Treatment planning for heavy-ion radiotherapy: physical beam model and dose optimization

We describe a novel code system, TRiP, dedicated to the planning of radiotherapy with energetic ions, in particular 12C. The software is designed to cooperate with three-dimensional active dose shaping devices like the GSI raster scan system. This unique beam delivery system allows us to select any combination from a list of 253 individual beam energies, 7 different beam spot sizes and 15 intensity levels. The software includes a beam model adapted to and verified for carbon ions. Inverse planning techniques are implemented in order to obtain a uniform target dose distribution from clinical input data, i.e. CT images and patient contours. This implies the automatic generation of intensity modulated fields of heavy ions with as many as 40000 raster points, where each point corresponds to a specific beam position, energy and particle fluence. This set of data is directly passed to the beam delivery and control system. The treatment planning code has been in clinical use since the start of the GSI pilot project in December 1997. Forty-eight patients have been successfully planned and treated.

Treatment planning for heavy-ion radiotherapy: calculation and optimization of biologically effective dose

We describe a novel approach to treatment planning for heavy-ion radiotherapy based on the local effect model (LEM) which allows us to calculate the biologically effective dose not only for the target region but also for the entire irradiation volume. LEM is ideally suited for use as an integral part of treatment planning code systems for active dose shaping devices like the GSI raster scan system. Thus it has been incorporated into our standard treatment planning system for ion therapy (TRiP). Single intensity modulated fields can be optimized with respect to a homogeneous biologically effective dose. The relative biological effectiveness (RBE) is calculated separately for each voxel of the patient CT. Our radiobiologically oriented code system has been used since 1995 for the planning of irradiation experiments with cell cultures and animals such as rats and minipigs. It has been in regular and successful use for patient treatment planning since 1997.

Metabolic engineering for microbial production of aromatic amino acids and derived compounds

Metabolic engineering to design and construct microorganisms suitable for the production of aromatic amino acids and derivatives thereof requires control of a complicated network of metabolic reactions that partly act in parallel and frequently are in rapid equilibrium. Engineering the regulatory circuits, the uptake of carbon, the glycolytic pathway, the pentose phosphate pathway, and the common aromatic amino acid pathway as well as amino acid importers and exporters that have all been targeted to effect higher productivities of these compounds are discussed.

Accuracy of the local effect model for the prediction of biologic effects of carbon ion beams in vitro and in vivo

PURPOSE

To analyze the accuracy of relative biologic effectiveness (RBE) values for treatment planning in carbon ion radiotherapy based on the local effect model (LEM) and to discuss the implications on the clinically relevant depth dose profiles.

METHODS AND MATERIALS

Predictions of the LEM are compared with a broad panel of experimental data in vitro and to the tolerance of the rat spinal cord in vivo. To improve the accuracy of the LEM, the description of track structure is modified by taking into account a velocity-dependent extension of the inner part of the track.

RESULTS

The original version of the LEM (LEM I) underestimates the therapeutic ratio of carbon ions (i.e., the ratio of RBE in the Bragg peak region as compared with the RBE in the entrance channel). Although significantly reduced, the cluster extension of the LEM (LEM II) still shows the same tendency. Implementation of the modified track structure (LEM III) almost completely compensates these systematic deviations, and predictions of RBE by LEM III for high and low energetic carbon ions show good agreement for a wide panel of different cell lines, as well as for the tolerance of the rat spinal cord. As a consequence, the expected RBE in the normal tissue surrounding the tumor becomes significantly lower than estimated with the LEM in its original version (LEM I).

CONCLUSIONS

The modified track structure description represents an empiric approach to improve the accuracy of the LEM for treatment planning. This will be particularly useful for further optimization of carbon ion therapy in general and with respect to comparison with other treatment modalities, such as protons or intensity-modulated radiotherapy.

Kill-painting of hypoxic tumours in charged particle therapy

Solid tumours often present regions with severe oxygen deprivation (hypoxia), which are resistant to both chemotherapy and radiotherapy. Increased radiosensitivity as a function of the oxygen concentration is well described for X-rays. It has also been demonstrated that radioresistance in anoxia is reduced using high-LET radiation rather than conventional X-rays. However, the dependence of the oxygen enhancement ratio (OER) on radiation quality in the regions of intermediate oxygen concentrations, those normally found in tumours, had never been measured and biophysical models were based on extrapolations. Here we present a complete survival dataset of mammalian cells exposed to different ions in oxygen concentration ranging from normoxia (21%) to anoxia (0%). The data were used to generate a model of the dependence of the OER on oxygen concentration and particle energy. The model was implemented in the ion beam treatment planning system to prescribe uniform cell killing across volumes with heterogeneous radiosensitivity. The adaptive treatment plans have been validated in two different accelerator facilities, using a biological phantom where cells can be irradiated simultaneously at three different oxygen concentrations. We thus realized a hypoxia-adapted treatment plan, which will be used for painting by voxel of hypoxic tumours visualized by functional imaging.

Effects of acute prolactin manipulation on sexual drive and function in males

The neuroendocrine response to sexual activity in humans is characterized by a pronounced orgasm-dependent increase of plasma levels of prolactin. In contrast to the well-known inhibitory effects of chronic hyperprolactinemia on sexual drive and function, the impact of acute prolactin alterations on human sexual physiology is unknown. Therefore, this study was designed to investigate the effects of acute manipulation of plasma prolactin on sexual behavior. Ten healthy males participated in a single-blind, placebo-controlled, balanced cross-over design. Prolactin levels were pharmacologically increased to high levels (protirelin, 50 micro g i.v.) or reduced to low physiological concentrations (cabergoline, 0.5 mg p.o.). Sexual arousal and orgasm were then induced by an erotic film and masturbation. In addition to continuous neuroendocrine and cardiovascular recordings, the quality and intensity of the acute sexual drive, arousal, orgasm and refractory period were assessed by extensive psychometric measures. Administration of cabergoline decreased prolactin levels and significantly enhanced all parameters of sexual drive (P<0.05), function (P<0.01) and positive perception of the refractory period (P<0.01). Administration of protirelin increased prolactin concentrations and produced small, but not significant reductions of sexual parameters. The sexual effects observed from cabergoline were completely abrogated by coadministration of protirelin. Although different pharmacological sites of action of prolactin-altering drugs have to be considered, these data demonstrate that acute changes in prolactin plasma levels may be one factor modulating sexual drive and function. Therefore, besides a neuroendocrine reproductive reflex, a post-orgasmic prolactin increase may represent one factor modulating central nervous system centers controlling sexual drive and behavior. These findings may offer a new pharmacological approach for the treatment of sexual disorders.

Effects of SO2 exposure on allergic sensitization in the guinea pig

The effect of sulfur dioxide (SO2) exposure on local bronchial sensitization to inhaled antigen was studied in the guinea pig. Exposure to SO2 (0.1 to 16.6 ppm) was performed in a 20 L exposure chamber for 8 hours on 5 consecutive days, while temperature, moisture, and concentration of SO2 were monitored and kept constant. SO2 concentrations were measured hourly by Schiff's reaction. On the last 3 days, SO2 exposure was followed by inhalation of nebulized ovalbumin (OA) for 45 minutes. One week later, specific bronchial provocation with inhaled OA (0.1%) followed by plethysmographic measurements of airway obstruction were performed every 2 days during a 2-week period. Specific antibodies against OA were measured in serum and bronchoalveolar fluid by a direct enzyme immunoassay. The SO2-exposed group (N = 17) demonstrated 67% to 100% positive bronchial reactions to inhaled OA, depending on the concentration of SO2, whereas the control group without previous SO2 exposure (N = 14) demonstrated bronchial reactions in only one animal (7%: p less than 0.05). The degree of bronchial obstruction was significantly higher in the exposed group, compared to the control group, for all SO2 concentrations (p less than 0.05). OA-specific antibodies in serum and bronchoalveolar fluid increased in SO2-exposed groups significantly, compared to the control group (p less than 0.05). It is concluded from these results that exposure to SO2 in low and medium concentrations can facilitate local allergic sensitization in the guinea pig.

UV-induced transcription from the human immunodeficiency virus type 1 (HIV-1) long terminal repeat and UV-induced secretion of an extracellular factor that induces HIV-1 transcription in nonirradiated cells

UV irradiation, but not visible sunlight, induces the transcription of human immunodeficiency virus type 1 (HIV-1). Chimeric constructs carrying all or parts of the HIV-1 long terminal repeat linked to an indicator gene were transfected into HeLa cells or murine and human T-cell lines, and their response to irradiation was tested. The cis-acting element conferring UV responsiveness is identical to the sequence binding transcription factor NF kappa B. UV irradiation enhances NF kappa B binding activity as assayed by gel retardation experiments. Interestingly, the requirement for UV irradiation can be replaced by cocultivation of transfected cells with UV-irradiated nontransfected (HIV-1-negative) cells. A UV-induced extracellular protein factor is detected in the culture medium conditioned by UV-treated cells. The factor is produced upon UV irradiation by several murine and human cell lines, including HeLa, Molt-4, and Jurkat, and acts on several cells. These data suggest that the UV response of keratinocytes in human skin can be magnified and spread to deeper layers that are more shielded, including the Langerhans cells, and that this indirect UV response may contribute to the activation of HIV-1 in humans.

Dendritic polyamines: simple access to new materials with defined treelike structures for application in nonviral gene delivery

Polycationic dendrimers are interesting nonviral vectors for in vitro DNA delivery. We describe a simple approach to the synthesis of dendritic polyamines with different molecular weights and adjustable flexibility (degrees of branching; DB). Both parameters influence the transfection efficiency and the cell toxicity of the polymer. Functionalization of hyperbranched polyethylenimine (PEI) by a two-step procedure generated fully branched pseudodendrimers (analogues of polypropylenimine (PPI) and polyamidoamine (PAMAM) dendrimers). The DNA transfection efficiencies observed for these polymers depended on the cell line investigated. The highest efficiencies were observed for polymers whose unfunctionalized PEI cores had molecular weights in the range M(w)=6000-25 000 g mol(-1). The cytotoxicity of the dendrimers generally rises with increasing core size. The data collected for NIH/3T3 and COS-7 cells indicate a maximum transfection efficiency at around 60 % branching for the PPI analogues, and at a PEI-core molecular weight of M(w)=25 000 g mol(-1). PAMAM functionalization of PEI (M(w)=5000 and 21 000 g mol(-1)) leads to polymers with little or no cytotoxity in the cell lines investigated.

Radiotherapy for chordomas and low-grade chondrosarcomas of the skull base with carbon ions

PURPOSE

Compared to photon irradiation, carbon ions provide physical and biologic advantages that may be exploited in chordomas and chondrosarcomas.

METHODS AND MATERIALS

Between August 1998 and December 2000, 37 patients with chordomas (n = 24) and chondrosarcomas (n = 13) were treated with carbon ion radiotherapy within a Phase I/II trial. Tumor conformal application of carbon ion beams was realized by intensity-controlled raster scanning with pulse-to-pulse energy variation. Three-dimensional treatment planning included biologic plan optimization. The median tumor dose was 60 GyE (GyE = Gy x relative biologic effectiveness).

RESULTS

The mean follow-up was 13 months. The local control rate after 1 and 2 years was 96% and 90%, respectively. We observed 2 recurrences outside the gross tumor volume in patients with chordomas. Progression-free survival was 100% for chondrosarcomas and 83% for chordomas at 2 years. Partial remission after carbon ion radiotherapy was observed in 6 patients. Treatment toxicity was mild.

CONCLUSION

These are the first data demonstrating the clinical feasibility, safety, and effectiveness of scanning beam delivery of ion beams in patients with skull base tumors. The preliminary results in patients with skull base chordomas and low-grade chondrosarcomas are encouraging, although the follow-up was too short to draw definite conclusions concerning outcome. In the absence of major toxicity, dose escalation might be considered.

Treatment planning for heavy ion radiotherapy: clinical implementation and application

The clinical implementation and application of a novel treatment planning system (TPS) for scanned ion beams is described, which is in clinical use for carbon ion treatments at the German heavy ion facility (GSI). All treatment plans are evaluated on the basis of biologically effective dose distributions. For therapy control, in-beam positron emission tomography (PET) and an online monitoring system for the beam intensity and position are used. The absence of a gantry restricts the treatment plans to horizontal beams. Most of the treatment plans consist of two nearly opposing lateral fields or sometimes orthogonal fields. In only a very few cases a single beam was used. For patients with very complex target volumes lateral and even distal field patching techniques were applied. Additional improvements can be achieved when the patient's head is fixed in a tilted position, in order to achieve sparing of the organs at risk. In order to test the stability of dose distributions in the case of patient misalignments we routinely simulate the effects of misalignments for patients with critical structures next to the target volume. The uncertainties in the range calculation are taken into account by a margin around the target volume of typically 2-3 mm, which can, however, be extended if the simulation demonstrates larger deviations. The novel TPS developed for scanned ion beams was introduced into clinical routine in December 1997 and was used for the treatment planning of 63 patients with head and neck tumours until July 2000. Planning strategies and methods were developed for this tumour location that facilitate the treatment of a larger number of patients with the scanned heavy ion beam in a clinical setting. Further developments aim towards a simultaneous optimization of the treatment field intensities and more effective procedures for the patient set-up. The results demonstrate that ion beams can be integrated into a clinical environment for treatment planning and delivery.

LET-painting increases tumour control probability in hypoxic tumours

LET-painting was suggested as a method to overcome tumour hypoxia. In vitro experiments have demonstrated a well-established relationship between the oxygen enhancement ratio (OER) and linear energy transfer (LET), where OER approaches unity for high-LET values. However, high-LET radiation also increases the risk for side effects in normal tissue. LET-painting attempts to restrict high-LET radiation to compartments that are found to be hypoxic, while applying lower LET radiation to normoxic tissues. Methods. Carbon-12 and oxygen-16 ion treatment plans with four fields and with homogeneous dose in the target volume, are applied on an oropharyngeal cancer case with an identified hypoxic entity within the tumour. The target dose is optimised to achieve a tumour control probability (TCP) of 95% when assuming a fully normoxic tissue. Using the same primary particle energy fluence needed for this plan, TCP is recalculated for three cases assuming hypoxia: first, redistributing LET to match the hypoxic structure (LET-painting). Second, plans are recalculated for varying hypoxic tumour volume in order to investigate the threshold volume where TCP can be established. Finally, a slight dose boost (5-20%) is additionally allowed in the hypoxic subvolume to assess its impact on TCP. Results. LET-painting with carbon-12 ions can only achieve tumour control for hypoxic subvolumes smaller than 0.5 cm(3). Using oxygen-16 ions, tumour control can be achieved for tumours with hypoxic subvolumes of up to 1 or 2 cm(3). Tumour control can be achieved for tumours with even larger hypoxic subvolumes, if a slight dose boost is allowed in combination with LET-painting. Conclusion. Our findings clearly indicate that a substantial increase in tumour control can be achieved when applying the LET-painting concept using oxygen-16 ions on hypoxic tumours, ideally with a slight dose boost.

Rapid calculation of biological effects in ion radiotherapy

We describe a method for fast calculation of biological effects after ion irradiation. It is an alternative derivative of the established local effect model (LEM) and has been integrated into GSI's TRiP98 treatment planning system. We show that deviations from our classic approach for treatment planning are less than 5% for therapeutical doses, but calculational speed can be improved by one to two orders of magnitude. This will allow sophisticated methods of treatment planning for ion irradiation, taking biological effects fully into account.

Impact of enhancements in the local effect model (LEM) on the predicted RBE-weighted target dose distribution in carbon ion therapy

Biological optimization for treatment planning in carbon ion therapy is currently based on the first version of the local effect model (LEM I). Further developments implemented in the latest version (LEM IV) allowed to predict more accurately the Relative Biological Effectiveness (RBE) in-vitro. The main goal of this study is to compare the LEM IV against LEM I under treatment-like conditions for idealized target geometries. Therefore, physical dose distributions resulting from the biological optimization with LEM I were used to recalculate the RBE-weighted dose distribution based on LEM IV. Input parameters representing the clinical endpoints late toxicity in the central nervous system and the tumor control for chordoma were chosen to investigate the impact of changes on the predicted isoeffective dose levels. The recalculated RBE-weighted dose distributions show an increase within the target region, and the mean RBE-weighted dose values are dependent on the geometry and decrease with increasing target dimension. The differences between predictions of LEM IV and LEM I are less than 10% for typical tumor volumes treated in the pilot project at GSI. Median RBE-weighted doses predicted by LEM IV in the target region are consistent with clinically observed dose-response behavior as demonstrated by comparison to the 5-year local control curve for skull base chordoma.

The increased biological effectiveness of heavy charged particles: from radiobiology to treatment planning

The increased biological effectiveness of heavy charged particle beams like e.g., carbon ions in the tumor volume in comparison to the lower effectiveness in the surrounding healthy tissue represents one of the major rationales for their application in tumor therapy. This increased effectiveness also characterizes the advantage of heavier ions compared to proton beams. The increased effectiveness has to be taken into account in treatment planning in order to estimate the corresponding photon equivalent doses in normal and tumor tissues, thus allowing a link e.g., to normal tissue dose limits in conventional photon therapy. Due to the complex dependencies of RBE on parameters like dose, beam energy, LET, atomic number and cell or tissue type, the relevant RBEs cannot be solely determined from experimental data. Therefore, within the framework of the pilot project of tumor therapy with carbon ions performed at GSI Darmstadt, treatment planning is based on a biophysical model, which has been extensively tested. The paper first summarizes the essential systematic dependencies of RBE on different parameters like e.g., dose, LET, atomic number and cell type. The basic principle of the biophysical model is then introduced, and special emphasis is given to the application of the model to in vivo and clinical endpoints. Model predictions are compared to experimental data in vitro and in vivo. Finally, the implementation of the biophysical model in the treatment planning procedure is presented. The biological verification of the whole treatment planning procedure is explained and examples of patient treatment plans are given.

Long-term effects of pregnancy and childbirth on sleep satisfaction and duration of first-time and experienced mothers and fathers

STUDY OBJECTIVES

To examine the changes in mothers' and fathers' sleep satisfaction and sleep duration across prepregnancy, pregnancy, and the postpartum period of up to 6 years after birth; it also sought to determine potential protective and risk factors for sleep during that time.

METHODS

Participants in a large population-representative panel study from Germany reported sleep satisfaction and sleep duration in yearly interviews. During the observation period (2008-2015), 2541 women and 2118 men reported the birth of their first, second, or third child and provided longitudinal data for analysis. Fixed-effects regression models were used to analyze changes in sleep associated with childbirth.

RESULTS

Sleep satisfaction and duration sharply declined with childbirth and reached a nadir during the first 3 months postpartum, with women more strongly affected (sleep satisfaction reduction compared with prepregnancy: women, 1.81 points on a 0 to 10 scale, d = 0.79 vs. men, 0.37 points, d = 0.16; sleep duration reduction compared with prepregnancy: women, 62 min, d = 0.90 vs. men, 13 min, d = 0.19). In both women and men, sleep satisfaction and duration did not fully recover for up to 6 years after the birth of their first child. Breastfeeding was associated with a slight decrease in maternal sleep satisfaction (0.72 points, d = 0.32) and duration (14 min, d = 0.21). Parental age, household income, and dual vs. single parenting were unrelated, or only very weakly related, to improved sleep.

CONCLUSIONS

Following the sharp decline in sleep satisfaction and duration in the first months postpartum, neither mothers' nor fathers' sleep fully recovers to prepregnancy levels up to 6 years after the birth of their first child.

Metabolic activation of haloalkanes and tests in vitro for mutagenicity

1. During incubation of 14CCl4, 14CHCl3, [14C]halothane, or 14CCl3F with liver microsomes and NADPH, considerable radioactivity is bound irreversibly to endoplasmic protein and lipid. However, no 14C was detected in the ribosomal RNA. 2. None of the four haloalkanes studied induced mutations after incubation with liver microsomes and the bacterial tester strains S. typhimurium TA 1535 and TA 1538. 3. Very low or no activity was associated with soluble protein or RNA added to incubation mixtures of the four haloalkanes with liver microsomes.

Syntheses and Phase-Transfer Properties of Dendritic Nanocarriers That Contain Perfluorinated Shell Structures

Perfect dendrimers that contain perfluorinated shells have recently attracted attention because they have been shown to encapsulate polar molecules in supercritical CO(2) and catalytically active metal nanoparticles in perfluorinated solvents. Moreover, they can then be easily separated after reaction from the biphasic organic/fluorous system. In this paper several dendritic architectures that contain perfluorinated shells were derived by covalent modification of glycerol dendrimers ([G0.5]-[G3.5]), hyperbranched polyglycerol, and polyethyleneimine. These core-shell architectures show interesting physicochemical properties. For example, they are soluble in fluorinated solvents, they are able to transport different guest molecules, and they display thermomorphic behavior. The transport capacity of these molecular nanocarriers increases significantly when amino groups are present in the core. Certain functionalized polyethyleneimines that contain perfluorinated shells show high transport capacities (up to 3 dye molecules per nanocarrier) in perfluorinated solvents. Moreover, these perfluoro-functionalized dendritic polyethyleneimines can act as templates that stabilize nanoparticles; for example, encapsulation and subsequent chemical reduction of Ag(I) ions. Silver nanoparticles with a narrow size distribution (3.9+/-1 nm) have been prepared and characterized by transmission electron microscopy. Furthermore, it has been demonstrated that the encapsulated guest molecules remain accessible to small molecules after transport into the fluorous phase. Therefore, dendritic nanocarriers that contain perfluorinated shells are currently being investigated as polar environments in nonpolar reaction media such as fluorous phases and supercritical CO(2), in particular, for application in homogenous catalysis.