An ionizing radiation acoustic imaging (iRAI) technique for real-time dosimetric measurements for FLASH radiotherapy

Resolution limits for radiation-induced acoustic imaging forin vivoradiation dosimetry

Objective.Radiation-induced acoustic (RA) computed tomographic (RACT) imaging is being thoroughly explored for radiation dosimetry. It is essential to understand how key machine parameters like beam pulse, size, and energy deposition affect image quality in RACT. We investigate the intricate interplay of these parameters and how these factors influence dose map resolution in RACT.Approach.We first conduct an analytical assessment of time-domain RA signals and their corresponding frequency spectra for certain testcases, and computationally validate these analyses. Subsequently, we simulated a series of x-ray-based RACT (XACT) experiments and compared the simulations with experimental measurements.In-silicoreconstruction studies have also been conducted to demonstrate the resolution limits imposed by the temporal pulse profiles on RACT. XACT experiments were performed using clinical machines and the reconstructions were analyzed for resolution capabilities.Main results.Our paper establishes the theory for predicting the time- and frequency-domain behavior of RA signals. We illustrate that the frequency content of RA signal is not solely dependent on the spatial energy deposition characteristics but also on the temporal features of radiation. The same spatial energy deposition through a Gaussian pulse and a rectangular pulse of equal pulsewidths results in different frequency spectra of the RA signals. RA signals corresponding to the rectangular pulse exhibit more high-frequency content than their Gaussian pulse counterparts and hence provide better resolution in the reconstructions. XACT experiments with ∼3.2 us and ∼4 us rectangular radiation pulses were performed, and the reconstruction results were found to correlate well with thein-silicoresults.Significance.Here, we discuss the inherent resolution limits for RACT-based radiation dosimetric systems. While our study is relevant to the broader community engaged in research on photoacoustics, x-ray-acoustics, and proto/ionoacoustics, it holds particular significance for medical physics researchers aiming to set up RACT for dosimetry and radiography using clinical radiation machines.

Toward real-time, volumetric dosimetry for FLASH-capable clinical synchrocyclotrons using protoacoustic imaging

BACKGROUND

Fast low angle shot hyperfractionation (FLASH) radiotherapy (RT) holds promise for improving treatment outcomes and reducing side effects but poses challenges in radiation delivery accuracy due to its ultra-high dose rates. This necessitates the development of novel imaging and verification technologies tailored to these conditions.

PURPOSE

Our study explores the effectiveness of proton-induced acoustic imaging (PAI) in tracking the Bragg peak in three dimensions and in real time during FLASH proton irradiations, offering a method for volumetric beam imaging at both conventional and FLASH dose rates.

METHODS

We developed a three-dimensional (3D) PAI technique using a 256-element ultrasound detector array for FLASH dose rate proton beams. In the study, we tested protoacoustic signal with a beamline of a FLASH-capable synchrocyclotron, setting the distal 90% of the Bragg peak around 35 mm away from the ultrasound array. This configuration allowed us to assess various total proton radiation doses, maintaining a consistent beam output of 21 pC/pulse. We also explored a spectrum of dose rates, from 15 Gy/s up to a FLASH rate of 48 Gy/s, by administering a set number of pulses. Furthermore, we implemented a three-dot scanning beam approach to observe the distinct movements of individual Bragg peaks using PAI. All these procedures utilized a proton beam energy of 180 MeV to achieve the maximum possible dose rate.

RESULTS

Our findings indicate a strong linear relationship between protoacoustic signal amplitudes and delivered doses (R2 = 0.9997), with a consistent fit across different dose rates. The technique successfully provided 3D renderings of Bragg peaks at FLASH rates, validated through absolute Gamma index values.

CONCLUSIONS

The protoacoustic system demonstrates effectiveness in 3D visualization and tracking of the Bragg peak during FLASH proton therapy, representing a notable advancement in proton therapy quality assurance. This method promises enhancements in protoacoustic image guidance and real-time dosimetry, paving the way for more accurate and effective treatments in ultra-high dose rate therapy environments.

Simulation study of protoacoustics as a real-time in-line dosimetry tool for FLASH proton therapy

BACKGROUND

Applying ultra-high dose rates to radiation therapy, otherwise known as FLASH, has been shown to be just as effective while sparing more normal tissue compared to conventional radiation therapy. However, there is a need for a dosimeter that is able to detect such high instantaneous dose, particularly in vivo. To fulfill this need, protoacoustics is introduced, which is an in vivo range verification method with submillimeter accuracy.

PURPOSE

The purpose of this work is to demonstrate the feasibility of using protoacoustics as a method of in vivo real-time monitoring during FLASH proton therapy and investigating the resulting protoacoustic signal when dose per pulse and pulsewidth are varied through multiple simulation studies.

METHODS

The dose distribution of a proton pencil beam was calculated through a Monte Carlo toolbox, TOPAS. Next, the k-Wave toolbox in MATLAB was used for performing protoacoustic simulations, where the initial proton dose deposition was inputted to model acoustic propagations, which were also used for reconstructions. Simulations involving the manipulation of the dose per pulse and pulsewidth were performed, and the temporal and spatial resolution for protoacoustic reconstructions were investigated as well. A 3D reconstruction was performed with a multiple beam spot profile to investigate the spatial resolution as well as determine the feasibility of 3D imaging with protoacoustics.

RESULTS

Our results showed consistent linearity in the increasing dose-per-pulse, even up to rates considered for FLASH. The simulations and reconstructions were performed for a range of pulsewidths from 0.1 to 10 μs. The results show the characteristics of the proton beam after convolving the protoacoustic signal with the varying pulsewidths. 3D reconstruction was successfully performed with each beam being distinguishable using an 8 cm × 8 cm planar array. These simulation results show that measurements using protoacoustics has the potential for in vivo dosimetry in FLASH therapy during patient treatments in real time.

CONCLUSION

Through this simulation study, the use of protoacoustics in FLASH therapy was verified and explored through observations of varying parameters, such as the dose per pulse and pulsewidth. 2D and 3D reconstructions were also completed. This study shows the significance of using protoacoustics and provides necessary information, which can further be explored in clinical settings.

4Din vivodosimetry for a FLASH electron beam using radiation-induced acoustic imaging

Objective. The primary goal of this research is to demonstrate the feasibility of radiation-induced acoustic imaging (RAI) as a volumetric dosimetry tool for ultra-high dose rate FLASH electron radiotherapy (FLASH-RT) in real time. This technology aims to improve patient outcomes by accurate measurements ofin vivodose delivery to target tumor volumes.Approach. The study utilized the FLASH-capable eRT6 LINAC to deliver electron beams under various doses (1.2 Gy pulse-1to 4.95 Gy pulse-1) and instantaneous dose rates (1.55 × 105Gy s-1to 2.75 × 106Gy s-1), for imaging the beam in water and in a rabbit cadaver with RAI. A custom 256-element matrix ultrasound array was employed for real-time, volumetric (4D) imaging of individual pulses. This allowed for the exploration of dose linearity by varying the dose per pulse and analyzing the results through signal processing and image reconstruction in RAI.Main Results. By varying the dose per pulse through changes in source-to-surface distance, a direct correlation was established between the peak-to-peak amplitudes of pressure waves captured by the RAI system and the radiochromic film dose measurements. This correlation demonstrated dose rate linearity, including in the FLASH regime, without any saturation even at an instantaneous dose rate up to 2.75 × 106Gy s-1. Further, the use of the 2D matrix array enabled 4D tracking of FLASH electron beam dose distributions on animal tissue for the first time.Significance. This research successfully shows that 4Din vivodosimetry is feasible during FLASH-RT using a RAI system. It allows for precise spatial (∼mm) and temporal (25 frames s-1) monitoring of individual FLASH beamlets during delivery. This advancement is crucial for the clinical translation of FLASH-RT as enhancing the accuracy of dose delivery to the target volume the safety and efficacy of radiotherapeutic procedures will be improved.

Clinical Linear Accelerator-Based Electron FLASH: Pathway for Practical Translation to FLASH Clinical Trials

PURPOSE

Ultrahigh-dose-rate (UHDR) radiation therapy (RT) has produced the FLASH effect in preclinical models: reduced toxicity with comparable tumor control compared with conventional-dose-rate RT. Early clinical trials focused on UHDR RT feasibility using specialized devices. We explore the technical feasibility of practical electron UHDR RT on a standard clinical linear accelerator (LINAC).

METHODS AND MATERIALS

We tuned the program board of a decommissioned electron energy for UHDR electron delivery on a clinical LINAC without hardware modification. Pulse delivery was controlled using the respiratory gating interface. A short source-to-surface distance (SSD) electron setup with a standard scattering foil was configured and tested on an anthropomorphic phantom using circular blocks with 3- to 20-cm field sizes. Dosimetry was evaluated using radiochromic film and an ion chamber profiler.

RESULTS

UHDR open-field mean dose rates at 100, 80, 70, and 59 cm SSD were 36.82, 59.52, 82.01, and 112.83 Gy/s, respectively. At 80 cm SSD, mean dose rate was ∼60 Gy/s for all collimated field sizes, with an R80 depth of 6.1 cm corresponding to an energy of 17.5 MeV. Heterogeneity was <5.0% with asymmetry of 2.2% to 6.2%. The short SSD setup was feasible under realistic treatment conditions simulating broad clinical indications on an anthropomorphic phantom.

CONCLUSIONS

Short SSD and tuning for high electron beam current on a standard clinical LINAC can deliver flat, homogenous UHDR electrons over a broad, clinically relevant range of field sizes and depths with practical working distances in a configuration easily reversible to standard clinical use.

Harnessing progress in radiotherapy for global cancer control

The pace of technological innovation over the past three decades has transformed the field of radiotherapy into one of the most technologically intense disciplines in medicine. However, the global barriers to access this highly effective treatment are complex and extend beyond technological limitations. Here, we review the technological advancement and current status of radiotherapy and discuss the efforts of the global radiation oncology community to formulate a more integrative 'diagonal approach' in which the agendas of science-driven advances in individual outcomes and the sociotechnological task of global cancer control can be aligned to bring the benefit of this proven therapy to patients with cancer everywhere.

Real-time, volumetric imaging of radiation dose delivery deep into the liver during cancer treatment

Ionizing radiation acoustic imaging (iRAI) allows online monitoring of radiation's interactions with tissues during radiation therapy, providing real-time, adaptive feedback for cancer treatments. We describe an iRAI volumetric imaging system that enables mapping of the three-dimensional (3D) radiation dose distribution in a complex clinical radiotherapy treatment. The method relies on a two-dimensional matrix array transducer and a matching multi-channel preamplifier board. The feasibility of imaging temporal 3D dose accumulation was first validated in a tissue-mimicking phantom. Next, semiquantitative iRAI relative dose measurements were verified in vivo in a rabbit model. Finally, real-time visualization of the 3D radiation dose delivered to a patient with liver metastases was accomplished with a clinical linear accelerator. These studies demonstrate the potential of iRAI to monitor and quantify the 3D radiation dose deposition during treatment, potentially improving radiotherapy treatment efficacy using real-time adaptive treatment.

Framework for Quality Assurance of Ultrahigh Dose Rate Clinical Trials Investigating FLASH Effects and Current Technology Gaps

FLASH radiation therapy (FLASH-RT), delivered with ultrahigh dose rate (UHDR), may allow patients to be treated with less normal tissue toxicity for a given tumor dose compared with currently used conventional dose rate. Clinical trials are being carried out and are needed to test whether this improved therapeutic ratio can be achieved clinically. During the clinical trials, quality assurance and credentialing of equipment and participating sites, particularly pertaining to UHDR-specific aspects, will be crucial for the validity of the outcomes of such trials. This report represents an initial framework proposed by the NRG Oncology Center for Innovation in Radiation Oncology FLASH working group on quality assurance of potential UHDR clinical trials and reviews current technology gaps to overcome. An important but separate consideration is the appropriate design of trials to most effectively answer clinical and scientific questions about FLASH. This paper begins with an overview of UHDR RT delivery methods. UHDR beam delivery parameters are then covered, with a focus on electron and proton modalities. The definition and control of safe UHDR beam delivery and current and needed dosimetry technologies are reviewed and discussed. System and site credentialing for large, multi-institution trials are reviewed. Quality assurance is then discussed, and new requirements are presented for treatment system standard analysis, patient positioning, and treatment planning. The tables and figures in this paper are meant to serve as reference points as we move toward FLASH-RT clinical trial performance. Some major questions regarding FLASH-RT are discussed, and next steps in this field are proposed. FLASH-RT has potential but is associated with significant risks and complexities. We need to redefine optimization to focus not only on the dose but also on the dose rate in a manner that is robust and understandable and that can be prescribed, validated, and confirmed in real time. Robust patient safety systems and access to treatment data will be critical as FLASH-RT moves into the clinical trials.

Single-Pulse X-ray Acoustic Computed Tomographic Imaging for Precision Radiation Therapy

Purpose

High-precision radiation therapy is crucial for cancer treatment. Currently, the delivered dose can only be verified via simulations with phantoms, and an in-tumor, online dose verification is still unavailable. An innovative detection method called x-ray-induced acoustic computed tomography (XACT) has recently shown the potential for imaging the delivered radiation dose within the tumor. Prior XACT imaging systems have required tens to hundreds of signal averages to achieve high-quality dose images within the patient, which reduces its real-time capability. Here, we demonstrate that XACT dose images can be reproduced from a single x-ray pulse (4 µs) with sub-mGy sensitivity from a clinical linear accelerator.

Methods and Materials

By immersing an acoustic transducer in a homogeneous medium, it is possible to detect pressure waves generated by the pulsed radiation from a clinical linear accelerator. After rotating the collimator, signals of different angles are obtained to perform a tomographic reconstruction of the dose field. Using 2-stage amplification with further bandpass filtering increases the signal-to-noise ratio (SNR).

Results

Acoustic peak SNR and voltage values were recorded for singular and dual-amplifying stages. The SNR for single-pulse mode was able to satisfy the Rose criterion, and the collected signals were able to reconstruct 2-dimensional images from the 2 homogeneous media.

Conclusions

By overcoming the low SNR and requirement of signal averaging, single-pulse XACT imaging holds great potential for personalized dose monitoring from each individual pulse during radiation therapy.

Advances in Radiation Therapy for Primary Liver Cancer

During the past 30 years, several advances have been made allowing for safer and more effective treatment of patients with liver cancer. This report reviews recent advances in radiation therapy for primary liver cancers including hepatocellular carcinoma and intrahepatic cholangiocarcinoma. First, studies focusing on liver stereotactic body radiation therapy (SBRT) are reviewed focusing on lessons learned and knowledge gained from early pioneering trials. Then, new technologies to enhance SBRT treatments are explored including adaptive therapy and MRI-guided and biology-guided radiation therapy. Finally, treatment with Y-90 transarterial radioembolization is reviewed with a focus on novel approaches focused on personalized therapy.

On the potential biological impact of radiation-induced acoustic emissions during ultra-high dose rate electron radiotherapy: a preliminary study

Ionizing radiation pulses delivered at ultra-high dose rates in emerging FLASH radiotherapy can result in high-intensity low-frequency thermoacoustic emissions that may have a biological impact. This study aims at providing insights into the thermoacoustic emissions expected during FLASH radiotherapy and their likelihood of inducing acoustic cavitation. The characteristics of acoustic waves induced by the energy deposition of a pulsed electron beam similar to previous pre-clinical FLASH radiotherapy studies and their propagation in murine head-like phantoms are investigated in-silico. The results show that the generated pressures are sufficient to produce acoustic cavitation due to resonance in the irradiated object. It suggests that thermoacoustics may, in some irradiation scenarios, contribute to the widely misunderstood FLASH effect or cause adverse effects if not taken into account at the treatment planning stage.

Single pulse protoacoustic range verification using a clinical synchrocyclotron

Objective.Proton therapy as the next generation radiation-based cancer therapy offers dominant advantages over conventional radiation therapy due to the utilization of the Bragg peak; however, range uncertainty in beam delivery substantially mitigates the advantages of proton therapy. This work reports using protoacoustic measurements to determine the location of proton Bragg peak deposition within a water phantom in real time during beam delivery.Approach.In protoacoustics, proton beams have a definitive range, depositing a majority of the dose at the Bragg peak; this dose is then converted to heat. The resulting thermoelastic expansion generates a 3D acoustic wave, which can be detected by acoustic detectors to localize the Bragg peak.Main results.Protoacoustic measurements were performed with a synchrocyclotron proton machine over the exhaustive energy range from 45.5 to 227.15 MeV in clinic. It was found that the amplitude of the acoustic waves is proportional to proton dose deposition, and therefore encodes dosimetric information. With the guidance of protoacoustics, each individual proton beam (7 pC/pulse) can be directly visualized with sub-millimeter (<0.7 mm) resolution using single beam pulse for the first time.Significance.The ability to localize the Bragg peak in real-time and obtain acoustic signals proportional to dose within tumors could enable precision proton therapy and hope to progress towardsin vivomeasurements.

Reconstruction of thermoacoustic emission sources induced by proton irradiation using numerical time reversal

Objective.Mapping of dose delivery in proton beam therapy can potentially be performed by analyzing thermoacoustic emissions measured by ultrasound arrays. Here, a method is derived and demonstrated for spatial mapping of thermoacoustic sources using numerical time reversal, simulating re-transmission of measured emissions into the medium.Approach.Spatial distributions of thermoacoustic emission sources are shown to be approximated by the analytic-signal form of the time-reversed acoustic field, evaluated at the time of the initial proton pulse. Given calibration of the array sensitivity and knowledge of tissue properties, this approach approximately reconstructs the acoustic source amplitude, equal to the product of the time derivative of the radiation dose rate, mass density, and Grüneisen parameter. This approach was implemented using two models for acoustic fields of the array elements, one modeling elements as line sources and the other as rectangular radiators. Thermoacoustic source reconstructions employed previously reported measurements of emissions from proton energy deposition in tissue-mimicking phantoms. For a phantom incorporating a bone layer, reconstructions accounted for the higher sound speed in bone. Dependence of reconstruction quality on array aperture size and signal-to-noise ratio was consistent with previous acoustic simulation studies.Main results.Thermoacoustic source distributions were successfully reconstructed from acoustic emissions measured by a linear ultrasound array. Spatial resolution of reconstructions was significantly improved in the azimuthal (array) direction by incorporation of array element diffraction. Source localization agreed well with Monte Carlo simulations of energy deposition, and was improved by incorporating effects of inhomogeneous sound speed.Significance.The presented numerical time reversal approach reconstructs thermoacoustic sources from proton beam radiation, based on straightforward processing of acoustic emissions measured by ultrasound arrays. This approach may be useful for ranging and dosimetry of clinical proton beams, if acoustic emissions of sufficient amplitude and bandwidth can be generated by therapeutic proton sources.

Image guidance for FLASH radiotherapy

FLASH radiotherapy (FLASH-RT) is an emerging ultra-high dose (>40 Gy/s) delivery that promises to improve the therapeutic potential by limiting toxicities compared to conventional RT while maintaining similar tumor eradication efficacy. Image guidance is an essential component of modern RT that should be harnessed to meet the special emerging needs of FLASH-RT and its associated high risks in planning and delivering of such ultra-high doses in short period of times. Hence, this contribution will elaborate on the imaging requirements and possible solutions in the entire chain of FLASH-RT treatment, from the planning, through the setup and delivery with online in vivo imaging and dosimetry, up to the assessment of biological mechanisms and treatment response. In patient setup and delivery, higher temporal sampling than in conventional RT should ensure that the short treatment is delivered precisely to the targeted region. Additionally, conventional imaging tools such as cone-beam computed tomography will continue to play an important role in improving patient setup prior to delivery, while techniques based on magnetic resonance imaging or positron emission tomography may be extremely valuable for either linear accelerator (Linac) or particle FLASH therapy, to monitor and track anatomical changes during delivery. In either planning or assessing outcomes, quantitative functional imaging could supplement conventional imaging for more accurate utilization of the biological window of the FLASH effect, selecting for or verifying things such as tissue oxygen and existing or transient hypoxia on the relevant timescales of FLASH-RT delivery. Perhaps most importantly at this time, these tools might help improve the understanding of the biological mechanisms of FLASH-RT response in tumor and normal tissues. The high dose deposition of FLASH provides an opportunity to utilize pulse-to-pulse imaging tools such as Cherenkov or radiation acoustic emission imaging. These could provide individual pulse mapping or assessing the 3D dose delivery superficially or at tissue depth, respectively. In summary, the most promising components of modern RT should be used for safer application of FLASH-RT, and new promising developments could be advanced to cope with its novel demands but also exploit new opportunities in connection with the unique nature of pulsed delivery at unprecedented dose rates, opening a new era of biological image guidance and ultrafast, pulse-based in vivo dosimetry.

Ring artifacts removal in X-ray-induced acoustic computed tomography

X-ray-induced acoustic computed tomography (XACT) is a hybrid imaging modality for detecting X-ray absorption distribution via ultrasound emission. It facilitates imaging from a single projection X-ray illumination, thus reducing the radiation exposure and improving imaging speed. Nonuniform detector response caused by the interference between multichannel data acquisition for ring array transducers and amplifier systems yields ring artifacts in the reconstructed XACT images, which compromises the image quality. We propose model-based algorithms for ring artifacts corrected XACT imaging and demonstrate their efficacy on numerical and experimental measurements. The corrected reconstructions indicate significantly reduced ring artifacts as compared to their conventional counterparts.

Response of diamond detectors in ultra-high dose-per-pulse electron beams for dosimetry at FLASH radiotherapy

Objective. With increasing investigation of the so-called FLASH effect, the need for accurate real time dosimetry for ultra-high dose rates is also growing. Considering the ultra-high dose-per-pulse (DPP) necessary to produce the ultra-high dose rates for investigations of the FLASH effect, real time dosimetry is a major challenge. In particular, vented ionization chambers, as used for dosimetry in conventional radiotherapy, show significant deviations from linearity with increasing DPP. This is due to recombination losses in the sensitive air volume. Solid state detectors could be an alternative. Due to their good stability of the response with regard to the accumulated dose, diamond detectors such as the microDiamond could be suitable here. The aims of this work are to investigate the response of microDiamond and adapted microDiamond prototypes in ultra-high DPP electron beams, to understand the underlying effects and to draw conclusions for further detector developments. Approach. For the study, an electron beam with a DPP up to 6.5 Gy and a pulse duration of 2.5 μs was used to fulfill the conditions under which the FLASH effect was observed. As a dose rate-independent reference, alanine dosimeters were used. Main Results. It has been shown that the commercially available microDiamond detectors have limitations in terms of linearity at ultra-high DPP. But this is not an intrinsic limitation of the detector principle. The deviations from linearity were correlated with the series resistance and the sensitivity. It could be shown that the linear range can be extended towards ultra-high DPP range by reducing the sensitivity in combination with a low series resistance of the detectors. Significance. The work shows that synthetic single crystal diamond detectors working as Schottky photodiodes are in principle suitable for FLASH-RT dosimetry at electron linear accelerators.

Development of Ultra-High Dose-Rate (FLASH) Particle Therapy

Research efforts in FLASH radiotherapy have increased at an accelerated pace recently. FLASH radiotherapy involves ultra-high dose rates and has shown to reduce toxicity to normal tissue while maintaining tumor response in pre-clinical studies when compared to conventional dose rate radiotherapy. The goal of this review is to summarize the studies performed to-date with proton, electron, and heavy ion FLASH radiotherapy, with particular emphasis on the physical aspects of each study and the advantages and disadvantages of each modality. Beam delivery parameters, experimental set-up, and the dosimetry tools used are described for each FLASH modality. In addition, modeling efforts and treatment planning for FLASH radiotherapy is discussed along with potential drawbacks when translated into the clinical setting. The final section concludes with further questions that have yet to be answered before safe clinical implementation of FLASH radiotherapy.

Model-Based X-Ray-Induced Acoustic Computed Tomography

X-ray-induced acoustic computed tomography (XACT) provides X-ray absorption-based contrast with acoustic detection. For its clinical translation, XACT imaging often has a limited field of view. This can result in image artifacts and overall loss of quantification accuracy. In this article, we aim to demonstrate model-based XACT image reconstruction to address these problems. An efficient matrix-free implementation of the regularized LSQR (MF-LSQR)-based minimization scheme and a noniterative model back-projection (MBP) scheme for computing XACT reconstructions have been demonstrated in this article. The proposed algorithms have been numerically validated and then used to perform reconstructions from experimental measurements obtained from an XACT setup. While the commonly used back-projection (BP) algorithm produces limited-view and noisy artifacts in the region of interest (ROI), model-based LSQR minimization overcomes these issues. The model-based algorithms also reduce the ring artifacts caused due to the nonuniformity response of the multichannel data acquisition. Using the model-based reconstruction algorithms, we are able to obtain reasonable XACT reconstructions for acoustic measurements of up to 120° view. Although the MBP is more efficient than the model-based LSQR algorithm, it provides only the structural information of the ROI. Overall, it has been demonstrated that the model-based image reconstruction yields better image quality for XACT than the standard BP. Moreover, the combination of model-based image reconstruction with different regularization methods can solve the limited-view problem for XACT imaging (in many realistic cases where the full-view dataset is unavailable), and hence pave the way for future clinical translation.

A simulation study of ionizing radiation acoustic imaging (iRAI) as a real-time dosimetric technique for ultra-high dose rate radiotherapy (UHDR-RT)

PURPOSE

Electron-based ultra-high dose rate radiation therapy (UHDR-RT), also known as Flash-RT, has shown the ability to improve the therapeutic index in comparison to conventional radiotherapy (CONV-RT) through increased sparing of normal tissue. However, the extremely high dose rates in UHDR-RT have raised the need for accurate real-time dosimetry tools. This work aims to demonstrate the potential of the emerging technology of Ionized Radiation Acoustic Imaging (iRAI) through simulation studies and investigate its characteristics as a promising relative in vivo dosimetric tool for UHDR-RT.

METHODS

The detection of induced acoustic waves following a single UHDR pulse of a modified 6 MeV 21EX Varian Clinac in a uniform porcine gelatin phantom that is brain-tissue equivalent was simulated for an ideal ultrasound transducer. The full 3D dose distributions in the phantom for a 1 × 1 cm2 field were simulated using EGSnrc (BEAMnrc∖DOSXYZnrc) Monte Carlo (MC) codes. The relative dosimetry simulations were verified with dose experimental measurements using Gafchromic films. The spatial dose distribution was converted into an initial pressure source spatial distribution using the medium-dependent dose-pressure relation. The MATLAB-based toolbox k-Wave was then used to model the propagation of acoustic waves through the phantom and perform time-reversal (TR)-based imaging reconstruction. The effect of the various linear accelerator (linac) operating parameters, including linac pulse duration and pulse repetition rate (frequency), were investigated as well.

RESULTS

The MC dose simulation results agreed with the film measurement results, specifically at the central beam region up to 80% dose within approximately 5% relative error for the central profile region and a local relative error of <6% for percentage dose depth. IRAI-based FWHM of the radiation beam was within approximately 3 mm relative to the MC-simulated beam FWHM at the beam entrance. The real-time pressure signal change agreed with the dose changes proving the capability of the iRAI for predicting the beam position. IRAI was tested through 3D simulations of its response to be based on the temporal changes in the linac operating parameters on a dose per pulse basis as expected theoretically from the pressure-dose proportionality. The pressure signal amplitude obtained through 2D simulations was proportional to the dose per pulse. The instantaneous pressure signal amplitude decreases as the linac pulse duration increases, as predicted from the pressure wave generation equations, such that the shorter the linac pulse the higher the signal and the better the temporal (spatial) resolutions of iRAI. The effect of the longer linac pulse duration on the spatial resolution of the 3D constructed iRAI images was corrected for linac pulse deconvolution. This correction has improved the passing rate of the 1%/1 mm gamma test criteria, between the pressure-constructed and dosimetric beam characteristics, to as high as 98%.

CONCLUSIONS

A full simulation workflow was developed for testing the effectiveness of iRAI as a promising relative dosimetry tool for UHDR-RT radiation therapy. IRAI has shown the advantage of 3D dose mapping through the dose signal linearity and, hence, has the potential to be a useful dosimeter at depth dose measurement and beam localization and, hence, potentially for in vivo dosimetry in UHDR-RT.

Translational Research in FLASH Radiotherapy-From Radiobiological Mechanisms to In Vivo Results

FLASH radiotherapy, or the administration of ultra-high dose rate radiotherapy, is a new radiation delivery method that aims to widen the therapeutic window in radiotherapy. Thus far, most in vitro and in vivo results show a real potential of FLASH to offer superior normal tissue sparing compared to conventionally delivered radiation. While there are several postulations behind the differential behaviour among normal and cancer cells under FLASH, the full spectra of radiobiological mechanisms are yet to be clarified. Currently the number of devices delivering FLASH dose rate is few and is mainly limited to experimental and modified linear accelerators. Nevertheless, FLASH research is increasing with new developments in all the main areas: radiobiology, technology and clinical research. This paper presents the current status of FLASH radiotherapy with the aforementioned aspects in mind, but also to highlight the existing challenges and future prospects to overcome them.

Biological and Mechanical Synergies to Deal With Proton Therapy Pitfalls: Minibeams, FLASH, Arcs, and Gantryless Rooms

Proton therapy has advantages and pitfalls comparing with photon therapy in radiation therapy. Among the limitations of protons in clinical practice we can selectively mention: uncertainties in range, lateral penumbra, deposition of higher LET outside the target, entrance dose, dose in the beam path, dose constraints in critical organs close to the target volume, organ movements and cost. In this review, we combine proposals under study to mitigate those pitfalls by using individually or in combination: (a) biological approaches of beam management in time (very high dose rate “FLASH” irradiations in the order of 100 Gy/s) and (b) modulation in space (a combination of mini-beams of millimetric extent), together with mechanical approaches such as (c) rotational techniques (optimized in partial arcs) and, in an effort to reduce cost, (d) gantry-less delivery systems. In some cases, these proposals are synergic (e.g., FLASH and minibeams), in others they are hardly compatible (mini-beam and rotation). Fixed lines have been used in pioneer centers, or for specific indications (ophthalmic, radiosurgery,…), they logically evolved to isocentric gantries. The present proposals to produce fixed lines are somewhat controversial. Rotational techniques, minibeams and FLASH in proton therapy are making their way, with an increasing degree of complexity in these three approaches, but with a high interest in the basic science and clinical communities. All of them must be proven in clinical applications.