Radiation Therapy With Charged Particles

Dose and linear energy transfer distributions of primary and secondary particles in carbon ion radiation therapy: A Monte Carlo simulation study in water

The factors influencing carbon ion therapy can be predicted from accurate knowledge about the production of secondary particles from the interaction of carbon ions in water/tissue-like materials, and subsequently the interaction of the secondary particles in the same materials. The secondary particles may have linear energy transfer (LET) values that potentially increase the relative biological effectiveness of the beam. Our primary objective in this study was to classify and quantify the secondary particles produced, their dose averaged LETs, and their dose contributions in the absorbing material. A 1 mm diameter carbon ion pencil beam with energies per nucleon of 155, 262, and 369 MeV was used in a geometry and tracking 4 Monte Carlo simulation to interact in a 27 L water phantom containing 3000 rectangular detector voxels. The dose-averaged LET and the dose contributions of primary and secondary particles were calculated from the simulation. The results of the simulations show that the secondary particles that contributed a major dose component had LETs <100 keV/µm. The secondary particles with LETs >600 keV/µm contributed only <0.3% of the dose.

Acute Toxicity and Quality of Life in Patients With Prostate Cancer Treated With Protons or Carbon Ions in a Prospective Randomized Phase II Study--The IPI Trial

PURPOSE

The purpose of this study was to compare safety and feasibility of proton therapy with that of carbon ion therapy in hypofractionated raster-scanned irradiation of the prostate, in a prospective randomized phase 2 trial.

METHODS AND MATERIALS

In this trial, 92 patients with localized prostate cancer were enrolled. Patients were randomized to receive either proton therapy (arm A) or carbon ion therapy (arm B) and treated with a total dose of 66 Gy(relative biological effectiveness [RBE]) administered in 20 fractions (single dose of 3.3 Gy[RBE]). Patients were stratified by the use of antihormone therapy. Primary endpoint was the combined assessment of safety and feasibility. Secondary endpoints were specific toxicities, prostate-specific antigen progression-free survival (PFS), overall survival (OS), and quality of life (QoL).

RESULTS

Ninety-one patients completed therapy and have had a median follow-up of 22.3 months. Among acute genitourinary toxicities, grade 1 cystitis rates were 34.1% (39.1% in A; 28.9% in B) and 17.6% grade 2 (21.7% in A; 13.3% in B). Seven patients (8%) required urinary catheterization during treatment due to urinary retention, 5 of whom were in arm A. Regarding acute gastrointestinal toxicities, 2 patients treated with protons developed grade 3 rectal fistulas. Grade 1 radiation proctitis occurred in 12.1% (13.0% in A; 11.1% in B) and grade 2 in 5.5% (8.7% in A; 2.2% in B). No statistically significant differences in toxicity profiles between arms were found. Reduced QoL was evident mainly in fatigue, pain, and urinary symptoms during therapy and 6 weeks thereafter. All European Organization for Research and Treatment of Cancer QLQ-C30 and -PR25 scores improved during follow-up.

CONCLUSIONS

Hypofractionated irradiation using either carbon ions or protons results in comparable acute toxicities and QoL parameters. We found that hypofractionated particle irradiation is feasible and may be safe. Due to the occurrence of gel in the rectal wall and the consecutive occurrence of 2 rectal fistulas, we stopped using the insertion of spacer gel. Longer follow-up is necessary for evaluation of PFS and OS. (Ion Prostate Irradiation (IPI); NCT01641185; ClinicalTrials.gov.).

Evolving Clinical Cancer Radiotherapy: Concerns Regarding Normal Tissue Protection and Quality Assurance

Radiotherapy, which is one of three major cancer treatment methods in modern medicine, has continued to develop for a long period, more than a century. The development of radiotherapy means allowing the administration of higher doses to tumors to improve tumor control rates while minimizing the radiation doses absorbed by surrounding normal tissues through which radiation passes for administration to tumors, thereby reducing or removing the incidence of side effects. Such development of radiotherapy was accomplished by the development of clinical radiation oncology, the development of computers and machine engineering, the introduction of cutting-edge imaging technology, a deepened understanding of biological studies on the effects of radiation on human bodies, and the development of quality assurance (QA) programs in medical physics. The development of radiotherapy over the last two decades has been quite dazzling. Due to continuous improvements in cancer treatment, the average five-year survival rate of cancer patients has been close to 70%. The increases in cancer patients' complete cure rates and survival periods are making patients' quality of life during or after treatment a vitally important issue. Radiotherapy is implemented in approximately 1/3 to 2/3s of all cancer patients; and has improved the quality of life of cancer patients in the present age. Over the last century, as a noninvasive treatment, radiotherapy has unceasingly enhanced complete tumor cure rates and the side effects of radiotherapy have been gradually decreasing, resulting in a tremendous improvement in the quality of life of cancer patients.

Effect of hydrogen ion implantation on cholesterol sensing using enzyme-free LAPONITE®-montmorillonite electrodes

Electrochemical profiling of LAPONITE®-montmorillonite/indium tin oxide (L-MMT/ITO) electrodes irradiated with 20 keV H₂⁺ ion beam with variable fluence ranging from 10¹² to 10¹⁶ ions per cm².

Colorectal Carcinogenesis, Radiation Quality, and the Ubiquitin-Proteasome Pathway

Adult colorectal epithelium undergoes continuous renewal and maintains homeostatic balance through regulated cellular proliferation, differentiation, and migration. The canonical Wnt signaling pathway involving the transcriptional co-activator β-catenin is important for colorectal development and normal epithelial maintenance, and deregulated Wnt/β-catenin signaling has been implicated in colorectal carcinogenesis. Colorectal carcinogenesis has been linked to radiation exposure, and radiation has been demonstrated to alter Wnt/β-catenin signaling, as well as the proteasomal pathway involved in the degradation of the signaling components and thus regulation of β-catenin. The current review discusses recent progresses in our understanding of colorectal carcinogenesis in relation to different types of radiation and roles that radiation quality plays in deregulating β-catenin and ubiquitin-proteasome pathway (UPP) for colorectal cancer initiation and progression.

The Effect of p53 Status of Tumor Cells on Radiosensitivity of Irradiated Tumors With Carbon-Ion Beams Compared With γ-Rays or Reactor Neutron Beams

Background

The aim of the study was to clarify the effect of p53 status of tumor cells on radiosensitivity of solid tumors following accelerated carbon-ion beam irradiation compared with γ-rays or reactor neutron beams, referring to the response of intratumor quiescent (Q) cells.

Methods

Human head and neck squamous cell carcinoma cells transfected with mutant TP53 (SAS/mp53) or with neo vector (SAS/neo) were injected subcutaneously into hind legs of nude mice. Tumor-bearing mice received 5-bromo-2’-deoxyuridine (BrdU) continuously to label all intratumor proliferating (P) cells. They received γ-rays or accelerated carbon-ion beams at a high or reduced dose-rate. Other tumor-bearing mice received reactor thermal or epithermal neutrons at a reduced dose-rate. Immediately or 9 hours after the high dose-rate irradiation (HDRI), or immediately after the reduced dose-rate irradiation (RDRI), the tumor cells were isolated and incubated with a cytokinesis blocker, and the micronucleus (MN) frequency in cells without BrdU labeling (Q cells) was determined using immunofluorescence staining for BrdU.

Results

The difference in radiosensitivity between the total (P + Q) and Q cells after γ-ray irradiation was markedly reduced with reactor neutron beams or carbon-ion beams, especially with a higher linear energy transfer (LET) value. Following γ-ray irradiation, SAS/neo tumor cells, especially intratumor Q cells, showed a marked reduction in sensitivity due to the recovery from radiation-induced damage, compared with the total or Q cells within SAS/mp53 tumors that showed little repair capacity. In both total and Q cells within both SAS/neo and SAS/mp53 tumors, carbon-ion beam irradiation, especially with a higher LET, showed little recovery capacity through leaving an interval between HDRI and the assay or decreasing the dose-rate. The recovery from radiation-induced damage after γ-ray irradiation was a p53-dependent event, but little recovery was found after carbon-ion beam irradiation. With RDRI, the radiosensitivity to reactor thermal and epithermal neutron beams was slightly higher than that to carbon-ion beams.

Conclusion

For tumor control, including intratumor Q-cell control, accelerated carbon-ion beams, especially with a higher LET, and reactor thermal and epithermal neutron beams were very useful for suppressing the recovery from radiation-induced damage irrespective of p53 status of tumor cells.

Predictive Value of Early-Stage Uptake of 3'-Deoxy-3'-18F-Fluorothymidine in Cancer Cells Treated with Charged Particle Irradiation

The aim of this study was to investigate whether 3'-deoxy-3'-(18)F-fluorothymidine ((18)F-FLT) can monitor the early response of tumor cell proliferation to charged particle irradiation in vitro and in vivo.

METHODS

In vitro, after 0.1, 0.5, 1, 5, and 10 Gy of proton or carbon ion irradiation, (18)F-FLT cell uptake was examined at 24 h and cell proliferation ability was measured from days 1 to 4. In vivo, after 0.5, 1, and 5 Gy of proton or carbon ion irradiation, (18)F-FLT PET imaging was performed on tumor-bearing BALB/c nu/nu mice at 24 h and tumor growth was measured from days 1 to 7. Tumor-to-background ratios of standardized uptake values were calculated to assess the (18)F-FLT accumulation in tumors. Both cells and mice also received x-irradiation as a control.

RESULTS

In vitro, (18)F-FLT cell uptake was significantly lower after 1 Gy of proton irradiation (P < 0.05) and carbon ion irradiation (P < 0.05) and after 5 Gy of x-irradiation (P < 0.01), but cell proliferation ability at these doses did not show significant differences until day 3. In vivo, (18)F-FLT tumor uptake was significantly lower after 1 Gy of proton (P < 0.001) and carbon ion irradiation (P < 0.01) and after 5 Gy of x-irradiation (P < 0.001), but tumor growth did not significantly differ at these doses until day 4 after proton irradiation, day 3 after carbon ion irradiation, and day 5 after x-irradiation.

CONCLUSION

The reduction in (18)F-FLT uptake after charged particle irradiation was more rapid than the change in tumor growth in vivo or the change in cell proliferation ability in vitro. Therefore, (18)F-FLT is a promising tracer for monitoring the early response of cancer to charged particle irradiation.

Reirradiation Using Carbon Ions in Patients with Locally Recurrent Rectal Cancer at HIT: First Results

BACKGROUND

Locally recurrent rectal cancer remains a dreaded event because curative resection is unlikely to be performed in a large number of cases. Carbon ion radiotherapy offers physical and biologic advantages. A high precise local dose deposition and sparing of normal tissue is possible. This work summarizes our experience on feasibility and early toxicity of carbon ion radiotherapy in previously irradiated and operated patients.

METHODS

Between 2010 and 2013, a total of 19 patients with a median age of 62 years (range 14-76 years) received carbon ion irradiation to treat locally recurrent rectal cancer at the Heidelberg Ion Beam Therapy Center (HIT). All patients had a history of surgery and pelvic radiotherapy of at least 50.4 Gy. Median dose was 36 Gy [relative biologic efficacy (RBE)] [range 36-51 Gy(RBE)], and median planning target volume was 456 ml (range 75-1,597 ml). Some patients were treated in the recruiting phase I/II of the PANDORA study (NCT01528683).

RESULTS

Median follow-up was 7.8 months. Four patients were diagnosed with local relapse after carbon ion radiotherapy, and three patients developed distant metastases. Estimated mean local progression-free survival was 20.6 months by the Kaplan-Meier estimator. Two patients had preexisting rectovaginal fistula, and another patient had a preexisting presacral localized abscess formation in which the local relapse took place. No grade III or higher toxicities were observed.

CONCLUSIONS

Our first experiences in a pretreated patient group with a dismal prognosis are encouraging, and therapy-related side effects are mild. Longer follow-up is required to determine possible late effects and long-term disease control.

Future development of biologically relevant dosimetry

Proton and ion beams are radiotherapy modalities of increasing importance and interest. Because of the different biological dose response of these radiations as compared with high-energy photon beams, the current approach of treatment prescription is based on the product of the absorbed dose to water and a biological weighting factor, but this is found to be insufficient for providing a generic method to quantify the biological outcome of radiation. It is therefore suggested to define new dosimetric quantities that allow a transparent separation of the physical processes from the biological ones. Given the complexity of the initiation and occurrence of biological processes on various time and length scales, and given that neither microdosimetry nor nanodosimetry on their own can fully describe the biological effects as a function of the distribution of energy deposition or ionization, a multiscale approach is needed to lay the foundation for the aforementioned new physical quantities relating track structure to relative biological effectiveness in proton and ion beam therapy. This article reviews the state-of-the-art microdosimetry, nanodosimetry, track structure simulations, quantification of reactive species, reference radiobiological data, cross-section data and multiscale models of biological response in the context of realizing the new quantities. It also introduces the European metrology project, Biologically Weighted Quantities in Radiotherapy, which aims to investigate the feasibility of establishing a multiscale model as the basis of the new quantities. A tentative generic expression of how the weighting of physical quantities at different length scales could be carried out is presented.

Nitric oxide increases the invasion of pancreatic cancer cells via activation of the PI3K-AKT and RhoA pathways after carbon ion irradiation

Previous studies have shown that serine proteases and Rho-associated kinase contribute to carbon ion radiation-enhanced invasion of the human pancreatic cancer cell line PANC-1. The results presented here show that nitric oxide synthase (NOS) also plays a critical role in this process. Irradiation of PANC-1 cells promoted invasion and production of nitric oxide (NO), which activated the PI3K-AKT signaling pathway, while independently activating RhoA. Inhibition of PI3K, Rho-associated kinase, and serine protease alone or in conjunction with NOS suppressed the radiation-enhanced invasion of PANC-1 cells, suggesting that they could serve as possible targets for the management of tumor metastasis.

On the probability of cure for heavy-ion radiotherapy

The probability of a cure in radiation therapy (RT)-viewed as the probability of eventual extinction of all cancer cells-is unobservable, and the only way to compute it is through modeling the dynamics of cancer cell population during and post-treatment. The conundrum at the heart of biophysical models aimed at such prospective calculations is the absence of information on the initial size of the subpopulation of clonogenic cancer cells (also called stem-like cancer cells), that largely determines the outcome of RT, both in an individual and population settings. Other relevant parameters (e.g. potential doubling time, cell loss factor and survival probability as a function of dose) are, at least in principle, amenable to empirical determination. In this article we demonstrate that, for heavy-ion RT, microdosimetric considerations (justifiably ignored in conventional RT) combined with an expression for the clone extinction probability obtained from a mechanistic model of radiation cell survival lead to useful upper bounds on the size of the pre-treatment population of clonogenic cancer cells as well as upper and lower bounds on the cure probability. The main practical impact of these limiting values is the ability to make predictions about the probability of a cure for a given population of patients treated to newer, still unexplored treatment modalities from the empirically determined probability of a cure for the same or similar population resulting from conventional low linear energy transfer (typically photon/electron) RT. We also propose that the current trend to deliver a lower total dose in a smaller number of fractions with larger-than-conventional doses per fraction has physical limits that must be understood before embarking on a particular treatment schedule.

The effect of microdosimetric 12C6+ heavy ion irradiation and Mg2+ on canthaxanthin production in a novel strain of Dietzia natronolimnaea

Background

Dietzia natronolimnaea is one of the most important bacterial bioresources for high efficiency canthaxanthin production. It produces the robust and stable pigment canthaxanthin, which is of special interest for the development of integrated biorefineries. Mutagenesis employing ¹²C⁶⁺ irradiation is a novel technique commonly used to improve microorganism productivity. This study presents a promising route to obtaining the highest feasible levels of biomass dry weight (BDW), and total canthaxanthin by using a microdosimetric model of ¹²C⁶⁺ irradiation mutation in combination with the optimization of nutrient medium components.

Results

This work characterized the rate of both lethal and non-lethal dose mutations for ¹²C⁶⁺ irradiation and the microdosimetric kinetic model using the model organism, D. natronolimnaea svgcc1.2736. Irradiation with ¹²C⁶⁺ ions resulted in enhanced production of canthaxanthin, and is therefore an effective method for strain improvement of D. natronolimnaea svgcc1.2736. Based on these results an optimal dose of 0.5–4.5 Gy, Linear energy transfer (LET) of 80 keV μm^-1and energy of 60 MeV u^-1 for ¹²C⁶⁺ irradiation are ideal for optimum and specific production of canthaxanthin in the bacterium. Second-order empirical calculations displaying high R-squared (0.996) values between the responses and independent variables were derived from validation experiments using response surface methodology. The highest canthaxanthin yield (8.14 mg) was obtained with an optimized growth medium containing 21.5 g L^-1 D-glucose, 23.5 g L^-1 mannose and 25 ppm Mg²⁺ in 1 L with an irradiation dose of 4.5 Gy.

Conclusions

The microdosimetric ¹²C⁶⁺ irradiation model was an effective mutagenic technique for the strain improvement of D. natronolimnaea svgcc1.2736 specifically for enhanced canthaxanthin production. At the very least, random mutagenesis methods using ¹²C⁶⁺ions can be used as a first step in a combined approach with long-term continuous fermentation processes. Central composite design-response surface methodologies (CCD-RSM) were carried out to optimize the conditions for canthaxanthin yield. It was discovered D-glucose, Mg²⁺ and mannose have significant influence on canthaxanthin biosynthesis and growth of the mutant strain.

Four-dimensional radiotherapeutic dose calculation using biomechanical respiratory motion description

PURPOSE

Organ motion due to patient breathing introduces a technical challenge for dosimetry and lung tumor treatment by hadron therapy. Accurate dose distribution estimation requires patient-specific information on tumor position, size, and shape as well as information regarding the material density and stopping power of the media along the beam path. A new 4D dosimetry method was developed, which can be coupled to any motion estimation method. As an illustration, the new method was implemented and tested with a biomechanical model and clinical data.

METHODS

First, an anatomical model of the lung and tumor was synthesized with deformable tetrahedral grids using computed tomography (CT) images. The CT attenuation values were estimated at the grid vertices. Respiratory motion was simulated biomechanically based on nonlinear finite element analysis. Contrary to classical image-based methods where motion is described using deformable image registration algorithms, the dose distribution was accumulated over tetrahedral meshes that are deformed using biomechanical modeling based on finite element analysis.

RESULTS

The new method preserves the mass of the objects during simulation with an error between 1.6 and 3.6%. The new method was compared to an existing dose calculation method demonstrating significant differences between the two approaches and overall superior performance using the new method.

CONCLUSION

A unified model of 4D radiotherapy respiratory effects was developed where biomechanical simulations are coupled with dose calculations. Promising results demonstrate that this approach has significant potential for the treatment for moving tumors.

A patient-specific planning target volume used in 'plan of the day' adaptation for interfractional motion mitigation

We propose a patient-specific planning target volume (PTV) to deal with interfractional variations, and test its feasibility in a retrospective treatment-planning study. Instead of using one planning image only, multiple scans are taken on different days. The target and organs at risk (OARs) are delineated on each images. The proposed PTV is generated from a union of those target contours on the planning images, excluding voxels of the OARs, and is denoted the PTV 'GP-OAR' (global prostate-organs at risk). The study is performed using 'plan of the day' adaptive workflow, which selects a daily plan from a library of plans based on a similarity comparison between the daily scan and planning images. The daily plans optimized for GP-OAR volumes are compared with those optimized for PTVs generated from a single prostate contour (PTV SP). Four CT serials of prostate cancer patient datasets are included in the test, and in total 28 fractions are simulated. The results show that the daily chosen GP-OAR plans provide excellent target coverage, with V95 values of the prostate mostly > 95%. In addition, dose delivered to the OARs as calculated from applying daily chosen GP-OAR plans is slightly increased but comparable to that calculated from applying daily SP plans. In general, the PTV GP-OARs are able to cover possible target variations while keeping dose delivered to the OARs at a similar level to that of the PTV SPs.

Dose and dose averaged LET comparison of ¹H, ⁴He, ⁶Li, ⁸Be, ¹⁰B, ¹²C, ¹⁴N, and ¹⁶O ion beams forming a spread-out Bragg peak

PURPOSE

Modern clinical accelerators are capable of producing ion beams from protons up to neon. This work compares the depth dose distribution and corresponding dose averaged linear energy transfer (LET) distribution, which is related to the biological effectiveness, for different ion beams (¹H, ⁴He, ⁶Li, ⁸Be, ¹⁰B, ¹²C, ¹⁴N, and ¹⁶O) using multi-energetic spectra in order to configure spread-out Bragg peaks (SOBP).

METHODS

Monte Carlo simulations were performed in order to configure a 5 cm SOBP at 8 cm depth in water for all the different ion beams. Physical dose and dose averaged LET distributions as a function of depth were then calculated and compared. The superposition of dose distribution of all ions is also presented for a two opposing fields configuration. Additional simulations were performed for (12)C beams to investigate the dependence of dose and dose averaged LET distributions on target depth and size, as well as beam configuration. These included simulations for a 3 cm SOBP at 7, 10, and 13 cm depth in water, a 6 cm SOBP at 7 depth in water, and two opposing fields of 6 cm SOBP.

RESULTS

Alpha particles and protons present superior physical depth dose distributions relative to the rest of the beams studied. Dose averaged LET distributions results suggest higher biological effectiveness in the target volume for carbon, nitrogen and oxygen ions. This is coupled, however, with relatively high LET values-especially for the last two ion species-outside the SOBP where healthy tissue would be located. Dose averaged LET distributions for ⁸Be and ¹⁰B beams show that they could be attractive alternatives to ¹²C for the treatment of small, not deeply seated lesions. The potential therapeutic effect of different ion beams studied in this work depends on target volume and position, as well as the number of beams used.

CONCLUSIONS

The optimization of beam modality for specific tumor cites remains an open question that warrants further investigation and clinically relevant results.

Basics of particle therapy II: relative biological effectiveness

In the previous review, the physical aspect of heavy particles, with a focus on the carbon beam was introduced. Particle beam therapy has many potential advantages for cancer treatment without increasing severe side effects in normal tissue, these kinds of radiation have different biologic characteristics and have advantages over using conventional photon beam radiation during treatment. The relative biological effectiveness (RBE) is used for many biological, clinical endpoints among different radiation types and is the only convenient way to transfer the clinical experience in radiotherapy with photons to another type of radiation therapy. However, the RBE varies dependent on the energy of the beam, the fractionation, cell types, oxygenation status, and the biological endpoint studied. Thus this review describes the concerns about RBE related to particle beam to increase interests of the Korean radiation oncologists' society.

[From the carbon track to therapeutic efficiency of hadrontherapy]

Carbon ions, thanks to their relative biological effectiveness much higher than that of photons and protons and their ballistic characteristics similar to those of protons, can effectively treat radioresistant tumours. The reasons for this increased efficiency are found in the microdosimetric and radiobiological features of ions. The energy deposit or linear energy transfer increases along the range and reaches a very high level at the end producing the Bragg peak, where the linear energy transfer is about hundred times higher than that of photons. These massive energy deposits create multiple DNA lesions that are difficult to repair. DNA repair is associated with longer blockage of the cell cycle and more frequent chromosomal aberrations that are lethal to cells. The types of cell death are identical to those triggered in response to photon irradiation, but the response is earlier and more important at equivalent physical dose. Radiobiological differences between carbon ions and photons have been studied for some years and many aspects remain to be explored. In general, these phenomena tend to reduce the differences of radiosensitivity among different tissues. It is therefore in situation where tumours are relatively radioresistant compared to healthy tissue, that carbon ions must be used and not in the opposite situations where the fractionation of low linear energy transfer radiation is sufficient to provide the necessary differential effect to cure the tumour.

Accelerated hematopoietic toxicity by high energy (56)Fe radiation

PURPOSE

There is little information on the relative toxicity of highly charged (Z) high-energy (HZE) radiation in animal models compared to γ or X-rays, and the general assumption based on in vitro studies has been that acute toxicity is substantially greater.

METHODS

C57BL/6J mice were irradiated with (56)Fe ions (1 GeV/nucleon), and acute (within 30 d) toxicity compared to that of γ rays or protons (1 GeV). To assess relative hematopoietic and gastrointestinal toxicity, the effects of (56)Fe ions were compared to γ rays using complete blood count (CBC), bone marrow granulocyte-macrophage colony forming unit (GM-CFU), terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay for apoptosis in bone marrow, and intestinal crypt survival.

RESULTS

Although onset was more rapid, (56)Fe ions were only slightly more toxic than γ rays or protons with lethal dose (LD)(50/30) (a radiation dose at which 50% lethality occurs at 30-day) values of 5.8, 7.25, and 6.8 Gy, respectively, with relative biologic effectiveness for (56)Fe ions of 1.25 and 1.06 for protons.

CONCLUSIONS

(56)Fe radiation caused accelerated and more severe hematopoietic toxicity. Early mortality correlated with more profound leukopenia and subsequent sepsis. Results indicate that there is selective enhanced toxicity to bone marrow progenitor cells, which are typically resistant to γ rays, and bone marrow stem cells, because intestinal crypt cells did not show increased HZE toxicity.

Iron-ion radiation accelerates atherosclerosis in apolipoprotein E-deficient mice

Radiation exposure from a number of terrestrial sources is associated with an increased risk for atherosclerosis. Recently, concern over whether exposure to cosmic radiation might pose a similar risk for astronauts has increased. To address this question, we examined the effect of 2 to 5 Gy iron ions ((56)Fe), a particularly damaging component of cosmic radiation, targeted to specific arterial sites in male apolipoprotein E-deficient (apoE(-/-)) mice. Radiation accelerated the development of atherosclerosis in irradiated portions of the aorta independent of any systemic effects on plasma lipid profiles or circulating leukocytes. Further, radiation exposure resulted in a more rapid progression of advanced aortic root lesions, characterized by larger necrotic cores associated with greater numbers of apoptotic macrophages and reduced lesional collagen compared to sham-treated mice. Intima media thickening of the carotid arteries was also exacerbated. Exposure to (56)Fe ions can therefore accelerate the development of atherosclerotic lesions and promote their progression to an advanced stage characterized by compositional changes indicative of increased thrombogenicity and instability. We conclude that the potential consequences of radiation exposure for astronauts on prolonged deep-space missions are a major concern. Knowledge gained from further studies with animal models should lead to a better understanding of the pathophysiological effects of accelerated ion radiation to better estimate atherogenic risk and develop appropriate countermeasures to mitigate its damaging effects.

Proton radiography and fluoroscopy of lung tumors: a Monte Carlo study using patient-specific 4DCT phantoms

PURPOSE

Monte Carlo methods are used to simulate and optimize a time-resolved proton range telescope (TRRT) in localization of intrafractional and interfractional motions of lung tumor and in quantification of proton range variations.

METHODS

The Monte Carlo N-Particle eXtended (MCNPX) code with a particle tracking feature was employed to evaluate the TRRT performance, especially in visualizing and quantifying proton range variations during respiration. Protons of 230 MeV were tracked one by one as they pass through position detectors, patient 4DCT phantom, and finally scintillator detectors that measured residual ranges. The energy response of the scintillator telescope was investigated. Mass density and elemental composition of tissues were defined for 4DCT data.

RESULTS

Proton water equivalent length (WEL) was deduced by a reconstruction algorithm that incorporates linear proton track and lateral spatial discrimination to improve the image quality. 4DCT data for three patients were used to visualize and measure tumor motion and WEL variations. The tumor trajectories extracted from the WEL map were found to be within 1 mm agreement with direct 4DCT measurement. Quantitative WEL variation studies showed that the proton radiograph is a good representation of WEL changes from entrance to distal of the target.

CONCLUSIONS

MCNPX simulation results showed that TRRT can accurately track the motion of the tumor and detect the WEL variations. Image quality was optimized by choosing proton energy, testing parameters of image reconstruction algorithm, and comparing to ground truth 4DCT. The future study will demonstrate the feasibility of using the time resolved proton radiography as an imaging tool for proton treatments of lung tumors.

Heavy charged particle radiobiology: using enhanced biological effectiveness and improved beam focusing to advance cancer therapy

Ionizing radiation causes many types of DNA damage, including base damage and single- and double-strand breaks. Photons, including X-rays and γ-rays, are the most widely used type of ionizing radiation in radiobiology experiments, and in radiation cancer therapy. Charged particles, including protons and carbon ions, are seeing increased use as an alternative therapeutic modality. Although the facilities needed to produce high energy charged particle beams are more costly than photon facilities, particle therapy has shown improved cancer survival rates, reflecting more highly focused dose distributions and more severe DNA damage to tumor cells. Despite early successes of charged particle radiotherapy, there is room for further improvement, and much remains to be learned about normal and cancer cell responses to charged particle radiation.

International Conference on Advances in Radiation Oncology (ICARO): outcomes of an IAEA meeting

The IAEA held the International Conference on Advances in Radiation Oncology (ICARO) in Vienna on 27-29 April 2009. The Conference dealt with the issues and requirements posed by the transition from conventional radiotherapy to advanced modern technologies, including staffing, training, treatment planning and delivery, quality assurance (QA) and the optimal use of available resources. The current role of advanced technologies (defined as 3-dimensional and/or image guided treatment with photons or particles) in current clinical practice and future scenarios were discussed.

ICARO was organized by the IAEA at the request of the Member States and co-sponsored and supported by other international organizations to assess advances in technologies in radiation oncology in the face of economic challenges that most countries confront. Participants submitted research contributions, which were reviewed by a scientific committee and presented via 46 lectures and 103 posters. There were 327 participants from 70 Member States as well as participants from industry and government. The ICARO meeting provided an independent forum for the interaction of participants from developed and developing countries on current and developing issues related to radiation oncology.

Dosimetry for ion beam radiotherapy

Recently, ion beam radiotherapy (including protons as well as heavier ions) gained considerable interest. Although ion beam radiotherapy requires dose prescription in terms of iso-effective dose (referring to an iso-effective photon dose), absorbed dose is still required as an operative quantity to control beam delivery, to characterize the beam dosimetrically and to verify dose delivery. This paper reviews current methods and standards to determine absorbed dose to water in ion beam radiotherapy, including (i) the detectors used to measure absorbed dose, (ii) dosimetry under reference conditions and (iii) dosimetry under non-reference conditions. Due to the LET dependence of the response of films and solid-state detectors, dosimetric measurements are mostly based on ion chambers. While a primary standard for ion beam radiotherapy still remains to be established, ion chamber dosimetry under reference conditions is based on similar protocols as for photons and electrons although the involved uncertainty is larger than for photon beams. For non-reference conditions, dose measurements in tissue-equivalent materials may also be necessary. Regarding the atomic numbers of the composites of tissue-equivalent phantoms, special requirements have to be fulfilled for ion beams. Methods for calibrating the beam monitor depend on whether passive or active beam delivery techniques are used. QA measurements are comparable to conventional radiotherapy; however, dose verification is usually single field rather than treatment plan based. Dose verification for active beam delivery techniques requires the use of multi-channel dosimetry systems to check the compliance of measured and calculated dose for a representative sample of measurement points. Although methods for ion beam dosimetry have been established, there is still room for developments. This includes improvement of the dosimetric accuracy as well as development of more efficient measurement techniques.

[Particle therapy: carbon ions]

Carbon ion therapy is an innovative radiation therapy. It has been first proposed in the forties by Robert Wilson, however the first dedicated centres for human care have been build up only recently in Japan and Germany. The interest of carbon ion is twofold: 1) the very sharp targeting of the tumour with the so called spread out Bragg peak that delivers most of the beam energy in the tumour and nothing beyond it, sparing very efficiently the healthy tissues; 2) the higher relative biological efficiency compared to X rays or protons, able to kill radioresistant tumour cells. Both properties make carbon ions the elective therapy for non resectable radioresistant tumours loco-regionally threatening. The technical and clinical experience accumulated during the recent decades is summarized in this paper along with a detailed presentation of the elective indications. A short comparison between conventional radiotherapy and hadrontherapy is proposed for the indications which are considered as priority for carbon ions.

Water equivalent thickness values of materials used in beams of protons, helium, carbon and iron ions

Heavy charged particle beam radiotherapy for cancer is of increasing interest because it delivers a highly conformal radiation dose to the target volume. Accurate knowledge of the range of a heavy charged particle beam after it penetrates a patient's body or other materials in the beam line is very important and is usually stated in terms of the water equivalent thickness (WET). However, methods of calculating WET for heavy charged particle beams are lacking. Our objective was to test several simple analytical formulas previously developed for proton beams for their ability to calculate WET values for materials exposed to beams of protons, helium, carbon and iron ions. Experimentally measured heavy charged particle beam ranges and WET values from an iterative numerical method were compared with the WET values calculated by the analytical formulas. In most cases, the deviations were within 1 mm. We conclude that the analytical formulas originally developed for proton beams can also be used to calculate WET values for helium, carbon and iron ion beams with good accuracy.

Real-time imaging for dose evaluation during antiproton irradiation

Online monitoring of the stopping distribution of particle beams used for radiotherapy provides the possibility of detecting possible errors in dose deposition early during a given treatment session, and may therefore help to improve the quality of the therapy. Antiproton annihilation events produce several long-range secondary particles which can be detected in real time by standard high energy particle physics detector systems. In this note, Monte Carlo calculations are performed in order to study the feasibility of real-time imaging by detecting charged pions produced during antiproton irradiation of typical biological targets. A simple treatment plan in a water phantom is simulated and the results show that by detecting pi+/- the position and the size of the planned target volume can be located with precision in the order of 1 mm.

Medical physics aspects of particle therapy

Charged particle beams offer an improved dose conformation to the target volume when compared with photon radiotherapy, with better sparing of normal tissue structures close to the target. In addition, beams of heavier ions exhibit a strong increase of the linear energy transfer in the Bragg peak when compared with the entrance region. These physical and biological properties make ion beams more favourable for radiation therapy of cancer than photon beams. As a consequence, particle therapy with protons and heavy ions has gained increasing interest worldwide. This contribution summarises the physical and biological principles of charged particle therapy with ion beams and highlights some of the developments in the field of beam delivery, the principles of treatment planning and the determination of absorbed dose in ion beams. The clinical experience gathered so far with carbon ion therapy is briefly reviewed.

Heavy ion beam irradiation regulates the mRNA expression in megakaryocytopoiesis from human hematopoietic stem/progenitor cells

Heavy ion beams are a high-LET radiation that has greater biological effect than electron beams or X-rays. However, little is known about the effect of heavy ion beams on the proliferation and differentiation of human hematopoietic stem/progenitor cells (HSPCs). The present study examined the effect of heavy ion beams on gene expression in human HSPCs, especially during early stage of megakaryocytopoiesis. Human CD34+ cells were exposed to monoenergetic carbon-ion beams (290 MeV/nucleon, LET = 50 KeV/m) that were generated by an accelerator (Heavy Ion Medical Accelerator in Chiba). The expression of various genes related to early hematopoiesis, megakaryocytopoiesis/erythropoiesis, cytokine receptors and oxidative stress were analyzed by real-time RT-PCR. Friend leukemia virus integration 1, an early hematopoiesis-related gene, showed significantly higher mRNA expression than the control at 6 hr after irradiation. In contrast, no significant differences were observed in almost all of the other early hematopoiesis-related genes, cytokine receptor-coded genes and megakaryocytopoiesis/erythropoiesis-differentiation pathway-related genes, respectively. An analysis of the response of the genes to oxidative stress revealed the expression of heme oxygenase 1 to show a 1.5-fold and 11.9-fold increase from the day 0 control at 24 hr after 0.5 Gy and 2 Gy irradiation, respectively. Similarly, the NAD(P)H dehydrogenase-quinone 1 expression also showed a 22.0-fold and a 21.8-fold increase at 6 hr in comparison to the initial control. These results showed that the heavy ion beams affect megakaryocytopoiesis/ erythropoiesis differentiation of human HSPCs on the gene expression level.

Ion beam radiobiology and cancer: time to update ourselves

High-energy protons and carbon ions exhibit an inverse dose profile allowing for increased energy deposition with penetration depth. Additionally, heavier ions like carbon beams have the advantage of a markedly increased biological effectiveness characterized by enhanced ionization density in the individual tracks of the heavy particles, where DNA damage becomes clustered and therefore more difficult to repair, but is restricted to the end of their range. These superior biophysical and biological profiles of particle beams over conventional radiotherapy permit more precise dose localization and make them highly attractive for treating anatomically complex and radioresistant malignant tumors but without increasing the severe side effects in the normal tissue. More than half a century since Wilson proposed their use in cancer therapy, the effects of particle beams have been extensively investigated and the biological complexity of particle beam irradiation begins to unfold itself. The goal of this review is to provide an as comprehensive and up-to-date summary as possible of the different radiobiological aspects of particle beams for effective application in cancer treatment.

Technological advances in radiation oncology for central nervous system tumors

Advances in computer software technology have led to enormous progress that has enabled increasing levels of complexity to be incorporated into radiotherapy treatment planning systems. Because of these changes, the delivery of radiotherapy evolved from therapy designed primarily on plain 2-dimensional X-ray images and hand calculations to therapy based on 3-dimensional images incorporating increasingly complex computer algorithms in the planning process. In addition, challenges in treatment planning and radiation delivery, such as problems with setup error and organ movement, have begun to be systematically addressed, ushering in an era of so-called 4-dimensional radiotherapy. This review article discusses how these advances have changed the way in which many common neoplasms of the central nervous system are being treated at present.

The radiosensitivity of total and quiescent cell populations in solid tumors to 290 MeV/u carbon ion beam irradiation in vivo

PURPOSE

To clarify the radiosensitivity of intratumor total and quiescent (Q) cells in vivo to accelerated carbon ion beams compared with gamma-ray irradiation.

MATERIALS AND METHODS

SCC VII tumor-bearing mice received a continuous administration of 5-bromo-2'-deoxyuridine (BrdU) to label all intratumor proliferating (P) cells. Then they received 290 MeV/u carbon ions or gamma-rays. Immediately or 12 hours after the irradiation, the radiosensitivity of Q cells was assessed in terms of the micronucleus frequency using immunofluorescence staining for BrdU. That of the total (=P+Q) tumor cells was determined from the BrdU non-treated tumors based on the micronucleus frequency and clonogenic cell survival.

RESULTS

The apparent difference in radiosensitivity between total and Q cell populations under gamma-ray irradiation was markedly reduced with carbon ion beam, especially with a higher linear energy transfer (LET) value. Clearer repair in Q cells than total cells through delayed assay under gamma-ray irradiation was efficiently inhibited with carbon ion beams, especially with a higher LET.

CONCLUSION

In terms of tumor cell-killing effect as a whole, including intratumor Q cells, carbon ion beams, especially with higher LET values, were very useful for suppressing the dependency on the heterogeneity within solid tumors as well as depositing radiation dose precisely.

Proteomics and pathway analysis identifies JNK signaling as critical for high linear energy transfer radiation-induced apoptosis in non-small lung cancer cells

During the past decade, we have witnessed an explosive increase in generation of large proteomics data sets, not least in cancer research. There is a growing need to extract and correctly interpret information from such data sets to generate biologically relevant hypotheses. A pathway search engine (PSE) has recently been developed as a novel tool intended to meet these requirements. Ionizing radiation (IR) is an anticancer treatment modality that triggers multiple signal transduction networks. In this work, we show that high linear energy transfer (LET) IR induces apoptosis in a non-small cell lung cancer cell line, U-1810, whereas low LET IR does not. PSE was applied to study changes in pathway status between high and low LET IR to find pathway candidates of importance for high LET-induced apoptosis. Such pathways are potential clinical targets, and they were further validated in vitro. We used an unsupervised shotgun proteomics approach where high resolution mass spectrometry coupled to nanoflow liquid chromatography determined the identity and relative abundance of expressed proteins. Based on the proteomics data, PSE suggested the JNK pathway (p = 6.10(-6)) as a key event in response to high LET IR. In addition, the Fas pathway was found to be activated (p = 3.10(-5)) and the p38 pathway was found to be deactivated (p = 0.001) compared with untreated cells. Antibody-based analyses confirmed that high LET IR caused an increase in phosphorylation of JNK. Moreover pharmacological inhibition of JNK blocked high LET-induced apoptotic signaling. In contrast, neither an activation of p38 nor a role for p38 in high LET IR-induced apoptotic signaling was found. We conclude that, in contrast to conventional low LET IR, high LET IR can trigger activation of the JNK pathway, which in turn is critical for induction of apoptosis in these cells. Thus PSE predictions were largely confirmed, and PSE was proven to be a useful hypothesis-generating tool.

Radiation therapy for visual pathway tumors

The multimodality management of visual pathway tumors frequently involves radiation. Most commonly, photons are delivered via multiple focused beams aimed at the tumor while sparing adjacent tissues. The dose can be delivered in multiple treatments (radiation therapy) or in a single treatment (radiosurgery). Children with visual pathway gliomas should be treated with chemotherapy alone, delaying the use of radiation therapy until progression. Definitive radiation therapy of optic nerve sheath meningiomas results in stable vision in most patients. Radiation therapy or radiosurgery for pituitary tumors can result in control of both tumor growth and hormone hypersecretion. Postoperative radiation therapy or radiosurgery of craniopharyngiomas significantly improves local control rates compared with surgery alone. Radiation therapy is highly effective for eradicating orbital pseudolymphoma and lymphoma. The risk of complications from radiation treatment is dependent on the organ at risk, the cumulative dose it receives, and the dose delivered per fraction.

Recent insights into the biological action of heavy-ion radiation

Biological effectiveness varies with the linear energy transfer (LET) of ionizing radiation. During cancer therapy or long-term interplanetary manned explorations, humans are exposed to high-LET energetic heavy ions that inactivate cells more effectively than low-LET photons like X-rays and gamma-rays. Recent biological studies have illustrated that heavy ions overcome tumor radioresistance caused by Bcl-2 overexpression, p53 mutations and intratumor hypoxia, and possess antiangiogenic and antimetastatic potential. Compared with heavy ions alone, the combination with chemical agents (a Bcl-2 inhibitor HA14-1, an anticancer drug docetaxel, and a halogenated pyrimidine analogue 5-iodo-2'-deoxyuridine) or hyperthermia further enhances tumor cell killing. Beer, its certain constituents, or melatonin ameliorate heavy ion-induced damage to normal cells. In addition to effects in cells directly targeted with heavy ions, there is mounting evidence for nontargeted biological effects in cells that have not themselves been directly irradiated. The bystander effect of heavy ions manifests itself as the loss of clonogenic potential, a transient apoptotic response, delayed p53 phosphorylation, alterations in gene expression profiles, and the elevated frequency of gene mutations, micronuclei and chromosome aberrations, which arise in nonirradiated cells having received signals from irradiated cells. Proposed mediating mechanisms involve gap junctional intercellular communication, reactive oxygen species and nitric oxide. This paper reviews briefly the current knowledge of the biological effects of heavy-ion irradiation with a focus on recent findings regarding its potential benefits for therapeutic use as well as on the bystander effect.

Dose to normal tissues outside the radiation therapy patient's treated volume: a review of different radiation therapy techniques

Radiation therapy treatment planning and delivery capabilities have changed dramatically since the introduction of three-dimensional treatment planning and are continuing to change relatively rapidly in response to the implementation of new advanced technologies. Three-dimensional conformal radiation therapy (3DCRT) is now firmly in place as the standard of practice in clinics around the world. Medical accelerator manufacturers have employed advanced computer technology to produce treatment planning/delivery systems capable of precise shaping of dose distributions via computer-controlled multileaf collimator (MLC) systems, by which the beam fluence is varied optimally to achieve the desired dose distribution. This mode of conformal therapy is referred to as intensity modulated radiation therapy (IMRT), and is capable of generating dose distributions (including concave isodose volumes) that closely conform the prescription dose to the target volume and/or avoid specific sensitive normal structures. The increasing use of IMRT has focused attention on the need to better account for the intra- and inter-fraction spatial uncertainties in the dose delivery process. This has helped spur the development of treatment machines with integrated planar and volumetric advanced imaging capabilities, providing a new treatment modality referred to as image-guided IMRT (IG-IMRT), or simply image-guided radiation therapy (IGRT). In addition, there is a growing interest in replacing x rays with protons because of the physical characteristics of the depth dose curve, which peaks at the end of particle range, and eventually with even heavier charged particles to take advantage of the greater density of energy deposition close to the Bragg peak and hence larger relative biological effectiveness (RBE). Three-dimensional CRT, IMRT and proton beam therapy all provide improved target coverage and lower doses to surrounding normal tissues as compared to the previously used two-dimensional radiation therapy techniques. However, this is achieved at the expense of a greater volume of normal tissue in the irradiated volume receiving some dose and a higher whole body dose (or peripheral dose) to distant normal tissues. The higher whole body dose is a result of the increased x-ray leakage radiation to the patient due to the longer beam-on times associated with IMRT, and also from neutron leakage radiation associated with high energy x-ray beams (>10 MV) and proton beams. Dose distributions for the various CRT techniques and the current status of available data for normal tissues, and whole body dose are reviewed.

Motion compensation with a scanned ion beam: a technical feasibility study

Background

Intrafractional motion results in local over- and under-dosage in particle therapy with a scanned beam. Scanned beam delivery offers the possibility to compensate target motion by tracking with the treatment beam.

Methods

Lateral motion components were compensated directly with the beam scanning system by adapting nominal beam positions according to the target motion. Longitudinal motion compensation to mitigate motion induced range changes was performed with a dedicated wedge system that adjusts effective particle energies at isocenter.

Results

Lateral compensation performance was better than 1% for a homogeneous dose distribution when comparing irradiations of a stationary radiographic film and a moving film using motion compensation. The accuracy of longitudinal range compensation was well below 1 mm.

Conclusion

Motion compensation with scanned particle beams is technically feasible with high precision.

Feasibility of MRI guided proton therapy: magnetic field dose effects

Many methods exist to improve treatment outcome in radiotherapy. Two of these are image-guided radiotherapy (IGRT) and proton therapy. IGRT aims at a more precise delivery of the radiation, while proton therapy is able to achieve more conformal dose distributions. In order to maximally exploit the sharp dose gradients from proton therapy it has to be combined with soft-tissue based IGRT. MRI-guided photon therapy (currently under development) offers unequalled soft-tissue contrast and real-time image guidance. A hybrid MRI proton therapy system would combine these advantages with the advantageous dose steering capacity of proton therapy. This paper addresses a first technical feasibility issue of this concept, namely the impact of a 0.5 T magnetic field on the dose distribution from a 90 MeV proton beam. In contrast to photon therapy, for MR-guided proton therapy the impact of the magnetic field on the dose distribution is very small. At tissue-air interfaces no effect of the magnetic field on the dose distribution can be detected. This is due to the low-energy of the secondary electrons released by the heavy protons.

Responses of total and quiescent cell populations in solid tumors to carbon ion beam irradiation (290 MeV/u) in vivo

PURPOSE

The aim of this study was to clarify the radiosensitivity of intratumor total cells and quiescent (Q) cells in vivo to accelerated carbon ion beams compared with gamma-ray irradiation.

MATERIALS AND METHODS

Squamous cell carcinoma (SCC) VII tumor-bearing mice received continuous administration of 5-bromo-2'-deoxyuridine (BrdU) to label all intratumor proliferating (P) cells. They then were exposed to carbon ions (290 MeV/u) or gamma-rays. Immediately after and 12 h after irradiation, immunofluorescence staining for BrdU was used to assess the response of Q cells in terms of micronucleus frequency. The response of the total (P + Q) tumor cells was determined from the tumors not treated with BrdU.

RESULTS

The apparent difference in radiosensitivity between total and Q cell populations under gamma-ray irradiation was markedly reduced with carbon ion beams, especially with a higher linear energy transfer (LET) value. Clearer recovery in Q cells than in total cells through delayed assay under gamma-ray irradiation was efficiently inhibited by carbon ion beams, especially those with a higher LET.

CONCLUSION

In terms of the tumor cell-killing effect as a whole, including intratumor Q cells, carbon ion beams, especially with higher LET values, were extremely useful for suppressing the dependence on the heterogeneity within solid tumors as well as depositing the radiation dose precisely.