A Pilot Study of Simulation-Free Hippocampal-Avoidance Whole Brain Radiotherapy Using Diagnostic MRI-Based and Online Adaptive Planning

PURPOSE

We aimed to demonstrate the clinical feasibility and safety of simulation-free hippocampal avoidance whole brain radiation therapy (HA-WBRT) in a pilot study (NCTXXX).

MATERIALS/METHODS

Ten HA-WBRT candidates were enrolled for treatment on a commercially available computed tomography (CT)-guided linear accelerator with online adaptive capabilities. Planning structures were contoured on patient-specific diagnostic MRIs, which were registered to a CT of similar head shape, obtained from an atlas-based database (AB-CT). These patient-specific diagnostic MRI and AB-CT datasets were used for pre-plan calculation, using NRG-CC001 constraints. At first fraction, AB-CTs were used as primary datasets and deformed to patient-specific cone-beam CTs (CBCT) to give patient-matched density information. Brain, ventricle, and brainstem contours were matched through rigid translation and rotation to the corresponding anatomy on CBCT. Lens, optic nerve, and brain contours were manually edited based on CBCT visualization. Pre-plans were then re-optimized through online adaptation to create final, simulation-free plans, which were utilized if they met all objectives. Workflow tasks were timed. In addition, patients underwent CT-simulation to create immobilization devices and for prospective dosimetric comparison of simulation-free and simulation-based plans.

RESULTS

Median time from MRI importation to completion of "pre-plan" was one week-day (range: 1-4). Median on-table workflow duration was 41 minutes (range: 34-70). NRG-CC001 constraints were achieved by 90% of the simulation-free plans. One patient's simulation-free plan failed a planning target volume (PTV) coverage objective (89% instead of 90% coverage); this was deemed acceptable for first-fraction delivery, with an offline replan used for subsequent fractions. Both simulation-free and simulation-CT-based plans otherwise met constraints, without clinically meaningful differences.

CONCLUSION

Simulation-free HA-WBRT using online ART is feasible, safe, and results in dosimetrically comparable treatment plans to simulation-CT-based workflows while providing convenience and time-savings for patients.

Functional network disorganization and cognitive decline following fractionated whole-brain radiation in mice

Cognitive dysfunction following radiotherapy (RT) is one of the most common complications associated with RT delivered to the brain, but the precise mechanisms behind this dysfunction are not well understood, and to date, there are no preventative measures or effective treatments. To improve patient outcomes, a better understanding of the effects of radiation on the brain's functional systems is required. Functional magnetic resonance imaging (fMRI) has shown promise in this regard, however, compared to neural activity, hemodynamic measures of brain function are slow and indirect. Understanding how RT acutely and chronically affects functional brain organization requires more direct examination of temporally evolving neural dynamics as they relate to cerebral hemodynamics for bridging with human studies. In order to adequately study the underlying mechanisms of RT-induced cognitive dysfunction, the development of clinically mimetic RT protocols in animal models is needed. To address these challenges, we developed a fractionated whole-brain RT protocol (3Gy/day for 10 days) and applied longitudinal wide field optical imaging (WFOI) of neural and hemodynamic brain activity at 1, 2, and 3 months post RT. At each time point, mice were subject to repeated behavioral testing across a variety of sensorimotor and cognitive domains. Disruptions in cortical neuronal and hemodynamic activity observed 1 month post RT were significantly worsened by 3 months. While broad changes were observed in functional brain organization post RT, brain regions most impacted by RT occurred within those overlapping with the mouse default mode network and other association areas similar to prior reports in human subjects. Further, significant cognitive deficits were observed following tests of novel object investigation and responses to auditory and contextual cues after fear conditioning. Our results fill a much-needed gap in understanding the effects of whole-brain RT on systems level brain organization and how RT affects neuronal versus hemodynamic signaling in the cortex. Having established a clinically-relevant injury model, future studies can examine therapeutic interventions designed to reduce neuroinflammation-based injury following RT. Given the overlap of sequelae that occur following RT with and without chemotherapy, these tools can also be easily incorporated to examine chemotherapy-related cognitive impairment.

Cardiac radiation improves ventricular function in mice and humans with cardiomyopathy

BACKGROUND

Rapidly dividing cells are more sensitive to radiation therapy (RT) than quiescent cells. In the failing myocardium, macrophages and fibroblasts mediate collateral tissue injury, leading to progressive myocardial remodeling, fibrosis, and pump failure. Because these cells divide more rapidly than cardiomyocytes, we hypothesized that macrophages and fibroblasts would be more susceptible to lower doses of radiation and that cardiac radiation could therefore attenuate myocardial remodeling.

METHODS

In three independent murine heart failure models, including models of metabolic stress, ischemia, and pressure overload, mice underwent 5 Gy cardiac radiation or sham treatment followed by echocardiography. Immunofluorescence, flow cytometry, and non-invasive PET imaging were employed to evaluate cardiac macrophages and fibroblasts. Serial cardiac magnetic resonance imaging (cMRI) from patients with cardiomyopathy treated with 25 Gy cardiac RT for ventricular tachycardia (VT) was evaluated to determine changes in cardiac function.

FINDINGS

In murine heart failure models, cardiac radiation significantly increased LV ejection fraction and reduced end-diastolic volume vs. sham. Radiation resulted in reduced mRNA abundance of B-type natriuretic peptide and fibrotic genes, and histological assessment of the LV showed reduced fibrosis. PET and flow cytometry demonstrated reductions in pro-inflammatory macrophages, and immunofluorescence demonstrated reduced proliferation of macrophages and fibroblasts with RT. In patients who were treated with RT for VT, cMRI demonstrated decreases in LV end-diastolic volume and improvements in LV ejection fraction early after treatment.

CONCLUSIONS

These results suggest that 5 Gy cardiac radiation attenuates cardiac remodeling in mice and humans with heart failure.

FUNDING

NIH, ASTRO, AHA, Longer Life Foundation.

Bridging the Gap of Radiotherapy Treatment Planning Quality between High-Income, and Low- and Middle-Income Countries Using Knowledge-Based Planning

PURPOSE/OBJECTIVE(S)

Radiotherapy departments in low- and middle-income countries (LMICs) like Guatemala have recently introduced intensity-modulated radiotherapy (IMRT). IMRT has become the standard of care in high-income countries (HIC) due to reduced toxicity and improved outcomes in some cancers. The purpose of this work is to show the feasibility of adapting knowledge-based (KB) models established in a HIC to a LMIC lacking experience in IMRT to improve plan quality and planning efficiency.

MATERIALS/METHODS

A Halcyon Linac was installed at our clinic in Guatemala in 2019 and has been used to treat approximately 90 patients daily with IMRT. A model developed on a cohort of head and neck cancer patients at a US academic radiotherapy center were applied at our center to create 20head and neck VMAT plans with different prescriptions, including simultaneous-integrated and sequential boosts.

RESULTS

The plans created using the KB models achieved similar coverage of the planning target volume for each plan KB plans showed better 1) Parotid sparing with a mean dose reduction between 5%-25% and spinal cord maximum dose reduction between 3%-15%. The time efficiency to create VMAT plans using KB model versus manual planning improved four-fold, on average one hour versus more than 4 hours, respectively.

CONCLUSION

Despite different prescriptions, guidelines and demographics of cancer patients between two institutions in a HIC and LMIC, this work demonstrates that KB planning can be used to generate better and more consistent VMAT plans versus manually created plans. In addition, KB planning has the potential to greatly increase planning efficiency higher efficiency and help address the shortage of medical physicists and dosimetrists in LMICs.

A Pilot Study of Simulation-Free Hippocampal-Avoidance Whole Brain Radiotherapy Using Diagnostic MR-Based and Online Adaptive Planning

PURPOSE/OBJECTIVE(S)

We aimed to demonstrate the clinical feasibility and safety of a simulation-free hippocampal avoidance whole brain radiotherapy (HA-WBRT) workflow in a Phase I clinical trial (NCT05096286). Feasibility was defined as successful completion of the simulation-free HA-WBRT workflow through treatment delivery in at last 70% of treated patients.

MATERIALS/METHODS

Ten candidates for HA-WBRT were enrolled for treatment on a ring gantry CT-guided Linac with online adaptive capabilities. Structures were contoured on the diagnostic brain MRI, which was then registered to a separate head computed tomography (CT) of similar head shape, obtained from an atlas-based database. A HA-WBRT "pre-plan" was generated using the atlas-based CT (AB-CT) and the NRG-CC001 constraints. At first fraction, the AB-CT was used as the primary dataset and deformed to the patient's cone-beam CT (CBCT) for dose calculation. The brain, ventricles, and brainstem contours were matched through rigid translation and rotation to the corresponding anatomy on the CBCT to aid in alignment, given the differences in rotational head positioning from diagnostic MRI to CBCT setup. Lastly, the lens, optic nerves, and brain contours were manually edited based on CBCT visualization. Plans were then optimized, and the adaptive plan was chosen for treatment if the plan met all objectives. Workflow tasks were timed. In addition, conventional plans using patients' sim CTs were created for each patient for the purpose of prospective dosimetric comparison. The dosimetric parameters were compared for each patient between the delivered sim-free plan and the conventional sim CT plan using the sign test via statistical software, with p<.05 indicating significance.

RESULTS

Median time from approved sim order to first fraction was 4 days (range: 2-7); median time in room (door-to-door) was 49 minutes (range: 35-70). All patients successfully completed all ten fractions and 90% of the simulation-free radiation plans met all NRG-CC001 constraints. For one patient, the sim-free plan at fraction one failed the planning target volume (PTV) coverage objective (coverage of 89%); this was deemed acceptable for delivery by the treating radiation oncologist. An offline replan was then performed to meet NRG-CC001 constraints and used for the subsequent nine fractions. There was no clinically meaningful difference in dosimetric constraints between the sim-free plan (calculated on AB-CT) and conventional CT sim plan. Statistically, the sim-free plans provided improved PTV coverage to higher doses compared to the conventional plans (Table). At a median follow-up of 43 days (range: 9 -280), the intracranial progression-free survival rate was 90%.

CONCLUSION

Simulation-free HA-WBRT is feasible, results in plans that are dosimetrically comparable to conventional CT sim workflows and succeeds in decreasing time to initiation of HA-WBRT by at least 50%. Further studies with a larger cohort are warranted to optimize the workflow.

Standardizing LT Chest Wall Radiotherapy Treatment Planning in a Low- or Middle- Income Country Radiotherapy Clinic Using Knowledge Based Planning

PURPOSE/OBJECTIVE(S)

Radiotherapy departments in low- or middle-income countries (LMICs) tend to lag behind introducing emerging technologies like intensity-modulated radiotherapy (IMRT). IMRT has become the standard of care in high-income countries (HIC) due to reduced toxicity and improved outcomes in a wide variety of cancers. The purpose of this work is showing the results of left Chest-Wall knowledge-based planning (KBP) standardization and implementation in a LMIC setting.

MATERIALS/METHODS

A Halcyon Linac was installed at our clinic in Guatemala in 2019 and currently used to treat ∼90 IMRT patients daily. The standardization of IMRT procedures has been difficult for complex sites like chest-wall. The steps for standardization included: AAPM TG-263 nomenclature implementation, and planning workflows within the TPS, creation of optimization structures, and plan quality evaluation following RTOG1005 protocol hypofractionation arm. 25 plans were created manually achieving all RTOG1005 protocol constraints. The statistics were analyzed trough the model analytics tool provided by KPB manufacturer.

RESULTS

The results show that more plans are needed to improve the KBP model. This initial model was used to create a standardized clinical protocol in the TPS in order to continue adding plans to the KBP model database. This approach ensures that we obtain consistent plan quality and standardize our planning. The manual planning objectives achieved: CONCLUSION: The experience using the TPS to standardize our treatment planning process achieved good consistency in our planning objectives. This approach will help create KBP models according to our own clinic-specific requirements. Future work will be made to compare our LMIC KBP models with those made at a HIC academic radiotherapy center.

In silico trial of simulation-free hippocampal-avoidance whole brain adaptive radiotherapy

Background and Purpose

Hippocampal-avoidance whole brain radiotherapy (HA-WBRT) can be a time-consuming process compared to conventional whole brain techniques, thus potentially limiting widespread utilization. Therefore, we evaluated the in silico clinical feasibility, via dose-volume metrics and timing, by leveraging a computed tomography (CT)-based commercial adaptive radiotherapy (ART) platform and workflow in order to create and deliver patient-specific, simulation-free HA-WBRT.

Materials and methods

Ten patients previously treated for central nervous system cancers with cone-beam computed tomography (CBCT) imaging were included in this study. The CBCT was the adaptive image-of-the-day to simulate first fraction on-board imaging. Initial contours defined on the MRI were rigidly matched to the CBCT. Online ART was used to create treatment plans at first fraction. Dose-volume metrics of these simulation-free plans were compared to standard-workflow HA-WBRT plans on each patient CT simulation dataset. Timing data for the adaptive planning sessions were recorded.

Results

For all ten patients, simulation-free HA-WBRT plans were successfully created utilizing the online ART workflow and met all constraints. The median hippocampi D100% was 7.8 Gy (6.6-8.8 Gy) in the adaptive plan vs 8.1 Gy (7.7-8.4 Gy) in the standard workflow plan. All plans required adaptation at first fraction due to both a failing hippocampal constraint (6/10 adaptive fractions) and sub-optimal target coverage (6/10 adaptive fractions). Median time for the adaptive session was 45.2 min (34.0-53.8 min).

Conclusions

Simulation-free HA-WBRT, with commercially available systems, was clinically feasible via plan-quality metrics and timing, in silico.

Clinical application of a template-guided automated planning routine

PURPOSE

Determine the dosimetric quality and the planning time reduction when utilizing a template-based automated planning application.

METHODS

A software application integrated through the treatment planning system application programing interface, QuickPlan, was developed to facilitate automated planning using configurable templates for contouring, knowledge-based planning structure matching, field design, and algorithm settings. Validations are performed at various levels of the planning procedure and assist in the evaluation of readiness of the CT image, structure set, and plan layout for automated planning. QuickPlan is evaluated dosimetrically against 22 hippocampal-avoidance whole brain radiotherapy patients. The required times to treatment plan generation are compared for the validations set as well as 10 prospective patients whose plans have been automated by QuickPlan.

RESULTS

The generations of 22 automated treatment plans are compared against a manual replanning using an identical process, resulting in dosimetric differences of minor clinical significance. The target dose to 2% volume and homogeneity index result in significantly decreased values for automated plans, whereas other dose metric evaluations are nonsignificant. The time to generate the treatment plans is reduced for all automated plans with a median difference of 9' 50″ ± 4' 33″.

CONCLUSIONS

Template-based automated planning allows for reduced treatment planning time with consistent optimization structure creation, treatment field creation, plan optimization, and dose calculation with similar dosimetric quality. This process has potential expansion to numerous disease sites.

A reconstruction approach for proton computed tomography by modeling the integral depth dose of the scanning proton pencil beam

PURPOSE

To present a proton computed tomography (pCT) reconstruction approach that models the integral depth dose (IDD) of the clinical scanning proton beam into beamlets. Using a multi-layer ionization chamber (MLIC) as the imager, the proposed pCT system and the reconstruction approach can minimize the extra ambient neutron dose and simplify the beamline design by eliminating an additional collimator to confine the proton beam.

METHODS

Monte Carlo simulation was applied to digitally simulate the IDDs of the exiting proton beams detected by the MLIC. A forward model was developed to model each IDD into the weighted sum of percentage depth doses (PDDs) of the constituent beamlets separated laterally by 1mm. The water equivalent path lengths (WEPLs) of the beamlets were determined by iteratively minimizing the squared L2-norm of the forward projected and simulated IDDs. The final WEPL values were reconstructed to pCT images, i.e., proton Stopping Power Ratio (SPR) maps, through simultaneous algebraic reconstruction technique with total variation regularization (SART-TV). The reconstruction process was tested with a digital cylindrical water-based phantom and an ICRP adult reference computational phantom. The mean of SPR within regions of interest (ROIs) and the WEPLs along 4 mm-wide beams (WEPL_4mm ) were compared to the reference values. The spatial resolution was analyzed at the edge of a cortical insert of the cylindrical phantom.

RESULTS

The percentage deviations from reference SPR were within ±1% in all selected ROIs. The mean absolute error of the reconstructed SPR was 0.33%, 0.19%, and 0.27% for the cylindrical phantom, the adult phantom at the head and lung region, respectively. The corresponding percentage deviations from reference WEPL_4mm were 0.48%±0.64%, 0.28% ± 0.48%, and 0.22% ± 0.49%. The full width at half maximum (FWHM) of the line spread function (LSF) derived from the radial edge spread function (ESF) of a cortical insert was 0.13 cm. The frequency at 10% of the modulation transfer function (MTF) was 6.38 cm^-1 . The mean signal-to-noise ratio (SNR) of all the inserts was 2.45. The mean imaging dose was 0.29 cGy and 0.25 cGy at the head and lung region of the adult phantom, respectively.

CONCLUSION

A new pCT reconstruction approach was developed by modeling the IDDs of the uncollimated scanning proton beams in the pencil beam geometry. SPR accuracy within ±1%, spatial resolution of better than 2mm at 10% MTF, and imaging dose at the magnitude of mGy were achieved. Potential side effects caused by neutron dose were eliminated by removing the extra beam collimator. This article is protected by copyright. All rights reserved.

Development and Implementation of an Open Source Template Interpretation Class Library for Automated Treatment Planning

PURPOSE

Widespread implementation of automated treatment planning in radiation therapy remains elusive due to variability in clinic and physician preferences making it difficult to ensure consistent plan parameters. We have developed an open-source class library with the aim to improve efficiency and consistency for automated treatment planning in radiation therapy.

METHODS AND MATERIALS

An open source class library has been developed that interprets clinical templates within a commercial treatment planning system into a treatment plan for automated planning. This code was leveraged for the automated planning of 39 patients and retrospectively compared to the 78 clinically approved manual plans.

RESULTS

From the initial 39 patients, 74 of 78 plans were successfully generated without manual intervention. Target dose was more homogenous for automated plans, with an average homogeneity index of 3.30 vs 3.11 for manual and automated plans, respectively (p = 0.107). Generalized equivalent uniform dose decreased in the femurs and rectum for automated plans, with mean gEUD of 3746 cGy vs 3338 cGy (p ≤ 0.001) and 5761 cGy vs 5634 cGy (p ≤ 0.001) for femurs and rectum, respectively. Dose metrics for bladder and rectum (V6500 cGy and V4000 cGy) show recognizable but insignificant improvements. All automated plans delivered for quality assurance passed a gamma analysis (>95%) with an average composite pass rate of 99.3% and 98.8% for pelvis and prostate plans, respectively. Deliverability parameters such as total monitor units and aperture complexity indicate deliverable plans.

CONCLUSIONS

Prostate cancer and pelvic node radiotherapy can be automated using VMAT planning and clinical templates based on a standardized clinical workflow. The class library developed in this study conveniently interfaces between the plan template and the treatment planning system to automatically generate high quality plans on customizable templates.

Quantification of gold nanoparticle photon radiosensitization from direct and indirect effects using a complete human genome single cell model based on Geant4

PURPOSE

To investigate the radiosensitization properties of gold nanoparticles (GNPs) and better understand the intricate deoxyribonucleic acid (DNA) damage induction mechanisms involved in GNP-aided radiotherapy, a single cell model with complete human genome based on the Geant4 Monte Carlo toolkit was applied.

MATERIALS AND METHODS

A Geant4-DNA model was implemented to simulate direct and indirect DNA damage generated in the physical and chemical stages. In the physical stage, a mixed-physics approach was taken by using Geant4-DNA in water and Livermore in gold. Water radiolysis was created posteriorly in the physicochemical and chemical stages to simulate indirect damage from reactions between DNA molecules and OH• radicals. A mono-energetic photon beam (100 keV) and two clinical photon sources (250-kVp, 6-MV flattening-filter free) were simulated for modeling the irradiation of a single cell with or without GNPs. In order to study the effects of GNP size on radiosensitization, 15, 30, and 100 nm GNPs were simulated. The effects of intracellular distribution were simulated using 90-nm GNPs with different characteristics of distribution within the cell. The time dependence of DNA damage enhancement was also studied with chemistry stage simulation end-time no larger than 10 ns.

RESULTS

Double strand break (DSB) enhancement due to direct and indirect action was quantified under different scenarios. Under realistic cellular uptake condition, the 100-nm GNPs had the most significant increase in DSBs: 40.9% and 28.5% for 100 keV and 250-kVp photon irradiation, respectively. The intracellular localization showed differing levels of radiosensitization with a maximum of 64%, 27%, and 6% DSB enhancements for 100 keV, 250-kVp, and 6-MV respectively, when 90-nm GNPs congregate around the nucleus.

CONCLUSION

The results indicate that photon energy, GNP size, and intracellular distribution play an important role in the enhancement of DSB from direct and indirect damage under scenarios close to cell experiments. The radiosensitization effects due to indirect damage are significant and should be considered carefully.

Application programming interface guided QA plan generation and analysis automation

Purpose

Linear accelerator quality assurance (QA) in radiation therapy is a time consuming but fundamental part of ensuring the performance characteristics of radiation delivering machines. The goal of this work is to develop an automated and standardized QA plan generation and analysis system in the Oncology Information System (OIS) to streamline the QA process.

Methods

Automating the QA process includes two software components: the AutoQA Builder to generate daily, monthly, quarterly, and miscellaneous periodic linear accelerator QA plans within the Treatment Planning System (TPS) and the AutoQA Analysis to analyze images collected on the Electronic Portal Imaging Device (EPID) allowing for a rapid analysis of the acquired QA images. To verify the results of the automated QA analysis, results were compared to the current standard for QA assessment for the jaw junction, light‐radiation coincidence, picket fence, and volumetric modulated arc therapy (VMAT) QA plans across three linacs and over a 6‐month period.

Results

The AutoQA Builder application has been utilized clinically 322 times to create QA patients, construct phantom images, and deploy common periodic QA tests across multiple institutions, linear accelerators, and physicists. Comparing the AutoQA Analysis results with our current institutional QA standard the mean difference of the ratio of intensity values within the field‐matched junction and ball‐bearing position detection was 0.012 ± 0.053 (P = 0.159) and is 0.011 ± 0.224 mm (P = 0.355), respectively. Analysis of VMAT QA plans resulted in a maximum percentage difference of 0.3%.

Conclusion

The automated creation and analysis of quality assurance plans using multiple APIs can be of immediate benefit to linear accelerator quality assurance efficiency and standardization. QA plan creation can be done without following tedious procedures through API assistance, and analysis can be performed inside of the clinical OIS in an automated fashion.

Modeling double-strand breaks from direct and indirect action in a complete human genome single cell Geant4 model

The aim of this work is to develop and validate a computational model to investigate direct and indirect DNA damage by directly quantifying DNA strand breaks. A detailed geometrical target model was created in the Monte Carlo toolkit Geant4 to represent the nucleus of a single human cell with complete human genome. A calculation framework to simulate double-strand breaks (DSBs) was implemented using this single cell model in the Geant4-DNA extension. A detailed ellipsoidal single cell model was implemented using a compacted DNA structure representing the fibroblast cell in the G0/G1 phase of the cycle using a total of 6 Gbp within the nucleus to represent the complete human genome. This geometry was developed from the publicly available Geant4-DNA example (wholeNuclearDNA), and modified to record DNA damage for both the physical and chemical stages. A clustering algorithm was implemented in the analysis process in order to quantify direct, indirect, and mixed DSBs. The model was validated against published experimental and computational results for DSB Gy^-1Gbp^-1and the relative biological effectiveness (RBE) values for 250 kVp and Co-60 photons, as well as 2-100 MeV mono-energetic protons. A general agreement was observed over the whole simulated proton energy range, Co-60 beam, and 250 kVp in terms of the yield of DSB Gy^-1Gbp^-1and RBE. The DSB yield was 8.0 ± 0.3 DSB Gy^-1Gbp^-1for Co-60, and 9.2 ± 0.2 DSB Gy^-1Gbp^-1for 250 kVp, and between 11.1 ± 0.9 and 8.1 ± 0.5 DSB Gy^-1Gbp^-1for 2-100 MeV protons. The results also show mixed DSBs composed of direct and indirect SSBs make up more than half of the total DSBs. The results presented indicate that the current model reliably predicts the DSB yield and RBE for proton and photon irradiations, and allows for the detailed computational investigation of direct and indirect effects in DNA damage.

Influence of 0.35 T magnetic field on the response of EBT3 and EBT-XD radiochromic films

PURPOSE

To investigate the inconsistency of recent literature on the effect of magnetic field on the response of radiochromic films, we studied the influence of 0.35 T magnetic field on dosimetric response of EBT3 and EBT-XD Gafchromic^TM films.

METHODS

Two different models of radiochromic films, EBT3 and EBT-XD, were investigated. Pieces of films samples from two different batches for each model were irradiated at different dose levels ranging from 1 to 20 Gy using 6 MV flattening filter free (FFF) x-rays generated by a clinical MR-guided radiotherapy system (B = 0.35 T). Film samples from the same batch were irradiated at corresponding dose levels using 6 MV FFF beam from a conventional linac (B = 0) for comparison. The net optical density was measured 48 h postirradiation using a flatbed scanner. The absorbance spectra were also measured over 500-700 nm wavelength range using a fiber-coupled spectrometer with 2.5 nm resolution. To study the effect of fractionated dose delivery to EBT3 (/EBT-XD) films, 8 (/16) Gy dose was delivered in four 2 (/4) Gy fractions with 24 h interval between fractions.

RESULTS

No significant difference was found in the net optical density and net absorbance of the films irradiated with or without the presence of magnetic field. No dependency on the orientation of the film during irradiation with respect to the magnetic field was observed. The fractionated dose delivery resulted in the same optical density as delivering the whole dose in a single fraction.

CONCLUSIONS

The 0.35 T magnetic field employed in the ViewRay^® MR-guided radiotherapy system did not show any significant influence on the response of EBT3 and EBT-XD Gafchromic^TM films.

Automated and robust beam data validation of a preconfigured ring gantry linear accelerator using a 1D tank with synchronized beam delivery and couch motions

PURPOSE

To develop an efficient and automated methodology for beam data validation for a preconfigured ring gantry linear accelerator using scripting and a one-dimensional (1D) tank with automated couch motions.

MATERIALS AND METHODS

Using an application programming interface, a program was developed to allow the user to choose a set of beam data to validate with measurement. Once selected the program generates a set of instructions for radiation delivery with synchronized couch motions for the linear accelerator in the form of an extensible markup language (XML) file to be delivered on the ring gantry linear accelerator. The user then delivers these beams while measuring with the 1D tank and data logging electrometer. The program also automatically calculates this set of beams on the measurement geometry within the treatment planning system (TPS) and extracts the corresponding calculated dosimetric data for comparison to measurement. Once completed the program then returns a comparison of the measurement to the predicted result from the TPS to the user and prints a report. In this work lateral, longitudinal, and diagonal profiles were taken for fields sizes of 6 × 6, 8 × 8, 10 × 10, 20 × 20, and 28 × 28 cm² at depths of 1.3, 5, 10, 20, and 30 cm. Depth dose profiles were taken for all field sizes.

RESULTS

Using this methodology, the TPS was validated to agree with measurement. All compared points yielded a gamma value less than 1 for a 1.5%/1.5 mm criteria (100% passing rate). Off axis profiles had >98.5% of data points producing a gamma value <1 with a 1%/1 mm criteria. All depth profiles produced 100% of data points with a gamma value <1 with a 1%/1 mm criteria. All data points measured were within 1.5% or 2 mm distance to agreement.

CONCLUSIONS

This methodology allows for an increase in automation in the beam data validation process. Leveraging the application program interface allows the user to use a single system to create the measurement files, predict the result, and then compare to actual measurement increasing efficiency and reducing the chance for user input errors.

Lateral head flexion as a noncoplanar solution for ring gantry stereotactic radiosurgery

PURPOSE

Ring gantry radiotherapy devices are often limited to deliver beams in the axial plane, severely limiting beam entrance angles and rendering noncoplanar beam delivery impossible. However, a ring gantry geometry greatly simplifies delivery machines and increases the efficiency of treatment with the potential to decrease the overall costs of radiotherapy. This study explores the use of lateral head flexion in order to increase beam entrance angles and extend the available solid angle space for a ring gantry stereotactic radiosurgery (SRS) application.

MATERIALS AND METHODS

A 1.5 T magnetic resonance imaging scanner was used to scan seven healthy volunteers at three different head positions: a neutral position, a left lateral flexion position and a right lateral flexion position. The lateral flexion scans were co-registered to the neutral head position scan using rigid registration and extracting the rotational transformation. The head pitch, roll, and yaw were computed for each registration to evaluate the natural range of motion for all volunteers. A ring gantry plan geometry was used to generate two sets of single fraction SRS plans (21 Gy): one coplanar set for head neutral scans, and a three-arc plan set using the head neutral and lateral head flexion scans. The conformity index (CI), intermediate dose fall-off (R50), low dose spillage (R10), and gradient measure (GM) were used to evaluate both sets of plans. The treatment plans were generated for a ring-gantry linear accelerator (linac) (Varian Halcyon 2.0) as well as radiosurgery linac (Varian Edge) for comparison.

RESULTS

The average pitch, yaw, and roll for the lateral head flexion scans were 4.1° ± 4.7°, 16.9° ± 3.7°, and 2.5° ± 4.9° for the right flexion and 4.9° ± 4.3°, 14.0° ± 3.7° and 2.8° ± 5.4° for left flexion. When comparing the head flexion technique with a fully coplanar geometry, the ring gantry plans showed an average improvement in CI of 7.3% (1.46 ± 0.25 vs 1.36 ± 0.28), a decrease of 13% in R50 (5.46 ± 1.14 vs 4.78 ± 1.12), a decrease of 32% in R10 (85.7 ± 20.3 vs 58.2 ± 15.1), and a decrease of 7.8% in GM (0.53 ± 0.05 vs 0.49 ± 0.04). The Edge plans showed an average improvement in CI of 3.0% (1.49 ± 0.26 vs 1.45 ± 0.25), a decrease of 6.8% in R50 (5.19 ± 1.03 vs 4.82 ± 0.83), a decrease of 29% in R10 (84.1 ± 16.3 vs 59.9 ± 12.5), and a decrease of 5.0% in GM (0.50 ± 0.04 vs 0.47 ± 0.03).

CONCLUSION

Lateral head flexion was shown to increase beam entrance angles considerably improving plan conformity and normal tissue sparing in this pilot study of seven sets of plans. Rigid registrations demonstrated each lateral flexion to be analogous to a 15° couch kick. The head flexion technique outlined here was shown to be a feasible solution for SRS treatments being delivered on ring gantry devices.

A novel design of proton computed tomography detected by multiple-layer ionization chamber with strip chambers: A feasibility study with Monte Carlo simulation

PURPOSE

Uncertainty in proton range can be reduced by proton computed tomography (CT). A novel design of proton CT using a multiple-layer ionization chamber with two strip ionization chambers on the surface is proposed to simplify the imaging acquisition and reconstruction.

METHODS

Two strip ionization chambers facing the proton source were coupled into a multiple-layer ionization chamber (MLIC). The strip chambers measured locations and lateral profiles of incident proton beamlets after exiting the imaging object, while the integral of depth dose measured in the MLIC was translated into the residual energy of the beamlet. The simulation was performed at five levels of imaging dose to demonstrate the feasibility and performance expectations of our design. The energy of the proton beamlet was set to 150 ± 0.6 MeV. A collimator with a round slit of 1 cm in diameter was placed in the central beam axis upstream from steering magnets. Proton stopping power ratio (SPR) was reconstructed through inverse radon transform on sinograms generated with proton beamlets scanning through an imaging phantom from a half-circle gantry rotation. The imaging phantom was 10 cm in diameter. The base was made of water-equivalent material holding 13-tissue equivalent inserts constructed according to ICRP 1975 (Task Group on Reference Man. "Report of the Task Group on Reference Man: A Report", Pergamon Press 23, 1975). All inserts were 1 cm in diameter with materials ranging from lung to cortical bone. Percentage discrepancies were reported by comparing to the ground truths. The imaging dose and quality were also evaluated.

RESULTS

The maximum deviation in reconstructed proton SPR from the ground truths was reported to be 1.02% in one of the 13 inserts when the number of protons per beamlet passing through the slit dropped to 10³ . Imaging dose was correlated linearly to incident protons and was determined to be 0.54 cGy if 5 × 10² protons per beamlet were used. Imaging quality was acceptable for planning purpose and held consistently through all levels of imaging dose. Spatial resolution was measured as five line pairs per cm consistently in all simulations varying in imaging dose.

CONCLUSIONS

Proton CT using a multiple-layer ionization chamber with two strip ionization chambers on the surface simplifies data acquisition while achieving excellent accuracy in proton SPR and acceptable spatial resolution. The imaging dose is lower compared to kV CBCT, making it potentially a great tool for localization and plan adaption in proton therapy.

Technical Note: A benchtop cone-beam x-ray fluorescence computed tomography (XFCT) system with a high-power x-ray source and transmission CT imaging capability

PURPOSE

This report describes upgrades and performance characterization of an experimental benchtop cone-beam x-ray fluorescence computed tomography (XFCT) system capable of determining the spatial distribution and concentration of metal probes such as gold nanoparticles (GNPs). Specifically, a high-power (~3 kW) industrial x-ray source and transmission CT capability were deployed in the same platform under the cone-beam geometry.

METHODS

All components of the system are described in detail, including the x-ray source, imaging stage, cadmium-telluride detector for XFCT, and flat-panel detector for transmission CT imaging. The general data acquisition scheme for XFCT and transmission CT is also explicated. The detection limit of the system was determined using calibration samples containing water and GNPs at various concentrations. Samples were then embedded in a small-animal-sized phantom and imaged with XFCT and CT. The reconstructed XFCT and CT images were compared and analyzed using the contrast-to-noise ratio for each GNP-containing region of interest. Also, measurements of the incident beam spectra used for XFCT and CT imaging were made and the corresponding x-ray dose rates were estimated, along with the imaging dose.

RESULTS

The present configuration produced a GNP detection limit of 0.03 wt. % with the delivery of an effective dose of 1.87 cGy per projection. XFCT scan of an animal-sized phantom containing low concentrations (down to 0.03 wt. %) of GNP-loaded inserts can be performed within an hour.

CONCLUSIONS

The high performance of the system combined with the ability to perform transmission CT in tandem with XFCT suggests that the currently developed benchtop cone-beam XFCT/CT system, in conjunction with GNPs, can be used for routine multimodal preclinical imaging tasks with less stringent dose constraints such as ex vivo imaging. With further effort to minimize XFCT imaging dose as discussed in this report, it may also be used for in vivo imaging.

Technical Note: Monte Carlo calculations of the AAPM TG-43 brachytherapy dosimetry parameters for a new titanium-encapsulated Yb-169 source

Due to a number of distinct advantages resulting from the relatively low energy gamma ray spectrum of Yb‐169, various designs of Yb‐169 sources have been developed over the years for brachytherapy applications. Lately, Yb‐169 has also been suggested as an effective and practical radioisotope option for a novel radiation treatment approach often known as gold nanoparticle‐aided radiation therapy (GNRT). In a recently published study, the current investigators used the Monte Carlo N‐Particle Version 5 (MCNP5) code to design a novel titanium‐encapsulated Yb‐169 source optimized for GNRT applications. In this study, the original MC source model was modified to accurately match the specifications of the manufactured Yb‐169 source. The modified MC model was then used to obtain a complete set of the AAPM TG‐43 parameters for the new titanium‐encapsulated Yb‐169 source. The MC‐calculated dose rate constant for this titanium‐encapsulated Yb‐169 source was 1.19 ± 0.03 cGy·h−1·U−1, indicating no significant change from the values reported for stainless steel‐encapsulated Yb‐169 sources. The source anisotropy and radial dose function for the new source were also found similar to those reported for the stainless steel‐encapsulated Yb‐169 sources. The current results suggest that the use of titanium, instead of stainless steel, to encapsulate the Yb‐169 core would not lead to any major change in the dosimetric characteristics of the Yb‐169 source. The results also show that the titanium encapsulation of the Yb‐169 source could be accomplished while meeting the design goals as described in the current investigators’ published MC optimization study for GNRT applications.

Quantitative imaging of gold nanoparticle distribution in a tumor-bearing mouse using benchtop x-ray fluorescence computed tomography

X-ray fluorescence computed tomography (XFCT) is a technique that can identify, quantify, and locate elements within objects by detecting x-ray fluorescence (characteristic x-rays) stimulated by an excitation source, typically derived from a synchrotron. However, the use of a synchrotron limits practicality and accessibility of XFCT for routine biomedical imaging applications. Therefore, we have developed the ability to perform XFCT on a benchtop setting with ordinary polychromatic x-ray sources. Here, we report our postmortem study that demonstrates the use of benchtop XFCT to accurately image the distribution of gold nanoparticles (GNPs) injected into a tumor-bearing mouse. The distribution of GNPs as determined by benchtop XFCT was validated using inductively coupled plasma mass spectrometry. This investigation shows drastically enhanced sensitivity and specificity of GNP detection and quantification with benchtop XFCT, up to two orders of magnitude better than conventional x-ray CT. The results also reaffirm the unique capabilities of benchtop XFCT for simultaneous determination of the spatial distribution and concentration of nonradioactive metallic probes, such as GNPs, within the context of small animal imaging. Overall, this investigation identifies a clear path toward in vivo molecular imaging using benchtop XFCT techniques in conjunction with GNPs and other metallic probes.

Design of an Yb-169 source optimized for gold nanoparticle-aided radiation therapy

PURPOSE

To find an optimum design of a new high-dose rate ytterbium (Yb)-169 brachytherapy source that would maximize the dose enhancement during gold nanoparticle-aided radiation therapy (GNRT), while meeting practical constraints for manufacturing a clinically relevant brachytherapy source.

METHODS

Four different Yb-169 source designs were considered in this investigation. The first three source models had a single encapsulation made of one of the following materials: aluminum, titanium, and stainless steel. The last source model adopted a dual encapsulation design with an inner aluminum capsule surrounding the Yb-core and an outer titanium capsule. Monte Carlo (MC) simulations using the Monte Carlo N-Particle code version 5 (MCNP5) were conducted initially to investigate the spectral changes caused by these four source designs and the associated variations in macroscopic dose enhancement across the tumor loaded with gold nanoparticles (GNPs) at 0.7% by weight. Subsequent MC simulations were performed using the EGSnrc and norec codes to determine the secondary electron spectra and microscopic dose enhancement as a result of irradiating the GNP-loaded tumor with the mcnp-calculated source spectra.

RESULTS

Effects of the source filter design were apparent in the current MC results. The intensity-weighted average energy of the Yb-169 source varied from 108.9 to 122.9 keV, as the source encapsulation material changed from aluminum to stainless steel. Accordingly, the macroscopic dose enhancement calculated at 1 cm away from the source changed from 51.0% to 45.3%. The sources encapsulated by titanium and aluminum/titanium combination showed similar levels of dose enhancement, 49.3% at 1 cm, and average energies of 113.0 and 112.3 keV, respectively. While the secondary electron spectra due to the investigated source designs appeared to look similar in general, some differences were noted especially in the low energy region (<50 keV) of the spectra suggesting the dependence of the photoelectron yield on the atomic number of source filter material, consistent with the macroscopic dose enhancement results. A similar trend was also shown in the so-called microscopic dose enhancement factor, for example, resulting in the maximum values of 138 and 119 for the titanium- and the stainless steel-encapsulated Yb-169 sources, respectively.

CONCLUSIONS

The current results consistently show that the dose enhancement achievable from the Yb-169 source is closely related with the atomic number (Z) of source encapsulation material. While the observed range of improvement in the dose enhancement may be considered moderate after factoring all uncertainties in the MC results, the current study provides a reasonable support for the encapsulation of the Yb-core with lower-Z materials than stainless steel, for GNRT applications. Overall, the titanium capsule design can be favored over the aluminum or dual aluminum/titanium capsule designs, due to its superior structural integrity and improved safety during manufacturing and clinical use.

Experimental demonstration of direct L-shell x-ray fluorescence imaging of gold nanoparticles using a benchtop x-ray source

PURPOSE

To develop a proof-of-principle L-shell x-ray fluorescence (XRF) imaging system that locates and quantifies sparse concentrations of gold nanoparticles (GNPs) using a benchtop polychromatic x-ray source and a silicon (Si)-PIN diode x-ray detector system.

METHODS

12-mm-diameter water-filled cylindrical tubes with GNP concentrations of 20, 10, 5, 0.5, 0.05, 0.005, and 0 mg∕cm3 served as calibration phantoms. An imaging phantom was created using the same cylindrical tube but filled with tissue-equivalent gel containing structures mimicking a GNP-loaded blood vessel and approximately 1 cm3 tumor. Phantoms were irradiated by a 3-mm-diameter pencil-beam of 62 kVp x-rays filtered by 1 mm aluminum. Fluorescence∕scatter photons from phantoms were detected at 90° with respect to the beam direction using a Si-PIN detector placed behind a 2.5-mm-diameter lead collimator. The imaging phantom was translated horizontally and vertically in 0.3-mm steps to image a 6 mm×15 mm region of interest (ROI). For each phantom, the net L-shell XRF signal from GNPs was extracted from background, and then corrected for detection efficiency and in-phantom attenuation using a fluorescence-to-scatter normalization algorithm.

RESULTS

XRF measurements with calibration phantoms provided a calibration curve showing a linear relationship between corrected XRF signal and GNP mass per imaged voxel. Using the calibration curve, the detection limit (at the 95% confidence level) of the current experimental setup was estimated to be a GNP mass of 0.35 μg per imaged voxel (1.73×10(-2) cm3). A 2D XRF map of the ROI was also successfully generated, reasonably matching the known spatial distribution as well as showing the local variation of GNP concentrations.

CONCLUSIONS

L-shell XRF imaging can be a highly sensitive tool that has the capability of simultaneously imaging the spatial distribution and determining the local concentration of GNPs presented on the order of parts-per-million level within subcentimeter-sized ex vivo samples and superficial tumors during preclinical animal studies.

Monitoring of magnetic targeting to tumor vasculature through MRI and biodistribution

AIMS

The development of noninvasive imaging techniques for the assessment of cancer treatment is rapidly becoming highly important. The aim of the present study is to show that magnetic cationic liposomes (MCLs), incorporating superparamagnetic iron oxide nanoparticles (SPIONs), are a versatile theranostic nanoplatform for enhanced drug delivery and monitoring of cancer treatment.

MATERIALS & METHODS

MCLs (with incorporated high SPION cargo) were administered to a severe combined immunodeficiency mouse with metastatic (B16-F10) melanoma grown in the right flank. Pre- and post-injection magnetic resonance (MR) images were used to assess response to magnetic targeting effects. Biodistribution studies were conducted by ¹¹¹In-labeled MCLs and the amount of radioactivity recovered was used to confirm the effect of targeting for intratumoral administrations.

RESULTS

We have shown that tumor signal intensities in T₂-weighted MR images decreased by an average of 20 ± 5% and T₂* relaxation times decreased by 14 ± 7 ms 24 h after intravenous administration of our MCL formulation. This compares to an average decrease in tumor signal intensity of 57 ± 12% and a T₂* relaxation time decrease of 27 ± 8 ms after the same time period with the aid of magnetic guidance.

CONCLUSION

MR and biodistribution analysis clearly show the efficacy of MCLs as MRI contrast agents, prove the use of magnetic guidance, and demonstrate the potential of MCLs as agents for imaging, guidance and therapeutic delivery.