Dose rate effect of 125I irradiation on normal rabbit eyes and experimental choroidal melanoma

The dose rate effect of radiation by 125I plaque on choroidal melanoma and normal intraocular tissue was studied. In the first part of the experiment, high activity plaques (HAP) and low activity plaques (LAP) were implanted on rabbit eyes with experimental Greene choroidal melanoma to deliver a total dose of 10,000 cGy to the tumor apex. The mean dose rate calculated at 0.5 mm from the inner sclera in eight eyes with high activity plaques was 3341.5 cGy hr-1 (1 cGy = 1 rad) while that in ten eyes with low activity plaques was 239.9 cGy hr-1. For tumors less than 1.0 mm in height, both groups showed complete tumor regression at the tumor implantation site after plaque treatment. For tumors more than 1.0 mm in height, two out of two eyes in the low activity plaque group and one of four eyes in the high activity plaque group failed to show complete tumor regression. Both LAP and HAP were effective in eradicating tumors, but logistic regression analysis demonstrates that HAP was more effective than LAP when adjustment was made for initial tumor height (P = 0.032). Nine tumor control eyes without 125I plaque implantation demonstrated marked tumor growth within 3 weeks. In the second part of the experiment, 125I plaques were implanted on the sclera of 12 normal rabbits' eyes. Six received high dose rate plaque treatment, while the other six received low dose rate plaque treatment. Clinical and histologic examinations demonstrated more damaging effects to the normal chorioretinal tissues at the plaque implantation site in the high dose rate plaque group at 24 weeks of follow-up. These results suggest that high dose rate plaques are more effective than low dose rate plaques when tumor height is statistically controlled. However, high dose rate delivery increases the damaging effects on normal intraocular tissue.

Computer controlled stereotaxic radiotherapy system

A computer-controlled stereotaxic radiotherapy system based on a low-frequency magnetic field technology integrated with a single fixation point stereotaxic guide has been designed and instituted. The magnetic field, generated in space by a special field source located in the accelerator gantry, is digitized in real time by a field sensor that is six degree-of-freedom measurement device. As this sensor is an integral part of the patient stereotaxic halo, the patient position (x, y, z) and orientation (azimuth, elevation, roll) within the accelerator frame of reference are always known. Six parameters--three coordinates and three Euler space angles--are continuously transmitted to a computer where they are analyzed and compared with the stereotaxic parameters of the target point. Hence, the system facilitates rapid and accurate patient set-up for stereotaxic treatment as well as monitoring of patient during the subsequent irradiation session. The stereotaxic system has been developed to promote the integration of diagnostic and therapeutic procedures, with the specific aim of integrating CT and/or MR aided tumor localization and long term (4- to 7-week) fractionated radiotherapy of small intracranial and ocular lesions.

Dose determination in high dose-rate brachytherapy

Although high dose-rate brachytherapy with a single, rapidly moving radiation source is becoming a common treatment modality, a suitable formalism for determination of the dose delivered by a moving radiation source has not yet been developed. At present, brachytherapy software simulates high dose-rate treatments using only a series of stationary sources, and consequently fails to account for the dose component delivered while the source is in motion. We now describe a practical model for determination of the true, total dose administered. The algorithm calculates both the dose delivered while the source is in motion within and outside of the implanted volume (dynamic component), and the dose delivered while the source is stationary at a series of fixed dwell points. It is shown that the dynamic dose element cannot be ignored because it always increases the dose at the prescription points and, in addition, distorts the dose distribution within and outside of the irradiated volume. Failure to account for the dynamic dose component results in dosimetric errors that range from significant (> 10%) to negligible (< 1%), depending on the prescribed dose, source activity, and source speed as defined by the implant geometry.

Optimization of high dose-rate cervix brachytherapy; Part I: Dose distribution

Computer controlled high dose-rate (HDR) brachytherapy afterloading machines are equipped with a single, miniaturized, high activity Ir-192 source that can be rapidly moved in fine increments among several channels. Consequently, by appropriate programming of source dwell positions and times, the dose distribution can be optimized as desired. We have explored the optimization potential of this new technology for two applications: (a) cervix brachytherapy, and (b) transvaginal irradiation. Cervix brachytherapy with a gynecologic ring applicator was simulated by 48 sources of relative activities ranging from 0.17 to 1.00 that were equally distributed between the tandem and the ring. The results confirmed that the optimized distribution of physical doses are superior to those achievable with standard brachytherapy sources and applicators. For example, with five-point optimization, the relative dose-rate in the rectum was only 47% of that in point A; for standard application the dose rate was 47% higher. For transvaginal application 27 sources of relative activities between 0.07-0.79 were placed in the ring and a single source of unit strength in the tandem. Using dose distribution homogeneity as an optimization criterion, the results (+/- 2.5%) were again superior to those obtained for commonly used double ovoid (+/- 15%), linear cylinder (+/- 27%), or a "T" source (31%).

Scattering effects on the dosimetry of iridium-192

Dosimetry calculations for iridium-192 sources generally assume that a sufficient medium surrounds both the iridium source(s) and the point of calculation so that full scattering conditions exist. In several clinical applications the iridium sources may be anatomically located so that the full scattering requirement is not satisfied. To assess the magnitude of this problem, relative measurements were made with a small ionization chamber in phantoms near air and lung-equivalent interfaces. Dose reduction caused by decreasing the volume of scattering material near these interfaces was then evaluated for a few clinical applications. The results show that reductions on the order of 8% may be expected at the interface with minimal dose reduction within the volume of the implant itself. In addition, the results indicate the verification of source strength of iridium sources in phantom require phantom dimensions determined by the source-chamber separation distance.

MR technique for localization and verification procedures in episcleral brachytherapy

Spatial definition of an intraocular tumor and subsequent determination of the actual position of an implanted eye plaque are essential for adequate ocular brachytherapy treatment planning. However, a method for verification of the plaque placement which would provide required 3-dimensional information is not available at present. In addition, tumor localization procedures, including ultrasonography and CT techniques, cannot always offer the precision needed for 3-dimensional definition of an intraocular target. This communication describes a magnetic resonance imaging technique specifically developed for both localization and verification procedures. A 1.5 Tesla magnetic resonance scanner, spin-echo pulse sequence (echo time 30 msec, repetition time 700 msec), and commercially available surface coil were used to obtain a series of transverse, coronal, and sagittal images of a slice thickness of 3 mm. Usually, eight scans in each of the three planes were needed for adequate coverage of the orbit. The required patient set-up and data acquisition time did not exceed 40 minutes. With a data matrix size of 256 X 256 pixels and 13 cm field of view, localization and verification were accomplished with a precision of 0.5 mm. Our results suggest that the magnetic resonance imaging technique permits precise integration of diagnostic and therapeutic procedures, and in addition provides adequate data for accurate treatment planning. We conclude that magnetic resonance imaging is the preferred diagnostic technique for episcleral brachytherapy.

MR characterization of brain and brain tumor response to radiotherapy

This paper describes our experience in using the T1 and T2 relaxation times for quantitative evaluation of brain and brain tumor response to radiation therapy. Twenty-two computed T1 and 22 computed T2 images were obtained from 66 routine inversion-recovery and spin-echo magnetic resonance (MR) brain scans. The relaxation times of the brain tissues, determined from the computed images, were examined as a function of the absorbed dose. Statistical evaluation of the results showed no significant difference between the relaxation times of irradiated and not irradiated tissues, including tumor and normal white matter. Influence of the magnetic field strength and imaging techniques on the computed T1 and T2 values was confirmed. We conclude that the relaxation time values, as obtained today using conventional MR scanner and standard software, are not specific enough to warrant a correct assessment of the acute radiation effect on the brain tissues.

Drug-induced agranulocytosis

An unexpected precipitous fall in peripheral leucocyte count may occur during treatment of certain sensitised individuals with drugs usually well tolerated by most people. Three basic mechanisms for drug sensitivity have been found. One is characterised by sudden destruction of large numbers of leucocytes in peripheral blood by antibodies elicited in response to drug sensitivity. A prototype for this type of reaction is aminopyrine. A second mechanism involves the production of a lupus-like syndrome followed by leucopenia in response to sensitisation to drugs such as procainamide. A third type involves development of agranulocytosis following a latent period during which a sensitive patient is treated with large amounts of chlorpromazine. This type of reaction is associated with production of bone marrow insufficiency in a patient who is believed to have a limited proliferative potential of bone marrow cells, which limit compensatory bone marrow response during treatment with a drug (e.g. chlorpromazine) that has limited bone marrow toxicity.