Multimodal approach to assess tumour vasculature and potential treatment effect with DCE-US and DCE-MRI quantification in CWR22 prostate tumour xenografts

The aim of this study was to compare intratumoural heterogeneity and longitudinal changes assessed by dynamic contrast-enhanced ultrasound (DCE-US) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in prostate tumour xenografts. In vivo DCE-US and DCE-MRI were obtained 24 h pre- (day 0) and post- (day 2) radiation treatment with a single dose of 7.5 Gy. Characterization of the tumour vasculature was determined by Brix pharmacokinetic analysis of the time-intensity curves. Histogram analysis of voxels showed significant changes (p < 0.001) from day 0 to day 2 in both modalities for kep , the exchange rate constant from the extracellular extravascular space to the plasma, and kel , the elimination rate constant of the contrast. In addition, kep and kel values from DCE-US were significantly higher than those derived from DCE-MRI at day 0 (p < 0.0001) for both groups. At day 2, kel followed the same tendency for both groups, whereas kep showed this tendency only for the treated group in intermediate-enhancement regions. Regarding kep median values, longitudinal changes were not found for any modality. However, at day 2, kep linked to DCE-US was correlated to MVD in high-enhancement areas for the treated group (p = 0.05). In contrast, correlation to necrosis was detected for the control group in intermediate-enhancement areas (p < 0.1). Intratumoural heterogeneity and longitudinal changes in tumour vasculature were assessed for both modalities. Microvascular parameters derived from DCE-US seem to provide reliable biomarkers during radiotherapy as validated by histology. Furthermore, DCE-US could be a stand-alone or a complementary technique.

Dose distribution in the thyroid gland following radiation therapy of breast cancer--a retrospective study

Purpose

To relate the development of post-treatment hypothyroidism with the dose distribution within the thyroid gland in breast cancer (BC) patients treated with loco-regional radiotherapy (RT).

Methods and materials

In two groups of BC patients postoperatively irradiated by computer tomography (CT)-based RT, the individual dose distributions in the thyroid gland were compared with each other; Cases developed post-treatment hypothyroidism after multimodal treatment including 4-field RT technique. Matched patients in Controls remained free for hypothyroidism. Based on each patient's dose volume histogram (DVH) the volume percentages of the thyroid absorbing respectively 20, 30, 40 and 50 Gy were then estimated (V20, V30, V40 and V50) together with the individual mean thyroid dose over the whole gland (MeanTotGy). The mean and median thyroid dose for the included patients was about 30 Gy, subsequently the total volume of the thyroid gland (VolTotGy) and the absolute volumes (cm³) receiving respectively < 30 Gy and ≥ 30 Gy were calculated (Vol < 30 and Vol ≥ 30) and analyzed.

Results

No statistically significant inter-group differences were found between V20, V30, V40 and V50Gy or the median of MeanTotGy. The median VolTotGy in Controls was 2.3 times above VolTotGy in Cases (ρ = 0.003), with large inter-individual variations in both groups. The volume of the thyroid gland receiving < 30 Gy in Controls was almost 2.5 times greater than the comparable figure in Cases.

Conclusions

We concluded that in patients with small thyroid glands after loco-radiotherapy of BC, the risk of post-treatment hypothyroidism depends on the volume of the thyroid gland.

Neoadjuvant chemotherapy in breast cancer-response evaluation and prediction of response to treatment using dynamic contrast-enhanced and diffusion-weighted MR imaging

Objective

To explore the predictive value of MRI parameters and tumour characteristics before neoadjuvant chemotherapy (NAC) and to compare changes in tumour size and tumour apparent diffusion coefficient (ADC) during treatment, between patients who achieved pathological complete response (pCR) and those who did not.

Methods

Approval by the Regional Ethics Committee and written informed consent were obtained. Thirty-one patients with invasive breast carcinoma scheduled for NAC were enrolled (mean age, 50.7; range, 37–72). Study design included MRI before treatment (Tp0), after four cycles of NAC (Tp1) and before surgery (Tp2). Data in pCR versus non-pCR groups were compared and cut-off values for pCR prediction were evaluated.

Results

Before NAC, HER2 overexpression was the single significant predictor of pCR (p = 0.006). At Tp1 ADC, tumour size and changes in tumour size were all significantly different in the pCR and non-pCR groups. Using 1.42 × 10⁻³ mm²/s as the cut-off value for ADC, pCR was predicted with sensitivity and specificity of 88% and 80%, respectively. Using a cut-off value of 83% for tumour volume reduction, sensitivity and specificity for pCR were 91% and 80%.

Conclusion

ADC, tumour size and tumour size reduction at Tp1 were strong independent predictors of pCR.

Cancer treatment by radiotherapy in Western Nepal: a hospital-based study

OBJECTIVE

The aim of this study was to describe utilization of radiotherapy and treatment compliance in the context of Nepal.

METHODS

A retrospective study was carried out on data collected from the radiotherapy treatment records of patients treated at Manipal Teaching Hospital (MTH), Pokhara, between 28 September 2000 and 30 May 2008.

RESULTS

In the 944 patients, the gender distribution showed a slight female preponderance (53.7 vs. 46.3%). Curative treatment was given to 62.8% (n= 593) and palliative to the remaining 37.2% (n= 351). Patients older than 50 years were more likely to receive palliative radiotherapy (p= 0.001). The commonest cancers treated were head and neck at 23.7% (n= 224), followed by lung at 21.3% (n= 201) and cervix at 16.1% (n= 152). The majority of patients were between 50-70 years of age (n= 564). Nineteen percent (n= 179) did not complete the prescribed dose of radiation. Unplanned treatment interruptions were found in 35.6% (n= 336) and this was not affected by age (p= 0.1) or gender (p= 0.1). The most frequent treatment interruption compromising optimal effectiveness of cancer treatment was observed for head and neck cancers, constituting 43% (n= 96) of patients in the group.

CONCLUSION

Head and neck in both sexes and cervix in females were the most common cancers treated with a curative intent. Lung cancer, the second most common in both genders, was treated with palliative intent in a large number of cases. This indicates the need for early diagnosis for a possible curative treatment.

Reduction in dose from CT examinations of liver lesions with a new postprocessing filter: a ROC phantom study

BACKGROUND

It is desirable to lower the dose from computed tomography (CT) examinations as much as possible without reducing diagnostic performance. Mathematical postprocessing filters are one tool to achieve dose reduction.

PURPOSE

To evaluate the possibilities of reducing CT doses from liver examinations using a new postprocessing filter.

MATERIAL AND METHODS

An anthropomorphic upper-abdomen phantom was used in receiver operating characteristic (ROC) studies of the detectability of liver lesions. A standard abdominal CT protocol was used. Only mA settings were changed; all other scan parameters were constant. The postprocessing filter used was SharpView CT, which provides context-controlled restoration of digital images using adaptive filters. Six readers were given a set of 10 images obtained at five different dose levels, each image with 32 predefined areas to be evaluated on a five-point scale. In total, 1920 areas were evaluated. At each dose level, the readers evaluated five images without enhancement and five images based on postprocessing filters. All images were randomized with respect to dose level.

RESULTS

The postprocessing filter improved the diagnostic performance significantly compared to the unenhanced images at all dose levels. Radiation dose for abdominal CT examinations of liver lesions in the range 2-7 mm was reduced by 30% using postprocessing filters, while diagnostic performance of the examination was maintained or even improved.

CONCLUSION

This study indicates great potential for lowering doses for CT examinations of liver lesions using the new postprocessing filter. The software must be fully tested clinically to reliably assess the benefits of this filtration.

Consequences of leaf calibration errors on IMRT delivery

IMRT treatments using multi-leaf collimators may involve a large number of segments in order to spare the organs at risk. When a large proportion of these segments are small, leaf positioning errors may become relevant and have therapeutic consequences. The performance of four head and neck IMRT treatments under eight different cases of leaf positioning errors has been studied. Systematic leaf pair offset errors in the range of +/-2.0 mm were introduced, thus modifying the segment sizes of the original IMRT plans. Thirty-six films were irradiated with the original and modified segments. The dose difference and the gamma index (with 2%/2 mm criteria) were used for evaluating the discrepancies between the irradiated films. The median dose differences were linearly related to the simulated leaf pair errors. In the worst case, a 2.0 mm error generated a median dose difference of 1.5%. Following the gamma analysis, two out of the 32 modified plans were not acceptable. In conclusion, small systematic leaf bank positioning errors have a measurable impact on the delivered dose and may have consequences for the therapeutic outcome of IMRT.

Comparative analyses of the dynamic properties of the bladder wall studied by repetitive pelvic CT scans of patients and cryo-sections of cadavers

In radiotherapy planning systems, delineation of hollow normal tissue organs, such as the bladder, is time-consuming. Automated delineation may presuppose two assumptions: (1) the bladder resembles a spherical shell and (2) the volume of bladder tissue is preserved regardless of the volume of urine (luminal volume) inside. The purpose of the present study was to test these assumptions. 22 CT scans from 7 patients were studied retrospectively. Transverse cross-sectional areas enclosed by the outer contour (A(out)) and inner contour of the bladder (A(in)) were recorded from the images. Hence, the transverse cross-sectional area of the wall, A(wall)=A(out)-A(in), and the volume of bladder tissue at various luminal volumes, could be calculated. To quantify the method uncertainty, the same procedure was applied on three spherical plastic phantoms. The results were also compared with data from the Visible Human Project's photographs of cadaver cryo-sections. Assumption no. 1 stated above, implies that A(wall) is constant regardless of the level of intersection of the sphere. The data from cryo-sections revealed a positive correlation for A(wall) and A(out), in contradiction to assumption no. 1 (p<0.001). The corresponding association derived from the repetitive CT scans of patients was also statistically significant (p<0.001) although linear regression revealed a less steep slope. A relationship was found between the volume of bladder tissue and luminal volume, hence contradicting assumption no. 2 (p<0.001). In conclusion the cross-sectional wall areas of the bladder, measured from patient CT scans, increase slightly with luminal cross-sectional areas in contradiction to expected values derived from a simplistic spherical shell model. In addition, the volume of bladder tissue is related to the luminal volume. Our results may be of practical value when developing automated delineation tools in radiotherapy planning systems.

Comparative analyses of the dynamic properties of the rectum studied by cryo-sections of human cadavers and pelvic CT scans of patients

Optimization of radiotherapy treatment plans based on dose-volume histograms relies on accurate organ delineation. Hollow organs, such as the rectum, are difficult and time-consuming to delineate owing to unclear visualization of the border between wall tissue and filling. Automated hollow organ delineation would be a valuable tool, but its development depends upon improved understanding of the dynamics of the rectum in response to filling. Two reasonable assumptions proposed in the literature are that (1) the rectal wall tissue along a constant length of the rectal cylinder is preserved over time and (2) the rectal wall tissue is distributed homogeneously along the cylinder. Therefore, variations in wall thickness can be explained by variable rectal filling. To investigate these assumptions, transversal cross-sectional areas enclosed by the outer contour (A(out)) and inner contour (A(in)) of the rectum were recorded from digital photographs of cadaver cryo-sections from the U.S. National Library of Medicine's Visible Human Project. In addition, A(out) and A(in) were recorded from 19 CT scans of 5 of our own patients. The transversal cross-sectional area of the wall of the rectum, A(wall)=A(out)-A(in), was calculated. The data derived both from cryo-sections and repetitive CT scans of patients, revealed that there was a significant correlation between A(wall) and A(out), in contradiction to assumption (1) stated above (male cryo-sections: p<0.001, female cryo-sections: p=0.03, repetitive CT scans p<0.001). Moreover, the mean A(wall) calculated from one CT scan differed significantly from the mean A(wall) from other CT scans and was correlated with the mean A(out), i.e. rectal filling (p<0.001). This finding was confirmed by careful analysis of another study (p=0.001) and opposes assumption (2). Hence, the amount of wall tissue within a constant length of rectum is not preserved over time, but increases with increased filling. This implies that the longitudinal length of the rectum decreases in response to distension of the organ.

Long-term renal function after treatment for malignant germ-cell tumours

OBJECTIVE

To evaluate prospectively renal function in patients with malignant germ-cell tumours (MGCTs) >10 years after retroperitoneal lymph node dissection alone (RPLND), radiotherapy alone (RAD) or different schedules of cisplatin-based chemotherapy with or without surgery/radiotherapy (CHEM).

PATIENTS AND METHODS

In 85 patients, three groups were identified: RPLND, 14; RAD, 18; CHEM, 53, with subdivision of the latter group according to the cumulative cisplatin dose or the additional use of radiotherapy. Renal function was determined by 131Iodine Hippuran clearance or 99m DTPA glomerular filtration rate, and was assessed before treatment and four times during 14 years of follow-up. A value of <70% of the upper limit of the normal range identified impaired renal function.

RESULTS

Twenty-five patients displayed long-term impaired renal function, 23 of them from the RAD or CHEM group. In the RAD group, renal function decreased by 8%, whereas a 14% reduction of renal function was observed in the CHEM group. In the CHEM group the cumulative dose of cisplatin, and in the RAD group the age at treatment, were associated with impairment of renal function. Combining all patients, age at treatment and the type of treatment were associated with impaired renal function.

CONCLUSIONS

In 20-30% of the patients with germ-cell tumour, standard radiotherapy and chemotherapy strategies are followed by long-term subclinical impaired renal function. These findings support current intentions to avoid overtreatment with these treatment modalities.

Inter fraction variations in rectum and bladder volumes and dose distributions during high dose rate brachytherapy treatment of the uterine cervix investigated by repetitive CT-examinations

PURPOSE

To evaluate variation of dose to organs at risk for patients receiving fractionated high dose rate gynaecological brachytherapy by using CT-based 3D treatment planning and dose-volume histograms (DVH).

MATERIALS AND METHODS

Fourteen patients with cancer of the uterine cervix underwent three to six CT examinations (mean 4.9) during their course of high-dose-rate brachytherapy using radiographically compatible applicators. The rectal and bladder walls were delineated and DVHs were calculated.

RESULTS

Inter fraction variation of the bladder volume (CV(mean)=44.1%) was significantly larger than the inter fraction variation of the mean dose (CV(mean)=19.9%, P=0.005) and the maximum dose (CV(mean)=17.5%, P=0.003) of the bladder wall. The same trend was seen for rectum, although the figures were not significantly different. Performing CT examinations at four of seven brachytherapy fractions reduced the uncertainty to 4 and 7% for the bladder and rectal doses, respectively. A linear regression analysis showed a significant, negative relationship between time after treatment start and the whole bladder volume (P=0.018), whereas no correlation was found for the rectum. For both rectum and bladder a linear regression analysis revealed a significant, negative relationship between the whole volume and median dose (P<0.05).

CONCLUSION

Preferably a CT examination should be provided at every fraction. However, this is logistically unfeasible in most institutions. To obtain reliable DVHs the patients will in the future undergo 3-4 CT examinations during the course of brachytherapy at our institution. Since this study showed an association between large bladder volumes and dose reductions, the patients will be treated with a standardized bladder volume.

[The radiotherapy satellite in Kristiansand--a model for Norwegian regional hospitals?]

BACKGROUND

During the first decade of 2000, significant increase of radiotherapy capacity in Norway will take place, as the number of linear accelerators will increase from 24 to 36. In Norway, radiotherapy departments are traditionally located only in university hospitals. However, six of the new accelerators will not be installed in existing radiotherapy centres, but in small, new radiotherapy units, set up in selected county hospitals and organized as satellites of the university hospitals, in order to secure the treatment quality. The university hospital is responsible for both medical and technical standards in the satellite, while the county hospitals have the financial responsibility.

RESULTS

The satellite model combines two important aspects of hospital management; treatment is geographically decentralized, while treatment quality is centralized. The first radiotherapy satellite was established in the town of Kristiansand in January 2001. We report our experience with this new concept in radiotherapy.

INTERPRETATION

The satellite model should be evaluated also for other medical specialties within the university hospitals.

Production of human type I collagen in yeast reveals unexpected new insights into the molecular assembly of collagen trimers

Substantial evidence supports the role of the procollagen C-propeptide in the initial association of procollagen polypeptides and for triple helix formation. To evaluate the role of the propeptide domains on triple helix formation, human recombinant type I procollagen, pN-collagen (procollagen without the C-propeptides), pC-collagen (procollagen without the N-propeptides), and collagen (minus both propeptide domains) heterotrimers were expressed in Saccharomyces cerevisiae. Deletion of the N- or C-propeptide, or both propeptide domains, from both proalpha-chains resulted in correctly aligned triple helical type I collagen. Protease digestion assays demonstrated folding of the triple helix in the absence of the N- and C-propeptides from both proalpha-chains. This result suggests that sequences required for folding of the triple helix are located in the helical/telopeptide domains of the collagen molecule. Using a strain that does not contain prolyl hydroxylase, the same folding mechanism was shown to be operative in the absence of prolyl hydroxylase. Normal collagen fibrils were generated showing the characteristic banding pattern using this recombinant collagen. This system offers new opportunities for the study of collagen expression and maturation.

Dose distribution measurements by MRI of a phantom containing lung tissue equivalent compartments made of ferrous sulphate gel

Gel dosimetry based on magnetic resonance imaging (MRI) has previously been shown to provide verification of calculated dose distributions in soft tissue equivalent homogeneous phantoms. This study demonstrates how measurements of dose distribution can also be achieved in a phantom containing porous, lung-equivalent, Fricke gel. A phantom was made of Fe2+ infused low-density gel and conventional ferrous sulphate gel, filled in separate compartments in a Perspex container. Absorbed dose measurements were accomplished by MR imaging and by calibrating the proton spin-lattice relaxation rate (R1) versus absorbed dose by means of TLD measurements. This study shows that the production of lung-equivalent low-density (LD) dosimeter gel (mean CT number of -610 HU) is feasible. The MR signal detected in the LD gel dosimeter was substantially more noisy (i.e. displayed larger random fluctuations) than the signal from conventional gel, as expected. A deviation between calculated (TPS) and measured dose of about 3% (6 MV) and 4-7% (15 MV) was found in the LD region of the phantom. These results correspond well with data from other studies of dose distribution in lung-equivalent phantoms. The Fe2+ infused LD gel therefore seems suitable for measurement of absorbed dose distribution in phantoms that contain lung tissue compartments.

Exposure of human osteosarcoma and bone marrow cells to tumour-targeted alpha-particles and gamma-irradiation: analysis of cell survival and microdosimetry

PURPOSE

This study was designed to compare the cytotoxic effects of an alpha-emitting radioimmunoconjugate, which binds to osteosarcoma but not to bone marrow cells, with those of external gamma-irradiation.

MATERIALS AND METHODS

The human osteosarcoma cell line, OHS-s1, and mononuclear cells from bone marrow (BM) harvested from healthy donors, were used for these experiments. Cells in suspension were added to various activity concentrations of the anti-osteosarcoma monoclonal antibody TP-3 radiolabelled with 211At. Following incubation for 1 h, unbound radioactivity was washed off and cell survival was determined from clonogenic assays. Microdosimetry was calculated based on binding and retention kinetics of 211At to the cells, as well as cellular and nuclear diameters. For comparison, cell suspensions were irradiated with a single dose of 60Co gamma-rays.

RESULTS

211At-labelled TP-3 showed heterogeneous binding to OHS-s1 cells, with a considerable variation among experiments. About 78% of the initially bound 211At decayed while associated with the OHS-s1 cells. D0 values estimated by microdosimetry were 0.33 (0.22-0.48, range) Gy and 1.18 (0.89-1.89) Gy for OHS-s1 and BM cells, respectively, whereas D0 values after external beam irradiation were 0.86+/-0.07Gy and 1.71+/-0.22Gy. The relative biological effectiveness (RBE) of 211At-labelled TP-3 at 37% survival was 3.43 for OHS-s1 and 1.55 for BM.

CONCLUSIONS

High-LET targeted alpha-particle exposure killed osteosarcoma cells more effectively than bone marrow cells, although heterogeneous antigen expression among these tumour cells limited the magnitude of this effect.

Production of recombinant human type I procollagen trimers using a four-gene expression system in the yeast Saccharomyces cerevisiae

The expression of stable recombinant human collagen requires an expression system capable of post-translational modifications and assembly of the procollagen polypeptides. Two genes were expressed in the yeast Saccharomyces cerevisiae to produce both propeptide chains that constitute human type I procollagen. Two additional genes were expressed coding for the subunits of prolyl hydroxylase, an enzyme that post-translationally modifies procollagen and that confers heat (thermal) stability to the triple helical conformation of the collagen molecule. Type I procollagen was produced as a stable heterotrimeric helix similar to type I procollagen produced in tissue culture. A key requirement for glutamate was identified as a medium supplement to obtain high expression levels of type I procollagen as heat-stable heterotrimers in Saccharomyces. Expression of these four genes was sufficient for correct assembly and processing of type I procollagen in a eucaryotic system that does not produce collagen.

Modeling normal tissue complication probability from repetitive computed tomography scans during fractionated high-dose-rate brachytherapy and external beam radiotherapy of the uterine cervix

PURPOSE

To calculate the normal tissue complication probability (NTCP) of late radiation effects on the rectum and bladder from repetitive CT scans during fractionated high-dose-rate brachytherapy (HDRB) and external beam radiotherapy (EBRT) of the uterine cervix and compare the NTCP with the clinical frequency of late effects.

METHODS AND MATERIALS

Fourteen patients with cancer of the uterine cervix (Stage IIb-IVa) underwent 3-6 (mean, 4.9) CT scans in treatment position during their course of HDRB using a ring applicator with an Iridium stepping source. The rectal and bladder walls were delineated on the treatment-planning system, such that a constant wall volume independent of organ filling was achieved. Dose-volume histograms (DVH) of the rectal and bladder walls were acquired. A method of summing multiple DVHs accounting for variable dose per fraction were applied to the DVHs of HDRB and EBRT together with the Lyman-Kutcher NTCP model fitted to clinical dose-volume tolerance data from recent studies.

RESULTS

The D(mean) of the DVH from EBRT was close to the D(max) for both the rectum and bladder, confirming that the DVH from EBRT corresponded with homogeneous whole-organ irradiation. The NTCP of the rectum was 19.7% (13.5%, 25. 9%) (mean and 95% confidence interval), whereas the clinical frequency of late rectal sequelae (Grade 3-4, RTOG/EORTC) was 13% based on material from 200 patients. For the bladder the NTCP was 61. 9% (46.8%, 76.9%) as compared to the clinical frequency of Grade 3-4 late effects of 14%. If only 1 CT scan from HDRB was assumed available, the relative uncertainty (standard deviation or SD) of the NTCP value for an arbitrary patient was 20-30%, whereas 4 CT scans provided an uncertainty of 12-13%.

CONCLUSION

The NTCP for the rectum was almost consistent with the clinical frequency of late effects, whereas the NTCP for bladder was too high. To obtain reliable (SD of 12-13%) NTCP values, 3-4 CT scans are needed during 5-7 fractions of HDRB treatments.

[Radiotherapy of skeletal metastases]

INTRODUCTION

Patients with skeletal metastases represent a large cohort in clinical oncology, and the single most frequent indication for palliative radiotherapy. Patients with cancer of the breast, lung, prostate and those with myelomatosis, constitute approximately 80% of this group.

MATERIAL AND METHODS

This paper summarizes data from relevant published clinical trials employing external irradiation for painful skeletal metastases. More recent randomised trials support the view that a single radiation dose of 8-10 Gy is equally efficient as ten treatments of 3 Gy delivered over two weeks. However, some still believe that fractioned regimes to a higher total dose provide better pain relief of a longer duration than a single fraction.

RESULTS

We review the current diagnosis and treatment of patients with skeletal metastases and discuss some aspect of tumour biology. The etiology of pain and the pathogenesis of tumour cells affecting bone tissue, resulting in osteolysis and/or osteosclerosis, are discussed. Associated leukocyte-derived osteoclast-activating cytokines that stimulate pain receptors locally, can in part explain why radiotherapy gives such rapid pain relief.

INTERPRETATION

The aims of radiotherapy must be assessed in relation to the life expectancy of the patient. Based on actual publications and own experiences, we suggest treatment with 8 Gy x 1 for the majority of patients, and reserve 3 Gy x 10 for patients with longer life expectancy. Both regimes allow retreatment, if and when pain eventually reoccur in previously irradiated areas.

Intra-operative irradiation (IORT) for primary advanced and recurrent rectal cancer. a need for randomised studies

The aim of this study was to determine the impact of intra-operative irradiation (IORT) combined with pre-operative external beam irradiation (EBRT) and surgical resection in patients with locally advanced primary or recurrent rectal cancer. 64 patients with locally advanced primary cancer and 104 with recurrence had EBRT (46-50 Gy) before surgery. 80 patients received IORT (median dose 15 Gy energy 12 MeV). 80 patients had R0 resections, 47 R1 and 41 R2 resections. More R1 resections were performed in the IORT group, more R0 and R2 resections in the non-IORT group. Median follow-up was around 22 months. 146 patients were resected, 22 had exploratory laparotomy. The cumulative overall survival was similar for both the IORT and non-IORT groups. 5-year survival for primary cancers was 48% versus 28% for recurrences. No R2 resections survived 3.5 years. 5-year-survival for R0 resections was nearly 60% and around 30% for R1 resections. The survival curves of the patients given and not given IORT treatment was not statistically different when R0, R1 and R2 resections were analysed separately. IORT did not seem to influence the local recurrence rate when R0 and R1 resections were analysed separately or in a multivariate analysis. The IORT and non-IORT groups were not identical with regard to type of cancer and R-stage. Still the lack of an identifiable impact of IORT suggests that there is a need for randomised studies of the IORT effect.

Telemedicine in radiotherapy treatment planning: requirements and applications

BACKGROUND AND PURPOSE

Telemedicine facilitates decentralized radiotherapy services by allowing remote treatment planning and quality assurance of treatment delivery. A prerequisite is digital storage of relevant data and an efficient and reliable telecommunication system between satellite units and the main radiotherapy clinic. The requirements of a telemedicine system in radiotherapy is influenced by the level of support needed. In this paper we differentiate between three categories of telemedicine support in radiotherapy.

RESULTS AND DISCUSSION

Level 1 features video conferencing and display of radiotherapy images and dose plans. Level 2 involves replication of selected data from the radiotherapy database - facilitating remote treatment planning and evaluation. Level 3 includes real-time, remote operations, e.g. target volume delineation and treatment planning performed by the team at the satellite unit under supervision and guidance from more experienced colleagues at the main clinic.

Monitoring of tumor reoxygenation following irradiation by 31P magnetic resonance spectroscopy: an experimental study of human melanoma xenografts

BACKGROUND AND PURPOSE

Inadequate tumor reoxygenation during radiation therapy may cause local treatment failure. This study was aimed at investigating the potential usefulness of 31P-MRS in monitoring tumor reoxygenation following radiation treatment.

MATERIALS AND METHODS

Tumors of two human melanoma xenograft lines (BEX-t and HUX-t) were exposed to 15.0 Gy, and then the fraction of radiobiologically hypoxic cells, measured by using the paired survival curve method, or tumor bioenergetic status, measured by 31P-MRS as the (PCr + NTPbeta)/Pi resonance ratio, was determined versus time after the radiation exposure.

RESULTS

Untreated BEX-t and HUX-t tumors showed similar fractions of radiobiologically hypoxic cells and similar bioenergetic status, whereas both parameters differed substantially between the lines in irradiated tumors. A close association was found between radiation-induced changes in tumor bioenergetic status and radiation-induced changes in the fraction of radiobiologically hypoxic cells.

CONCLUSION

31P-MRS is a potentially useful method for monitoring tumor reoxygenation following radiation treatment.

Effects of hyperthermia on bioenergetic status and phosphorus T1S in human melanoma xenografts monitored by 31P-MRS

Conventional hyperthermia enhances tumor response to radiotherapy through thermal cell inactivation and vascular shut-down, whereas mild hyperthermia potentiates the effect of radiotherapy by improving tumor oxygenation. The work reported here was aimed at investigating whether 31P-magnetic resonance spectroscopy (31P-MRS) measurements of tumor bioenergetic status; i.e., the (PCr + NTPbeta)/Pi resonance ratio, and/or the spin lattice relaxation times, T1s, of the Pi and NTPbeta resonances can be used to distinguish between the effects of conventional and mild hyperthermia. BEX-t human melanoma xenografts were treated at 43.0 degrees C for 15 or 60 min, and bioenergetic status and T1s were measured as function-of-time after treatment. Hyperthermia-induced effects on tumor blood flow was measured by using the 86Rb uptake method. The morphology of the capillary network in treated and untreated tumors was studied by histologic examination. Tumors treated for 15 min showed increased blood flow and dilated capillaries, whereas tumors treated for 60 min showed decreased blood flow and capillary occlusions; i.e., 43.0 degrees C for 15 min was a treatment consistent with mild hyperthermia and 43.0 degrees C for 60 min was consistent with conventional hyperthermia treatment of BEX-t tumors. Bioenergetic status increased after treatment at 43.0 degrees C for 15 min, and decreased after treatment at 43.0 degrees C for 60 min, similar to the blood flow. Likewise, the T1 of the Pi resonance increased after treatment at 43.0 degrees C for 15 min, and decreased after treatment at 43.0 degrees C for 60 min. The T1 of the NTPbeta resonance showed a similar change as the T1 of the Pi resonance, but less pronounced. Consequently, 31P-MRS measurements of tumor bioenergetic status and the T1 of the Pi resonance may perhaps be utilized to distinguish between vascular effects of mild and conventional hyperthermia.

Measurement of dose rate at the interface of cell culture medium and glass dishes by means of ESR dosimetry using thin films of alanine

Previous studies on human cervical cancer cells (NHIK 3025) have indicated that the cells, when X-irradiated in suspension, appeared to be more radiosensitive than when they were irradiated attached to glass dishes. However, this result depends on dosimetry, which is difficult in the situation where cells are attached to glass dishes due to backscattering electrons at the glass-liquid interface. Recently developed dosimetry that is based on detection of radiation-induced stable radicals in alanine and uses ESR spectroscopy offers a possibility for more relevant dosimetry at the glass-liquid interface than the previous estimates of doses based on Fricke dosimetry. Thin alanine films (>/=10 microm) were used to measure dose at the interface by irradiating the films while they were placed tightly against the bottom of dishes and covered with 1 mm of wax simulating the medium above cells. Fricke dosimetry was also performed, with different depths of Fricke solution in the dishes, to elucidate the contribution to the dose delivered by backscattering electrons at the glass-liquid interface. A dose rate of 1.9 Gy/min was measured with a thin layer (0.2-0.3 mm) of Fricke solution in petri dishes made of glass. However, this estimate appears to be too high, due to a contribution to dose by short-ranged electrons generated when the X rays passed through a steel lid 4.5 cm above the dishes. Dosimetry using alanine films resulted in dose rates of 1.15 and 0.87 Gy/min at the interfaces of glass-liquid and plastic- liquid, respectively. Hence there is a significant contribution to dose from backscattering electrons on dishes made of glass. The reason for our previous observation of a difference in radiosensitivity between cells irradiated in suspension and cells irradiated attached to glass appears to be a lack of accurate dosimetry at the glass-liquid interface.

Inverse dose-rate effect due to pre-mitotic accumulation during continuous low dose-rate irradiation of cervix carcinoma cells

PURPOSE

To investigate the radiation sensitivity of asynchronous and synchronized cancer cervix cells irradiated with low dose rates.

MATERIALS AND METHODS

Cells were exposed to 60Co gamma-rays at dose rates ranging from 0.33 to 0.94 Gy/h. Synchronized cells were obtained by collecting detached mitotic cells after a shaking procedure. Cell survival was measured as the ability of cells to form colonies. Cell-cycle distributions were calculated by computer analysis of a DNA histogram recorded by flow cytometry.

RESULTS

Irradiation of asynchronous cells at either 0.33 or 0.86 Gy/h resulted in exponential dose-survival curves with equal alpha-values, i.e. same radiation sensitivity, when dose-survival data for irradiation periods less than 20h were considered. However, the radiation sensitivity was higher by a factor of two when analysing dose-survival data for irradiation periods exceeding 20h. This increase in radiation sensitivity occurred when 80% of the cells accumulated in a pre-mitotic stage of the cell cycle. Irradiation of synchronized cell populations confirmed that these cells were a factor of two more sensitive to radiation in G2 than in G1.

CONCLUSIONS

An inverse dose-rate effect, i.e. more efficient inactivation of cells at lower rather than at higher dose rates, was observed for radiation doses exceeding 7 Gy due to pre-mitotic accumulation of cells during low dose-rate irradiation.

Long-term morbidity and quality of life in patients with localized prostate cancer undergoing definitive radiotherapy or radical prostatectomy

PURPOSE

To assess morbidity, side effects, and quality of life (QoL) in patients treated for localized prostate cancer with curative aim.

METHODS AND MATERIALS

This descriptive cross-sectional study comprises 154 patients who had undergone definitive radiotherapy (RAD) and 108 patients with radical prostatectomy (PRECT) at the Norwegian Radium Hospital during 1987-1995. At least 1 year after treatment the patients completed several questionnaires assessing quality of life (European Organization for Research and Treatment of Cancer QLQ-C30 instrument [EORTC QLQ-C30]), lower urinary tract symptoms (LUTS): International Prostate Symptom Score (IPSS), or sexuality (selected questions from the Psychosocial Adjustment to Illness Scale [PAIS]). Urinary incontinence and bowel distress were evaluated by ad hoc constructed questionnaires. A control group (OBS) consisted of 38 patients following the watch-and-wait policy.

RESULTS

Twenty percent of the patients from the RAD Group had moderate (14%) or severe (6%) LUTS as compared to 12% in the PRECT group. However, 35% of men from the latter group reported moderate to severe urinary incontinence. "Overall" sexuality was moderately or severely impaired in 71% of the PRECT and 50% of the RAD patients. In the former group high age was correlated with erectile impotency (p < 0.001). In the RAD comorbidity was associated with erectile impotency (p < 0.001). Between 13-38% of the patients recorded moderate or severe bowel distress (blood per rectum: 13%; bowel cramps: 26%; flatulence: 38%), without significant differences comparing patients who had received conventional small 4-field box radiotherapy and patients who had undergone strictly conformal radiotherapy. Despite malignancy and/or treatment-related morbidity, QoL was comparable in both groups with respectively 9% and 6% RAD and PRECT patients, reporting moderately or severely impaired QoL. In the multivariate analysis physical function, emotional function and fatigue were significantly correlated with QoL, whereas sexuality, lower urinary symptoms, and urinary incontinence correlated with QoL only in the univariate analysis.

CONCLUSION

In spite of considerable malignancy and/or treatment-related morbidity QoL was good or only slightly impaired in the majority of patients with localized prostate cancer who presented with stable disease > 1 year after definitive radiotherapy or radical prostatectomy with no difference as compared to the age-matched normal population. Clinicians should be aware of the fact that general QoL dimensions (physical function, emotional function, fatigue) are as a rule of greater significance for QoL than sexuality and lower urinary tract symptoms.

Normal tissue complication probabilities correlated with late effects in the rectum after prostate conformal radiotherapy

PURPOSE

Radiation therapy of deep-sited tumours will always result in normal tissue doses to some extent. The aim of this study was to calculate different risk estimates of late effects in the rectum for a group of cancer prostate patients treated with conformal radiation therapy (CRT) and correlate these estimates with the occurrences of late effects. Since the rectum is a hollow organ, several ways of generating dose-volume distributions over the organ are possible, and we wanted to investigate two of them.

METHODS AND MATERIALS

A mathematical model, known as the Lyman-Kutcher model, conventionally used to estimate normal tissue complication probabilities (NTCP) associated with radiation therapy, was applied to a material of 52 cancer prostate patients. The patients were treated with a four field box technique, with the rectum as organ at risk. Dose-volume histograms (DVH) were generated for the whole rectum (including the cavity) and of the rectum wall. One to two years after the treatment, the patients completed a questionnaire concerning bowel (rectum) related morbidity quantifying the extent of late effects.

RESULTS

A correlation analysis using Spearman's rank correlation coefficient, for NTCP values calculated from the DVHs and the patients' scores, gave correlation coefficients which were not statistically significant at the p<0.01 level. The correlation coefficients based on histograms of the whole rectum were larger than those derived from histograms of the rectum wall. Also, simpler descriptive measures as Dmax, of the whole rectum, correlated better to observed late toxicity than Dmax derived from histograms of the rectum wall. Correlation coefficients from "high-dose" measures were larger than those calculated from the NTCP values. Accordingly, as the volume parameter of the Lyman-Kutcher model was reduced, raising the impact of small high-dose volumes on the NTCP values, the correlation between observed effects and NTCP values became significant at p<0.01 level.

CONCLUSIONS

1) High-dose levels corresponding to small volume fractions of the cumulative dose-volume histograms were best correlated with the occurrences of late effects in the rectum as measured with questionnaires. This is compatible with a more serial organisation of the rectal tissue architecture than previously reported. 2) Reducing the Lyman-Kutcher model's volume parameter, thus allowing small high-dose regions to determine the NTCP, improved the correlation, but not beyond that of high-dose levels corresponding to small volume fractions of the cumulative dose-volume histograms.

Expression of eukaryotic proteins in soluble form in Escherichia coli

At the optimum temperature for its growth (37 degrees C), Escherichia coli tends to accumulate heterologous proteins in insoluble form. Fusion protein technology has been used to increase the solubility of overexpressed proteins in this organism, but with variable degrees of success. Fusion to a mutant form of DsbA (DsbAmut) confers higher levels of solubility to heterologous proteins in a reproducible way, even when E. coli is grown at 37 degrees C. We have shown this to be true with a diverse sample of eukaryotic proteins: IGF-I, IGFBP-3, 3C proteinase, TGF beta-2, sTGF beta-RII, BDNF, GDNF, mEGFBP, leptin, and GFP. In addition, we have investigated the effects of charge average and proline content on the solubility of DsbAmut fusions. Coexpression of a protein prolyl isomerase [cyclophilin (L-)] and modification of selected asparagine residues to aspartic acid appear to have beneficial effects on the accumulation of soluble heterologous proteins.

Abutting orthogonal electron and photon beams in the head and neck region using asymmetrical photon beam edges

Irradiation of target volumes within the ethmoid sinus and nasal cavity region has, at our institution, been performed using one anterior electron beam, abutted to two opposing lateral photon beams, in order to exclude the orbit from the irradiated volume. However, this technique give rise to larger dose hetereogeneities within the target volume, as well as undesired hot spots in the chiasma region. To reduce the inhomogenious distribution, we have introduced asymmetrical photon beam edges to broaden the penumbra of the two opposing photon beams resembling the dose gradient of the perpendicular electron beam. The achieved reduction in dose heterogeneity, measured from the differential dose-volume-histogram, is in the order of 30-40% when applying the asymmetrical abutting technique compared with the conventional two opposing photon beam technique. As demonstrated by calculating the tumour control probability (TCP), the increase in dose homogeneity within the target volume, may be of clinical significance.

Radiation-induced changes in phosphorus T1 values in human melanoma xenografts studied by 31P-MRS

31P-magnetic resonance spectroscopy (MRS) has been shown to be a promising method for monitoring tumor response to radiation therapy. The purpose of the work reported here was to investigate whether the usefulness of 31P-MRS might be enhanced by measurement of spin-lattice relaxation times (T1s) in addition to resonance ratios. The work was based on the hypothesis that tumors having a high probability of being controlled locally would show shortened T1s during the treatment course due to reoxygenation and development of necrosis. BEX-t human melanoma xenografts, which show efficient reoxygenation and development of necrosis following single dose irradiation, were used as tumor models. Tumors were treated with single doses of 5.0 or 15.0 Gy and the T1s of the inorganic phosphate and nucleoside triphosphate beta resonances were measured as a function of time after irradiation by using the superfast inversion recovery method. Fractional tumor water content was determined by drying excised tumors at 50 degrees C until a constant weight was reached. The T1s in irradiated tumors were either longer than or not significantly different from those in unirradiated control tumors. The increase in the T1s following irradiation coincided in time with a radiation-induced increase in tumor water content, suggesting a causal relationship. The effects of reoxygenation and development of necrosis on T1s were probably overshadowed by the effects of tumor water content. Consequently, the usefulness of 31P-MRS in monitoring tumor response to radiation therapy might not be significantly enhanced by measurement of T1s.

Combined modality treatment including intraoperative radiotherapy in locally advanced and recurrent rectal cancer

BACKGROUND

Treatment of locally advanced and recurrent rectal cancer usually has a high local recurrence rate and poor survival. Promising results have been reported by combined external radiotherapy, extensive surgery and intraoperative radiotherapy (IORT).

METHODS

One hundred fifteen patients with locally advanced rectal cancers fixed to the pelvic wall or locally recurrent rectal cancers underwent preoperative external radiotherapy with 46-50 Gy. Six to 8 weeks later radical pelvic surgery was attempted, and was combined with intraoperative electron beam radiotherapy (15-20 Gy) in 66 patients. The patients were followed closely to evaluate complication rate, local and distant recurrence rate and survival.

RESULTS

Surgery with no macroscopic tumour remaining was obtained in 65% of the patients with no postoperative deaths. Pelvic infection was the major complication (21%). Although the observation time is short (3-60 months), the local recurrence rate seems low (22%) and survival seems promising (about 60% at 4 years) in patients with complete tumour resection, in contrast to patients with residual tumour (none living at 4 years).

CONCLUSIONS

The combined modality treatment with preoperative external radiotherapy and extensive pelvic surgery with IORT is sufficiently promising to start a randomized trial on the clinical value of IORT as a boost treatment in the multidisciplinary approach to this disease.

Measurement of the ferric diffusion coefficient in agarose and gelatine gels by utilization of the evolution of a radiation induced edge as reflected in relaxation rate images

A method has been developed to determine the diffusion coefficients of ferric ions in ferrous sulphate doped gels. A radiation induced edge was created in the gel, and two spin-echo sequences were used to acquire a pair of images of the gel at different points of time. For each of these image pairs, a longitudinal relaxation rate image was derived. From profiles through these images, the standard deviations of the Gaussian functions that characterize diffusion were determined. These data provided the basis for the determination of the ferric diffusion coefficients by two different methods. Simulations indicate that the use of single spin-echo images in this procedure may in some cases lead to a significant underestimation of the diffusion coefficient. The technique was applied to different agarose and gelatine gels that were prepared, irradiated and imaged simultaneously. The results indicate that the diffusion coefficient is lower in a gelatine gel than in an agarose gel. Addition of xylenol orange to a gelatine gel lowers the diffusion coefficient from 1.45 to 0.81 mm2 h-1, at the cost of significantly lower Rl sensitivity. The addition of benzoic acid to the latter gel did not increase the Rl sensitivity.

Determination of 3D dose distribution from intracavitary brachytherapy of cervical cancer by MRI of irradiated ferrous sulphate gel

BACKGROUND AND PURPOSE

MRI ferrous sulphate gel dosimetry has proven to be a valuable method for assessment of dose delivered in teletherapy. The intention of this study was to investigate ferrous sulphate gel as a possible dosimeter for intracavitary brachytherapy applications.

MATERIALS AND METHODS

A plastic duplicate of a cervix ring applicator set was submerged in Fe2(+)-infused gelatin gel. The gel was subsequently irradiated by a stepwise moving 192Ir source, using automatic afterloading equipment (Microselectron, Nucletron-Oldelft International BV, Veenendaal, The Netherlands). A 3D dose distribution was reconstructed from MR images of the gel.

RESULTS

The gel dose measurements were found to be of the same accuracy as TLD measurements. Isodose curves based on gel dosimetry and isodose curves computed by a dose planning system were generally less than 2 mm apart. MR images showing the position of the applicator set in a patient during treatment were used to obtain images describing patient anatomy in the sagittal and ring planes of the applicator set. Isodose curves computed from the gel measurements were then superimposed on these images, illustrating one possible way of linking dosimetrical and anatomical data.

CONCLUSIONS

Our study shows that MRI ferrous sulphate gel dosimetry is a useful tool for studies of dose distributions in brachytherapy and their relation to critical organs. Possible improvements of the gel dosimeter lie in reducing the diffusion of ferric ions and increasing the radiation sensitivity of the gel.

External beam abdominal radiotherapy in patients with seminoma stage I: field type, testicular dose, and spermatogenesis

PURPOSE

To establish a predictive model for the estimation of the gonadal dose during adjuvant para-aortic (PA) or dog leg (DL: PA plus ipsilateral iliac) field radiotherapy in patients with testicular seminoma.

METHODS AND MATERIALS

The surface gonadal dose was measured in patients with seminoma Stage I receiving PA or DL radiotherapy. Sperm cell analysis was performed before and 1 year after irradiation. PA and DL radiotherapy were simulated in the Alderson phantom while we measured the dose to the surface and middle of an artificial testicle, varying its position within realistic anatomical constraints. The symphysis-to-testicle distance (STD), field length, and thickness of the patient were experimental variables. The developed mathematical model was validated in subsequent patients.

RESULTS

The mean gonadal dose in patients was 0.09 and 0.32 Gy after PA and DL irradiation, respectively (p < 0.001). DL radiotherapy, but not PA irradiation led to significant reduction of the sperm count 1 year after irradiation. The gonadal dose-reducing effect of PA irradiation was confirmed in the Alderson phantom. A significant correlation was found between the STD and the gonadal dose during DL irradiation. A mathematical model was established for calculation of the gonadal dose and confirmed by measurements in patients.

CONCLUSIONS

During radiotherapy of seminoma, the gonadal dose decreases with increasing STD. It is possible to predict the individual gonadal dose based on delivered midplane dose and STD.

Inhibition of corneal fibrosis by topical application of blocking antibodies to TGF beta in the rabbit

Previous studies have shown that TGF beta 1 induces activation and myofibroblast transformation of cultured rabbit corneal keratocytes. To determine whether TGF beta has a similar function in vivo, we evaluated the effect of TGF beta-blocking antibodies on corneal fibrosis after lamellar keratectomy (LK) in the rabbit. A total of 51 rabbits received standard LK wounds, and eyes were treated with 50 microliters of Celluvisc/PBS, containing 10, 50, or 100 micrograms of 1D11, a mouse monoclonal anti-TGF beta-blocking antibody. Control wounds received either 100 micrograms of an irrelevant mouse monoclonal antibody or vehicle alone. At days 14, 28, 42, and 56, eyes were evaluated by in vivo confocal microscopy (CM) and the mice were killed for light microscopy (LM) and immunostaining with antibodies to human fibronectin. In vivo CM of LK wounds clearly identified a disorganized layer that contained irregularly arranged fibroblasts and reflective extracellular matrix overlying normal corneal stroma. In a subset of 11 eyes stained with 5-(4,6-dichlorotriazinyl) aminofluorescein (DTAF) immediately after injury, the thickness of the disorganized layer identified by in vivo CM significantly correlated with both anterior corneal fibrosis (r = 0.627; p < 0.025) and depth of keratocyte activation (r = 0.8980; p < 0.0005), indicating that in vivo CM can be used quantitatively to assess anterior stromal fibrosis. In eyes treated with an irrelevant monoclonal antibody, in vivo corneal fibrosis averaged 100 +/- 26 microns thick at day 14, whereas treatment with 10, 50, and 100 micrograms anti-TGF beta significantly reduced (p < 0.0005) the anterior disorganization in a dose-dependent fashion to 101 +/- 32, 45 +/- 11, and 56 +/- 18 microns, respectively. Semiquantitative measurement of anti-fibronectin staining within the wound revealed that anti-TGF beta significantly reduced the intensity of anti-fibronectin staining in the anterior 50 microns of the corneal stroma (p < 0.003). These findings indicate that TGF beta plays an important in vivo role in keratocyte activation and myofibroblast transformation. Furthermore, the in vivo use of TGF beta-blocking antibody effects may allow modulation of corneal fibrosis after refractive surgery.

Implications of radiation induced apoptosis on calculated radial cell inactivation for a linear 192Ir source

The cell inactivation probability as a function of the radial distance from a 4 cm linear, low dose rate (LDR) 192Ir source was calculated using a modified linear-quadratic (LQ) equation, taking into account the effect of radiation induced apoptosis. As a measure of the therapeutic range of the source, the radial distance from the midpoint of the central axis of the source to the point of 50% inactivation probability was calculated. It was found that the therapeutic range increased with increasing values of the maximal radiation induced apoptotic fraction, Fa; but only as long as the ratio between the apoptotic cell kill susceptibility, zeta, and the alpha value is larger than unity. If the ratio was smaller than unity, a decrease in therapeutic range was found. The slope of the radial cell inactivation probability curve was measured as the distance between the point of 10% and 90% inactivation probability. The slope was found to be fairly independent of the repair half-time, T(1/2), but became steeper with decreasing values of Fa.

Specification of the dose to organs at risk in external beam radiotherapy

Reporting of the clinical relevant dose to organs at risk (OR) and other normal tissues is crucial in trials and protocols where the aim is to assess late complications and to increase the therapeutic ratio for external beam radiotherapy. The dose distribution in normal tissues and ORs are, however, most often heterogeneous, at least when more than two opposing beams are applied. To decide the most clinical relevant dose with respect to late occurring complications is therefore not a straight forward problem. In this work we discuss what parameters characterise the dose-volume-histogram (DVH) best by calculating normal tissue complication probabilities (NTCPs) by using the Lyman model and various sets of statistical parameters drawn out from the DVHs. These NTCPs are compared to NTCPs calculated from the full DVHs, when the sets of parameters are evaluated. Our calculations indicate that the NTCP based on the Lyman model is best correlated to the Dmax value for serially organised tissues such as the spinal cord. For organs, described largely as tissues organised in parallel, the Dmedian or Dmean of the DVH may be applied. Our calculations reveal that Dmean is the parameter of choice when Dmedian is quite small, but when the two parameters approach each other. Dmedian will be a better choice, using a unity volume fraction. For ORs characterised by a mixed serial and parallel functional structure, as the heart, neither Dmax, Dmedian nor Dmean may predict the actual NTCP.

Brain metastasis model in athymic nude mice using a novel MUC1-secreting human breast-cancer cell line, MA11

The MA11 human breast-cancer cell line was established with cells isolated from a bone-marrow sample using immunomagnetic beads conjugated to the anti-MUC1 antibody BM-2. The cell line showed a selective preference for metastasising to the brain in athymic nude mice. Following injection of MA11 cells into the left ventricle of the heart, brain metastases developed in 87% (20/23) animals, with a mean latency until development of neurological symptoms of 65 days. Necropsy and histological examination revealed tumour nodules of varying sizes throughout the brain, invading both grey and white matter of both hemispheres, and with extensive involvement of the cerebellum. MRI spin-echo images indicated brain lesions in some animals that were subsequently confirmed by histology. Three mice showed small tumour nodules (1-2 mm) in the lung, and 2 had solitary lesions (< 1 mm) within the spinal cord. Metastases were not detected in bone, liver, adrenal gland, kidney, spleen or heart. The human MUC1 mucin, as determined by a europium-based immunoradiometric assay, was detected in the serum of 9/11 animals that showed histological evidence of brain metastases. The mucin could not be found in mouse serum samples taken before day 46. The concentration range of MUC1 observed was from <1 to >50 U/ml, and did not appear to correlate with the size or number of tumours as determined from histological sections. This new model provides an opportunity to study the mechanisms of clinically relevant organ-selective metastases and may be of use in evaluating novel treatment for brain metastases in breast cancer.

Development of an experimental model for high dose rate endocavitary irradiation of the rat rectum

Experimental data indicate a greater tolerance for endocavitary than for external beam irradiation of the normal rectal tissue in the rat. Increased tolerance has been attributed to temperature induced rectal hypoxia and a reduction of the dose to the mesentery. The general scarcity of experimental work in the field and the problems concerning hypoxia and dosimetry motivated the development of the current model. An 8 mm diameter endocavitary applicator was used for symmetrical dilatation and central introduction of the 192Ir source into the rectum of male Fischer F344 rats. Pulse oximetry and pO2-electrode readings from the intubated rectum gave no indication of radiobiological hypoxia. In vitro and in vivo thermoluminescence dosimetry (TLD) was supported by MRI based ferrous sulphate gel dosimetry. Using a 25 mm length source configuration the 90% isodose incorporated a 13 mm length segment of the rectum, and a 5.6% maximum deviation from the calculated dose was observed by the TLD and MRI based gel dosimetry. The ureters, the bladder and the skin were the only organs other than the target organ which received doses greater than 10% of the rectal dose. The model seems to be suitable for dose effect studies since endocavitary irradiation of the rat rectum can be performed without induction of local tissue hypoxia.

Measurement of dynamic wedge angles and beam profiles by means of MRI ferrous sulphate gel dosimetry

The purpose of this study is to examine the possible value of measuring the dose distribution in dynamic wedge photon beams using ferrous sulphate gel phantoms analysed by MRI. The wedge angles and dose profiles were measured for a field size of 70 x 70 mm2 and for dynamic wedge angles of 15 degrees, 30 degrees, 45 degrees and 60 degrees using a 15 MV photon beam generated from a Clinac 2100 CD (Varian). The dose profiles obtained from MRI ferrous sulphate gel were in good agreement with the dose measurements performed with a diode detector array. Also, the wedge angles determined from the MRI ferrous sulphate gel agreed well with the values obtained by using film dosimetry and with calculations by use of TMS (treatment planning system) (Helax, Uppsala, Sweden). The study demonstrated that MRI ferrous sulphate gel dosimetry is an adequate tool for measurements of some beam characteristics of dynamic radiation fields.

Sensitivity and stability of LiF thermoluminescence dosimeters

Three different batches of LiF TLD-100 rods were subjected to investigation of their radiation sensitivity and the stability of the sensitivity after subsequent cycles of irradiation readouts. An old batch (circular rods from 1985), R85, showed an initial sensitivity of approximately 720 (nC/Gy). A new batch of circular rods (R0059) had an initial sensitivity more than a factor of 2.5 higher than the old batch. A batch of square rods (S3720) had an even higher sensitivity; a factor of almost 4 higher than batch R85. Both batches of circular rods showed a statistically significant change in sensitivity with increasing cycles of irradiations and readouts. No significant change was observed for the batch S3720. Batch R85 showed an increasing sensitivity with increasing number of cycles, and a small reduction in the width of the sensitivity distribution within the batch. However, the newer batch (R0059), showed a marked decrease in sensitivity and a doubling of the broadening of the sensitivity distribution after 10 cycles. No significant change in the sensitivity distribution within the S3720 batch was observed after 10 cycles.

Calculation of the biological effect of fractionated radiotherapy: the importance of radiation-induced apoptosis

The total effect (TE) has been calculated for two different fractionation formalisms: the consecutive and repetitive fractionation mechanism, using a modified linear quadratic (LQ) model which includes the effect of apoptosis. For a given total dose, an increase in TE is seen when increasing the dose per fraction as well as the apoptotic fraction (Fa). Also, the TE increases with increasing alpha/beta ratio (of the modified LQ model). The ratio of TE for tumour tissue and TE for late reacting tissue is calculated assuming the absence of apoptosis in late reacting tissue and a common value of alpha/beta (of the modified LQ model). The biological effect ratio (BR) is higher for a large Fa and low doses per fraction, than for large doses per fraction and a small Fa. Assuming a consecutive fractionation mechanism, the TE formalism is unable to predict a log cell kill of more than 3 for beta values of 0.010-0.028. It is less dependent on dose per fraction and Fa than the repetitive fractionation mechanism. The biological effect ratio is only slightly higher than 1, and is less influenced by Fa, dose per fraction and alpha/beta ratio. A repetitive fractionation mechanism is also consistent with the preliminary results of published fractionation experiments. The calculations indicate that designing fractionation regimes for optimization of biological effect is a process where the role of apoptotic cell inactivation must be maximized, and where the influence of mitotic cell inactivation may be of less importance.

Field homogeneity of bevelled intraoperative electron beam cones: the influence of virtual focus surface distance

Field flatness of bevelled intraoperative electron therapy cones were evaluated from dose profiles, taken at dmax, both in the longitudinal plane (long axis direction) and the transversal plane (short axis direction), and were found to depend strongly on the setting of the x-ray collimators. Dose gradients in the longitudinal plane of 10-12% were found for collimator settings of 5 mm larger than the cone diameter for low energies, while the dose gradient were smaller for higher energies, both decreasing with larger collimator setting. The dose increase, relative to the central dose, of the hot spots observed in the profile of the transversal plane were in the range of 5-10% for high energies and large collimator settings, decreasing to less than 3% for low electron beam energies and smaller collimator setting. A decrease in virtual focus to surface distance (VFSD) was found to accompany the increasing dose gradient in the longitudinal plane with decreasing collimator setting, this due to increased scatter of electrons at collimator level. Increasing scatter with smaller collimator setting is also indicated by the increase in photon contamination ranging from 1-2.5% for low energies and 3.5-5% for high energies.

31P NMR spectroscopy studies of phospholipid metabolism in human melanoma xenograft lines differing in rate of tumour cell proliferation

The concentration of phospholipid metabolites in tumours has been hypothesized to be related to rate of cell membrane turnover and may reflect rate of cell proliferation. The purpose of the study reported here was to investigate whether 31P NMR resonance ratios involving the phosphomonoester (PME) or phosphodiester (PDE) resonance are correlated to fraction of cells in S-phase or volume-doubling time in experimental tumours. Four human melanoma xenograft lines (BEX-t, HUX-t, SAX-t, WIX-t) were included in the study. The tumours were grown subcutaneously in male BALB/c-nu/nu mice. 31P NMR spectroscopy was performed at a magnetic field strength of 4.7 T. Fraction of cells in S-phase was measured by flow cytometry. Tumour volume-doubling time was determined by Gompertzian analysis of volumetric growth data. BEX-t and SAX-t tumours differed in fraction of cells in S-phase and volume-doubling time, but showed similar 31P NMR resonance ratios. BEX-t and WIX-t tumours showed significantly different 31P NMR resonance ratios but similar fractions of cells in S-phase. The 31P NMR resonance ratios were significantly different for small and large HUX-t tumours even though fraction of cells in S-phase and volume-doubling time did not differ with tumour volume. None of the 31P NMR resonance ratios showed significant increase with increasing fraction of cells in S-phase or significant decrease with increasing tumour volume-doubling time across the four xenograft lines.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of melanin on phosphorus T1S in human melanoma xenografts studied by 31P MRS

31P MRS resonance ratios of tumors depend on the T1S of the phosphorus compounds. The objective of the 31P MRS study reported here was to investigate whether the phosphorus T1S of melanomas are influenced by the presence of melanin. One amelanotic (COX-t) and one melanotic (ROX-t) human melanoma xenograft line were studied at two different tumor volumes: 200 and 1000 mm3. 31P MRS was performed in nonanaesthetized mice at 4.7 T. The T1S were measured by using the superfast inversion recovery technique. Fraction of necrotic tissue in the tumors was determined by histological examination. The ROX-t tumors showed shorter T1S than the COX-t tumors at a volume of 200 mm3, where the fraction of necrotic tissue in the tumors was insignificant. The difference was similar in magnitude for all resonances. The T1S were not significantly different for COX-t and ROX-t at a volume of 1000 mm3, where the tumors of both lines had developed significant necrosis. The phosphorus T1S of melanomas without necrosis can be shortened significantly by the presence of melanin. The magnitude of the T1 shortening is similar for all major compounds. 31P MRS resonance ratios of melanomas are not altered significantly by correcting for effects of partial saturation.

Spin-lattice relaxation time of inorganic phosphate in human tumor xenografts measured in vivo by 31P-magnetic resonance spectroscopy. Influence of oxygen tension

Previous 31P-magnetic resonance spectroscopy (31P-MRS) studies have suggested that the spin-lattice relaxation time (T1) of the inorganic phosphate (Pi) resonance is shorter in well-oxygenated than in poorly oxygenated tumors. Amelanotic human melanoma xenografts were therefore subjected to 31P-MRS to investigate whether the T1 of the Pi resonance might be a useful parameter for assessment of tumor oxygenation status. It was searched for possible correlations between the T1 of the Pi resonance and oxygen tension or parameters closely related to oxygen tension, including 31P-MRS tumor energy status and blood supply per viable tumor cell. Oxygen tension, tumor energy status, and blood supply per viable tumor cell decreased with increasing tumor volume. In contrast to previous suggestions, the T1 of the Pi resonance decreased with increasing tumor volume and decreasing oxygen tension, tumor energy status, and blood supply per viable tumor cell, possibly because the tumors developed necrotic regions concomitantly with the decrease in oxygenation status, resulting in increased concentrations of freely dissolved para-magnetic ions in the tissue. Consequently, the T1 of the Pi resonance can probably not be utilized to estimate the oxygenation status of tumors, at least not in tumors with necrotic regions.