, or MRI. A radioactive source -- most commonly Iridium-192 -- is then automatically guided through the applicator to the desired position using a computer-controlled mechanism.

The procedure comes in two main forms:

HDR Afterloading (High Dose Rate): A high-dose treatment delivered over a short period (a few minutes). Particularly suitable for outpatient treatment.
LDR Afterloading (Low Dose Rate): A low-dose treatment delivered over a longer period (hours to days), often involving temporary or permanent implantation of the radioactive source.

When is Afterloading Used?

Afterloading is used to treat a variety of cancers, including:

Cervical cancer and uterine cancer (gynecological tumors)
Prostate cancer
Breast cancer (intraoperative or postoperative irradiation)
Esophageal cancer and bronchial carcinoma
Rectal cancer
Head and neck tumors

It can be used as a standalone treatment or in combination with external beam radiation therapy or chemotherapy.

Advantages of Afterloading

The afterloading procedure offers several clinical advantages:

Highly precise dose delivery directly to the tumor
Reduced exposure to surrounding healthy tissue and adjacent organs
Shorter treatment times, especially with HDR afterloading
Possibility of outpatient treatment
Lower radiation exposure for medical staff due to remote-controlled source delivery

Side Effects and Risks

As with any form of radiation therapy, afterloading can cause side effects. These depend on the area being treated, the radiation dose, and the duration of treatment:

Acute side effects: Redness, swelling, or irritation at the treatment site, fatigue, mucositis (inflammation of mucous membranes)
Long-term side effects: Fibrosis (scarring) of tissue, dysfunction of adjacent organs (e.g., bladder or bowel in pelvic irradiation)
Rarely: fistula formation or late radiation damage to neighboring structures

Compared to external beam radiation, side effects are generally less severe because the radiation is delivered in a more targeted manner.

Treatment Process and Preparation

Before afterloading treatment begins, a detailed radiation treatment plan is created using cross-sectional imaging (CT or MRI). The dose distribution is calculated using specialized software to ensure optimal tumor coverage while minimizing damage to normal tissue. The patient is fully informed about the procedure, risks, and possible alternatives.

Treatment is carried out in specialized radiation oncology departments. Depending on the method and tumor type, multiple sessions may be required.

References

Deutsche Gesellschaft fur Radioonkologie (DEGRO): Guidelines on Brachytherapy, 2022.
Strnad V. et al. - Recommendations of GEC ESTRO for high-dose-rate brachytherapy. Radiotherapy and Oncology, 2021.
Devlin P.M. (ed.) - Brachytherapy: Applications and Techniques. 2nd edition, Demos Medical Publishing, 2015.

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