Current issues and actions in radiation protection of patients

Medical application of ionizing radiation is a massive and increasing activity globally. While the use of ionizing radiation in medicine brings tremendous benefits to the global population, the associated risks due to stochastic and deterministic effects make it necessary to protect patients from potential harm. Current issues in radiation protection of patients include not only the rapidly increasing collective dose to the global population from medical exposure, but also that a substantial percentage of diagnostic imaging examinations are unnecessary, and the cumulative dose to individuals from medical exposure is growing. In addition to this, continued reports on deterministic injuries from safety related events in the medical use of ionizing radiation are raising awareness on the necessity for accident prevention measures. The International Atomic Energy Agency is engaged in several activities to reverse the negative trends of these current issues, including improvement of the justification process, the tracking of radiation history of individual patients, shared learning of safety significant events, and the use of comprehensive quality audits in the clinical environment.

The importance and unique aspects of radiation protection in medicine

Radiation protection in medicine has unique aspects and is an essential element of medical practice. Medical uses of radiation occur throughout the world, from large cities to rural clinics. It has been estimated that the number of medical procedures using radiation grew from about 1.7 billion in 1980 to almost 4 billion in 2007. In spite of these large numbers, there are many parts of the world without adequate equipment, where the ability to perform additional medical procedures would likely result in a net benefit. Medicine accounts for more than 99.9% of the per caput effective dose from man-made sources. The goal in medical exposure is not to give the lowest dose, but to provide the correct dose to enable the practitioner to make the diagnosis or cure a tumour. Too little or too much dose is problematic and the risk of any given procedure ranges from negligible to potentially fatal. Radiation protection in medicine must deal with the issues of not having dose limits, purposely exposing sensitive subgroups, and purposely using doses that could cause deterministic effects. Radiation accidents involving medical uses have accounted for more acute radiation deaths than from any other source including Chernobyl. Many physicians have little or no training in radiation protection, and many have no qualified medical physics support. In many countries, medical radiation devices and uses are only minimally regulated and the rapidly evolving technology is a challenge. Medicine also accounts for the largest number of occupationally exposed workers and collective dose.

Escalated dose for non-small-cell lung cancer with accelerated hypofractionated three-dimensional conformal radiation therapy

BACKGROUND AND PURPOSE

To prospectively assess the feasibility and efficacy of a hypofractionated accelerated radiotherapy regimen (72 Gy in 24 daily fractions, 3 Gy per fraction) in patients (pts) with non-resectable non-small-cell lung cancer (NSCLC).

MATERIAL AND METHODS

We included 25 pts with a histologically or cytologically proven NSCLC, with KPS > or = 70 and < or =10% weight loss over prior three months, and with tumour stage I/II medically inoperable (9 pts) or non-resectable stage III a/b without pleural effusion (16 pts). Eleven pts received induction chemotherapy. No more than 30% of the combined lung volume could receive more than 25 Gy and the maximal biological effective dose to the spinal cord was maintained below 44 Gy.

RESULTS

No grade-4 acute toxicity event was reported. Two pts had a treatment break because of grade-3 acute oesophagitis. Twenty-two pts were evaluable for long-term toxicity (median follow-up=9.7 months, range 4 to 30.2 months). There were 4 Grade-1 pulmonary and 2 Grade-1 oesophageal long-term toxicity events. Twenty-two pts were evaluable for tumour response with 7 complete and 8 partial responses, 5 stable diseases and 2 progressive diseases. The actuarial 1-year overall and thoracic-progression-free survival rates were 68% and 72% respectively.

CONCLUSIONS

This study demonstrates the feasibility of the experimental radiotherapy schedule, however more data are needed to confirm its efficacy.

A Method of Predicting Workload and Staffing Level for Radiotherapy Treatment Planning as Plan Complexity Changes

When assessing the impact on workload from an expanding number of new patients and increasing treatment complexity, radiotherapy clinics find that oversimplified workload parameters, such as number of patients or number of fields, are not suitable for managing and predicting workload and organisational dimension. Although the basic treatment equivalent concept is available for predicting linear accelerator utilisation, no corresponding parameter has been available for radiotherapy treatment planning. In this study, we derive a simple workload indicator for treatment planning. The dose plan unit (DPU) takes the complexity of the treatment plan into account. Categorising plans according to complexity in their production, and measuring corresponding time for completing the plans in these categories, leads to the following baseline values for workload prediction: 1 DPU (non-computed tomography [CT]), 3 DPU (CT-contour) and 6 DPU (full-CT). The measured average productivity of 0.65 DPU per hour (1 standard deviation, SD = 0.08 DPU), or alternatively 1 DPU = 92 min, for a dosimetrist in this clinic indicates that 79.0 DPU can be produced by each dosimetrist per month within normal working hours. The predictive power of the DPU is shown in terms of using it to quantify the impact on workload in treatment planning of changing treatment protocols for a particular anatomic treatment site.

Analysis of dose distribution in the 'Rind'--a volume outside the PTV--in 3-dimensional conformal radiation therapy of non-small cell lung cancer

BACKGROUND AND PURPOSE

Appropriate planning target volume (PTV) definition is critical for local disease eradication in the treatment of non-small cell lung cancer (NSCLC). When margins are added to the gross tumour volume (GTV) in the standard way, the PTV formed may be too large to facilitate dose escalation due to normal tissue tolerance. To increase the feasibility of dose escalation with 3-dimensional conformal radiotherapy (3DCRT), this study examines an alternative method for the formation of the PTV in NSCLC. This strategy is based on the reduced probability of tumour cells from the GTV outwards and on the associated lower dose requirements to eradicate such subclinical disease.

MATERIALS AND METHODS

3DCRT plans were generated from the CT scans of 15 patients with NSCLC (stages Ib to IIIb). Each PTV was formed by adding a margin for geometric uncertainties directly onto the GTV. The success of this approach is dependent on the volume immediately outside this smaller PTV, the Rind volume, receiving 50 Gy, the minimum dose requirement that is considered sufficient for eradication of the reduced tumour cell density in this volume. While optimizing the treatment plans for each PTV to 70 Gy, the dose distribution in the Rind volume, and the factors affecting it, were assessed.

RESULTS

One hundred percent of each PTV received a minimum of 95% of the prescribed dose. The percentage of the Rind volume receiving 50 Gy or more (V50) had a median value of 94%. The minimum dose in this volume, however, ranged from 5.6 to 32.1 Gy. The V50 was highest for apical tumours (96.1%) and lowest for peripheral tumours (86%) and correlated positively with the size of the PTV (Kendall's rank correlation (Kt)=+0.3, P=0.05) and the number of beams used (Kt=+0.3, P=0.03) but not with the conformity index. The average volume outside the Rind which still received >/=50 Gy (the Wasted 50 Gy) increased significantly with the V50 of the Rind volume and was inversely proportional to the Rind <50 Gy, correlating significantly with the dose to the organs at risk.

CONCLUSIONS

Using this strategy with standard 3DCRT, all PTVs were irradiated to the required dose with this approach, but none of the corresponding Rind volumes had an acceptable dose distribution. The addition of dual volume planning or the use of intensity modulated radiation therapy may achieve an appropriate dose distribution in the Rind volume while not increasing the dose to the organs at risk and may thereby facilitate dose escalation.

Dose escalation of chart in non-small cell lung cancer: is three-dimensional conformal radiation therapy really necessary?

PURPOSE

To evaluate, preclinically, the potential for dose escalation of continuous, hyperfractionated, accelerated radiation therapy (CHART) for non small-cell lung cancer (NSCLC), we examined the strategy of omission of elective nodal irradiation with and without the application of three-dimensional conformal radiation technology (3DCRT).

METHODS AND MATERIALS

2D, conventional therapy plans were designed according to the specifications of CHART for 18 patients with NSCLC (Stages Ib, IIb, IIIa, and IIIb). Further plans were generated with the omission of elective nodal irradiation (ENI) from the treatment portals (2D minus ENI plans [2D-ENI plans]). Both sets were inserted in the patient's planning computed tomographies (CTs). These reconstructed plans were then compared to alternative, three-dimensional treatment plans which had been generated de novo, with the omission of ENI: 3D minus elective nodal irradiation (3D-ENI plans). Dose delivery to the planning target volumes (PTVs) and to the organs at risk were compared between the 3 sets of corresponding plans. The potential for dose escalation of each patient's 2D-ENI and 3D-ENI plan beyond 54 Gy, standard to CHART, was also determined.

RESULTS

PTV coverage was suboptimal in the 2D CHART and the 2D-ENI plans. Only in the 3D-ENI plans did 100% of the PTV get > or = 95% of the dose prescribed (i.e., 51.5 Gy [51.3-52.2]). Using 3D-ENI plans significantly reduced the dose received by the spinal cord, the mean and median doses to the esophagus and the heart. It did not significantly reduce the lung dose when compared to 2D-ENI plans. Escalation of the dose (minimum > or = 1 Gy) with optimal PTV coverage was possible in 55.5% of patients using 3D-ENI, but was possible only in 16.6% when using the 2D-ENI planning strategy.

CONCLUSIONS

3DCRT is fundamental to achieving optimal PTV coverage in NSCLC. A policy of omission of elective nodal irradiation alone (and using 2D technology) will not achieve optimal PTV coverage or dose escalation. 3DCRT with omission of ENI can achieve true escalation of CHART in 55.5% of tumors, depending on their site and N-stage.

What margins should be added to the clinical target volume in radiotherapy treatment planning for lung cancer?

BACKGROUND

The planning target volume in radiotherapy treatment planning takes into account both movements of the clinical target volume (CTV) and set-up deviations.

MATERIALS AND METHODS

A group of patients who received radiotherapy for lung cancer were studied. In order to measure the CTV movements due to respiration and other internal organ motions, fluoroscopy was performed for 20 patients. To study the accuracy and reproducibility of patient and beam set-up, 553 electronic portal images from 20 patients were evaluated. Discrepancies between planned and actual field positions were measured and the systematic and random errors were identified. The combined effect of these geometrical variations was evaluated.

RESULTS

The average CTV movement with quiet respiration was about 2.4 mm in the medio-lateral and dorso-ventral directions. Movement in the cranio-caudal direction was on average 3.9 mm with a range of 0-12 mm. The systematic set-up errors were on average 2.0 mm in the transversal plane and 3.0 mm in the cranio-caudal direction. The random errors can be described by their standard deviations of 3.2 and 2.6 mm. In this study, the combined effect of the two parameters (CTV movement and set-up deviations) varied between 7.5 and 10.3 mm in different anatomical directions.

CONCLUSIONS

In our daily clinical routine, we use a margin of 11 mm in the transversal plane and 15 mm cranially and caudally, also taking into account other unquantified variations and uncertainties.

Improvements in absorbed dose measurements for external radiation therapy using ferrous dosimeter gel and MR imaging (FeMRI)

A ferrous gel, based on ferrous (Fe) sulphate and agarose, was used with a clinical magnetic resonance imaging (MRI) scanner to obtain relative dose distribution data from therapeutic photon and electron beams. The FeMRI gel was scanned using a new MRI acquisition protocol optimized for T1 measurements. Thorough comparisons with silicon semiconductor detector and ionization chamber measurements, as well as with Monte Carlo calculations, were performed in order to quantify the improvements obtained using FeMRI for dose estimations. Most of the relative doses measured with FeMRI were within 2% of the doses measured with other methods. The larger discrepancies (2-4%) found at shallow depths are discussed. The uncertainty in relative dose measurements using FeMRI was significantly improved compared with previously reported results (5-10%, one standard deviation, 1 SD), and is today between 1.6% and 3.3% (depending on dose level, 2 SD). This corresponds to an improvement in the minimum detectable dose (3 SD above background) from approximately 2 Gy to better than 0.6 Gy. The results obtained in this study emphasize the importance of obtaining basic FeMRI dose data before the method is extended to complicated treatment regimes.

Effect of set-up uncertainties on the dose distribution in the match region of supraclavicular and tangential breast fields

BACKGROUND

The objective of this paper is to illustrate the effect of a gap of 5 mm, an overlap of 5 mm and a perfect match on the dose distribution across the junction of tangential breast fields and adjacent supraclavicular and axillary fields.

MATERIALS AND METHODS

For this purpose film dosimetry was applied to measure relative dose distributions in two sagittal planes in an anthropomorphic breast phantom having cork lungs, simulating a radiation therapy treatment of the breast and adjacent supraclavicular lymph nodes. Two different treatment techniques, an SSD match technique and a geometrically exact isocentric match technique, as routinely applied in the two institutes were examined. The three-dimensional treatment planning system of each institute was used to calculate the dose distribution in the match region of the supraclavicular fields and the two opposing tangential fields. The measured and calculated dose distributions were evaluated and compared along lines in two sagittal planes from the supraclavicular fields down to the tangential fields crossing the match planes. These dose distributions in the match region were extremely dependent on the set-up of the fields.

RESULTS

Although the reproducibility of the film measurements was within 2%, it became clear that the set-up of the fields to achieve a gap of 5 mm, a perfect match or an overlap of 5 mm required a lot of attention, even when using a phantom.

CONCLUSIONS

It can be concluded that in clinical practice, these set-up difficulties do influence the dose distribution in the match region much more than the systematic uncertainties in the dose calculation algorithms of the treatment planning systems and the type of treatment technique.

Respiratory burst activity of phagocytic cells isolated from the mammary glands and blood of camels (Camelus bactrianus)

The oxidative burst activity of phagocytic cells isolated from camel blood and mammary glands was studied using a chemiluminescence (Cl) assay. The polymorphonuclear leucocytes (PMNL) isolated from camel blood mounted a luminol-dependent Cl response upon stimulation with opsonized zymosan or opsonized Staphylococcus aureus. These responses showed an overall similarity to those described in other mammalian species. The leucocytes isolated from the mammary glands mounted Cl responses similar to those observed with blood PMNL but to a lower magnitude. Like the Cl responses of blood cells, the Cl responses induced by mammary gland leucocytes were associated with degranulation and the release of lysosomal enzymes such as myeloperoxidase (MPO).

In vivo determination of the accuracy of field matching in breast cancer irradiation using an electronic portal imaging device

The purpose of this study was to investigate the accuracy of field matching in patients treated by irradiation of the breast and adjacent lymph nodes. Field matching is performed by the radiographers during each session on a match line drawn on the patient's skin. Field edge positions were assessed in the cranial match plane of tangential breast fields and supraclavicular-axillary fields using an electronic portal imaging device and match line markers placed on the skin of the patients. The mean gap/overlap of the four fields for individual patients during each treatment session, derived from 374 marker projections, was +0.5 mm indicating that no systematic gap or overlap was observed. The uncertainty in the position of the four fields with respect to the match plane ranges from 3.1 to 5.1 mm (1 SD) for the individual patients. Gaps and overlaps between fields were also related to an absolute match line position, found by comparison of simulator and portal images, showing a small systematic uncertainty of 2.4 mm and a standard deviation of 3.3 mm. It can be concluded that the use of an electronic portal imaging device in combination with match line markers is a good method to quantify the accuracy of field matching in vivo. The results showed good stability and reproducibility in the field matching region for this treatment technique of breast cancer irradiation.

Isolation and purification of bovine myeloperoxidase from neutrophil granules

Bovine myeloperoxidase (MPO) was isolated and purified from neutrophil granules using protein extraction at pH 4 and gel filtration combined with fast protein liquid chromatography. The extracted protein was identified as MPO based on its absorption spectrum, amino acid composition, peroxidase activity and polypeptide structure. Bovine neutrophils contained three different forms of MPO (I, II and III). When subjected to sodium dodecyl sulphate polyacrylamide gel electrophoresis each of the three purified forms showed two distinct bands corresponding to heavy and light polypeptide chains of approximately 57,000 and 15,000 molecular radius. Amino acid analysis of the three forms showed that there was an overall similarity between them. Slight differences were found between MPO Form III and the other two forms. The three forms of bovine MPO were shown to differ in their specific enzyme activities in a luminol-dependent chemiluminescence assay. MPO Form III showed the highest enzyme activity. The amount recovered during purification of the respective MPO forms varied, with the recovery being highest for MPO I. Our findings suggest that there are intrinsic differences between the three forms of bovine MPO. In terms of their amino acid composition and molecular weight, the bovine MPO closely resembled human and canine MPO.

Species identification and some characteristics of coagulase-negative staphylococci isolated from bovine udders

The species of 203 strains of coagulase-negative staphylococci (CNS), isolated from bovine udder quarters was determined; all were tested for hydrophobicity and encapsulation, attributes that may relate to virulence. Twelve species were identified, of which Staphylococcus simulans, (34.5%), S. chromogenes (16.7%), S. epidermidis (13.8%) and S. xylosus (8.9%) were the most frequent. The majority of strains possessed a hydrophilic cell surface. However, strains from two species (S. chromogenes and S. epidermidis) were more hydrophobic than the others. Only five strains were encapsulated (S. xylosus, 3; S. saprophyticus, 1; and S. sciuri, 1). Judging from the low frequencies of hydrophobic and encapsulated strains, and comparing with strains isolated from clinical cases, it is suggested that these properties are not major virulence determinants of CNS.

Bacteriological investigations of clinical mastitis in heifers in Sweden

Bacterial analyses were carried out of 2069 udder secretions, isolated from 1481 heifers with mastitis in eight veterinary districts in Sweden. Streptococci, e.g. Streptococcus dysgalactiae and Str. uberis, dominated the bacterial flora, being isolated from 34.4 and 19.5% respectively of heifers with clinical mastitis occurring from puberty up to 14 d post partum. Bacterial species generally regarded as important pathogens in the summer mastitis complex, e.g. Actinomyces pyogenes, Stuart-Schwan coccus and strictly anaerobic bacteria such as Peptostreptococcus indolicus, Fusobacterium necrophorum and Bacteroides melaninogenicus were isolated at low frequencies (13.2, 6.3, 9.4, 3.8 and 1.3% respectively). When the cases of mastitis studied were restricted to those appearing in heifers pre partum, May 15 to October 14 (summer mastitis), these bacterial species were isolated at higher percentages (27.1, 14.4, 21.4, 13.5 and 5.2% respectively). These figures were, nevertheless, still lower than those published in reports from other countries. Whether considered up to 14 d post partum or only pre partum, there were no significant differences in the frequencies of A. pyogenes isolated at different seasons. There were geographical differences in bacterial incidence, e.g. Staphylococcus aureus was isolated significantly more often in northern regions whereas Str. dysgalactiae was more common in the south. This and other Swedish investigations support the theory that A. pyogenes and strictly anaerobic bacteria are 'secondary invaders' that depend on Str. dysgalactiae to cause a primary infection. It is stressed that the udders of all heifers should be examined daily so that cases of mastitis can be treated immediately.

Adhesive proteins of haemagglutinating Staphylococcus aureus isolated from bovine mastitis

Two proteins derived from the cell wall of Staphylococcus aureus, exhibiting apparent molecular masses of 116 kDa and 145 kDa, were found to bind to human buccal and bovine lactiferous sinus epithelial cells. By using antibodies specific for fibronectin-binding protein of S. aureus of human origin, the 116 kDa protein, but not the 145 kDa protein, was identified as a fibronectin-binding protein. The 145 kDa protein bound to bovine fat globule membranes, human buccal epithelial cells, bovine lactiferous sinus epithelial cells and sheep erythrocytes. The properties of the 145 kDa protein suggest that it is an adhesin with a possible role in the early stages of the development of bovine mastitis.