Investigation of effect of variations in bone fraction and red marrow cellularity on bone marrow dosimetry in radio-immunotherapy

SPECT/CT Image-Derived Absorbed Dose to Red Marrow Correlates with Hematologic Toxicity in Patients Treated with [177Lu]Lu-DOTATATE

Hematologic toxicity, although often transient, is the most common limiting adverse effect during somatostatin peptide receptor radionuclide therapy. This study investigated the association between Monte Carlo-derived absorbed dose to the red marrow (RM) and hematologic toxicity in patients being treated for their neuroendocrine tumors. Methods: Twenty patients each receiving 4 treatment cycles of [177Lu]Lu-DOTATATE were included. Multiple-time-point 177Lu SPECT/CT imaging-based RM dosimetry was performed using an artificial intelligence-driven workflow to segment vertebral spongiosa within the field of view (FOV). This workflow was coupled with an in-house macroscale/microscale Monte Carlo code that incorporates a spongiosa microstructure model. Absorbed dose estimates to RM in lumbar and thoracic vertebrae within the FOV, considered as representations of the whole-body RM absorbed dose, were correlated with hematologic toxicity markers at about 8 wk after each cycle and at 3- and 6-mo follow-up after completion of all cycles. Results: The median of absorbed dose to RM in lumbar and thoracic vertebrae within the FOV (D median,vertebrae) ranged from 0.019 to 0.11 Gy/GBq. The median of cumulative absorbed dose across all 4 cycles was 1.3 Gy (range, 0.6-2.5 Gy). Hematologic toxicity was generally mild, with no grade 2 or higher toxicity for platelets, neutrophils, or hemoglobin. However, there was a decline in blood counts over time, with a fractional value relative to baseline at 6 mo of 74%, 97%, 57%, and 97%, for platelets, neutrophils, lymphocytes, and hemoglobin, respectively. Statistically significant correlations were found between a subset of hematologic toxicity markers and RM absorbed doses, both during treatment and at 3- and 6-mo follow-up. This included a correlation between the platelet count relative to baseline at 6-mo follow up: D median,vertebrae (r = -0.64, P = 0.015), D median,lumbar (r = -0.72, P = 0.0038), D median,thoracic (r = -0.58, P = 0.029), and D average,vertebrae (r = -0.66, P = 0.010), where D median,lumbar and D median,thoracic are median absorbed dose to the RM in the lumbar and thoracic vertebrae, respectively, within the FOV and D average,vertebrae is the mass-weighted average absorbed dose of all vertebrae. Conclusion: This study found a significant correlation between image-derived absorbed dose to the RM and hematologic toxicity, including a relative reduction of platelets at 6-mo follow up. These findings indicate that absorbed dose to the RM can potentially be used to understand and manage hematologic toxicity in peptide receptor radionuclide therapy.

Quantification of the volume fraction of fat, water and bone mineral in spongiosa for red marrow dosimetry in molecular radiotherapy by using a dual-energy (SPECT/)CT

A patient-specific absorbed dose calculation for red marrow dosimetry requires quantifying patient-specific volume fractions of the red marrow, yellow marrow, and trabecular bone in the spongiosa of several skeletal sites. This quantification allows selecting appropriate S values calculated from the parameterized radiation transport models for bone and bone marrow dosimetry. Currently, no comprehensive, individualized, and non-invasive procedure is available for quantifying the volume fractions of red marrow, yellow marrow, and trabecular bone in the spongiosa. This study aims to provide a new quantitative method based on dual-energy computed tomography to fill this gap in red marrow dosimetry using a (SPECT/)CT system.

METHODS

First, a method for parametrizing the photon attenuation coefficients relative to water was implemented. Next, a method to calculate the effective atomic number (Z_eff) and effective mass density (ρ_eff) using dual-energy CT (DECT) was employed. Lastly, two- and three-material decomposition using a dual-energy quantitative CT method (DEQCT) was performed in an anthropomorphic spine phantom and two bone samples of a boar, respectively. The measurements of Z_eff and ρ_eff were compared with the syngo.CT DE Rho/Z tool (Siemens Healthineers). Furthermore, the DEQCT method implemented in this study (DEQCT-I) was compared with a second DEQCT method based on the use of external material standards (DEQCT-II). DEQCT-II was used as reference method for calculating relative errors.

RESULTS

The two-material decomposition in the anthropomorphic spine phantom presented a maximum relative error of -10% for the bone mineral density quantification. Furthermore, Z_eff and ρ_eff calculated by DEQCT-I differed from syngo.CT DE Rho/Z tool by less than 4.4% and 1.9%, respectively. The three-material decomposition in the two bone samples showed a maximum relative error of 21%, -17%, and 15% for the quantification of the volume fractions of fat, water, and bone mineral equivalent materials. Lastly, Z_eff and ρ_eff calculated by DEQCT-I differed from syngo.CT DE Rho/Z tool by less than 8.2% and 7.0%, respectively.

CONCLUSION

This study shows that quantifying the volume fraction of fat, water, and bone mineral using a phantom-independent and post-reconstruction DEQCT method is feasible. DEQCT-I has the advantage of not requiring prior information about the X-ray spectra or the detector sensitivity function, as is the case with spectral-based DEQCT methods. Instead, DEQCT-I, similar to other DEQCT methods depends on the chemical description of reference materials and a beam hardening correction function. DEQCT-I method provides an individualized and non-invasive procedure using a (SPECT/)CT system to apply S values based on the patient-specific volume fractions of yellow marrow, red marrow, and bone mineral in red marrow dosimetry.

Organ sparing of linac-based targeted marrow irradiation over total body irradiation

PURPOSE

Targeted marrow irradiation (TMI) is an alternative conditioning regimen to total body irradiation (TBI) before bone marrow transplantation in hematologic malignancies. Intensity-modulation methods of external beam radiation therapy are intended to permit significant organ sparing while maintaining adequate target coverage, improving the therapeutic ratio. This study directly compares the dose distributions to targets and organs at risk from TMI and TBI, both modalities conducted by general-use medical linacs at our institution.

METHODS

TMI treatments were planned for 10 patients using multi-isocentric feathered volumetric arc therapy (VMAT) plans, delivered by 6 MV photon beams of Elekta Synergy linacs. The computed tomography (CT) datasets used to obtain these plans were also used to generate dose distributions of TBI treatments given in the AP/PA extended-field method. We compared dose distributions normalized to the same prescription for both plan types. The generalized equivalent uniform dose (gEUD) of Niemierko for organs and target volumes was used to quantify effective whole structure dose and dose savings.

RESULTS

For the clinical target volume (CTV), no significant differences were found in mean dose or gEUD, although the radical dose homogeneity index (minimum dose divided by maximum dose) was 31.7% lower (P = 0.002) and the standard deviation of dose was 28.0% greater (P = 0.027) in the TMI plans than in the TBI plans. For the TMI plans, gEUD to the lungs, brain, kidneys, and liver was significantly lower (P < 0.001) by 47.8%, 33.3%, 55.4%, and 51.0%, respectively.

CONCLUSION

TMI is capable of maintaining CTV coverage as compared to that achieved in TBI, while significantly sparing organs at risk. Improvement on sparing organs at risk permits a higher prescribed dose to the target or the maximum number of times marrow conditioning may be delivered to a patient while maintaining similar typical tissue complication rates.

Quantification of the trabecular bone volume fraction for bone marrow dosimetry in molecular radiotherapy by using a dual-energy (SPECT/)CT

A complete characterization of spongiosa (bone marrow plus trabecular bone) is required to calculate the absorbed dose to active bone marrow. Due to the complex microanatomy, it is necessary to apply non-conventional imaging methods in nuclear medicine. The aim of this study is validating a phantomless quantification method using dual-energy quantitative computed tomography (DEQCT) for the quantification of trabecular bone volume fraction for bone marrow dosimetry in molecular radiotherapy. First, a phantomless quantification method (mass fraction method) based on x-ray beam and detector sensitivity was validated in an integrated dual energy SPECT/CT and in a dual source computed tomography (DSCT) system for comparison. The validation was performed in a phantom consisting of different water, fat and hydroxyapatite compositions. Moreover, the European spine phantom (ESP) was used to simulate the spine geometry. Bone mineral content (BMC) of the whole vertebra and bone mineral density (BMD) in the spongiosa region of each phantom vertebra were measured using DEQCT and dual energy x-ray absorptiometry (DEXA). Lastly, BMC was measured in a patient using DEQCT and DEXA. Measured values of hydroxyapatite fraction and nominal values in the homemade phantom showed a good correlation. The relative error remained below 14.2%. Quantification of BMC (in whole vertebra) and BMD (in spongiosa) in the ESP showed a good agreement between measured values and nominal values. The relative error remained between 0.7% and 7.5% for BMC_SPECT/CT, 1.1% and 7.7% for BMC_DSCT, 5.4% and 32.0 for BMD_SPECT/CT, and 59.4% and 10.0% for BMD_DSCT. Quantification of BMC in lumbar vertebrae 1 and 2 of a patient showed relative errors of 7.6% and -8.4% between DEXA and DSCT. Our study shows that DEQCT using a mass fraction method (phantomless) enables quantification of hydroxyapatite in a clinical nuclear medicine setting. An overestimation of the hydroxyapatite volume fraction was observed in all quantified regions, in particular in the spongiosa region of ESP. This result might be related to insufficient information about the x-ray spectra and the detector sensitivity function.

Quantitative impact of changes in marrow cellularity, skeletal size, and bone mineral density on active marrow dosimetry based upon a reference model

PURPOSE

The hematopoietically active tissues of skeletal bone marrow are a prime target for computational dosimetry given potential risks of leukemia and, at higher dose levels, acute marrow toxicity. The complex three-dimensional geometry of trabecular spongiosa, however, complicates schema for dose assessment in such a way that only a few reference skeletal models have been developed to date, and which are based upon microimaging of a limited number of cadaveric bone spongiosa cores. The question then arises as to what degree of accuracy is achievable from reference skeletal dose models when applied to individual patients or specific exposed populations?

METHODS

Patient variability in marrow dosimetry were quantified for three skeletal sites - the ribs, lumbar vertebrae, and cranium - for the beta-emitters ⁴⁵ Ca, ¹⁵³ Sm, and ⁹⁰ Y, and the alpha-particle emitters ²²³ Ra, ²¹⁹ Rn, and ²¹⁵ Po, the latter two being the immediate progeny of the former. For each radionuclide and bone site, three patient parameters were altered from their values in the reference model: (1) bone size as a surrogate for patient stature, (2) marrow cellularity as a surrogate for age- or disease-related changes in marrow adiposity, and (3) the trabecular bone volume fraction as a surrogate for bone mineral density. Marrow dose variability is expressed as percent differences in the radionuclide S value given by the reference model and the patient-parameterized model. The impact of radionuclide biokinetics on marrow dosimetry was not considered.

RESULTS

Variations in overall bone size play a very minor role in active marrow dose variability. Marrow cellularity is a significant factor in dose variability for active marrow self-irradiation, but it plays no role for radionuclides localized to the trabecular bone matrix. Variations in trabecular bone volume fractions impact the active marrow dose variability for short-range particle emitters ⁴⁵ Ca, ²²³ Ra, ²¹⁹ Rn, and ²¹⁵ Po in the vertebrae and ribs, skeletal sites with small spongiosa proportions of trabecular bone. In the cranium, with its relative high proportion of trabecular bone, significant differences in marrow dosimetry from the reference model were noted for all radionuclides.

CONCLUSIONS

Skeletal models of active marrow dosimetry should be more fully parameterized to permit closer matching to patient bone density and marrow cellularity, particularly when considering short-range particle emitters localized to either the bone trabeculae or active marrow, respectively.

Evaluation of dual energy quantitative CT for determining the spatial distributions of red marrow and bone for dosimetry in internal emitter radiation therapy

PURPOSE

To evaluate a three-equation three-unknown dual-energy quantitative CT (DEQCT) technique for determining region specific variations in bone spongiosa composition for improved red marrow dose estimation in radionuclide therapy.

METHODS

The DEQCT method was applied to 80/140 kVp images of patient-simulating lumbar sectional body phantoms of three sizes (small, medium, and large). External calibration rods of bone, red marrow, and fat-simulating materials were placed beneath the body phantoms. Similar internal calibration inserts were placed at vertebral locations within the body phantoms. Six test inserts of known volume fractions of bone, fat, and red marrow were also scanned. External-to-internal calibration correction factors were derived. The effects of body phantom size, radiation dose, spongiosa region segmentation granularity [single (∼17 × 17 mm) region of interest (ROI), 2 × 2, and 3 × 3 segmentation of that single ROI], and calibration method on the accuracy of the calculated volume fractions of red marrow (cellularity) and trabecular bone were evaluated.

RESULTS

For standard low dose DEQCT x-ray technique factors and the internal calibration method, the RMS errors of the estimated volume fractions of red marrow of the test inserts were 1.2-1.3 times greater in the medium body than in the small body phantom and 1.3-1.5 times greater in the large body than in the small body phantom. RMS errors of the calculated volume fractions of red marrow within 2 × 2 segmented subregions of the ROIs were 1.6-1.9 times greater than for no segmentation, and RMS errors for 3 × 3 segmented subregions were 2.3-2.7 times greater than those for no segmentation. Increasing the dose by a factor of 2 reduced the RMS errors of all constituent volume fractions by an average factor of 1.40 ± 0.29 for all segmentation schemes and body phantom sizes; increasing the dose by a factor of 4 reduced those RMS errors by an average factor of 1.71 ± 0.25. Results for external calibrations exhibited much larger RMS errors than size matched internal calibration. Use of an average body size external-to-internal calibration correction factor reduced the errors to closer to those for internal calibration. RMS errors of less than 30% or about 0.01 for the bone and 0.1 for the red marrow volume fractions would likely be satisfactory for human studies. Such accuracies were achieved for 3 × 3 segmentation of 5 mm slice images for: (a) internal calibration with 4 times dose for all size body phantoms, (b) internal calibration with 2 times dose for the small and medium size body phantoms, and (c) corrected external calibration with 4 times dose and all size body phantoms.

CONCLUSIONS

Phantom studies are promising and demonstrate the potential to use dual energy quantitative CT to estimate the spatial distributions of red marrow and bone within the vertebral spongiosa.

Tumor-Absorbed Dose Predicts Progression-Free Survival Following (131)I-Tositumomab Radioimmunotherapy

The study aimed at identifying patient-specific dosimetric and nondosimetric factors predicting outcome of non-Hodgkin lymphoma patients after (131)I-tositumomab radioimmunotherapy for potential use in treatment planning.

METHODS

Tumor-absorbed dose measures were estimated for 130 tumors in 39 relapsed or refractory non-Hodgkin lymphoma patients by coupling SPECT/CT imaging with the Dose Planning Method (DPM) Monte Carlo code. Equivalent biologic effect was calculated to assess the biologic effects of nonuniform absorbed dose including the effects of the unlabeled antibody. Evaluated nondosimetric covariates included histology, presence of bulky disease, and prior treatment history. Tumor level outcome was based on volume shrinkage assessed on follow-up CT. Patient level outcome measures were overall response (OR), complete response (CR), and progression-free survival (PFS), determined from clinical assessments that included PET/CT.

RESULTS

The estimated mean tumor-absorbed dose had a median value of 275 cGy (range, 94-711 cGy). A high correlation was observed between tracer-predicted and therapy-delivered mean tumor-absorbed doses (P < 0.001; r = 0.85). In univariate tumor-level analysis, tumor shrinkage correlated significantly with almost all of the evaluated dosimetric factors, including equivalent biologic effect. Regression analysis showed that OR, CR, and PFS were associated with the dosimetric factors and equivalent biologic effect. Both mean tumor-absorbed dose (P = 0.025) and equivalent biologic effect (P = 0.035) were significant predictors of PFS whereas none of the nondosimetric covariates were found to be statistically significant factors affecting PFS. The most important finding of the study was that in Kaplan-Meier curves stratified by mean dose, longer PFS was observed in patients receiving mean tumor-absorbed doses greater than 200 cGy than in those receiving 200 cGy or less (median PFS, 13.6 vs. 1.9 mo for the 2 dose groups; log-rank P < 0.0001).

CONCLUSION

A higher mean tumor-absorbed dose was significantly predictive of improved PFS after (131)I-tositumomab radioimmunotherapy. Hence tumor-absorbed dose, which can be estimated before therapy, can potentially be used to design radioimmunotherapy protocols to improve efficacy.