Treatment of a first patient with FLASH-radiotherapy

BACKGROUND

When compared to conventional radiotherapy (RT) in pre-clinical studies, FLASH-RT was shown to reproducibly spare normal tissues, while preserving the anti-tumor activity. This marked increase of the differential effect between normal tissues and tumors prompted its clinical translation. In this context, we present here the treatment of a first patient with FLASH-RT.

MATERIAL & METHODS

A 75-year-old patient presented with a multiresistant CD30+ T-cell cutaneous lymphoma disseminated throughout the whole skin surface. Localized skin RT has been previously used over 110 times for various ulcerative and/or painful cutaneous lesions progressing despite systemic treatments. However, the tolerance of these RT was generally poor, and it was hypothesized that FLASH-RT could offer an equivalent tumor control probability, while being less toxic for the skin. This treatment was given to a 3.5-cm diameter skin tumor with a 5.6-MeV linac specifically designed for FLASH-RT. The prescribed dose to the PTV was 15 Gy, in 90 ms. Redundant dosimetric measurements were performed with GafChromic films and alanine, to check the consistency between the prescribed and the delivered doses.

RESULTS

At 3 weeks, i.e. at the peak of the reactions, a grade 1 epithelitis (CTCAE v 5.0) along with a transient grade 1 oedema (CTCAE v5.0) in soft tissues surrounding the tumor were observed. Clinical examination was consistent with the optical coherence tomography showing no decrease of the thickness of the epidermis and no disruption at the basal membrane with limited increase of the vascularization. In parallel, the tumor response was rapid, complete, and durable with a short follow-up of 5 months. These observations, both on normal skin and on the tumor, were promising and prompt to further clinical evaluation of FLASH-RT.

CONCLUSION

This first FLASH-RT treatment was feasible and safe with a favorable outcome both on normal skin and the tumor.

Clinical translation of FLASH radiotherapy: Why and how?

Over the past decades, technological advances have transformed radiation therapy (RT) into a precise and powerful treatment for cancer patients. Nevertheless, the treatment of radiation-resistant tumors is still restricted by the dose-limiting normal tissue complications. In this context, FLASH-RT is emerging in the field. Consisting of delivering doses within an extremely short irradiation time, FLASH-RT has been identified as a promising new tool to enhance the differential effect between tumors and normal tissues. Indeed, preclinical studies on various animal models and a veterinarian clinical trial have recently shown that compared to conventional dose-rate RT, FLASH-RT could control tumors while minimizing normal tissue toxicity. In the present review, we summarize the main data supporting the clinical translation of FLASH-RT and explore its feasibility, the key irradiation parameters and the potential technologies needed for a successful clinical translation.

Long-term neurocognitive benefits of FLASH radiotherapy driven by reduced reactive oxygen species

Here, we highlight the potential translational benefits of delivering FLASH radiotherapy using ultra-high dose rates (>100 Gy⋅s-1). Compared with conventional dose-rate (CONV; 0.07-0.1 Gy⋅s-1) modalities, we showed that FLASH did not cause radiation-induced deficits in learning and memory in mice. Moreover, 6 months after exposure, CONV caused permanent alterations in neurocognitive end points, whereas FLASH did not induce behaviors characteristic of anxiety and depression and did not impair extinction memory. Mechanistic investigations showed that increasing the oxygen tension in the brain through carbogen breathing reversed the neuroprotective effects of FLASH, while radiochemical studies confirmed that FLASH produced lower levels of the toxic reactive oxygen species hydrogen peroxide. In addition, FLASH did not induce neuroinflammation, a process described as oxidative stress-dependent, and was also associated with a marked preservation of neuronal morphology and dendritic spine density. The remarkable normal tissue sparing afforded by FLASH may someday provide heretofore unrealized opportunities for dose escalation to the tumor bed, capabilities that promise to hasten the translation of this groundbreaking irradiation modality into clinical practice.

Model of ambient dose equivalent for radium contamination: Dependence on the geometry of the source

Industrial activities involving radium sources, such as watchmaking, were still common up until the 1960s. They produced contaminations in building materials and the soil in a large variety of geometries. The potential remediation of such places requires instruments that are properly calibrated as well as adequate procedures. We have developed a model that estimates the rate of ambient dose equivalent H˙^∗(10) at 10 cm and 1 m from a source of ²²⁶Ra and its progeny in both the soil or the building materials. Our model, described here, uses Monte Carlo (GEANT4) computed yield functions of H˙^∗(10) per unit activity induced by point-like sources in different contaminated materials. Fit functions of the yield curve of H˙^∗(10) are provided for outdoor contamination. The model can be used for any geometrical activity distribution and we present an example showing the dependency of H˙^∗(10) on the diameter and the depth profile of the sources, for both outdoor and indoor contamination.

The Advantage of FLASH Radiotherapy Confirmed in Mini-pig and Cat-cancer Patients

PURPOSE

Previous studies using FLASH radiotherapy (RT) in mice showed a marked increase of the differential effect between normal tissue and tumors. To stimulate clinical transfer, we evaluated whether this effect could also occur in higher mammals.

EXPERIMENTAL DESIGN

Pig skin was used to investigate a potential difference in toxicity between irradiation delivered at an ultrahigh dose rate called "FLASH-RT" and irradiation delivered at a conventional dose rate called "Conv-RT." A clinical, phase I, single-dose escalation trial (25-41 Gy) was performed in 6 cat patients with locally advanced T2/T3N0M0 squamous cell carcinoma of the nasal planum to determine the maximal tolerated dose and progression-free survival (PFS) of single-dose FLASH-RT.

RESULTS

Using, respectively, depilation and fibronecrosis as acute and late endpoints, a protective effect of FLASH-RT was observed (≥20% dose-equivalent difference vs. Conv-RT). Three cats experienced no acute toxicity, whereas 3 exhibited moderate/mild transient mucositis, and all cats had depilation. With a median follow-up of 13.5 months, the PFS at 16 months was 84%.

CONCLUSIONS

Our results confirmed the potential advantage of FLASH-RT and provide a strong rationale for further evaluating FLASH-RT in human patients.See related commentary by Harrington, p. 3.

Irradiation in a flash: Unique sparing of memory in mice after whole brain irradiation with dose rates above 100Gy/s

This study shows for the first time that normal brain tissue toxicities after WBI can be reduced with increased dose rate. Spatial memory is preserved after WBI with mean dose rates above 100Gy/s, whereas 10Gy WBI at a conventional radiotherapy dose rate (0.1Gy/s) totally impairs spatial memory.

CONVERTING SPECIFIC ACTIVITY INTO AMBIENT DOSE EQUIVALENT: UPDATED COEFFICIENTS FOR IN SITU GAMMA SPECTROMETRY

In situ gamma spectrometry is a valuable tool to assess the radionuclides released in the environment and the associated dose. This requires prior establishment of coefficients allowing the conversion of the specific activity into ambient equivalent dose. The aim of this work is to calculate updated conversion factors for monoenergetic photons and for a series of radionuclides of interest. The calculation was performed using the Monte Carlo (MC) method, the GEANT4 MC code, various activity distribution models and up-to-date nuclear decay data. A new set of conversion factors is established in the energy range extending from  <100 keV to 8.5 MeV. The coefficients calculated in this work were compared to the data published in the literature.

High dose-per-pulse electron beam dosimetry - A model to correct for the ion recombination in the Advanced Markus ionization chamber

PURPOSE

The purpose of this work was to establish an empirical model of the ion recombination in the Advanced Markus ionization chamber for measurements in high dose rate/dose-per-pulse electron beams. In addition, we compared the observed ion recombination to calculations using the standard Boag two-voltage-analysis method, the more general theoretical Boag models, and the semiempirical general equation presented by Burns and McEwen.

METHODS

Two independent methods were used to investigate the ion recombination: (a) Varying the grid tension of the linear accelerator (linac) gun (controls the linac output) and measuring the relative effect the grid tension has on the chamber response at different source-to-surface distances (SSD). (b) Performing simultaneous dose measurements and comparing the dose-response, in beams with varying dose rate/dose-per-pulse, with the chamber together with dose rate/dose-per-pulse independent Gafchromic™ EBT3 film. Three individual Advanced Markus chambers were used for the measurements with both methods. All measurements were performed in electron beams with varying mean dose rate, dose rate within pulse, and dose-per-pulse (10^-2  ≤ mean dose rate ≤ 10³ Gy/s, 10²  ≤ mean dose rate within pulse ≤ 10⁷  Gy/s, 10^-4  ≤ dose-per-pulse ≤ 10¹  Gy), which was achieved by independently varying the linac gun grid tension, and the SSD.

RESULTS

The results demonstrate how the ion collection efficiency of the chamber decreased as the dose-per-pulse increased, and that the ion recombination was dependent on the dose-per-pulse rather than the dose rate, a behavior predicted by Boag theory. The general theoretical Boag models agreed well with the data over the entire investigated dose-per-pulse range, but only for a low polarizing chamber voltage (50 V). However, the two-voltage-analysis method and the Burns & McEwen equation only agreed with the data at low dose-per-pulse values (≤ 10^-2 and ≤ 10^-1  Gy, respectively). An empirical model of the ion recombination in the chamber was found by fitting a logistic function to the data.

CONCLUSIONS

The ion collection efficiency of the Advanced Markus ionization chamber decreases for measurements in electron beams with increasingly higher dose-per-pulse. However, this chamber is still functional for dose measurements in beams with dose-per-pulse values up toward and above 10 Gy, if the ion recombination is taken into account. Our results show that existing models give a less-than-accurate description of the observed ion recombination. This motivates the use of the presented empirical model for measurements with the Advanced Markus chamber in high dose-per-pulse electron beams, as it enables accurate absorbed dose measurements (uncertainty estimation: 2.8-4.0%, k = 1). The model depends on the dose-per-pulse in the beam, and it is also influenced by the polarizing chamber voltage, with increasing ion recombination with a lowering of the voltage.

High dose-per-pulse electron beam dosimetry: Usability and dose-rate independence of EBT3 Gafchromic films

PURPOSE

The aim of this study was to assess the suitability of Gafchromic EBT3 films for reference dose measurements in the beam of a prototype high dose-per-pulse linear accelerator (linac), capable of delivering electron beams with a mean dose-rate (Ḋ_m ) ranging from 0.07 to 3000 Gy/s and a dose-rate in pulse (Ḋ_p ) of up to 8 × 10⁶ Gy/s. To do this, we evaluated the overall uncertainties in EBT3 film dosimetry as well as the energy and dose-rate dependence of their response.

MATERIAL AND METHODS

Our dosimetric system was composed of EBT3 Gafchromic films in combination with a flatbed scanner and was calibrated against an ionization chamber traceable to primary standard. All sources of uncertainties in EBT3 dosimetry were carefully analyzed using irradiations at a clinical radiotherapy linac. Energy dependence was investigated with the same machine by acquiring and comparing calibration curves for three different beam energies (4, 8 and 12 MeV), for doses between 0.25 and 30 Gy. Ḋ_m dependence was studied at the clinical linac by changing the pulse repetition frequency (f) of the beam in order to vary Ḋ_m between 0.55 and 4.40 Gy/min, while Ḋ_p dependence was probed at the prototype machine for Ḋ_p ranging from 7 × 10³ to 8 × 10⁶ Gy/s. Ḋ_p dependence was first determined by studying the correlation between the dose measured by films and the charge of electrons measured at the exit of the machine by an induction torus. Furthermore, we compared doses from the films to independently calibrated thermo-luminescent dosimeters (TLD) that have been reported as being dose-rate independent up to such high dose-rates.

RESULTS

We report that uncertainty below 4% (k = 2) can be achieved in the dose range between 3 and 17 Gy. Results also demonstrated that EBT3 films did not display any detectable energy dependence for electron beam energies between 4 and 12 MeV. No Ḋ_m dependence was found either. In addition, we obtained excellent consistency between films and TLDs over the entire Ḋ_p range attainable at the prototype linac confirming the absence of any dose-rate dependence within the investigated range (7 × 10³ to 8 × 10⁶ Gy/s). This aspect was further corroborated by the linear relationship between the dose-per-pulse (D_p ) measured by films and the charge per pulse (C_p ) measured at the prototype linac exit.

CONCLUSION

Our study shows that the use of EBT3 Gafchromic films can be extended to reference dosimetry in pulsed electron beams with a very high dose rate. The measurement results are associated with an overall uncertainty below 4% (k = 2) and are dose-rate and energy independent.

Evidence against solar influence on nuclear decay constants

The hypothesis that proximity to the Sun causes variation of decay constants at permille level has been tested and disproved. Repeated activity measurements of mono-radionuclide sources were performed over periods from 200 days up to four decades at 14 laboratories across the globe. Residuals from the exponential nuclear decay curves were inspected for annual oscillations. Systematic deviations from a purely exponential decay curve differ from one data set to another and are attributable to instabilities in the instrumentation and measurement conditions. The most stable activity measurements of alpha, beta-minus, electron capture, and beta-plus decaying sources set an upper limit of 0.0006% to 0.008% to the amplitude of annual oscillations in the decay rate. Oscillations in phase with Earth's orbital distance to the Sun could not be observed within a 10^-6 to 10^-5 range of precision. There are also no apparent modulations over periods of weeks or months. Consequently, there is no indication of a natural impediment against sub-permille accuracy in half-life determinations, renormalisation of activity to a distant reference date, application of nuclear dating for archaeology, geo- and cosmochronology, nor in establishing the SI unit becquerel and seeking international equivalence of activity standards.

Probing the Kinetic Parameters of Plutonium-Naturally Occurring Organic Matter Interactions in Freshwaters Using the Diffusive Gradients in Thin Films Technique

The interaction of trace metals with naturally occurring organic matter (NOM) is a key process of the speciation of trace elements in aquatic environments. The rate of dissociation of metal-NOM complexes will impact the amount of free metal available for biouptake. Assessing the bioavailability of plutonium (Pu) helps to predict its toxic effects on aquatic biota. However, the rate of dissociation of Pu-NOM complexes in natural freshwaters is currently unknown. Here, we used the technique of diffusive gradients in thin films (DGT) with several diffusive layer thicknesses to provide new insights into the dissociation kinetics of Pu-NOM complexes. Results show that Pu complexes with NOM (mainly fulvic acid) are somewhat labile (0.2 ≤ ξ ≤ 0.4), with kd = 7.5 × 10(-3) s(-1). DGT measurements of environmental Pu in organic-rich natural water confirm these findings. In addition, we determined the effective diffusion coefficients of Pu(V) in polyacrylamide (PAM) gel in the presence of humic acid using a diffusion cell (D = 1.70 ± 0.25 × 10(-6) cm(2) s(-1)). These results show that Pu(V) is a more mobile species than Pu(IV).

Calibration of the Politrack® system based on CR39 solid-state nuclear track detectors for passive indoor radon concentration measurements

Swiss national requirements for measuring radon gas exposures demand a lower detection limit of 50 kBq h m(-3), representing the Swiss concentration average of 70 Bq m(-3) over a 1-month period. A solid-state nuclear track detector (SSNTD) system (Politrack, Mi.am s.r.l., Italy) has been acquired to fulfil these requirements. This work was aimed at the calibration of the Politrack system with traceability to international standards and the development of a procedure to check the stability of the system. A total of 275 SSNTDs was exposed to 11 different radon exposures in the radon chamber of the Secondary Calibration Laboratory at the Paul Scherrer Institute, Switzerland. The exposures ranged from 50 to 15000 kBq h m(-3). For each exposure of 20 detectors, 5 SSNTDs were used to monitor possible background exposures during transport and storage. The response curve and the calibration factor of the whole system were determined using a Monte Carlo fitting procedure. A device to produce CR39 samples with a reference number of tracks using a (241)Am source was developed for checking the long-term stability of the Politrack system. The characteristic limits for the detection of a possible system drift were determined following ISO Standard 11929.

Development, design and validation of solid reference samples

We developed a method of sample preparation using epoxy compound, which was validated in two steps. First, we studied the homogeneity within samples by scanning tubes filled with radioactive epoxy. We found within-sample homogeneity better than 2%. Then, we studied the homogeneity between samples during a 4.5 h dispensing time. The homogeneity between samples was found to be better than 2%. This study demonstrates that we have a validated method, which assures the traceability of epoxy samples.

Calibration of surface contamination monitors for the detection of iodine incorporation in the thyroid gland

In Switzerland, individuals exposed to the risk of activity intake are required to perform regular monitoring. Monitoring consists in a screening measurement and is meant to be performed using commonly available laboratory instruments. More particularly, iodine intake is measured using a surface contamination monitor. The goal of the present paper is to report the calibration method developed for thyroid screening instruments. It consists of measuring the instrument response to a known activity located in the thyroid gland of a standard neck phantom. One issue of this procedure remains that the iodine radioisotopes have a short half-life. Therefore, the adequacy and limitations to simulate the short-lived radionuclides with so-called mock radionuclides of longer half-life were also evaluated. In light of the results, it has been decided to use only the appropriate iodine sources to perform the calibration.

Variability of radioiodine measurements in the thyroid

Monte Carlo simulations were carried out to study the response of a thyroid monitor for measuring intake activities of (125)I and (131)I. The aim of the study was 3-fold: to cross-validate the Monte Carlo simulation programs, to study the response of the detector using different phantoms and to study the effects of anatomical variations. Simulations were performed using the Swiss reference phantom and several voxelised phantoms. Determining the position of the thyroid is crucial for an accurate determination of radiological risks. The detector response using the Swiss reference phantom was in fairly good agreement with the response obtained using adult voxelised phantoms for (131)I, but should be revised for a better calibration for (125)I and for any measurements taken on paediatric patients.

A Comparison of the microstructure and tensile behaviour of irradiated fcc and bcc metals

As part of an on-going research program, findings are presented from a comparison of the microstructures and associated tensile properties of fcc and bcc materials after high energy proton irradiation, to fluences between 10−4 and 1 dpa, at 300-320 K. Results for this comparison between Cu, Pd, 304 and 316 stainless steel on one side and Fe and the F82H ferritic-martensitic low activation steel on the other are discussed, showing a strong difference in defect accumulation behaviour between the differing crystal structures. The overall deformation behaviour is similar, with an initial localised deformation taking place in all cases, even though the actual deformation mode itself might be different. Furthermore, a comparison is made with some of the materials that have also been irradiated with fission neutrons, showing no influence of the PKA spectra for these irradiation conditions.

Standardisation of 18F by a coincidence method using full solid angle detectors

A solution of (18)F was standardised with a 4pibeta-4pigamma coincidence counting system in which the beta detector is a one-inch diameter cylindrical UPS89 plastic scintillator, positioned at the bottom of a well-type 5''x5'' NaI(Tl) gamma-ray detector. Almost full detection efficiency-which was varied downwards electronically-was achieved in the beta-channel. Aliquots of this (18)F solution were also measured using 4pigamma NaI(Tl) integral counting and Monte Carlo calculated efficiencies as well as the CIEMAT-NIST method. Secondary measurements of the same solution were also performed with an IG11 ionisation chamber whose equivalent activity is traceable to the Système International de Référence through the contribution IRA-METAS made to it in 2001; IRA's degree of equivalence was found to be close to the key comparison reference value (KCRV). The (18)F activity predicted by this coincidence system agrees closely with the ionisation chamber measurement and is compatible within one standard deviation of the other primary measurements. This work demonstrates that our new coincidence system can standardise short-lived radionuclides used in nuclear medicine.

Activity measurements of 18F and 90Y with commercial radionuclide calibrators for nuclear medicine in Switzerland

The activity of radiopharmaceuticals in nuclear medicine is measured before patient injection with radionuclide calibrators. In Switzerland, the general requirements for quality controls are defined in a federal ordinance and a directive of the Federal Office of Metrology (METAS) which require each instrument to be verified. A set of three gamma sources (Co-57, Cs-137 and Co-60) is used to verify the response of radionuclide calibrators in the gamma energy range of their use. A beta source, a mixture of (90)Sr and (90)Y in secular equilibrium, is used as well. Manufacturers are responsible for the calibration factors. The main goal of the study was to monitor the validity of the calibration factors by using two sources: a (90)Sr/(90)Y source and a (18)F source. The three types of commercial radionuclide calibrators tested do not have a calibration factor for the mixture but only for (90)Y. Activity measurements of a (90)Sr/(90)Y source with the (90)Y calibration factor are performed in order to correct for the extra-contribution of (90)Sr. The value of the correction factor was found to be 1.113 whereas Monte Carlo simulations of the radionuclide calibrators estimate the correction factor to be 1.117. Measurements with (18)F sources in a specific geometry are also performed. Since this radionuclide is widely used in Swiss hospitals equipped with PET and PET-CT, the metrology of the (18)F is very important. The (18)F response normalized to the (137)Cs response shows that the difference with a reference value does not exceed 3% for the three types of radionuclide calibrators.

Purification and activity standardisation of a (166m)Ho solution

As part of a project to use the long-lived (T(1/2)=1200a) (166m)Ho as reference source in its reference ionisation chamber, IRA standardised a commercially acquired solution of this nuclide using the 4pibeta-gamma coincidence and 4pigamma (NaI) methods. The (166m)Ho solution supplied by Isotope Product Laboratories was measured to have about 5% Europium impurities (3% (154)Eu, 0.94% (152)Eu and 0.9% (155)Eu). Holmium had therefore to be separated from europium, and this was carried out by means of ion-exchange chromatography. The holmium fractions were collected without europium contamination: 162h long HPGe gamma measurements indicated no europium impurity (detection limits of 0.01% for (152)Eu and (154)Eu, and 0.03% for (155)Eu). The primary measurement of the purified (166m)Ho solution with the 4pi (PC) beta-gamma coincidence technique was carried out at three gamma energy settings: a window around the 184.4keV peak and gamma thresholds at 121.8 and 637.3keV. The results show very good self-consistency, and the activity concentration of the solution was evaluated to be 45.640+/-0.098kBq/g (0.21% with k=1). The activity concentration of this solution was also measured by integral counting with a well-type 5''x5'' NaI(Tl) detector and efficiencies computed by Monte Carlo simulations using the GEANT code. These measurements were mutually consistent, while the resulting weighted average of the 4pi NaI(Tl) method was found to agree within 0.15% with the result of the 4pibeta-gamma coincidence technique. An ampoule of this solution and the measured value of the concentration were submitted to the BIPM as a contribution to the Système International de Référence.

Primary activity measurements with 4πγ NaI(Tl) counting and Monte Carlo calculated efficiencies

The radioactive concentrations of (18)F, (88)Y and (152)Eu solutions and the activity of (222)Rn gas ampoules are measured using a primary method involving 4pigamma NaI(Tl) integral counting with a well-type NaI(Tl) detector and efficiencies computed by Monte Carlo simulations. The simulations use the GEANT code coupled with a routine (sch2for), which generates randomly the decay paths and emissions depending on the decay scheme parameters. The resulting radioactive concentrations of (88)Y, (152)Eu and (18)F are found to agree with those measured with other primary measurement methods, such as 4pi (beta, e, X)-gamma coincidence counting or liquid scintillation counting. Results of the determination of the activity of (222)Rn gas ampoules by this method also match the results of an absolute standardisation technique in which radon is condensed onto a cold surface and its alpha-emissions are detected through an accurately specified solid angle.