Deep inspiration breath hold real-time tumor-tracking radiation therapy (DBRT) as a novel stereotactic body radiation therapy approach for lung tumors

Radiotherapy with deep inspiration breath hold (DIBH) reduces doses to the lungs and organs at risk. The stability of breath holding and reproducibility of tumor location are higher during expiration than during inspiration; therefore, we developed an irradiation method combining DIBH and real-time tumor-tracking radiotherapy (RTRT) (DBRT). Nine patients were enrolled in this study. Fiducial markers were placed near tumors using bronchoscopy. Treatment planning computed tomography (CT) was performed thrice during DIBH, assisted by spirometer-based device. Each CT scan was fused using fiducial markers. Gross tumor volume (GTV) was contoured for each dataset and summed to create GTVsum; adding a 5-mm margin around GTVsum generated the planning target volume. The prescribed dose was mainly 42 Gy in four fractions. The treatment plan was created using DIBH CT (DBRT-plan), with a similar treatment plan created for expiratory CT for cases for which DBRT could not be performed (conv-plan). Vx defined as the volume of the lung received x Gy, and the mean lung dose, V20, V10, and V5 were evaluated. DBRT was completed in all patients. Mean dose, V20, and V10 were significantly lower in the DBRT-plan than in the conv-plan (all p = 0.003). Mean rates of decrease for mean dose, V20, and V10 were 14.0%, 27.6%, and 19.1%, respectively. No significant difference was observed in V5. We developed DBRT, a stereotactic body radiation therapy performed with the DIBH technique; it combines a spirometer-based breath-hold support system with an RTRT system. All patients who underwent DBRT completed the procedure without any technical or mechanical complications. This is a promising methodology that may significantly reduce lung doses.

Deep-Inspiration Breath-Hold Stereotactic Body Radiation Therapy by Combining Spirometer-Guided Breath-Hold and a Real-Time Tumor Tracking System: A Novel Approach

PURPOSE/OBJECTIVE(S)

There are several methods used against respiratory motion (RM). Expiratory breath-hold (BH) is considered more stable and reproducible than inspiratory BH; therefore, BH with spirometry is often used for expiration. The real-time tumor tracking radiotherapy (RTRT) system is a highly effective method for reducing the margin of RM. This system ambushes and irradiates tumors during the expiratory phase when tumors move slowly. Although these methods usually involve expiration, it is advantageous to expand the lungs with inspiration to reduce the risk of adverse events. Here, we developed a new approach of performing stereotactic body radiation therapy (SBRT) under deep-inspiration BH (DIBH) by combining these two methods.

MATERIALS/METHODS

Lung tumors with respiratory motion ≥ 1 cm were included. Three or four fiducial markers were placed near the tumor via bronchoscopy. DIBH CT (CT-IN) was performed under the guidance of spirometer. The PTV was obtained by adding a 5-mm margin to the GTV delineated on CT-IN. The prescribed dose was 42 Gy in four fractions for the D95 of the PTV. An error of 2.0 mm around the planned position of the fiducial marker on CT-IN was permitted along each orthogonal axis as a gating box. In preparation for cases in which the reproducibility of DIBH is low and treatment cannot be performed, light expiration BH CT (CT-EX) was also performed, and a radiotherapy plan was prepared for the conventional RTRT system so that it could be switched at any time. Lung volumes and doses (mean dose, V20 Gy, V10 Gy, and V5 Gy) on CT-EX and CT-IN were compared.

RESULTS

Five patients underwent SBRT with DIBH, and all completed the planned irradiation course. The median treatment time per fraction was 27.86 min (range, 25.5-40.6). Four tumors were located in the left lower lobe and one in the right lower lobe. The median volume of PTV was 12.4 (range, 5.2-26.2) mL. The lung volumes and doses on CT-EX and CT-IN are shown in the Table. The lung volume on CT-IN was 1.6 times larger than that on CT-EX. The PTV-to-lung ratio on CT-IN was significantly lower than that on CT-EX. V20 Gy and V10 Gy on CT-IN were significantly lower than those on CT-EX.

CONCLUSION

SBRT with DIBH was achieved by combining the spirometer and RTRT system. This can help to eliminate concerns about reproducibility and high-speed tumor movement during inspiration, which are weaknesses of spirometer-guided breath-hold and the RTRT system, respectively, while ensuring the accuracy of the RTRT system. DIBH SBRT is a promising method that can reduce lung dose.

Assessing liver fibrosis distribution through liver elasticity estimates obtained using a biomechanical model of respiratory motion with magnetic resonance elastography

Objective. This study aimed to produce a three-dimensional liver elasticity map using the finite element method (FEM) and respiration-induced motion captured by T1-weighted magnetic resonance images (FEM-E-map) and to evaluate whether FEM-E-maps can be an imaging biomarker comparable to magnetic resonance elastography (MRE) for assessing the distribution and severity of liver fibrosis. Approach. We enrolled 14 patients who underwent MRI and MRE. T1-weighted MR images were acquired during shallow inspiration and expiration breath-holding, and the displacement vector field (DVF) between two images was calculated using deformable image registration. FEM-E-maps were constructed using FEM and DVF. First, three Poisson’s ratio settings (0.45, 0.49, and 0.499995) were validated and optimized to minimize the difference in liver elasticity between the FEM-E-map and MRE. Then, the whole and regional liver elasticity values estimated using FEM-E-maps were compared with those obtained from MRE using Pearson’s correlation coefficients. Spearman rank correlations and chi-square histograms were used to compare the voxel-level elasticity distribution. Main results. The optimal Poisson’s ratio was 0.49. Whole liver elasticity estimated using FEM-E-maps was strongly correlated with that measured using MRE (r = 0.96). For regional liver elasticity, the correlation was 0.84 for the right lobe and 0.82 for the left lobe. Spearman analysis revealed a moderate correlation for the voxel-level elasticity distribution between FEM-E-maps and MRE (0.61 ± 0.10). The small chi-square distances between the two histograms (0.11 ± 0.07) indicated good agreement. Significance. FEM-E-maps represent a potential imaging biomarker for visualizing the distribution of liver fibrosis using only T1-weighted images obtained with a common MR scanner, without any additional examination or special elastography equipment. However, additional studies including comparisons with biopsy findings are required to verify the reliability of this method for clinical application.

Harmonisation of PET/CT contrast recovery performance for brain studies

PURPOSE

In order to achieve comparability of image quality, harmonisation of PET system performance is imperative. In this study, prototype harmonisation criteria for PET brain studies were developed.

METHODS

Twelve clinical PET/CT systems (4 GE, 4 Philips, 4 Siemens, including SiPM-based "digital" systems) were used to acquire 30-min PET scans of a Hoffman 3D Brain phantom filled with ~ 33 kBq·mL^-1 [¹⁸F]FDG. Scan data were reconstructed using various reconstruction settings. The images were rigidly coregistered to a template (voxel size 1.17 × 1.17 × 2.00 mm³) onto which several volumes of interest (VOIs) were defined. Recovery coefficients (RC) and grey matter to white matter ratios (GMWMr) were derived for eroded (denoted in the text by subscript e) and non-eroded grey (GM) and white (WM) matter VOIs as well as a mid-phantom cold spot (VOI_cold) and VOIs from the Hammers atlas. In addition, left-right hemisphere differences and voxel-by-voxel differences compared to a reference image were assessed.

RESULTS

Systematic differences were observed for reconstructions with and without point-spread-function modelling (PSF_ON and PSF_OFF, respectively). Normalising to image-derived activity, upper and lower limits ensuring image comparability were as follows: for PSF_ON, RC_GMe = [0.97-1.01] and GMWMr_e = [3.51-3.91] for eroded VOI and RC_GM = [0.78-0.83] and GMWMr = [1.77-2.06] for non-eroded VOI, and for PSF_OFF, RC_GMe = [0.92-0.99] and GMWMr_e = [3.14-3.68] for eroded VOI and RC_GM = [0.75-0.81] and GMWMr = [1.72-1.95] for non-eroded VOI.

CONCLUSIONS

To achieve inter-scanner comparability, we propose selecting reconstruction settings based on RC_GMe and GMWMr_e as specified in "Results". These proposed standards should be tested prospectively to validate and/or refine the harmonisation criteria.

Patient-specific radiotherapy quality assurance for estimating actual treatment dose

This study aimed to evaluate the optimal method for planning computed tomography (CT) for prostate cancer radiotherapy to avoid a dose difference of ≥3% between the actual and planned treatments using multiple acquisition planning CT (MPCT). We calculated the 3-dimensional (3D) displacement error between the pelvic bone and matching fiducial marker on MPCT and cone-beam CT scans of 25 patients who underwent prostate volumetric-modulated arc therapy for prostate cancer. The correlation of the 3D displacement error and the dose difference between planned and actual treatments was calculated using least squares second-order polynomial model. The 3D displacement error showed a moderate correlation with differences between planned and accumulated treatment doses (r = 0.587, p < 0.0001). Moreover, the improvement rate of the minimum 3D displacement error showed a strong correlation with the relative error between each MPCT image (r = 0.793, p < 0.0001). Significant differences were observed between planned and actual treatment doses (p < 0.0001) in the relative 3D displacement errors of <1 mm, 1 to 3 mm, and >3 mm. The 3D displacement error on MPCT (as the selection estimation index for optimal planning CT) is useful for monitoring patient-specific intensity-modulated radiation therapy quality assurance. This new method allows to estimate dose differences from the planned dose before commencing treatment, thereby ensuring high-quality therapy. As radiotherapy quality is critical for patient outcome, these findings may contribute to better management of prostate cancer.

A novel dynamic robotic moving phantom system for patient-specific quality assurance in real-time tumor-tracking radiotherapy

In this study, we assess a developed novel dynamic moving phantom system that can reproduce patient three-dimensional (3D) tumor motion and patient anatomy, and perform patient-specific quality assurance (QA) of respiratory-gated radiotherapy using SyncTraX. Three patients with lung cancer were enrolled in a study. 3D printing technology was adopted to obtain individualized lung phantoms using CT images. A water-equivalent phantom (WEP) with the 3D-printed plate lung phantom was set at the tip of the robotic arm. The log file that recorded the 3D positions of the lung tumor was used as the input to the dynamic robotic moving phantom. The WEP was driven to track 3D respiratory motion. Respiratory-gated radiotherapy was performed for driving the WEP. The tracking accuracy was calculated as the differences between the actual and measured positions. For the absolute dose and dose distribution, the differences between the planned and measured doses were calculated. The differences between the planned and measured absolute doses were <1.0% at the isocenter and <4.0% for the lung region. The gamma pass ratios of γ_3 mm/3% and γ_2 mm/2% under the conditions of gating and no-gating were 99.9 ± 0.1% and 90.1 ± 8.5%, and 97.5 ± 0.9% and 68.6 ± 17.8%, respectively, for all the patients. Furthermore, for all the patients, the mean ± SD of the root mean square values of the positional error were 0.11 ± 0.04 mm, 0.33 ± 0.04 mm, and 0.20 ± 0.04 mm in the LR, AP, and SI directions, respectively. Finally, we showed that patient-specific QA of respiratory-gated radiotherapy using SyncTraX can be performed under realistic conditions using the moving phantom.

Evaluation of the correlation between prostatic displacement and rectal deformation using the Dice similarity coefficient of the rectum

To estimate the relationship between the three-dimensional (3D) displacement error of the prostate and rectal deformation for reduction of deviation between the planned and treatment dose, using multiple acquisition planning CT (MPCT) and the Dice similarity coefficient (DSC) for rectal deformation for treatment of patients with prostate cancer. The 3D displacement error between the pelvic bone and a matching fiducial marker was calculated using MPCT in 24 patients who underwent prostate volumetric-modulated arc therapy for prostate cancer. We calculated the 3D displacement error between the pelvic bone and a matching fiducial marker on MPCT. The correlation of the 3D displacement error with the DSC of the rectum, calculated from MPCT images, was evaluated based on deformable image registration. The 3D displacement error of the prostate showed a slight correlation between MPCT and cone-beam computed tomography (adjusted r² = 0.241). The 3D displacement error, based on the pelvic bone and a fiducial marker on MPCT images, showed a moderate correlation with the DSC of the rectum (adjusted r² = 0.645) and was improved by a mean of 3.94 mm, based on MPCT, during the treatment period. The 3D displacement error on MPCT correlates with the 3D displacement error of daily cone-beam computed tomography; optimal selection of MPCT can potentially facilitate on-board setup of prostate patients to enable more accurate radiotherapy. The advance information of the 3D displacement error and rectal deformation is useful for optimal planning CT that can minimize the deviation between the planned dose and the treatment dose in patients receiving treatment for prostate cancer.

Evaluation of a combined respiratory-gating system comprising the TrueBeam linear accelerator and a new real-time tumor-tracking radiotherapy system: a preliminary study

A combined system comprising the TrueBeam linear accelerator and a new real‐time, tumor‐tracking radiotherapy system, SyncTraX, was installed in our institution. The goals of this study were to assess the capability of SyncTraX in measuring the position of a fiducial marker using color fluoroscopic images, and to evaluate the dosimetric and geometric accuracy of respiratory‐gated radiotherapy using this combined system for the simple geometry. For the fundamental evaluation of respiratory‐gated radiotherapy using SyncTraX, the following were performed: 1) determination of dosimetric and positional characteristics of sinusoidal patterns using a motor‐driven base for several gating windows; 2) measurement of time delay using an oscilloscope; 3) positional verification of sinusoidal patterns and the pattern in the case of a lung cancer patient; 4) measurement of the half‐value layer (HVL in mm AL), effective kVp, and air kerma, using a solid‐state detector for each fluoroscopic condition, to determine the patient dose. The dose profile in a moving phantom with gated radiotherapy having a gating window ≤4 mm was in good agreement with that under static conditions for each photon beam. The total time delay between TrueBeam and SyncTraX was <227 ms for each photon beam. The mean of the positional tracking error was <0.4 mm for sinusoidal patterns and for the pattern in the case of a lung cancer patient. The air‐kerma rates from one fluoroscopy direction were 1.93±0.01, 2.86±0.01, 3.92±0.04, 5.28±0.03, and 6.60±0.05 mGy/min for 70, 80, 90, 100, and 110 kV X‐ray beams at 80 mA, respectively. The combined system comprising TrueBeam and SyncTraX could track the motion of the fiducial marker and control radiation delivery with reasonable accuracy; therefore, this system provides significant dosimetric improvement. However, patient exposure dose from fluoroscopy was not clinically negligible.

PACS number(s): 87.53.Bn, 87.55.km, 87.55.Qr

Expression patterns of three α-expansin isoforms in Coffea arabica during fruit development

As a first step towards understanding the physiological role and regulation of the expansin gene (EXP) family in Coffea arabica fruits during growth and maturation, we identified 11 expansin genes, nine belonging to the α-expansin family (EXPA), one EXLA and one EXLB, through in silico analysis of expressed sequence tags (ESTs). Within the α-expansin family, three isoforms were selected for detailed examination based on their high expression in coffee fruits or because they were specifically induced during different fruit developmental stages, according to the EST information. The expression patterns were analysed in different fruit tissues (perisperm, endosperm and pericarp) of C. arabica cv. IAPAR-59 and C. arabica cv. IAPAR-59 Graúdo, the latter being a closely related cultivar with a larger fruit size. Accumulation of CaEXPA1 and CaEXPA3 transcripts was high in the perisperm (tissue responsible for coffee bean size) and in the early stages of pericarp development. Transcripts of CaEXPA2 were detected only in the pericarp during the later stages of fruit maturation and ripening. There was no detectable transcription of the three EXPs analysed in the endosperm. The observed differences in mRNA expression levels of CaEXPA1 and CaEXP3 in the perisperm of IAPAR-59 and IAPAR-59 Graúdo suggest the participation of these two isoforms in the regulation of grain size.

Refraction-enhanced tomography of mouse and rabbit lungs

In order to evaluate the effectiveness of edge enhancement by refraction in computed tomography, images of a cross section of a euthanized mouse thorax were recorded at low (20 keV) and high (72 keV) x-ray energies at a spatial resolution of about 40 microm. Compared with the images obtained with the detector at 30 cm from an object, when the object was located at 113 cm from the detector, the contrast between tissues and air was improved at both energies. The improvement was more pronounced at 72 keV where the absorption contrast was weaker. This effect was due to refraction at the surfaces of alveolar membranes and small airways which creates areas with apparently high and low linear attenuation coefficients within tissues. The edge enhancement by refraction was also effective in images of a euthanized rabbit thorax at x-ray energies of 40 and 70 keV at a spatial resolution of about 0.15 mm. These results raise the possibility that the refraction contrast may be utilized to obtain a high-resolution tomographic image of human lung and bone with low dose.

Antitumour activity and side effects of combined treatment with chitosan and cisplatin in sarcoma 180-bearing mice

We examined the possible modulation by chitosan of the antitumour effects and side effects of cisplatin (cis-diaminedichloroplatinum, CDDP). The study showed that CDDP had potent antitumour activity when administered orally as well as intraperitoneally. We also compared the antitumour activity and side effects of orally administered CDDP plus orally administered chitosan versus intraperitoneally administered CDDP plus orally administered chitosan in sarcoma 180-bearing mice. When CDDP (1.25 mgkg(-1) x 2 day(-1)) was intraperitoneally administered to sarcoma 180-bearing mice, myelotoxicity (the reduction of leucocyte and platelet numbers), nephrotoxicity (the increase of blood nitrogen urea level), immunotoxicity (the reduction of spleen and thymus weight) and a reduction in body weight resulted. These intraperitoneally administered CDDP-induced side effects were not prevented by oral administration of chitosan (150 mgkg(-1) x 2 day(-1) and 750 mgkg(-1) x 2 day(-1)) for 14 consecutive days. On the other hand, the side effects such as the reductions of body and spleen weights induced by orally administered CDDP (1.25 mgkg(-1) x 2 day(-1)) were prevented by the oral administration of chitosan (150 mgkg(-1) x 2 day(-1) and 750 mg kg(-1) x 2 day(-1)). From these results, we conclude that the orally administered chitosan plus CDDP might be useful for the prevention of body weight reduction and immunotoxicity (the reduction of spleen weight) induced by the orally administered CDDP without diminishing antitumour activity.

Disruption of higher-order folding by core histone acetylation dramatically enhances transcription of nucleosomal arrays by RNA polymerase III

We have examined the effects of core histone acetylation on the transcriptional activity and higher-order folding of defined 12-mer nucleosomal arrays. Purified HeLa core histone octamers containing an average of 2, 6, or 12 acetates per octamer (8, 23, or 46% maximal site occupancy, respectively) were assembled onto a DNA template consisting of 12 tandem repeats of a 208-bp Lytechinus 5S rRNA gene fragment. Reconstituted nucleosomal arrays were transcribed in a Xenopus oocyte nuclear extract and analyzed by analytical hydrodynamic and electrophoretic approaches to determine the extent of array compaction. Results indicated that in buffer containing 5 mM free Mg2+ and 50 mM KCl, high levels of acetylation (12 acetates/octamer) completely inhibited higher-order folding and concurrently led to a 15-fold enhancement of transcription by RNA polymerase III. The molecular mechanisms underlying the acetylation effects on chromatin condensation were investigated by analyzing the ability of differentially acetylated nucleosomal arrays to fold and oligomerize. In MgCl2-containing buffer the folding of 12-mer nucleosomal arrays containing an average of two or six acetates per histone octamer was indistinguishable, while a level of 12 acetates per octamer completely disrupted the ability of nucleosomal arrays to form higher-order folded structures at all ionic conditions tested. In contrast, there was a linear relationship between the extent of histone octamer acetylation and the extent of disruption of Mg2+-dependent oligomerization. These results have yielded new insight into the molecular basis of acetylation effects on both transcription and higher-order compaction of nucleosomal arrays.

Role of histone H1 as an architectural determinant of chromatin structure and as a specific repressor of transcription on Xenopus oocyte 5S rRNA genes

We explore the role of histone H1 as a DNA sequence-dependent architectural determinant of chromatin structure and of transcriptional activity in chromatin. The Xenopus laevis oocyte- and somatic-type 5S rRNA genes are differentially transcribed in embryonic chromosomes in vivo depending on the incorporation of somatic histone H1 into chromatin. We establish that this effect can be reconstructed at the level of a single nucleosome. H1 selectively represses oocyte-type 5S rRNA genes by directing the stable positioning of a nucleosome such that transcription factors cannot bind to the gene. This effect does not occur on the somatic-type genes. Histone H1 binds to the 5' end of the nucleosome core on the somatic 5S rRNA gene, leaving key regulatory elements in the promoter accessible, while histone H1 binds to the 3' end of the nucleosome core on the oocyte 5S rRNA genes, specifically blocking access to a key promoter element (the C box). TFIIIA can bind to the somatic 5S rRNA gene assembled into a nucleosome in the presence of H1. Because H1 binds with equivalent affinities to nucleosomes containing either gene, we establish that it is the sequence-selective assembly of a specific repressive chromatin structure on the oocyte 5S rRNA genes that accounts for differential transcriptional repression. Thus, general components of chromatin can determine the assembly of specific regulatory nucleoprotein complexes.

In vivo selection of basic region-leucine zipper proteins with altered DNA-binding specificities

A transcription interference assay was used to generate mutant basic region-leucine zipper proteins with altered DNA-binding specificities. A library of mutants of a CCAAT/enhancer binding protein was constructed by randomizing five DNA-contacting amino acids in the basic region Asn-18, Ala-15, Val-14, Ser-11, and Arg-10. These mutants were then selected for their ability to bind mutant recognition sequences containing substitutions at the 2 and 3 positions of the wild-type sequence 5'-A5T4T3G2C1G1'C2'A3A4'T5'-3'. Mutants containing the sequence Leu-18Tyr-15Xaa-14Tyr-11Arg-10, in which four of the five contact residues are altered, were identified that recognize the palindromic sequence 5'-ATCYCGY'GAT-3' (Xaa = asparagine when Y = G; Xaa = methionine when Y = A). Moreover, in a selection against the sequence 5'-ATTACGTAAT-3', mutants were obtained containing substitutions not only in the basic region but also in the hinge region between the basic and leucine zipper regions. The mutant proteins showed high specificity in a functional transcription interference assay. A model for the interaction of these mutants with the target DNA sequences is discussed.

A permutational approach toward protein-DNA recognition

The cI repressor of bacteriophage 434, known as 434 repressor, binds to 14-bp operator sequences by means of a helix-turn-helix motif. To probe the requirements for selective DNA recognition by this class of DNA binding proteins, as well as to generate new proteins with altered specificities, a library of approximately 3 x 10(6) mutants was generated that contains all permutations of five residues in the recognition helix (helix 3) of the repressor. These mutants were then selected in vivo for their ability to bind both wild-type (WT) and mutant operator sequences. The results of the selection demonstrate that four of these residues--Gln28, Gln29, Ser30, and Gln33--play a critical role in recognition of the WT operator. A number of repressors with mutations at Thr27 showed altered DNA binding affinities and specificities. The approach described here may also prove useful in studies of DNA recognition by other classes of DNA binding proteins.