A Novel Approach to Support Quality Assurance (QA) of Intensity Modulated Neutron Therapy (IMNT)

PURPOSE/OBJECTIVE(S)

Neutron therapy is a form of high linear energy transfer (LET) radiation treatment shown to be beneficial for the treatment of locally advanced head and neck cancers (HNC) resistant to low LET x-ray and proton therapy treatments. The Clinical Neutron Therapy System (CNTS) at our institution has been in clinical operation for over 35 years, and over 3,400 patients have been treated using 3D conformal neutron radiation therapy. In October of 2022, the clinical commissioning of IMNT was completed and the first-ever patient was treated. A novel patient specific quality assurance (PSQA) program has been developed to support IMNT. We present an analysis of our early experiences and PSQA findings for the first 16+ patients treated with IMNT.

MATERIALS/METHODS

Our pre-treatment IMNT PSQA program includes (1) ionization chamber measurements, (2) a log-file analysis of treatment delivery, and (3) a γ-analysis of the expected and measured doses (fluences) from a novel positron emission portal imaging system based on 12C(n,2n)11C reactions. Patient setup is confirmed on a daily basis with kV portal imaging. We use a modulation factor (MF), defined as the total number of monitor units (MU)/prescribed dose (cGy) per fraction, to identify and help anticipate IMNT plans that may fail our PSQA program.

RESULTS

We have found that IMNT treatments for large, irregularly shaped treatment volumes (e.g., chest wall or head and neck cancers that require treatment of nodes in the lower neck) are more likely to fail PSQA when the MF exceeds 3 MU/cGy. For smaller, more spherical treatment volumes (e.g., base of tongue cancers), plans with a MF up to 3.5 MU/cGy pass our PSQA criteria. Re-optimized plans subsequently passed PSQA with insignificant or no change in tumor coverage and organ-at-risk (OAR) dose. Re-optimized plans also reduced the total number of MU and number of segments, which has the added benefit of decreasing the overall treatment time and patient time on the table. About 10% of early IMNT patients have required plan re-optimization.

CONCLUSION

Our pre-treatment clinical PSQA program and workflow provides useful information to guide IMNT treatment planning and delivery, and helps ensure the safe and accurate delivery of IMNT. Our early experiences suggest IMNT plans with smaller MF values are more likely to pass PSQA than plans with larger values of the MF.

Influence of free charge carrier density on the magnetic behavior of (Zn,Co)O thin film studied by Field Effect modulation of magnetotransport

The origin of (ferro)magnetic ordering in transition metal doped ZnO is a still open question. For applications it is fundamental to establish if it arises from magnetically ordered impurity clusters embedded into the semiconducting matrix or if it originates from ordering of magnetic ions dilute into the host lattice. In this latter case, a reciprocal effect of the magnetic exchange on the charge carriers is expected, offering many possibilities for spintronics applications. In this paper we report on the relationship between magnetic properties and free charge density investigated by using Zinc oxide based field effect transistors, in which the charge carrier density is modulated by more than 4 order of magnitude, from 10¹⁶ to 10²⁰ e⁻/cm³. The magnetotransport properties are employed to probe the magnetic status of the channel both in pure and cobalt doped zinc oxide transistors. We find that it is widely possible to control the magnetic scattering rates by field effect. We believe that this finding is a consequence of the modulation of magnetization and carrier spin polarization by the electric field. The observed effects can be explained by the change in size of bound magnetic polarons that induces a percolation magnetic ordering in the sample.

Controlling the spin of co atoms on pt(111) by hydrogen adsorption

We investigate the effect of H adsorption on the magnetic properties of individual Co atoms on Pt(111) with scanning tunneling microscopy. For pristine Co atoms, we detect no inelastic features in the tunnel spectra. Conversely, CoH and CoH2 show a number of low-energy vibrational features in their differential conductance identified by isotope substitution. Only the fcc-adsorbed species present conductance steps of magnetic origin, with a field splitting identifying their effective spin as Seff=2 for CoH and 3/2 for CoH2. The exposure to H2 and desorption through tunnel electrons allow the reversible control of the spin in half-integer steps. Because of the presence of the surface, the hydrogen-induced spin increase is opposite to the spin sequence of CoHn molecules in the gas phase.

Electronic states of moiré modulated Cu films

We examined by low-energy electron diffraction and scanning tunneling microscopy the surface of thin Cu films on Pt(111). The Cu/Pt lattice mismatch induces a moiré modulation for films from 3 to about 10 ML thickness. We used angle-resolved photoemission spectroscopy to examine the effects of this structural modulation on the electronic states of the system. A series of hexagonal- and trigonal-like constant energy contours is found in the proximity of the Cu(111) zone boundaries. These electronic patterns are generated by Cu sp-quantum well state replicas, originating from multiple points of the reciprocal lattice associated with the moiré superstructure. Layer-dependent strain relaxation and hybridization with the substrate bands concur to determine the dispersion and energy position of the Cu Shockley surface state.

FISH-based analysis of 10- and 25-kV soft X-ray-induced DNA damage in 184A1 human mammary epithelial cells

Over the past years, several in vitro studies have been performed on DNA damage induced by soft X-rays, especially in the energy range below 50 keV. Radiation effects originating from such low-energy photons are relevant in the context of medical diagnostics, for example, mammography, or of accidental exposure to scattered radiation. The present study was initiated to investigate the X-ray energy-dependent induction of stable and unstable chromosomal aberrations in the human mammary epithelial cell line 184A1. Three colour fluorescence in situ hybridisation was applied to identify chromosomal damage in chromosomes 1, 8 and 17, induced by 10-kV or 25-kV soft X-rays as well as by 200-kV X-rays as a reference quality. The overall results confirm the X-ray energy dependencies published for human lymphocytes showing increasing chromosomal aberration frequencies and higher aberration complexity with decreasing X-ray energy and increasing dose. Comparing the obtained dose dependencies, ratios of 0.84 ± 0.09 and 1.22 ± 0.18 were revealed for stable translocations induced by 25- and 10-kV X-rays, respectively, using 200-kV X-rays as reference. Moreover, the analysis of the minimum number of breaks required to form the visible chromosomal damage resulted in similar ratios of 0.93 ± 0.07 for 25-kV X-rays and 1.25 ± 0.10 for 10-kV X-rays relative to 200-kV X-rays. In addition, non-DNA-proportional contributions of chromosomes 8 and 17 to the whole DNA damage and deviations from the expected 1:1 ratio of translocations and dicentrics were observed for cell line 184A1.

High resolution in situ magneto-optic Kerr effect and scanning tunneling microscopy setup with all optical components in UHV

A surface magneto-optic Kerr effect (MOKE) setup fully integrated in an ultrahigh vacuum chamber is presented. The system has been designed to combine in situ MOKE and scanning tunneling microscopy. Magnetic fields up to 0.3 T can be applied at any angle in the transverse plane allowing the study of in-plane and out-of-plane magnetization. The setup performance is demonstrated for a continuous film of 0.9 monolayers (ML) Co/Rh(111) with in-plane easy axis and for a superlattice of nanometric double layer Co islands on Au(11,12,12) with out-of-plane easy axis. For Co/Au(11,12,12) we demonstrate that the magnetic anisotropy energies deduced from thermally induced magnetization reversal and from applying a torque onto the magnetization by turning the field are the same. For the presented setup we establish a coverage detection limit of 0.5 ML for transverse and 0.1 ML for polar MOKE. For island superlattices with the density of Co/Au(11,12,12), the latter limit corresponds to islands composed of about 50 atoms. The detection limit can be further reduced when optimizing the MOKE setup for either one of the two Kerr configurations.

Diffusion characteristics of large molecules assessed by proton MRS on a whole-body MR system

Methods for examinations of diffusion of large molecules of the size of fatty acids or triglycerides were developed for whole body MR units. Samples of aliphatic molecules were examined to study the influence of chain length. Feasibility under in vivo conditions was tested on lard samples at 37 degrees C and on human subjects Three stimulated echo sequences with maximum b-values of 2000 s/mm(2), 20000 s/mm(2), and 80000 s/mm(2) were used to assess a wide range of mobility. Sequence timing was optimized to minimize relaxation losses of fatty tissue. Apparent diffusion coefficients (ADC) were determined from five spectra with different diffusion weighting. In-vitro experiments were performed on butanol, decanol, and oleic acid to study the influence of chain length. In vivo conditions were mimicked using lard at 37 degrees C representing a composition of substances of various chain lengths. Subcutaneous fat and tibial bone marrow were studied in three healthy volunteers. ADC of muscular lipids of the lower leg was determined in two subjects. ADC values of pure aliphatic substances were in the range between 3.2 x 10(-5) mm(2)/s for oleic acid and 37.8 x 10(-5) mm(2)/s for butanol. In vivo investigations revealed ADC values of 1.11-1.24 x 10(-5) mm(2)/s for tibial bone marrow and 1.21-2.05 x 10(-5) mm(2)/s for subcutaneous fat. Diffusion coefficients of extra- and intramyocellular lipids were 1.83-3.65 x 10(-5) mm(2)/s and 2.22-3.60 x 10(-5) mm(2)/s, respectively. The proposed technique enables determination of ADC values of relatively large molecules and of lipid tissue compartments under in vivo conditions. Diffusion properties in several human lipid compartments are reported for the first time. Incoherent voxel motion influences the in vivo results to an unknown degree because of high motion sensitivity. In vitro experiments revealed ADC values depending on the chain length of the substances, indicating a residual dependence of measured ADC's on sequence timing.

[Needle biopsy vs. conventional surgical biopsy - biochemical analysis of various prognostic factors]

OBJECTIVE

In which way is the biochemical analysis of fine needle biopsy comparable to the biochemical analysis of conventional surgical biopsy samples in the examination of prognosis factors in mammary carcinomas.

MATERIAL AND METHODS

Conventional surgical biopsy and fine needle biopsy were performed on 63 mammary carcinomas. The results from the biochemical analysis of tissue samples, from each form of biopsy, with respect to estradiol and progesterone receptor, UPA and PAI-1, as well as Kathepsin D and the EGF receptor, were compared and statistically analyzed.

RESULTS

When compared to conventional tissue biopsy samples, the sensitivity and specificity of the measured prognosis factors in fine needle biopsy tissue were variable for each parameter, but fell within the statistically safe margin of 86 to 100%.

CONCLUSIONS

The biochemical analysis of the prognosis factors found in fine needle biopsy samples showed that fine needle biopsy is a viable alternative to intraoperative conventional surgical biopsy.

A controlled study of deflazacort in the treatment of idiopathic nephrotic syndrome

Forty patients with steroid-dependent idiopathic nephrotic syndrome (INS), a mean follow-up of 5.5 years, and a mean number of relapses of ten were blindly assigned to either deflazacort (DFZ) (n = 20) or prednisone (PDN) (n = 20) according to a ratio of equivalence of DFZ/ PDN = 0.8. This treatment was given for 1 year. The number of relapses was significantly lower in patients receiving DFZ. After 1 year, 12 remained in remission with DFZ compared with 2 with PDN. Growth velocity was not different in the two groups. Bone mineral content, assessed by quantitative computed tomography of L1 L2 vertebrae, decreased after 1 year by 6% in the DFZ group versus 12% in the PDN group (NS). The mean body weight increase of +3.9 +/- 4.1 kg in the PDN group was higher than that of the DFZ group, +1.7 +/- 2.8 kg (P = 0.06). Cushingoid symptoms tended to be less after 12 months in the DFZ group. In conclusion, this study shows that DFZ was more effective than PDN in limiting relapses in steroid-dependent INS, and that cushingoid symptoms, weight gain, and decrease in bone mineral content tended to be less marked with this drug than with PDN.

[Value of cyclosporine in the treatment of the recurrence of nephrosis after renal transplantation]

From May 1992 to December 1994, 14 children with end stage renal failure secondary to steroid-resistant idiopathic nephrotic syndrome received a cadaver kidney graft. Immediate recurrence of the nephrotic syndrome occurred in four patients. In the four patients, a complete remission was observed shortly after the start of intravenous cyclosporin; two children received in addition methylprednisolone pulses for secondary rejection. Two children were still protein-free 9 and 15 months after transplantation. In the third patient, proteinuria relapsed after 9 months of complete remission and persisted in spite of the reintroduction of intravenous cyclosporin. The fourth graft was lost at 3.5 month from irreversible rejection. The creatinine clearance of the 3 functioning grafts was respectively: 73, 76 and 92 ml/mn/1.73 m2 16, 10 and 15 months after transplantation. Intravenous cyclosporin started shortly after the recurrence, maintaining blood levels between 200 and 300 ng/ml, may induce a remission in recurrent nephrotic syndrome after renal transplantation in childhood.

Craniosynostosis and kidney malformation in a case of Hennekam syndrome

Hennekam syndrome is a rare autosomal recessive syndrome which was described for the first time in 1989. Here, we present a girl with intestinal lymphangiectasia, severe lymphedema of limbs, seizures, mild mental retardation, and facial anomalies consistent with the diagnosis of Hennekam syndrome. In addition, she had an ectopic kidney and craniosynostosis of the coronal suture, 2 manifestations not previously reported in this syndrome. While the molecular basis of Hennekam syndrome remains, as yet, unknown, this report illustrates its variable clinical expression.

Effect of Viscum album L. on rapidly proliferating amniotic fluid cells. Sister chromatid exchange frequency and proliferation index

Amniotic fluid cells (AFC) from 10 women undergoing amniocentesis were investigated. The 5-bromo-2'-deoxyuridine-induced sister chromatid exchange (SCE) frequency of AFC remained stable after the addition of a therapeutical concentration of Viscum album L. preparation Iscador P but decreased significantly after administration of high drug doses. As the proliferation index remained stable, even at extremely high drug concentrations, this effect could not be ascribed to a reduction of proliferation. No indications of cytogenetic damage or effects of mutagenicity were seen after the addition of Viscum album L. preparation P.

Viscum album L. extracts reduce sister chromatid exchanges in cultured peripheral blood mononuclear cells

Increasing concentrations of Viscum album L. extracts were shown to significantly reduce sister chromatid exchange (SCE) frequency of phytohaemagglutinin (PHA)-stimulated peripheral blood mononuclear cells (PBMC) of healthy individuals. This decrease of SCE could not be explained either by changes in lymphocyte subpopulations, by cytostatic effects of the drug or by accelerated proliferation of PHA-stimulated PBMC. Currently, no other cells tested have shown this effect. One therapeutic effect of these anti-mutagenic drugs could be a stabilisation of mononuclear blood cell DNA.

[Acute heart insufficiency in an 8-month-old infant presenting with hypocalcemia and Epstein-Barr virus infection: acute myocarditis? Or primary hypokinetic dilated cardiomyopathy?]

An eight-month-old was admitted for acute congestive heart failure with fever. The respective parts played by hypocalcemia (due to vitamin-D deficiency rickets) and acute Epstein-Barr virus infection are discussed. Hypocalcemia was sufficiently marked to induce heart failure per se but replenishment of calcium stores was followed by only partial improvement in cardiac manifestations. Initial management was difficult because of the risks associated with concomitant administration of calcium and digitalis. After eighteen months during which the patient's status remained stable, evaluation showed that clinical features were consistent with sequelae of acute viral myocarditis. The possibility of primary hypokinetic dilated cardiomyopathy was then considered. Esterified carnitine levels were found to be increased leading to further investigations which outruled mitochondrial cytopathy.

Restenosis after balloon dilatation of coronary stenosis, multivariate analysis of potential risk factors

This study was undertaken to analyze change in stenosis caliber up to six months after PTCA with respect to regression or progression as well as to detect factors which possibly influencing the restenosis rate. A computer assisted system with high accuracy was used for two-dimensional quantitation of stenosis. A linear multivariate analysis was applied to quantitative and qualitative angiographic data as well as to clinical findings obtained before, immediately after and six months post-PTCA in 95 consecutive patients in whom 101 stenoses were dilatated. All patients were on a standard medical regimen of aspirin or coumadin and nifedipine. After six months, 56 patients showed a change in minimal stenosis area (mSA) of less than 1 mm2 (no progression), 33 patients showed a decrease in mSA of greater than 1 mm2 which rendered the stenosis with greater than 70% luminal reduction, and 12 patients showed a decrease in mSA of greater than 1 mm2 which did not, however, result in high-grade luminal narrowing. With regard to factors capable of affecting restenosis rate, there was no relationship between extent of dilatation achieved, local dissection, stenosis configuration or localization, calcification, patient age, sex, duration of symptoms, overweight, cholesterol, triglycerides, HDL, LDL, smoking, hypertension or diabetes. However, a relationship was found between the discontinuation of aspirin or coumadin as a result of GI side effects or bleeding (2% no progression; 20% progression). Thus, antiplatelet therapy appears to be important with respect to long-term results after PTCA.