Advances in in vivo EPR Tooth BIOdosimetry: Meeting the targets for initial triage following a large-scale radiation event

In Vivo Verification of Electron Paramagnetic Resonance Biodosimetry Using Patients Undergoing Radiation Therapy Treatment

PURPOSE

Electron paramagnetic resonance (EPR) biodosimetry, used to triage large numbers of individuals incidentally exposed to unknown doses of ionizing radiation, is based on detecting a stable physical response in the body that is subject to quantifiable variation after exposure. In vivo measurement is essential to fully characterize the radiation response relevant to a living tooth measured in situ. The purpose of this study was to verify EPR spectroscopy in vivo by estimating the radiation dose received in participants' teeth.

METHODS AND MATERIALS

A continuous wave L-band spectrometer was used for EPR measurements. Participants included healthy volunteers and patients undergoing head and neck and total body irradiation treatments. Healthy volunteers completed 1 measurement each, and patients underwent measurement before starting treatment and between subsequent fractions. Optically stimulated luminescent dosimeters and diodes were used to determine the dose delivered to the teeth to validate EPR measurements.

RESULTS

Seventy measurements were acquired from 4 total body irradiation and 6 head and neck patients over 15 months. Patient data showed a linear increase of EPR signal with delivered dose across the dose range tested. A linear least-squares weighted fit of the data gave a statistically significant correlation between EPR signal and absorbed dose (P < .0001). The standard error of inverse prediction (SEIP), used to assess the usefulness of fits, was 1.92 Gy for the dose range most relevant for immediate triage (≤7 Gy). Correcting for natural background radiation based on patient age reduced the SEIP to 1.51 Gy.

CONCLUSIONS

This study demonstrated the feasibility of using spectroscopic measurements from radiation therapy patients to validate in vivo EPR biodosimetry. The data illustrated a statistically significant correlation between the magnitude of EPR signals and absorbed dose. The SEIP of 1.51 Gy, obtained under clinical conditions, indicates the potential value of this technique in response to large radiation events.

Enhancing Precision in L-band Electron Paramagnetic Resonance Tooth Dosimetry: Incorporating Digital Image Processing and Radiation Therapy Plans for Geometric Correction

ABSTRACT

Following unforeseen exposure to radiation, quick dose determination is essential to prioritize potential patients that require immediate medical care. L-band electron paramagnetic resonance tooth dosimetry can be efficiently used for rapid triage as this poses no harm to the human incisor, although geometric variations among human teeth may hinder accurate dose estimation. Consequently, we propose a practical geometric correction method using a mobile phone camera. Donated human incisors were irradiated with calibrated 6-MV photon beam irradiation, and dose-response curves were developed by irradiation with a predetermined dose using custom-made poly(methyl methacrylate) slab phantoms. Three radiation treatment plans for incisors were selected and altered to suit the head phantom. The mean doses on tooth structures were calculated using a commercial treatment planning system, and the electron paramagnetic resonance signals of the incisors were measured. The enamel area was computed from camera-acquired tooth images. The relative standard uncertainty was rigorously estimated both with and without geometric correction. The effects on the electron paramagnetic resonance signal caused by axial and rotational movements of tooth samples were evaluated through finite element analysis. The mean absolute deviations of mean doses both with and without geometric correction showed marginal improvement. The average relative differences without and with geometric correction significantly decreased from 21.0% to 16.8% (p = 0.01). The geometric correction method shows potential in improving dose precision measurement with minimal delay. Furthermore, our findings demonstrated the viability of using treatment planning system doses in dose estimation for L-band electron paramagnetic resonance tooth dosimetry.

EPR biodosimetry: challenges and opportunities

This paper briefly examines electron paramagnetic resonance (EPR) techniques to measure dose from exposure to external radiation, assessing their current status, potential future uses and the challenges impacting their progress. We conclude the uses and potential value of different EPR techniques depend on the number of victims and whether they characterize short- or long-term risks from exposure. For large populations, EPR biodosimetry based on in vivo measurements or using co-located inanimate objects offer the greatest promise for assessing acute, life-threatening risk and the magnitude and extent of such risk. To assess long-term risk, ex vivo EPR methods using concentrated enamel from exfoliated teeth are most impactful. For small groups, ex vivo EPR biodosimetry based on available samples of teeth, nails and/or bones are most useful. The most important challenges are common to all approaches: improve the technique's technical capabilities and advance recognition by planning groups of the relative strengths EPR techniques offer for each population size. The most useful applications are likely to be for triage and medical guidance in large events and for radiation epidemiology to evaluate long-term risks.

Frequency-fixed motion compensation system for in-vivo electron paramagnetic resonance tooth dosimetry

This article describes the design process for a motion compensation system that can suppress the spectral distortion caused by human motion and breathing during in-vivo electron paramagnetic resonance (EPR) spectroscopy on an intact incisor. The developed system consists of two elements: an electronically controlled tunable resonator and an automatic control circuit (ACC). The resonator can modify the resonant frequency and impedance by tuning and matching the voltage, while the ACC can generate a feedback signal using phase-sensitive detection (PSD). The signal is transferred into the resonator to maintain the critical coupling state. The tunable frequency range of the resonator was measured at over 10 MHz, offering approximately eight times the required range. The bandwidth of the resonator fluctuated in a negligible range (0.14% relative standard error) following the resonant frequency. With the feedback signal on, in-vivo EPR measurements were demonstrated to be a stable baseline with 35% higher signal-to-noise ratio (SNR). When one incisor sample was irradiated by an X-ray instrument, the EPR signal responses to the absorbed doses of 0-10 Gy exhibited high linearity (R2 = 0.994). In addition, the standard error of inverse prediction was estimated to be 0.35 Gy. The developed system achieved a discrimination ability of 2 Gy, which is required for triage in large-scale radiation accidents. Moreover, the compensation is fully automated, meaning that the system can be operated with simple training in an emergency.

Early-response multiple-parameter biodosimetry and dosimetry: risk predictions

The accepted generic multiple-parameter and early-response biodosimetry and dosimetry assessment approach for suspected high-dose radiation (i.e. life-threatening) exposure includes measuring radioactivity associated with the exposed individual (if appropriate); observing and recording prodromal signs/symptoms; obtaining serial complete blood counts with white-blood-cell differential; sampling blood for the chromosome-aberration cytogenetic bioassay using the 'gold standard' dicentric assay (premature chromosome condensation assay for exposures >5 Gy photon acute doses equivalent), measurement of proteomic biomarkers and gene expression assays for dose assessment; bioassay sampling, if appropriate, to determine radioactive internal contamination; physical dose reconstruction, and using other available opportunistic dosimetry approaches. Biodosimetry and dosimetry resources are identified and should be setup in advance along with agreements to access additional national, regional, and international resources. This multifaceted capability needs to be integrated into a biodosimetry/dosimetry 'concept of operations' for use in a radiological emergency. The combined use of traditional biological-, clinical-, and physical-dosimetry should be use in an integrated approach to provide: (a) early-phase diagnostics to guide the development of initial medical-management strategy, and (b) intermediate and definitive assessment of radiation dose and injury. Use of early-phase (a) clinical signs and symptoms, (b) blood chemistry biomarkers, and (c) triage cytogenetics shows diagnostic utility to predict acute radiation injury severity.

Training of clinical triage of acute radiation casualties: a performance comparison ofon-siteversusonlinetraining due to the covid-19 pandemic

A collection of powerful diagnostic tools have been developed under the umbrellas of NATO for ionising radiation dose assessment (BAT, WinFRAT) and estimate of acute health effects in humans (WinFRAT, H-Module). We assembled a database of 191 ARS cases using the medical treatment protocols for radiation accident victims (n= 167) and the system for evaluation and archiving of radiation accidents based on case histories (n= 24) for training purposes of medical personnel. From 2016 to 2019, we trained 39 participants comprising MSc level radiobiology students in an on-site teaching class. Enforced by the covid-19 pandemic in 2020 for the first time, an online teaching of nine MSc radiobiology students replaced the on-site teaching. We found that: (a) limitations of correct diagnostic decision-making based on clinical signs and symptoms were experienced unrelated to the teaching format. (b) A significant performance decrease concerning online (first number in parenthesis) versus on-site teaching (reference and second number in parenthesis) was seen regarding the estimate time (31 vs 61 cases per hour, two-fold decrease,p= 0.005). Also, the accurate assessment of response categories (89.9% vs 96.9%,p= 0.001), ARS (92.4% vs 96.7%,p= 0.002) and hospitalisation (93.5% vs 97.0%,p= 0.002) decreased by around 3%-7%. The performances of the online attendees were mainly distributed within the lower quartile performance of on-site participants and the 25%-75% interquartile range increased 3-7-fold. (c) Comparison of dose estimates performed by training participants with hematologic acute radiation syndrome (HARS) severity mirrored the known limitations of dose alone as a surrogate parameter for HARS severity at doses less than 1.5 Gy, but demonstrated correct determination of HARS 2-4 and support for clinical decision making at dose estimates >1.5 Gy, regardless of teaching format. (d) Overall, one-third of the online participants showed substantial misapprehension and insecurities of elementary course content that did not occur after the on-site teaching.

Dependence of Radiation-induced Signals on Geometry of Tooth Enamel Using a 1.15 GHz Electron Paramagnetic Resonance Spectrometer: Improvement of Dosimetric Accuracy

ABSTRACT

We aim to improve the accuracy of electron paramagnetic resonance (EPR)-based in vivo tooth dosimetry using the relationship between tooth geometry and radiation-induced signals (RIS). A homebuilt EPR spectrometer at L-band frequency of 1.15 GHz originally designed for non-invasive and in vivo measurements of intact teeth was used to measure the RIS of extracted human teeth. Twenty human central incisors were scanned by microCT and irradiated by 220 kVp x-rays. The RISs of the samples were measured by the EPR spectrometer as well as simulated by using the finite element analysis of the electromagnetic field. A linear relationship between simulated RISs and tooth geometric dimensions, such as enamel area, enamel volume, and labial enamel volume, was confirmed. The dose sensitivity was quantified as a slope of the calibration curve (i.e., RIS vs. dose) for each tooth sample. The linear regression of these dose sensitivities was established for each of three tooth geometric dimensions. Based on these findings, a method for the geometry correction was developed by use of expected dose sensitivity of a certain tooth for one of the tooth geometric dimensions. Using upper incisors, the mean absolute deviation (MAD) without correction was 1.48 Gy from an estimated dose of 10 Gy; however, the MAD corrected by enamel area, volume, and labial volume was reduced to 1.04 Gy, 0.77 Gy, and 0.83 Gy, respectively. In general, the method corrected by enamel volume showed the best accuracy in this study. This homebuilt EPR spectrometer for the purpose of non-invasive and in vivo tooth dosimetry was successfully tested for achieving measurements in situ. We demonstrated that the developed correction method could reduce dosimetric uncertainties resulting from the variations in tooth geometric dimensions.

Screening of Lipids for Early Triage and Dose Estimation after Acute Radiation Exposure in Rat Plasma Based on Targeted Lipidomics Analysis

Rapid early triage and dose estimation is vital for limited medical resource allocation and treatment of a large number of the wounded after radiological accidents. Lipidomics has been utilized to delineate biofluid lipid signatures after irradiation. Here, high-coverage targeted lipidomics was employed to screen radiosensitive lipids after 0, 1, 2, 3, 5, and 8 Gy total body irradiation at 4, 24, and 72 h postirradiation in rat plasma. Ultra-performance liquid chromatography-tandem mass spectrometry with a multiple reaction monitoring method was utilized. In total, 416 individual lipids from 18 major classes were quantified and those biomarkers altered in a dose-dependent manner constituted panel A-panel D. Receiver operator characteristic curve analysis using combined lipids showed good to excellent sensitivity and specificity in triaging different radiation exposure levels (area under curve = 0.814-1.000). The equations for dose estimation were established by stepwise regression analysis for three time points. A novel strategy for radiation early triage and dose estimation was first established and validated using panels of lipids. Our study suggests that it is feasible to acquire quantitative lipid biomarker panels using targeted lipidomics platforms for rapid, high-throughput triage, which can provide further insights in developing lipidomics strategies for radiation biodosimetry in humans.

The hunt for radiation biomarkers: current situation

Purpose: The possibility of a large-scale acute radiation exposure necessitates the development of new methods that could provide a rapid assessment of the doses received by individuals using high-throughput technologies. There is also a great interest in developing new biomarkers of dose exposure, which could be used in large molecular epidemiological studies in order to correlate estimated doses received and health effects. The goal of this review was to summarize current literature focused on biological dosimetry, namely radiation-responsive biomarkers.Methods: The studies involved in this review were thoroughly selected according to the determined criteria and PRISMA guidelines.Results: We described briefly recent advances in radiation genomics and metabolomics, giving particular emphasis to proteomic analysis. The majority of studies were performed on animal models (rats, mice, and non-human primates). They have provided much beneficial information, but the most relevant tests have been done on human (oncological) patients. By inspecting the radiaiton biodosimetry literate of the last 10 years, we identified a panel of candidate markers for each -omic approach involved.Conslusions: We reviewed different methodological approaches and various biological materials, which can be exploited for dose-effect prediction. The protein biomarkers from human plasma are ideal for this specific purpose. From a plethora of candidate markers, FDXR is a very promising transcriptomic candidate, and importantly this biomarker was also confirmed by some studies at protein level in humans.

Saving normal tissues - a goal for the ages

Almost since the earliest utilization of ionizing radiation, many within the radiation community have worked toward either preventing (i.e. protecting) normal tissues from unwanted radiation injury or rescuing them from the downstream consequences of exposure. However, despite over a century of such investigations, only incremental gains have been made toward this goal and, with certainty, no outright panacea having been found. In celebration of the 60th anniversary of the International Journal of Radiation Biology and to chronicle the efforts that have been made to date, we undertook a non-rigorous survey of the articles published by normal tissue researchers in this area, using those that have appeared in the aforementioned journal as a road map. Three 'snapshots' of publications on normal tissue countermeasures were taken: the earliest (1959-1963) and most recent (2013-2018) 5-year of issues, as well as a 5-year intermediate span (1987-1991). Limiting the survey solely to articles appearing within International Journal of Radiation Biology likely reduced the number of translational studies interrogated given the basic science tenor of this particular publication. In addition, by taking 'snapshots' rather than considering the entire breadth of the journal's history in this field, important papers that were published during the interim periods were omitted, for which we apologize. Nonetheless, since the journal's inception, we observed that, during the chosen periods, the majority of studies undertaken in the field of normal tissue countermeasures, whether investigating radiation protectants, mitigators or treatments, have focused on agents that interfere with the physical, chemical and/or biological effects known to occur during the acute period following whole body/high single dose exposures. This relatively narrow approach to the reduction of normal tissue effects, especially those that can take months, if not years, to develop, seems to contradict our growing understanding of the progressive complexities of the microenvironmental disruption that follows the initial radiation injury. Given the analytical tools now at our disposal and the enormous benefits that may be reaped in terms of improving patient outcomes, as well as the potential for offering countermeasures to those affected by accidental or mass casualty exposures, it appears time to broaden our approaches to developing normal tissue countermeasures. We have no doubt that the contributors and readership of the International Journal of Radiation Biology will continue to contribute to this effort for the foreseeable future.

A normalization method of the volume and geometry of tooth for X-band in vivo EPR dosimetry

The accuracy of in vivo EPR tooth dosimetry may be influenced by the volume and geometry variations in teeth, especially when there is considerable non-uniform sensitivity distribution in the active detection area of the cavity. To solve this problem, the present research proposed a normalization method specifically for X-band EPR in vivo tooth dosimetry. The volume and geometry of the measured tooth were reconstructed by digital image processing with images of the tooth impression slices, which were obtained by a custom-made impression module. The sensitivity distribution in the active detection area was established based on experiments with a point sample. Consequently, a composite normalization process that could calibrate the evaluated dose effectively was carried out by taking into account the influences not only from tooth volume and geometry but also from the non-uniform distribution of sensitivity. The effect and practicability of the method were evaluated by incisor samples. Results showed that the standard deviation could be reduced a maximum of 54.8% approximately after the composite normalization, an improvement compared to results from solely tooth volume. The correlation coefficient of the dose-response curve could be improved from 0.731 to 0.986. The preliminary method provides an approach potentially useful on site after radiation accidents when dealing with the influence of variations in the tooth volume and geometry for X-band EPR in vivo dose estimations.

Development of a novel mouth model as an alternative tool to test the effectiveness of an in vivo EPR dosimetry system

In a large-scale radiation event, thousands may be exposed to unknown amounts of radiation, some of which may be life-threatening without immediate attention. In such situations, a method to quickly and reliably estimate dose would help medical responders triage victims to receive life-saving care. We developed such a method using electron paramagnetic resonance (EPR) to make in vivo measurements of the maxillary incisors. This report provides evidence that the use of in vitro studies can provide data that are fully representative of the measurements made in vivo. This is necessary because, in order to systematically test and improve the reliability and accuracy of the dose estimates made with our EPR dosimetry system, it is important to conduct controlled studies in vitro using irradiated human teeth. Therefore, it is imperative to validate whether our in vitro models adequately simulate the measurements made in vivo, which are intended to help guide decisions on triage after a radiation event. Using a healthy volunteer with a dentition gap that allows using a partial denture, human teeth were serially irradiated in vitro and then, using a partial denture, placed in the volunteer's mouth for measurements. We compared dose estimates made using in vivo measurements made in the volunteer's mouth to measurements made on the same teeth in our complex mouth model that simulates electromagnetic and anatomic properties of the mouth. Our results demonstrate that this mouth model can be used in in vitro studies to develop the system because these measurements appropriately model in vivo conditions.

Effect of the tooth surface water on the accuracy of dose reconstructions in the X-band in vivo EPR dosimetry

The X-band in vivo EPR tooth dosimetry is promising as a tool for the initial triage after a large-scale radiation accident. The dielectric losses caused by water on the tooth surface (WTS) are one of the major sources of inaccuracies in this method. The effect was studied by theoretical simulation calculations and experiments with water films of various thicknesses on teeth. The results demonstrate the possibility of sufficiently accurate measurements of the radiation-induced signal of the tooth enamel provided that the thickness of the water film on the tooth is below 60 µm. The sensitivity of the cavity decreases with increasing thickness of the water layer. The interference of WTS can be diminished by normalization of the radiation-induced signal to the signal of a reference sample permanently present in the cavity.

Guidance to Transfer 'Bench-Ready' Medical Technology into Usual Clinical Practice: Case Study - Sensors and Spectrometer Used in EPR Oximetry

This paper considers the critical role that academics can have in the development of clinical innovations and especially how their impact can be optimized. The focus should be on establishing the safety and efficacy of new approaches while also incorporating human factors and human use considerations into the inventions. It is very advantageous to work in concert with the end-users (operators and clinicians) to help ensure that the innovation will be useful and feasible to be incorporated into actual clinical practice as intended. This strategy enables developments to tackle real clinical needs by providing novel strategies to improve patient care while using solutions that fit into clinical practice and that are welcomed by patients and clinical staff. These principles are illustrated by a case study of the development of clinical in vivo EPR oximetry.

Metabolomic applications in radiation biodosimetry: exploring radiation effects through small molecules

PURPOSE

Exposure of the general population to ionizing radiation has increased in the past decades, primarily due to long distance travel and medical procedures. On the other hand, accidental exposures, nuclear accidents, and elevated threats of terrorism with the potential detonation of a radiological dispersal device or improvised nuclear device in a major city, all have led to increased needs for rapid biodosimetry and assessment of exposure to different radiation qualities and scenarios. Metabolomics, the qualitative and quantitative assessment of small molecules in a given biological specimen, has emerged as a promising technology to allow for rapid determination of an individual's exposure level and metabolic phenotype. Advancements in mass spectrometry techniques have led to untargeted (discovery phase, global assessment) and targeted (quantitative phase) methods not only to identify biomarkers of radiation exposure, but also to assess general perturbations of metabolism with potential long-term consequences, such as cancer, cardiovascular, and pulmonary disease.

CONCLUSIONS

Metabolomics of radiation exposure has provided a highly informative snapshot of metabolic dysregulation. Biomarkers in easily accessible biofluids and biospecimens (urine, blood, saliva, sebum, fecal material) from mouse, rat, and minipig models, to non-human primates and humans have provided the basis for determination of a radiation signature to assess the need for medical intervention. Here we provide a comprehensive description of the current status of radiation metabolomic studies for the purpose of rapid high-throughput radiation biodosimetry in easily accessible biofluids and discuss future directions of radiation metabolomics research.

Evolution and Optimization of Tooth Models for Testing In Vivo EPR Tooth Dosimetry

Testing and verification are an integral part of any cycle to design, manufacture and improve a novel device intended for use in humans. In the case of testing Dartmouth's electron paramagnetic resonance (EPR) in vivo tooth dosimetry device, in vitro studies are needed throughout its development to test its performance, i.e. to verify its current capability for assessing dose in individuals potentially exposed to ionizing radiation. Since the EPR device uses the enamel of human teeth to assess dose, models that include human teeth have been an integral mechanism to carry out in vitro studies during development and testing its ability to meet performance standards for its ultimate intended in vivo use. As the instrument improves over time, new demands for in vitro studies change as well. This paper describes the tooth models used to perform in vitro studies and their evolution to meet the changing demands for testing in vivo EPR tooth dosimetry.

ROC Analysis for Evaluation of Radiation Biodosimetry Technologies

Receiver operating characteristic (ROC) analysis is a fundamental tool used for the evaluation and comparison of diagnostic systems that provides estimates of the combinations of sensitivity and specificity that can be achieved with a given technique. Along with critical considerations of practical limitations, such as throughput and time to availability of results, ROC analyses can be applied to provide meaningful assessments and comparisons of available biodosimetry methods. Accordingly, guidance from the Food and Drug Administration to evaluate biodosimetry devices recommends using ROC analysis. However, the existing literature for the numerous biodosimetry methods that have been developed to address the needs for triage either do not contain ROC analyses or present ROC analyses where the dose distributions of the study samples are not representative of the populations to be screened. The use of non-representative sample populations can result in a significant spectrum bias, where estimated performance metrics do not accurately characterize the true performance under real-world conditions. Particularly, in scenarios where a large group of people is screened because they were potentially exposed in a large-scale radiation event, directly measured population data do not exist. However, a number of complex simulations have been performed and reported in the literature that provide estimates of the required dose distributions. Based on these simulations and reported data about the output and uncertainties of biodosimetry assays, we illustrate how ROC curves can be generated that incorporate a realistic representative sample. A technique to generate ROC curves for biodosimetry data is presented along with representative ROC curves, summary statistics and discussion based on published data for triage-ready electron paramagnetic resonance in vivo tooth dosimetry, the dicentric chromosome assay and quantitative polymerase chain reaction assay. We argue that this methodology should be adopted generally to evaluate the performance of radiation biodosimetry screening assays so that they can be compared in the context of their intended use.

L Band EPR Tooth Dosimetry for Heavy Ion Irradiation

Electron Paramagnetic Resonance (EPR) tooth dosimetry is being developed as a device to rapidly assess large populations that were potentially exposed to radiation during a major radiation accident or terrorist event. While most exposures are likely to be due to fallout and therefore involve low linear energy transfer (LET) radiation, there is also a potential for exposures to high LET radiation, for which the effect on teeth has been less well characterized by EPR. Therefore, the aim of this paper is to acquire fundamental response curves for high LET radiation in tooth dosimetry using L band EPR. For this purpose, we exposed human teeth to high energy carbon ions using the heavy ion medical accelerator in Chiba at the National Institute of Radiological Sciences. The primary findings were that EPR signals for carbon ion irradiation were about one-tenth the amplitude of the response to the same dose of 150 kVp X-rays.