Radiotherapy with laser-plasma accelerators: Monte Carlo simulation of dose deposited by an experimental quasimonoenergetic electron beam

First in vitro cell co-culture experiments using laser-induced high-energy electron FLASH irradiation for the development of anti-cancer therapeutic strategies

Radiation delivery at ultrahigh dose rates (UHDRs) has potential for use as a new anticancer therapeutic strategy. The FLASH effect induced by UHDR irradiation has been shown to maintain antitumour efficacy with a reduction in normal tissue toxicity; however, the FLASH effect has been difficult to demonstrate in vitro. The objective to demonstrate the FLASH effect in vitro is challenging, aiming to reveal a differential response between cancer and normal cells to further identify cell molecular mechanisms. New high-intensity petawatt laser-driven accelerators can deliver very high-energy electrons (VHEEs) at dose rates as high as 1013 Gy/s in very short pulses (10-13 s). Here, we present the first in vitro experiments carried out on cancer cells and normal non-transformed cells concurrently exposed to laser-plasma accelerated (LPA) electrons. Specifically, melanoma cancer cells and normal melanocyte co-cultures grown on chamber slides were simultaneously irradiated with LPA electrons. A non-uniform dose distribution on the cell cultures was revealed by Gafchromic films placed behind the chamber slide supporting the cells. In parallel experiments, cell co-cultures were exposed to pulsed X-ray irradiation, which served as positive controls for radiation-induced nuclear DNA double-strand breaks. By measuring the impact on discrete areas of the cell monolayers, the greatest proportion of the damaged DNA-containing nuclei was attained by the LPA electrons at a cumulative dose one order of magnitude lower than the dose obtained by pulsed X-ray irradiation. Interestingly, in certain discrete areas, we observed that LPA electron exposure had a different effect on the DNA damage in healthy normal human epidermal melanocyte (NHEM) cells than in A375 melanoma cells; here, the normal cells were less affected by the LPA exposure than cancer cells. This result is the first in vitro demonstration of a differential response of tumour and normal cells exposed to FLASH irradiation and may contribute to the development of new cell culture strategies to explore fundamental understanding of FLASH-induced cell effect.

Use of spatiotemporal couplings and an axiparabola to control the velocity of peak intensity

This paper presents the first experimental realization of a scheme that allows for the tuning of the velocity of peak intensity of a focal spot with relativistic intensity. By combining a tunable pulse-front curvature with the axial intensity deposition characteristics of an axiparabola, an aspheric optical element, this system provides control over the dynamics of laser-wakefield accelerators. We demonstrate the ability to modify the velocity of peak intensity of ultrashort laser pulses to be superluminal or subluminal. The experimental results are supported by theoretical calculations and simulations, strengthening the case for the axiparabola as a pertinent strategy to achieve more efficient acceleration.

Extending deterministic transport capabilities for very-high and ultra-high energy electron beams

Focused Very-High Energy Electron (VHEE, 50-300 MeV) and Ultra-High Energy Electron (UHEE, > 300 MeV) beams can accurately target both large and deeply seated human tumors with high sparing properties, while avoiding the spatial requirements and cost of proton and heavy ion facilities. Advanced testing phases are underway at the CLEAR facilities at CERN (Switzerland), NLCTA at Stanford (USA), and SPARC at INFN (Italy), aiming to accelerate the transition to clinical application. Currently, Monte Carlo (MC) transport is the sole paradigm supporting preclinical trials and imminent clinical deployment. In this paper, we propose an alternative: the first extension of the nuclear-reactor deterministic chain NJOY-DRAGON for VHEE and UHEE applications. We have extended the Boltzmann-Fokker-Planck (BFP) multigroup formalism and validated it using standard radio-oncology benchmarks, complex assemblies with a wide range of atomic numbers, and comprehensive irradiation of the entire periodic table. We report that [Formula: see text] of water voxels exhibit a BFP-MC deviation below [Formula: see text] for electron energies under [Formula: see text]. Additionally, we demonstrate that at least [Formula: see text] of voxels of bone, lung, adipose tissue, muscle, soft tissue, tumor, steel, and aluminum meet the same criterion between [Formula: see text] and [Formula: see text]. For water, the thorax, and the breast intra-operative benchmark, typical average BFP-MC deviations of [Formula: see text] and [Formula: see text] were observed at [Formula: see text] and [Formula: see text], respectively. By irradiating the entire periodic table, we observed similar performance between lithium ([Formula: see text]) and cerium ([Formula: see text]). Deficiencies observed between praseodymium ([Formula: see text]) and einsteinium ([Formula: see text]) have been reported, analyzed, and quantified, offering critical insights for the ongoing development of the Evaluated Nuclear Data File mode in NJOY.

Ultra‐High dose rate radiation production and delivery systems intended for FLASH

Higher dose rates, a trend for radiotherapy machines, can be beneficial in shortening treatment times for radiosurgery and mitigating the effects of motion. Recently, even higher doses (e.g., 100 times greater) have become targeted because of their potential to generate the FLASH effect (FE). We refer to these physical dose rates as ultra‐high (UHDR). The complete relationship between UHDR and the FE is unknown. But UHDR systems are needed to explore the relationship further and to deliver clinical UHDR treatments, where indicated. Despite the challenging set of unknowns, the authors seek to make reasonable assumptions to probe how existing and developing technology can address the UHDR conditions needed to provide beam generation capable of producing the FE in preclinical and clinical applications. As a preface, this paper discusses the known and unknown relationships between UHDR and the FE. Based on these, different accelerator and ionizing radiation types are then discussed regarding the relevant UHDR needs. The details of UHDR beam production are discussed for existing and potential future systems such as linacs, cyclotrons, synchrotrons, synchrocyclotrons, and laser accelerators. In addition, various UHDR delivery mechanisms are discussed, along with required developments in beam diagnostics and dose control systems.

Back to the Future: Very High-Energy Electrons (VHEEs) and Their Potential Application in Radiation Therapy

The development of innovative approaches that would reduce the sensitivity of healthy tissues to irradiation while maintaining the efficacy of the treatment on the tumor is of crucial importance for the progress of the efficacy of radiotherapy. Recent methodological developments and innovations, such as scanned beams, ultra-high dose rates, and very high-energy electrons, which may be simultaneously available on new accelerators, would allow for possible radiobiological advantages of very short pulses of ultra-high dose rate (FLASH) therapy for radiation therapy to be considered. In particular, very high-energy electron (VHEE) radiotherapy, in the energy range of 100 to 250 MeV, first proposed in the 2000s, would be particularly interesting both from a ballistic and biological point of view for the establishment of this new type of irradiation technique. In this review, we examine and summarize the current knowledge on VHEE radiotherapy and provide a synthesis of the studies that have been published on various experimental and simulation works. We will also consider the potential for VHEE therapy to be translated into clinical contexts.

A focused very high energy electron beam for fractionated stereotactic radiotherapy

An electron beam of very high energy (50-250 MeV) can potentially produce a more favourable radiotherapy dose distribution compared to a state-of-the-art photon based radiotherapy technique. To produce an electron beam of sufficiently high energy to allow for a long penetration depth (several cm), very large accelerating structures are needed when using conventional radio-frequency technology, which may not be possible due to economical or spatial constraints. In this paper, we show transport and focusing of laser wakefield accelerated electron beams with a maximum energy of 160 MeV using electromagnetic quadrupole magnets in a point-to-point imaging configuration, yielding a spatial uncertainty of less than 0.1 mm, a total charge variation below [Formula: see text] and a focal spot of [Formula: see text]. The electron beam was focused to control the depth dose distribution and to improve the dose conformality inside a phantom of cast acrylic slabs and radiochromic film. The phantom was irradiated from 36 different angles to obtain a dose distribution mimicking a stereotactic radiotherapy treatment, with a peak fractional dose of 2.72 Gy and a total maximum dose of 65 Gy. This was achieved with realistic constraints, including 23 cm of propagation through air before any dose deposition in the phantom.

Physics and biology of ultrahigh dose-rate (FLASH) radiotherapy: a topical review

Ultrahigh dose-rate radiotherapy (RT), or 'FLASH' therapy, has gained significant momentum following various in vivo studies published since 2014 which have demonstrated a reduction in normal tissue toxicity and similar tumor control for FLASH-RT when compared with conventional dose-rate RT. Subsequent studies have sought to investigate the potential for FLASH normal tissue protection and the literature has been since been inundated with publications on FLASH therapies. Today, FLASH-RT is considered by some as having the potential to 'revolutionize radiotherapy'. FLASH-RT is considered by some as having the potential to 'revolutionize radiotherapy'. The goal of this review article is to present the current state of this intriguing RT technique and to review existing publications on FLASH-RT in terms of its physical and biological aspects. In the physics section, the current landscape of ultrahigh dose-rate radiation delivery and dosimetry is presented. Specifically, electron, photon and proton radiation sources capable of delivering ultrahigh dose-rates along with their beam delivery parameters are thoroughly discussed. Additionally, the benefits and drawbacks of radiation detectors suitable for dosimetry in FLASH-RT are presented. The biology section comprises a summary of pioneering in vitro ultrahigh dose-rate studies performed in the 1960s and early 1970s and continues with a summary of the recent literature investigating normal and tumor tissue responses in electron, photon and proton beams. The section is concluded with possible mechanistic explanations of the FLASH normal-tissue protection effect (FLASH effect). Finally, challenges associated with clinical translation of FLASH-RT and its future prospects are critically discussed; specifically, proposed treatment machines and publications on treatment planning for FLASH-RT are reviewed.

Toward an effective use of laser-driven very high energy electrons for radiotherapy: Feasibility assessment of multi-field and intensity modulation irradiation schemes

Radiotherapy with very high energy electrons has been investigated for a couple of decades as an effective approach to improve dose distribution compared to conventional photon-based radiotherapy, with the recent intriguing potential of high dose-rate irradiation. Its practical application to treatment has been hindered by the lack of hospital-scale accelerators. High-gradient laser-plasma accelerators (LPA) have been proposed as a possible platform, but no experiments so far have explored the feasibility of a clinical use of this concept. We show the results of an experimental study aimed at assessing dose deposition for deep seated tumours using advanced irradiation schemes with an existing LPA source. Measurements show control of localized dose deposition and modulation, suitable to target a volume at depths in the range from 5 to 10 cm with mm resolution. The dose delivered to the target was up to 1.6 Gy, delivered with few hundreds of shots, limited by secondary components of the LPA accelerator. Measurements suggest that therapeutic doses within localized volumes can already be obtained with existing LPA technology, calling for dedicated pre-clinical studies.

Focused very high-energy electron beams as a novel radiotherapy modality for producing high-dose volumetric elements

The increased inertia of very high-energy electrons (VHEEs) due to relativistic effects reduces scattering and enables irradiation of deep-seated tumours. However, entrance and exit doses are high for collimated or diverging beams. Here, we perform a study based on Monte Carlo simulations of focused VHEE beams in a water phantom, showing that dose can be concentrated into a small, well-defined volumetric element, which can be shaped or scanned to treat deep-seated tumours. The dose to surrounding tissue is distributed over a larger volume, which reduces peak surface and exit doses for a single beam by more than one order of magnitude compared with a collimated beam.

Expanding the therapeutic index of radiation therapy by normal tissue protection

Normal tissue damages induced by radiation therapy remain dose-limiting factors in radiation oncology and this is still true despite recent advances in treatment planning and delivery of image-guided radiation therapy. Additionally, as the number of long-term cancer survivors increases, unacceptable complications emerge and dramatically reduce the patients' quality of life. This means that patients and clinicians expect discovery of new options for the therapeutic management of radiation-induced complications. Over the past four decades, research has enhanced our understanding of the pathophysiological, cellular and molecular processes governing normal tissue toxicity. Those processes are complex and involve the cross-talk between the various cells of a tissue, including fibroblasts, endothelial, immune and epithelial cells as well as soluble paracrine factors including growth factors and proteases. We will review the translatable pharmacological approaches that have been developed to prevent, mitigate, or reverse radiation injuries based upon the targeting of cellular and signalling pathways. We will summarize the different steps of the research strategy, from the definition of initial biological hypotheses to preclinical studies and clinical translation. We will also see how novel research and therapeutic hypotheses emerge along the way as well as briefly highlight innovative approaches based upon novel radiotherapy delivery procedures.

Note: Real-time monitoring via second-harmonic interferometry of a flow gas cell for laser wakefield acceleration

The use of a gas cell as a target for laser wakefield acceleration (LWFA) offers the possibility to obtain stable and manageable laser-plasma interaction process, a mandatory condition for practical applications of this emerging technique, especially in multi-stage accelerators. In order to obtain full control of the gas particle number density in the interaction region, thus allowing for a long term stable and manageable LWFA, real-time monitoring is necessary. In fact, the ideal gas law cannot be used to estimate the particle density inside the flow cell based on the preset backing pressure and the room temperature because the gas flow depends on several factors like tubing, regulators, and valves in the gas supply system, as well as vacuum chamber volume and vacuum pump speed/throughput. Here, second-harmonic interferometry is applied to measure the particle number density inside a flow gas cell designed for LWFA. The results demonstrate that real-time monitoring is achieved and that using low backing pressure gas (<1 bar) and different cell orifice diameters (<2 mm) it is possible to finely tune the number density up to the 10(19) cm(-3) range well suited for LWFA.

Dosimetric evaluation of new approaches in GRID therapy using nonconventional radiation sources

PURPOSE

Spatial fractionation of the dose has proven to be a promising approach to increase the tolerance of healthy tissue, which is the main limitation of radiotherapy. A good example of that is GRID therapy, which has been successfully used in the management of large tumors with low toxicity. The aim of this work is to explore new avenues using nonconventional sources: GRID therapy by using kilovoltage (synchrotron) x-rays, the use of very high-energy electrons, and proton GRID therapy. They share in common the use of the smallest possible grid sizes in order to exploit the dose-volume effects.

METHODS

Monte Carlo simulations (penelope/peneasy and geant4/GATE codes) were used as a method to study dose distributions resulting from irradiations in different configurations of the three proposed techniques. As figure of merit, percentage (peak and valley) depth dose curves, penumbras, and central peak-to-valley dose ratios (PVDR) were evaluated. As shown in previous biological experiments, high PVDR values are requested for healthy tissue sparing. A superior tumor control may benefit from a lower PVDR.

RESULTS

High PVDR values were obtained in the healthy tissue for the three cases studied. When low energy photons are used, the treatment of deep-seated tumors can still be performed with submillimetric grid sizes. Superior PVDR values were reached with the other two approaches in the first centimeters along the beam path. The use of protons has the advantage of delivering a uniform dose distribution in the tumor, while healthy tissue benefits from the spatial fractionation of the dose. In the three evaluated techniques, there is a net reduction in penumbra with respect to radiosurgery.

CONCLUSIONS

The high PVDR values in the healthy tissue and the use of small grid sizes in the three presented approaches might constitute a promising alternative to treat tumors with such spatially fractionated radiotherapy techniques. The dosimetric results presented here support the interest of performing radiobiology experiments in order to evaluate these new avenues.

Comparison study of in vivo dose response to laser-driven versus conventional electron beam

The long-term goal to integrate laser-based particle accelerators into radiotherapy clinics not only requires technological development of high-intensity lasers and new techniques for beam detection and dose delivery, but also characterization of the biological consequences of this new particle beam quality, i.e. ultra-short, ultra-intense pulses. In the present work, we describe successful in vivo experiments with laser-driven electron pulses by utilization of a small tumour model on the mouse ear for the human squamous cell carcinoma model FaDu. The already established in vitro irradiation technology at the laser system JETI was further enhanced for 3D tumour irradiation in vivo in terms of beam transport, beam monitoring, dose delivery and dosimetry in order to precisely apply a prescribed dose to each tumour in full-scale radiobiological experiments. Tumour growth delay was determined after irradiation with doses of 3 and 6 Gy by laser-accelerated electrons. Reference irradiation was performed with continuous electron beams at a clinical linear accelerator in order to both validate the dedicated dosimetry employed for laser-accelerated JETI electrons and above all review the biological results. No significant difference in radiation-induced tumour growth delay was revealed for the two investigated electron beams. These data provide evidence that the ultra-high dose rate generated by laser acceleration does not impact the biological effectiveness of the particles.

Dosimetry of very high energy electrons (VHEE) for radiotherapy applications: using radiochromic film measurements and Monte Carlo simulations

Very high energy electrons (VHEE) in the range from 100-250 MeV have the potential of becoming an alternative modality in radiotherapy because of their improved dosimetry properties compared with MV photons from contemporary medical linear accelerators. Due to the need for accurate dosimetry of small field size VHEE beams we have performed dose measurements using EBT2 Gafchromic® film. Calibration of the film has been carried out for beams of two different energy ranges: 20 MeV and 165 MeV from conventional radio frequency linear accelerators. In addition, EBT2 film has been used for dose measurements with 135 MeV electron beams produced by a laser-plasma wakefield accelerator. The dose response measurements and percentage depth dose profiles have been compared with calculations carried out using the general-purpose FLUKA Monte Carlo (MC) radiation transport code. The impact of induced radioactivity on film response for VHEEs has been evaluated using the MC simulations. A neutron yield of the order of 10(-5) neutrons cm(-2) per incident electron has been estimated and induced activity due to radionuclide production is found to have a negligible effect on total dose deposition and film response. Neutron and proton contribution to the equivalent doses are negligible for VHEE. The study demonstrates that EBT2 Gafchromic film is a reliable dosimeter that can be used for dosimetry of VHEE. The results indicate an energy-independent response of the dosimeter for 20 MeV and 165 MeV electron beams and has been found to be suitable for dosimetry of VHEE.

Quasimonoenergetic electron beams with relativistic energies and ultrashort duration from laser-solid interactions at 0.5 kHz

We investigate the production of electron beams from the interaction of relativistically-intense laser pulses with a solid-density SiO(2) target in a regime where the laser pulse energy is approximately mJ and the repetition rate approximately kHz. The electron beam spatial distribution and spectrum were investigated as a function of the plasma scale length, which was varied by deliberately introducing a moderate-intensity prepulse. At the optimum scale length of lambda/2, the electrons are emitted in a collimated beam having a quasimonoenergetic distribution that peaked at approximately 0.8 MeV. A highly reproducible structure in the spatial distribution exhibits an evacuation of electrons along the laser specular direction and suggests that the electron beam duration is comparable to that of the laser pulse. Particle-in-cell simulations which are in good agreement with the experimental results offer insights on the acceleration mechanism by the laser field.

Controlled injection and acceleration of electrons in plasma wakefields by colliding laser pulses

In laser-plasma-based accelerators, an intense laser pulse drives a large electric field (the wakefield) which accelerates particles to high energies in distances much shorter than in conventional accelerators. These high acceleration gradients, of a few hundreds of gigavolts per metre, hold the promise of compact high-energy particle accelerators. Recently, several experiments have shown that laser-plasma accelerators can produce high-quality electron beams, with quasi-monoenergetic energy distributions at the 100 MeV level. However, these beams do not have the stability and reproducibility that are required for applications. This is because the mechanism responsible for injecting electrons into the wakefield is based on highly nonlinear phenomena, and is therefore hard to control. Here we demonstrate that the injection and subsequent acceleration of electrons can be controlled by using a second laser pulse. The collision of the two laser pulses provides a pre-acceleration stage which provokes the injection of electrons into the wakefield. The experimental results show that the electron beams obtained in this manner are collimated (5 mrad divergence), monoenergetic (with energy spread <10 per cent), tuneable (between 15 and 250 MeV) and, most importantly, stable. In addition, the experimental observations are compatible with electron bunch durations shorter than 10 fs. We anticipate that this stable and compact electron source will have a strong impact on applications requiring short bunches, such as the femtolysis of water, or high stability, such as radiotherapy with high-energy electrons or radiography for materials science.