The effect of exercise on left ventricular global longitudinal strain: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Cancer Research Institute, Allied Health and Human Performance, University of South Australia

Background/Introduction

Left ventricular global longitudinal strain (LVGLS) can detect early myocardial changes prior to clinical abnormalities arising, and is a strong prognostic indicator of future cardiovascular (CV) dysfunction and mortality. It is well established that exercise improves CV function and reduces risk of CV disease. However, the impact of exercise on LVGLS is currently unclear. If LVGLS increases in response to habitual exercise, it could offer a sensitive measure that can determine the effectiveness of an exercise regime on CV health.

Purpose

The aim of this systematic review and meta-analysis was to determine whether exercise impacts LVGLS across a range of healthy and diseased populations.

Methods

Four databases (Medline, Scopus, eMbase, SPORTDiscus) were searched in November 2020. Included studies assessed LVGLS before and after an exercise intervention (minimum 2 weeks) in adults aged 18 years and over, and were published in English from 2000 onwards. Random-effects meta-analyses were performed at a study level using Stata (v16.1) to calculate summary standardized mean differences (SMD) and 95% confidence intervals (CI). 39 studies met selection criteria, with 35 included in meta-analyses (1765 participants).

Primary meta-analyses included only studies that compared outcomes between one or more intervention arms to a standard (non-exercising) control arm (RCT’s, N-RCT’s, randomised crossover). Secondary analyses included data from studies with intervention arms only (single group pre-post studies, intervention group from RCT’s, N-RCT’s, randomised crossover).

Results

Primary:

In populations with CV disease, a moderate effect of exercise was observed compared to non-exercising controls (SMD = 0.59; 95% CI, 0.16-1.02; p = 0.01 – figure 1a). No significant effect of exercise was observed for CV risk (SMD = 0.07; 95% CI, -0.15-0.29; p = 0.56 – figure 1b) and healthy (SMD = -0.20; 95% CI, -0.73-0.33; p = 0.45) populations compared to non-exercising controls.

Secondary

In secondary meta-analyses, significant effects of exercise were observed in CV disease (SMD = 0.26; 95% CI, 0.07-0.46; p = 0.01), CV risk (SMD = 0.54; 95% CI, 0.15-0.93; p = 0.01), chronic kidney disease (SMD = 0.65; 95% CI, 0.03-1.28; p = 0.04) and athletic (SMD = 0.30; 95% CI, 0.20-0.41; p= <0.001) populations.

Conclusion(s)

Increases in LVGLS observed in populations with CV disease may assist the prevention of secondary CV events. Secondary findings may support the use of exercise across a range of populations to increase LVGLS and enhance CV function. Future research must address the methodological limitations that currently exist, including improving upon study designs and reporting of individual data. Abstract Figure.

Leadership and mentoring in medical physics: The experience of a medical physics international mentoring program

Mentoring aims to improve careers and create benefits for the participants' personal and professional lives. Mentoring can be an individual or a shared experience for a group, while the mentor's role remains the same in both models. Mentors should increase confidence, teach, inspire, and set examples, helping the mentees to mould their path, contributing to the pursuit of their personal and professional goals. This study aims to report on the experience of early-career medical physics professionals and postgraduate students participating in a global mentoring program and to assess the impact of this activity on their professional development. The objectives of this mentoring program are to develop leadership roles among young medical physicists and to provide guidance and support. An online questionnaire was administered to the mentee participants. The analysis of their responses is reported in this work and the current status of the programme was examined using a SWOT analysis. In general, the mentoring experience had a positive impact on the mentees. The mentors were found especially helpful in the decision-making situations and in other conflicts that may arise with career development. Additionally, the mentees felt that mentoring contributed to the development of leadership skills required for the job market and assist in personal development. This paper concludes that participation of young medical physicists in a mentoring group program is beneficial to their career and therefore should be encouraged.

Development of a transmission alpha particle dosimetry technique using A549 cells and a Ra-223 source for targeted alpha therapy

PURPOSE

In targeted radionuclide therapy, regional tumors are targeted with radionuclides delivering therapeutic radiation doses. Targeted alpha therapy (TAT) is of particular interest due to its ability to deliver alpha particles of high linear energy transfer within the confines of the tumor. However, there is a lack of data related to alpha particle distribution in TAT. These data are required to more accurately estimate the absorbed dose on a cellular level. As a result, there is a need for a dosimeter that can estimate, or better yet determine the absorbed dose deposited by alpha particles in cells. In this study, as an initial step, the authors present a transmission dosimetry design for alpha particles using A549 lung carcinoma cells, an external alpha particle emitting source (radium 223; Ra-223) and a Timepix pixelated semiconductor detector.

METHODS

The dose delivery to the A549 lung carcinoma cell line from a Ra-223 source, considered to be an attractive radionuclide for alpha therapy, was investigated in the current work. A549 cells were either unirradiated (control) or irradiated for 12, 1, 2, or 3 h with alpha particles emitted from a Ra-223 source positioned below a monolayer of A549 cells. The Timepix detector was used to determine the number of transmitted alpha particles passing through the A549 cells and DNA double strand breaks (DSBs) in the form of γ-H2AX foci were examined by fluorescence microscopy. The number of transmitted alpha particles was correlated with the observed DNA DSBs and the delivered radiation dose was estimated. Additionally, the dose deposited was calculated using Monte Carlo code SRIM.

RESULTS

Approximately 20% of alpha particles were transmitted and detected by Timepix. The frequency and number of γ-H2AX foci increased significantly following alpha particle irradiation as compared to unirradiated controls. The equivalent dose delivered to A549 cells was estimated to be approximately 0.66, 1.32, 2.53, and 3.96 Gy after 12, 1, 2, and 3 h irradiation, respectively, considering a relative biological effectiveness of alpha particles of 5.5.

CONCLUSIONS

The study confirmed that the Timepix detector can be used for transmission alpha particle dosimetry. If cross-calibrated using biological dosimetry, this method will give a good indication of the biological effects of alpha particles without the need for repeated biological dosimetry which is costly, time consuming, and not readily available.

Monte-Carlo model development for evaluation of current clinical target volume definition for heterogeneous and hypoxic glioblastoma

Clinical target volume (CTV) determination may be complex and subjective. In this work a microscopic-scale tumour model was developed to evaluate current CTV practices in glioblastoma multiforme (GBM) external radiotherapy. Previously, a Geant4 cell-based dosimetry model was developed to calculate the dose deposited in individual GBM cells. Microscopic extension probability (MEP) models were then developed using Matlab-2012a. The results of the cell-based dosimetry model and MEP models were combined to calculate survival fractions (SF) for CTV margins of 2.0 and 2.5 cm. In the current work, oxygenation and heterogeneous radiosensitivity profiles were incorporated into the GBM model. The genetic heterogeneity was modelled using a range of α/β values (linear-quadratic model parameters) associated with different GBM cell lines. These values were distributed among the cells randomly, taken from a Gaussian-weighted sample of α/β values. Cellular oxygen pressure was distributed randomly taken from a sample weighted to profiles obtained from literature. Three types of GBM models were analysed: homogeneous-normoxic, heterogeneous-normoxic, and heterogeneous-hypoxic. The SF in different regions of the tumour model and the effect of the CTV margin extension from 2.0-2.5 cm on SFs were investigated for three MEP models. The SF within the beam was increased by up to three and two orders of magnitude following incorporation of heterogeneous radiosensitivities and hypoxia, respectively, in the GBM model. However, the total SF was shown to be overdominated by the presence of tumour cells in the penumbra region and to a lesser extent by genetic heterogeneity and hypoxia. CTV extension by 0.5 cm reduced the SF by a maximum of 78.6  ±  3.3%, 78.5  ±  3.3%, and 77.7  ±  3.1% for homogeneous and heterogeneous-normoxic, and heterogeneous hypoxic GBMs, respectively. Monte-Carlo model was developed to quantitatively evaluate SF for genetically heterogeneous and hypoxic GBM with two CTV margins and three MEP distributions. The results suggest that photon therapy may not provide cure for hypoxic and genetically heterogeneous GBM. However, the extension of the CTV margin by 0.5 cm could be beneficial to delay the recurrence time for this tumour type due to significant increase in tumour cell irradiation.

Evaluation of current clinical target volume definitions for glioblastoma using cell-based dosimetry stochastic methods

OBJECTIVE

Determination of an optimal clinical target volume (CTV) is complex and remains uncertain. The aim of this study was to develop a glioblastoma multiforme (GBM) model to be used for evaluation of current CTV practices for external radiotherapy.

METHODS

The GBM model was structured as follows: (1) a Geant4 cellular model was developed to calculate the absorbed dose in individual cells represented by cubic voxels of 20 μm sides. The system was irradiated with opposing 6 MV X-ray beams. The beams encompassed planning target volumes corresponding to 2.0- and 2.5-cm CTV margins; (2) microscopic extension probability (MEP) models were developed using MATLAB(®) 2012a (MathWorks(®), Natick, MA), based on clinical studies reporting on GBM clonogenic spread; (3) the cellular dose distribution was convolved with the MEP models to evaluate cellular survival fractions (SFs) for both CTV margins.

RESULTS

A CTV margin of 2.5 cm, compared to a 2.0-cm CTV margin, resulted in a reduced total SF from 12.9% ± 0.9% to 3.6% ± 0.2%, 5.5% ± 0.4% to 1.2% ± 0.1% and 11.1% ± 0.7% to 3.0% ± 0.2% for circular, elliptical and irregular MEP distributions, respectively.

CONCLUSION

A Monte Carlo model was developed to quantitatively evaluate the impact of GBM CTV margins on total and penumbral SF. The results suggest that the reduction in total SF ranges from 3.5 to 5, when the CTV is extended by 0.5 cm.

ADVANCES IN KNOWLEDGE

The model provides a quantitative tool for evaluation of different CTV margins in terms of cell kill efficacy. Cellular platform of the tool allows future incorporation of cellular properties of GBM.

Lack of high-dose radiation mediated prostate cancer promotion and low-dose radiation adaptive response in the TRAMP mouse model

Cancer of the prostate is a highly prevalent disease with a heterogeneous aetiology and prognosis. Current understanding of the biological mechanisms underlying the responses of prostate tissue to ionizing radiation exposure, including cancer induction, is surprisingly limited for both high- and low-dose exposures. As population exposure to radiation increases, largely through medical imaging, a better understanding of the response of the prostate to radiation exposure is required. Low-dose radiation-induced adaptive responses for increased cancer latency and decreased cancer frequency have been demonstrated in mouse models, largely for hematological cancers. This study examines the effects of high- and low-dose whole-body radiation exposure on prostate cancer development using an autochthonous mouse model of prostate cancer: TRansgenic Adenocarcinoma of the Mouse Prostate (TRAMP). TRAMP mice were exposed to single acute high (2 Gy), low (50 mGy) and repeated low (5 × 50 mGy) doses of X rays to evaluate both the potential prostate cancer promoting effects of high-dose radiation and low-dose adaptive response phenomena in this prostate cancer model. Prostate weights and histopathology were examined to evaluate gross changes in cancer development and, in mice exposed to a single 2 Gy dose, time to palpable tumor was examined. Proliferation (Ki-67), apoptosis, DNA damage (γ-H2AX) and transgene expression (large T-antigen) were examined within TRAMP prostate sections. Neither high- nor low-dose radiation-induced effects on prostate cancer progression were observed for any of the endpoints studied. Lack of observable effects of high- or low-dose radiation exposure suggests that modulation of tumorigenesis in the TRAMP model is largely resistant to such exposures. However, further study is required to better assess the effects of radiation exposure using alternative prostate cancer models that incorporate normal prostate and in those that are not driven by SV40 large T antigen.

Risk of second primary cancer after breast cancer treatment

Technological advances in both diagnosis and treatment of breast cancer lead to early detection and better treatment management. Consequently, the population of long-term survivors is on the rise. The risk of developing second cancers among breast cancer survivors was shown to be higher than that for the general population. The aim of this work was to review the literature on the risk of second primary cancer (SPC) after breast irradiation. Pubmed search of population-based studies on SPC after breast irradiation was conducted and the findings (in terms of Standardised Incidence Ratio) were collated and discussed. Several studies confirmed the link between breast tumour irradiation and risk of SPC, showing a small, but valid risk. There are, however, confounding factors that can either underestimate or overestimate risks: misclassification of tumour status, genetic inheritance, smoking, environmental factors, and the lack of accurate data in cancer registries. While isolating these potential triggers might be difficult, this approach would allow better discernability between radiotherapy-related risks and those generated by other factors. It is also important to evaluate the current status of treatment-related late effects and to lower such risks by minimising the dose delivered to normal tissues.

Altered fractionation outcomes for hypoxic head and neck cancer using the HYP-RT Monte Carlo model

OBJECTIVE

Altered fractionation radiotherapy is simulated on a set of virtual tumours to assess the total doses required for tumour control compared with clinical head and neck data and the doses required to control hypoxic vs well-oxygenated tumours with different radiobiological properties.

METHODS

The HYP-RT model is utilised to explore the impact of tumour oxygenation and the onset times of accelerated repopulation (AR) and reoxygenation (ROx) during radiotherapy. A biological effective dose analysis is used to rank the schedules based on their relative normal tissue toxicities.

RESULTS

Altering the onset times of AR and ROx has a large impact on the doses required to achieve tumour control. Immediate onset of ROx and 2-week onset time of AR produce results closely predicting average human outcomes in terms of the total prescription doses in clinical trials. Modifying oxygen enhancement ratio curves based on dose/fraction significantly reduces the dose (5-10 Gy) required for tumour control for hyperfractionated schedules. HYP-RT predicts 10×1.1 Gy per week to be most beneficial, whereas the conventional schedule is predicted as beneficial for early toxicity but has average-poor late toxicity.

CONCLUSION

HYP-RT predicts that altered radiotherapy schedules increase the therapeutic ratio and may be used to make predictions about the prescription doses required to achieve tumour control for tumours with different oxygenation levels and treatment responses.

ADVANCES IN KNOWLEDGE

Oxic and hypoxic tumours have large differences in total radiation dose requirements, affected by AR and ROx onset times by up to 15-25 Gy for the same fractionation schedule.

Influence of stem-cell cycle time on accelerated re-population during radiotherapy in head and neck cancer

OBJECTIVES

Tumour re-population during radiotherapy was identified as an important reason for treatment failure in head and neck cancers. The process of re-population is suggested to be caused by various mechanisms, one of the most plausible one being accelerated division of stem-cells (i.e. drastic shortening of cell cycle duration). However, the literature lacks quantitative data regarding the length of tumour stem-cell cycle time during irradiation.

MATERIALS AND METHODS

The presented work suggests that if accelerated stem-cell division is indeed a key mechanism behind tumour re-population, the stem-cell cycle time can drop below 10 h during radiotherapy. To illustrate the possible implications, the mechanism of accelerated division was implemented into a Monte Carlo model of tumour growth and response to radiotherapy. Tumour response to radiotherapy was simulated with different stem-cell cycle times (between 2 and 10 h) after the initiation of radiotherapy.

RESULTS

It was found that very short stem-cell cycle times lead to tumour re-population during treatment, which cannot be overcome by radiation-induced cell kill. Increasing the number of radiation dose fractions per week might be effective, but only for longer cell cycle times.

CONCLUSION

It is of crucial importance to quantitatively assess the mechanisms responsible for tumour re-population, given that conventional treatment regimens are not efficient in delivering lethal doses to advanced head and neck tumours.

Four dimensional CT imaging: a review of current technologies and modalities

Organ motion is a substantial concern in the treatment of thoracic tumours using radiotherapy. A number of technologies have evolved in order to address this both during computed tomography (CT) imaging and radiation delivery. This review paper investigates the various technologies which have been developed in the field of CT scanning as well as their accuracy, cost and the implications of their clinical implementation. The scanning modalities covered include: slow CT, breath hold CT, gated CT and retrospectively correlated CT (4DCT). It was found that there are advantages and drawbacks to each of the mentioned techniques relating to patient dose, scan time, extra equipment and workload. Also some scanning techniques are only compatible with certain treatment modalities which would further influence the decision as to which technologies to implement.

The use of enriched 6Li and 7Li Lif:Mg,Cu,P glass-rod thermoluminescent dosemeters for linear accelerator out-of-field radiation dose measurements

(6)LiF:Mg,Cu,P and (7)LiF:Mg,Cu,P glass-rod thermoluminescent dosemeters (TLDs) were used for measurements of out-of-field photon and neutron doses produced by Varian iX linear accelerator. Both TLDs were calibrated using 18-MV X-ray beam to investigate their dose-response sensitivity and linearity. CR-39 etch-track detectors (Luxel+, Landauer) were employed to provide neutron dose data to calibrate (6)LiF:Mg,Cu,P TLDs at various distances from the isocentre. With cadmium filters employed, slow neutrons (<0.5 eV) were distinguished from fast neutrons. The average in-air photon dose equivalents per monitor unit (MU) ranged from 1.5±0.4 to 215.5±94.6 μSv at 100 and 15 cm from the isocentre, respectively. Based on the cross-calibration factors obtained with CR-39 etch-track detectors, the average in-air fast neutron dose equivalents per MU range from 10.6±3.8 to 59.1±49.9 μSv at 100 and 15 cm from the isocentre, respectively. Contribution of thermal neutrons to total neutron dose equivalent was small: 3.1±7.2 μSv per MU at 15 cm from the isocentre.

Monte Carlo radiotherapy simulations of accelerated repopulation and reoxygenation for hypoxic head and neck cancer

OBJECTIVE

A temporal Monte Carlo tumour growth and radiotherapy effect model (HYP-RT) simulating hypoxia in head and neck cancer has been developed and used to analyse parameters influencing cell kill during conventionally fractionated radiotherapy. The model was designed to simulate individual cell division up to 10(8) cells, while incorporating radiobiological effects, including accelerated repopulation and reoxygenation during treatment.

METHOD

Reoxygenation of hypoxic tumours has been modelled using randomised increments of oxygen to tumour cells after each treatment fraction. The process of accelerated repopulation has been modelled by increasing the symmetrical stem cell division probability. Both phenomena were onset immediately or after a number of weeks of simulated treatment.

RESULTS

The extra dose required to control (total cell kill) hypoxic vs oxic tumours was 15-25% (8-20 Gy for 5 × 2 Gy per week) depending on the timing of accelerated repopulation onset. Reoxygenation of hypoxic tumours resulted in resensitisation and reduction in total dose required by approximately 10%, depending on the time of onset. When modelled simultaneously, accelerated repopulation and reoxygenation affected cell kill in hypoxic tumours in a similar manner to when the phenomena were modelled individually; however, the degree was altered, with non-additive results. Simulation results were in good agreement with standard linear quadratic theory; however, differed for more complex comparisons where hypoxia, reoxygenation as well as accelerated repopulation effects were considered.

CONCLUSION

Simulations have quantitatively confirmed the need for patient individualisation in radiotherapy for hypoxic head and neck tumours, and have shown the benefits of modelling complex and dynamic processes using Monte Carlo methods.

Measurement of reoxygenation during fractionated radiotherapy in head and neck squamous cell carcinoma xenografts

Hypoxic tissues lack adequate oxygenation and it has been long established that tumours commonly exhibit hypoxia and that hypoxia is a factor contributing towards resistance to radiotherapy. To develop computer models and make predictions about the affects of tumour hypoxia on treatment outcome, quantitative tumour oxygenation and reoxygenation data from in vivo systems is required. The aim of this study was to investigate the timing and degree of reoxygenation during radiotherapy in a human head and neck squamous cell carcinoma xenograft mouse model (FaDu). Mice were immobilised using a novel restraining system and exposed unanaesthetised in 3 or 5 Gy fractions, up to a maximum of 40 Gy. Partial pressures of oxygen (pO2) measurements were recorded at six time points throughout the 2 week course of radiotherapy, using a fibre optic system. Tumours receiving 0-30 Gy did not exhibit an increase in pO2. However, the mean pO2 after 2 weeks of accelerated fractionated radiotherapy (40 Gy) was significantly increased (P<0.01) compared to the mean pO2 of tumours not receiving the full schedule (0-30 Gy). These results lead to the conclusion of an average reoxygenation onset time of 2 weeks in this group of xenografts. A relatively large range of pO2 values measured at each dose point in the study indicate a large inter-tumour variation in oxygenation among the tumours. Data from this experimental work will be used to define the range of reoxygenation onset times implemented in a Monte Carlo computer model, simulating hypoxic head and neck cancer growth and radiotherapy.

Investigation of source position uncertainties & balloon deformation in MammoSite brachytherapy on treatment effectiveness

The MammoSite breast high dose rate brachytherapy is used in treatment of early-stage breast cancer. The tumour bed volume is irradiated with high dose per fraction in a relatively small number of fractions. Uncertainties in the source positioning and MammoSite balloon deformation will alter the prescribed dose within the treated volume. They may also expose the normal tissues in balloon proximity to excessive dose. The purpose of this work is to explore the impact of these two uncertainties on the MammoSite dose distribution in the breast using dose volume histograms and Monte Carlo simulations. The Lyman-Kutcher and relative seriality models were employed to estimate the normal tissues complications associated with the MammoSite dose distributions. The tumour control probability was calculated using the Poisson model. This study gives low probabilities for developing heart and lung complications. The probability of complications of the skin and normal breast tissues depends on the location of the source inside the balloon and the volume receiving high dose. Incorrect source position and balloon deformation had significant effect on the prescribed dose within the treated volume. A 4 mm balloon deformation resulted in reduction of the tumour control probability by 24%. Monte Carlo calculations using EGSnrc showed that a deviation of the source by 1 mm caused approximately 7% dose reduction in the treated target volume at 1 cm from the balloon surface. In conclusion, accurate positioning of the (192)Ir source at the balloon centre and minimal balloon deformation are critical for proper dose delivery with the MammoSite brachytherapy applicator. On the basis of this study, we suggest that the MammoSite treatment protocols should allow for a balloon deformation of < or = 2 mm and a maximum source deviation of < or = 1 mm.

Evaluation of dosimetric characteristics of multi-leaf and conventional collimated radiation fields using a scanning liquid ionization chamber EPID

The characteristics of radiation fields set up using conventional and Multi-Leaf collimators were investigated using a Scanning Liquid Ionization Chamber Electronic Portal Imaging Device (SLIC-EPID). Results showed that the radiation fields set up using MLCs are generally larger than those set up using conventional collimators. A significant difference was observed between the penumbra width for conventional and MLC radiation fields. SLIC-EPID was found to be a sensitive device to evaluate the characteristics of the radiation fields generated with MLCs.

Technological approaches to in-room CBCT imaging

The use of Cone-Beam Computed Tomography (CBCT) in Image-Guided Radiation Therapy (IGRT) has become increasingly feasible and popular in recent years. Advances and developments in Flat-Panel Imager (FPI) technology and image reconstruction software allow for linac-mounted 3D CBCT imaging. Taking CBCT images on a daily/weekly basis, offers the possibility to guide the treatment beam according to tumour motion and to apply changes to the treatment plan if necessary. This however raises the issue of additional imaging dose and thus increases in secondary cancer risk. The performance characteristics of kV-CBCT and MV-CBCT solutions currently offered by Elekta, Siemens and Varian are compared in this paper in terms of additional imaging dose and image quality. The review also outlines applications of CBCT for IGRT and Adaptive Radiotherapy (ART). As CBCT is not the only in-room IGRT platform, helical MV-CT (Tomotherapy) and in-room CT designs are also presented.

Efficient Monte Carlo modelling of individual tumour cell propagation for hypoxic head and neck cancer

A Monte Carlo tumour model has been developed to simulate tumour cell propagation for head and neck squamous cell carcinoma. The model aims to eventually provide a radiobiological tool for radiation oncology clinicians to plan patient treatment schedules based on properties of the individual tumour. The inclusion of an oxygen distribution amongst the tumour cells enables the model to incorporate hypoxia and other associated parameters, which affect tumour growth. The object oriented program FORTRAN 95 has been used to create the model algorithm, with Monte Carlo methods being employed to randomly assign many of the cell parameters from probability distributions. Hypoxia has been implemented through random assignment of partial oxygen pressure values to individual cells during tumour growth, based on in vivo Eppendorf probe experimental data. The accumulation of up to 10 million virtual tumour cells in 15 min of computer running time has been achieved. The stem cell percentage and the degree of hypoxia are the parameters which most influence the final tumour growth rate. For a tumour with a doubling time of 40 days, the final stem cell percentage is approximately 1% of the total cell population. The effect of hypoxia on the tumour growth rate is significant. Using a hypoxia induced cell quiescence limit which affects 50% of cells with and oxygen levels less than 1 mm Hg, the tumour doubling time increases to over 200 days and the time of tumour growth for a clinically detectable tumour (10(9) cells) increases from 3 to 8 years. A biologically plausible Monte Carlo model of hypoxic head and neck squamous cell carcinoma tumour growth has been developed for real time assessment of the effects of multiple biological parameters which impact upon the response of the individual patient to fractionated radiotherapy.

Calculation of the positron distribution from 15O nuclei formed in nuclear reactions in human tissue during proton therapy

To measure and verify the dose distribution within a patient during proton therapy, indirect methods must be used. One such method is to use positron emission tomography (PET), which takes advantage of the nuclear reactions that take place between protons and nuclei in the tissue. The dominant nuclear reaction in human muscle tissue involves oxygen nuclei and produces radioactive oxygen-15. Oxygen-15 decays through positron emission, and it is these positrons that go on to annihilate that produce the signal used in the PET technique. Finding the distribution of annihilation points, however, is not analogous to finding the proton dose distribution. The oxygen-15 and positrons travel finite distances within the tissue, blurring the detected PET distribution from the desired proton distribution. Through Monte Carlo modelling, an analysis of the differences between the positron, oxygen-15 and proton distributions has been made. The program SRIM 2003 was used to find the correlation between the three distributions within simulated muscle tissue. Results show that the distal edge of the proton Bragg peak correlates with the detectable positron distribution, which is a section of the dose distribution of interest due to the steep dose gradient and position of adjacent critical structures.

Scheduling cisplatin and radiotherapy in the treatment of squamous cell carcinomas of the head and neck: a modelling approach

The aim of the present work was to implement the kinetics of cisplatin into a previously developed tumour growth model and to simulate the combined cisplatin-radiotherapy treatment with the emphasis on time sequencing and scheduling of drug and radiation. An investigation into whether the effect of cisplatin-radiation is determined by independent cell kill or by cisplatin-produced radiosensitization was also undertaken. It was shown that cisplatin administered before radiation conferred similar tumour control to the post-radiation sequencing of the drug. The killing effect of the combined modality treatment on tumour increased with the increase in cell recruitment. Furthermore, the individual cell kill produced by the two cytotoxins led to an additive only tumour response when the treatments were given concurrently, suggesting that for a synergistic effect, cisplatin must potentiate the effect of radiation, through the radiosensitizing mechanisms addressed in the literature. It was concluded that the optimal timing of cisplatin should be close to radiation. The model showed that daily administration of cisplatin led to a 35% improvement of tumour control as compared to radiation alone, while weekly cisplatin has improved radiotherapy by only 6%.

Comparison of two-dimensional transmitted dose maps: evaluation of existing algorithms

Composite analysis and the gamma function are often used to assess the agreement between a reference and an evaluated two-dimensional dose maps. The intent of the study is to compare advantages, disadvantages and limitations of dose evaluation tools reported in the literature. In addition, in order to improve the gamma function output, a "Signed Matrix" was introduced using the ratio of relative dose difference maps. Transmitted dose maps were acquired for a range of homogeneous phantoms using Extended Dose Range (EDR2) films and a Scanning Liquid Ionization Chamber Electronic Portal Imaging Device (SLIC-EPID). For inhomogeneous case, the transmitted dose maps were obtained from EDR2 films measurement and a Treatment Planning System (TPS). The corresponding dose maps were compared based on composite and gamma function algorithms. The results showed that the agreement between reference and evaluated dose maps for the composite analysis were generally greater than those obtained using the gamma function. For homogeneous phantom comparison, the difference between the agreeing fractions calculated using composite analysis and gamma function increases with the increase of phantom thickness for deltaD = 0.5% and 1%. For inhomogeneous cases, a significant difference (approximately 5% for deltaD = 1.5%) was observed between the percentage agreement as calculated by composite and gamma function techniques. The concept of the composite model is closer than gamma function to the idea of the two-dimensional dose verification protocol proposed originally by van Dyk. However, the composite model results only display the passed or failed regions in the dose maps. On the other hand, the gamma function provides continuos information by distinguishing the points within each region. The overdosed/underdosed regions (the ratio of reference and evaluated doses at a given point) and the direction of the misalignment can be recognized with the enhanced gamma map convolved with a "Signed Matrix".

The prediction of transmitted dose distributions using a 3D treatment planning system

Patient dose verification is becoming increasingly important with the advent of new complex radiotherapy techniques such as conformal radiotherapy (CRT) and intensity-modulated radiotherapy (IMRT). An electronic portal imaging device (EPID) has potential application for in vivo dosimetry. In the current work, an EPID has been modelled using a treatment planning system (TPS) to predict transmitted dose maps. A thin slab of RW3 material used to initially represent the EPID. A homogeneous RW3 phantom and the thin RW3 slab placed at a clinical distance away from the phantom were scanned using a CT simulator. The resulting CT images were transferred via DICOM to the TPS and the density of the CT data corresponding to the thin RW3 slab was changed to 1 g/cm3. Transmitted dose maps (TDMs) in the modelled EPID were calculated by the TPS using the collapsed-cone (C-C) convolution superposition (C/S) algorithm. A 6 MV beam was used in the simulation to deliver 300 MU to the homogenous phantom using an isocentric and SSD (source-to-surface) technique. The phantom thickness was varied and the calculated TDMs in the modelled EPID were compared with corresponding measurements obtained from a calibrated scanning liquid-filled ionisation chamber (SLIC) EPID. The two TDMs were compared using the gamma evaluation technique of Low et al. The predicted and measured TDMs agree to within 2 % (averaged over all phantom thicknesses) on the central beam axis. More than 90 % of points in the dose maps (excluding field edges) produce a gamma index less than or equal to 1, for dose difference (averaged over all phantom thicknesses), and distance-to-agreement criteria of 4 %, 3.8 mm, respectively. In addition, the noise level on the central axis in the predicted dose maps is less than 0.1 %. We found that phantom thickness changes of approximately 1 mm, which correspond to dose changes on the central beam axis of less than 0.6 %, can be detected in the predicted transmitted dose distributions.

Acceptance testing and commissioning of Kodak Directview CR-850 digital radiography system

This Technical Paper describes Acceptance Testing and Commissioning of the Kodak DirectView CR-850 digital radiography system installed at the Royal Adelaide Hospital. The first of its type installed in Australia, the system is a "dry" image processor, for which no chemicals are required to develop images. Rather, latent radiographic images are stored on photostimulable phosphor screens, which are scanned and displayed by a reader unit. The image can be digitally processed and enhanced before it is forwarded to a storage device, printer or workstation display, thereby alleviating the need to re-expose patients to achieve satisfactory quality images. The phosphor screens are automatically erased, ready for re-use. Results are reported of tests carried out using the optional "Total Quality Tool" quality assurance package installed with the system. This package includes analysis and reporting software which provides for simple testing and reporting of many important characteristics of the system, such as field uniformity, aspect ratio, line and pixel positions, image and system noise, exposure response, scan linearity, modulation transfer function (MTF) and image artefacts. Acceptance Tests were performed for kV and MV exposures. Resolution for MV exposures was at least 0.8 l/mm, and measured phantom dimensions were within 1.05% of expected magnification. Reproducibility between cassettes was within 1.6%. The mean pixel values on the central axis were close to linear for MV exposures from 3 to 10 MU and reached saturation level at around 20 MU for 6 MV and around 30 MV for 23 MV beams. Noise levels were below 0.2 %.

The linear accelerator mechanical and radiation isocentre assessment with an electronic portal imaging device (EPID)

Regular checks on the performance of radiotherapy treatment units are essential and a variety of protocols has been published. These protocols identify that the determination of isocentre must be accurate and unambiguous since both the localization of a radiation field on a patient and positioning aids are referenced to it. An EPID (BIS 710) with a combined light and radiation scintillation detector screen was used to assess mechanical and radiation isocentres for different collimator and gantry angles. Crosshair positions within light field images were determined from fitted Gaussian intensity profiles and then used to calculate the displacement of the mechanical isocentre. For comparison, the position of the crosshair was also recorded on a graph paper. The radiation field centre was first calculated from the set up geometry for given gantry/collimator angles and then compared with measured values to assess the displacement of the radiation isocentre. The radiation isocentre was also checked by locating a marker, positioned on the couch, on the EPID radiation images for different treatment couch angles. The mechanical and radiation isocentres were determined from the EPID light field and radiation images respectively with an accuracy of 0.3 mm using simple PC based programs. The study has demonstrated the feasibility of using the EPID to assess mechanical and radiation isocentres of a linear accelerator in a quick and efficient way with a higher degree of accuracy achieved as compared to more conventional methods, e.g. the star shot.

Tumour resistance to cisplatin: a modelling approach

Although chemotherapy has revolutionized the treatment of haematological tumours, in many common solid tumours the success has been limited. Some of the reasons for the limitations are: the timing of drug delivery, resistance to the drug, repopulation between cycles of chemotherapy and the lack of complete understanding of the pharmacokinetics and pharmacodynamics of a specific agent. Cisplatin is among the most effective cytotoxic agents used in head and neck cancer treatments. When modelling cisplatin as a single agent, the properties of cisplatin only have to be taken into account, reducing the number of assumptions that are considered in the generalized chemotherapy models. The aim of the present paper is to model the biological effect of cisplatin and to simulate the consequence of cisplatin resistance on tumour control. The 'treated' tumour is a squamous cell carcinoma of the head and neck, previously grown by computer-based Monte Carlo techniques. The model maintained the biological constitution of a tumour through the generation of stem cells, proliferating cells and non-proliferating cells. Cell kinetic parameters (mean cell cycle time, cell loss factor, thymidine labelling index) were also consistent with the literature. A sensitivity study on the contribution of various mechanisms leading to drug resistance is undertaken. To quantify the extent of drug resistance, the cisplatin resistance factor (CRF) is defined as the ratio between the number of surviving cells of the resistant population and the number of surviving cells of the sensitive population, determined after the same treatment time. It is shown that there is a supra-linear dependence of CRF on the percentage of cisplatin-DNA adducts formed, and a sigmoid-like dependence between CRF and the percentage of cells killed in resistant tumours. Drug resistance is shown to be a cumulative process which eventually can overcome tumour regression leading to treatment failure.

Assessment of flatness and symmetry of megavoltage x-ray beam with an electronic portal imaging device (EPID)

The input/output characteristics of the Wellhofer BIS 710 electronic portal imaging device (EPID) have been investigated to establish its efficacy for periodic quality assurance (QA) applications. Calibration curves have been determined for the energy fluence incident on the detector versus the pixel values. The effect of the charge coupled device (CCD) camera sampling time and beam parameters (such as beam field size, dose rate, photon energy) on the calibration have been investigated for a region of interest (ROI) around the central beam axis. The results demonstrate that the pixel output is a linear function of the incident exposure, as expected for a video-based electronic portal imaging system. The field size effects of the BIS 710 are similar to that of an ion chamber for smaller field sizes up to 10 x 10 cm2. However, for larger field sizes the pixel value increases more rapidly. Furthermore, the system is slightly sensitive to dose rate and is also energy dependent The BIS 710 has been used in the current study to develop a QA procedure for measurements of flatness and symmetry of a linac x-ray beam. As a two-dimensional image of the radiation field is obtained from a single exposure of the BIS 710, a technique has been developed to calculate flatness and symmetry from a defined radiation area. The flatness and symmetry values obtained are different from those calculated conventionally from major axes only (inplane, crossplane). This demonstrates that the technique can pick up the "cold" and "hot" spots in the analysed area, providing thus more information about the radiation beam. When calibrated against the water tank measurements, the BIS 710 can be used as a secondary device to monitor the x-ray beam flatness and symmetry.

Evaluation of the mechanical alignment of a linear accelerator with an electronic portal imaging device (EPID)

Mechanical misalignment of a medical linear accelerator can be caused by any combination of source position displacement relative to the collimator rotational axis, collimator jaw asymmetry, or when the rotational axes of the gantry and the collimator do not intersect. A test procedure sensitive to all of these problems has been developed using an Electronic Portal Imaging Device (EPID). Each marker is placed on top of the EPID housing and on the treatment couch, then two images are acquired for gantry positions 180 degrees apart. By comparing the positions of the markers and their distances to the beam centre, mechanical alignment of the linear accelerator can be assessed. By comparing the positions of the beam centre for another two images acquired at collimator angles 180 degrees apart, the three potential sources of misalignment can be distinguished. Results with Siemens' Beam View were presented and determination accuracy of better than 0.25 mm can be achieved.