Joseph Stancanello

Paramagnetic liposomes as innovative contrast agents for magnetic resonance (MR) molecular imaging applications.

This article illustrates some innovative applications of liposomes loaded with paramagnetic lanthanide‐based complexes in MR molecular imaging field. When a relatively high amount of a GdIII chelate is encapsulated in the vesicle, the nanosystem can simultaneously affect both the longitudinal (R1) and the transverse (R2) relaxation rate of the bulk H2O H‐atoms, and this finding can be exploited to design improved thermosensitive liposomes whose MRI response is not longer dependent on the concentration of the probe. The observation that the liposome compartmentalization of a paramagnetic LnIII complex induce a significant R2 enhancement, primarily caused by magnetic susceptibility effects, prompted us to test the potential of such agents in cell‐targeting MR experiments. The results obtained indicated that these nanoprobes may have a great potential for the MR visualization of cellular targets (like the glutamine membrane transporters) overexpressing in tumor cells. Liposomes loaded with paramagnetic complexes acting as NMR shift reagents have been recently proposed as highly sensitive CEST MRI agents. The main peculiarity of CEST probes is to allow the MR visualization of different agents present in the same region of interest, and this article provides an illustrative example of the in vivo potential of liposome‐based CEST agents.

Methods for an improved detection of the MRI-CEST effect

CEST imaging is a recently introduced MRI contrast modality based on the use of endogenous or exogenous molecules whose exchangeable proton pools transfer saturated magnetization to bulk water, thus creating negative contrast. One of the critical issues for further development of these agents is represented by their limited sensitivity in vivo. The aim of this work is to improve the detection of CEST agents by exploring new approaches through which the saturation transfer (ST) effect can be enhanced. The performance of the proposed methods has been tested in vitro and in vivo using highly sensitive and highly shifted lipoCEST agents, and the results were compared with the standard ST evaluation mode. The acquired Z-spectra were interpolated locally and voxel-by-voxel by smoothing splines. Besides expressing the ST in the standard mode, we explore two methods, enhanced and integral ST, which better exploit all the information contained in the Z-spectrum. By combining different modes for ST assessment a significant improvement in the detection of the lipoCEST agents, both in vitro and in vivo, has been found. The results obtained from the application of the proposed methods outline the importance of post-processing analysis for highlighting the CEST-MRI contrast.

Use of motion tracking in stereotactic body radiotherapy: Evaluation of uncertainty in off-target dose distribution and optimization strategies

Spatial accuracy in extracranial radiosurgery is affected by organ motion. Motion tracking systems may be able to avoid PTV enlargement while preserving treatment times, however special attention is needed when fiducial markers are used to identify the target can move with respect to organs at risk (OARs). Ten patients treated by means of the Synchrony system were taken into account. Sparing of irradiated volume and of complication probability were estimated by calculating treatment plans with a motion tracking system (Cyberknife Synchrony, Sunnyvale, CA, USA) and a PTV-enlargement strategy for ten patients. Six patients were also evaluated for possible inaccuracy of estimation of dose to OARs due to relative movement between PTV and OAR during respiration. Dose volume histograms (DVH) and Equivalent Uniform Dose (EUD) were calculated for the organs at risk. In the cases for which the target moved closer to the OAR (three cases of six), a small but significant increase was detected in the DVH and EUD of the OAR. In three other cases no significant variation was detected. Mean reduction in PTV volume was 38% for liver cases, 44% for lung cases and 8.5% for pancreas cases. NTCP for liver reduced from 23.1 to 14.5% on average, for lung it reduced from 2.5 to 0.1% on average. Significant uncertainty may arise from the use of a motion-tracking device in determination of dose to organs at risk due to the relative motion between PTV and OAR. However, it is possible to limit this uncertainty. The breathing phase in which the OAR is closer to the PTV should be selected for planning. A full understanding of the dose distribution would only be possible by means of a complete 4D-CT representation.

First ex‐vivo MRI co‐localization of two LIPOCEST agents

One of the major advantages of the CEST methodology deals with the possibility of visualizing more probes in the same MR image voxels. This is a unique property within the contrast media that act on the (1)H-NMR signal of water protons, and it might considerably improve the potential of the technique. In addition to displaying sufficiently different resonance frequencies of their mobile protons, it is also important that the CEST agents designed for this application are highly sensitive. LIPOCEST agents represent the most sensitive class of CEST systems developed so far. On this basis, two LIPOCEST samples, a spherical one and an osmotically shrunken nonspherical one, endowed with markedly different resonance frequencies of their intraliposomal water protons, 3 ppm and 15 ppm, respectively, were prepared and tested both in vitro and in ex-vivo on a bovine muscle used as tissue-surrogate. The response of the two agents did not interfere each other, thus allowing the multiple visualization of the two agents present at nanomolar concentrations in the same image voxels.

3T MRI evaluation of the accuracy of atlas-based subthalamic nucleus identification

Modulation of the activity of the subthalamic nucleus (STN) using deep brain stimulation (DBS) in patients with advanced Parkinsons disease is the most common procedure performed today by functional neurosurgeons. The STN contours cannot be entirely identified on common 1.5T images; in particular, the ventromedial border of the STN often blends with the substantia nigra. 3T magnetic resonance imaging (MRI) provides better resolution and can improve the identification of the STN borders. In this work, we have directly identified the STN using 3T MR imaging to validate the accuracy of a computer-aided atlas-based procedure for automatic STN identification. Coordinates of the STN were obtained from the Talairach and Tournoux atlas and transformed into the coordinates of the Montreal Neurological Institute (MNI) standard brain volume, creating a mask representation of the STN. 3T volumetric T1 and T2 weighted (T1w and T2w, respectively) acquisitions were obtained for ten patients. The MNI standard brain volume was registered onto each patient MRI, using a new approach based on global affine, region-of-interest affine, and local nonrigid registrations. The estimated deformation field was then applied to the STN atlas-based mask, providing its location on the patient MRI. The entire procedure required on average about 20min. Because STN is easily identifiable on 3T T2w-MRIs, it was manually delineated; the coordinates of the center of mass of the manually and automatically identified structures were compared. Additionally, volumetric overlapping indices were calculated and the spatial relationship between the midcommissural point and the STN center of mass was investigated. All indices indicated, on average, good agreement between manually and automatically identified structures; displacement of the centers of mass of the manually and automatically identified structures was less than or equal to 2.35mm, and more than 80% of the manually identified volume was covered by the automatic localization, on average. Bland-Altman analysis indicated that the automatic STN identification was within the limits of agreement with the manual localization on 3T MRIs. Automatic atlas-based STN localization provides an accurate and user-friendly tool and can enhance target identification when 1.5T scanners with limited capability to identify the STN boundaries are used.

Atlas-based identification of targets for functional radiosurgery

Functional disorders of the brain, such as Parkinsons disease, dystonia, epilepsy, and neuropathic pain, may exhibit poor response to medical therapy. In such cases, surgical intervention may become necessary. Modern surgical approaches to such disorders include radio-frequency lesioning and deep brain stimulation (DBS). The subthalamic nucleus (STN) is one of the most useful stereotactic targets available: STN DBS is known to induce substantial improvement in patients with end-stage Parkinsons disease. Other targets include the Globus Pallidus pars interna (GPi) for dystonia and Parkinsons disease, and the centromedian nucleus of the thalamus (CMN) for neuropathic pain. Radiosurgery is an attractive noninvasive alternative to treat some functional brain disorders. The main technical limitation to radiosurgery is that the target can be selected only on the basis of magnetic resonance anatomy without electrophysiological confirmation. The aim of this work is to provide a method for the correct atlas-based identification of the target to be used in functional neurosurgery treatment planning. The coordinates of STN, CMN, and GPi were identified in the Talairach and Tournoux atlas and transformed to the corresponding regions of the Montreal Neurological Institute (MNI) electronic atlas. Binary masks describing the target nuclei were created. The MNI electronic atlas was deformed onto the patient magnetic resonance imaging-T1 scan by applying an affine transformation followed by a local nonrigid registration. The first transformation was based on normalized cross correlation and the second on optimization of a two-part objective function consisting of similarity criteria and weighted regularization. The obtained deformation field was then applied to the target masks. The minimum distance between the surface of an implanted electrode and the surface of the deformed mask was calculated. The validation of the method consisted of comparing the electrode-mask distance to the clinical outcome of the treatments in ten cases of bilateral DBS implants. Electrode placement may have an effect within a radius of stimulation equal to 2 mm, therefore the registration process is considered successful if error is less than 2 mm. The registrations of the MNI atlas onto the patient space succeeded in all cases. The comparison of the distance to the clinical outcome revealed good agreement: where the distance was high (at least in one implant), the clinical outcome was poor; where there was a close correlation between the structures, clinical outcome revealed an improvement of the pathological condition. In conclusion, the proposed method seems to provide a useful tool for the identification of the target nuclei for functional radiosurgery. Also, the method is applicable to other types of functional treatment.

Preliminary study on the use of nonrigid registration for thoraco-abdominal radiosurgery.

The inclusion of organ deformation and movement in radiosurgery treatment planning is of increasing importance as research and clinical applications begin to take into consideration the effects of physiological processes, like breathing, on the shape and position of lesions. In this scenario, the challenge is to localize the target in toto (not only by means of marker sampling) and to calculate the dose distribution as the sum of all the contributions from the positions assumed by the target during the respiratory cycle. The aim of this work is to investigate the use of nonrigid registration for target tracking and dynamic treatment planning, i.e., treatment planning based not on one single CT scan but on multiple CT scans representative of the respiration. Twenty patients were CT scanned at end-inhale and end-exhale. An expert radiation oncologist identified the PTV in both examinations. The two CT data sets per patient were nonrigidly registered using a free-form deformation algorithm based on B-splines. The optimized objective function consisted of a weighted sum of a similarity criterion (Mutual Information) and a regularization factor which constrains the transformation to be locally rigid. Once the transformation was obtained and the registration validated, its parameters were applied to the target only. Finally, the deformed target was compared to the PTV delineated by the radiation oncologist in the other study. The results of this procedure show an agreement between the center of mass as well as volume of the target identified automatically by deformable registration and manually by the radiation oncologist. Moreover, obtained displacements were in agreement with body structure constraints and considerations usually accepted in radiation therapy practice. No significant influence of initial target volume on displacements was found. In conclusion, the proposed method seems to offer the possibility of using nonrigid registrations in radiosurgery treatment planning, even if more cases need to be investigated in order to give a statistical consistency to parameter setup and proposed considerations.

Correlation of a hypoxia based tumor control model with observed local control rates in nasopharyngeal carcinoma treated with chemoradiotherapy.

PURPOSE To extend the application of current radiation therapy (RT) based tumor control probability (TCP) models of nasopharyngeal carcinoma (NPC) to include the effects of hypoxia and chemoradiotherapy (CRT). METHODS A TCP model is described based on the linear-quadratic model modified to account for repopulation, chemotherapy, heterogeneity of dose to the tumor, and hypoxia. Sensitivity analysis was performed to determine which parameters exert the greatest influence on the uncertainty of modeled TCP. On the basis of the sensitivity analysis, the values of specific radiobiological parameters were set to nominal values reported in the literature for NPC or head and neck tumors. The remaining radiobiological parameters were determined by fitting TCP to clinical local control data from published randomized studies using both RT and CRT. Validation of the model was performed by comparison of estimated TCP and average overall local control rate (LCR) for 45 patients treated at the institution with conventional linear-accelerator-based or helical tomotherapy based intensity-modulated RT and neoadjuvant chemotherapy. RESULTS Sensitivity analysis demonstrates that the model is most sensitive to the radiosensitivity term alpha and the dose per fraction. The estimated values of alpha and OER from data fitting were 0.396 Gy(-1) and 1.417. The model estimate of TCP (average 90.9%, range 26.9%-99.2%) showed good correlation with the LCR (86.7%). CONCLUSIONS The model implemented in this work provides clinicians with a useful tool to predict the success rate of treatment, optimize treatment plans, and compare the effects of multimodality therapy.

Hypofractionation of partial breast irradiation using radiobiological models

PURPOSE To reduce the fraction number in Partial Breast Irradiation (PBI) with initial prescription of 40 Gy in 10 fractions using radiobiological models with specific focus on risk of moderate/severe radiation-induced fibrosis (RIF) and report clinical results. METHODS AND MATERIALS 68 patients (patient group A) were treated with 40 Gy in 10 fractions delivered by field-in-field, forward-planned IMRT. Isotoxic regimens with decreasing number of fractions were calculated using Biological Effective Dose (BED) to the breast. Risk for RIF in hypofractionated treatment was predicted by calculating NTCP from DVHs of group A rescaled to fractions and dose of novel regimens. Moderate/severe RIF was prospectively scored during follow-up. Various NTCP models, with and without incomplete repair correction, were assessed from difference to observed incidence of RIF. In order to verify the value for α/β of 3 Gy assumed for breast, we fitted α/β to observed incidences of moderate/severe RIF. RESULTS Treatments with 35 Gy/7f and 28 Gy/4f were selected for the fraction reduction protocol. 75 patients (group B) were treated in 35 Gy/7f. Incidence of moderate/severe RIF was 5.9% in group A, 5.3% in group B. The NTCP model with correction for incomplete repair had lowest difference from observed RIF. The α/β obtained from fitting was 2.8 (95%CIs 1.1-10.7) Gy. CONCLUSIONS The hypofractionated regimen was well tolerated. The model for NTCP corrected for incomplete repair was the most accurate and an assumed α/β value of 3 Gy is consistent with our patient data. The hypofractionation protocol is continuing with patients treated with 28 Gy/4f.

Direct validation of atlas-based red nucleus identification for functional radiosurgery

Treatment targets in functional neurosurgery usually consist of selected structures within the thalamus and basal ganglia, which can be stimulated in order to affect specific brain pathways. Chronic electrical stimulation of these structures is a widely used approach for selected patients with advanced movement disorders. An alternative therapeutic solution consists of producing a lesion in the target nucleus, for example by means of radiosurgery, a noninvasive procedure, and this prevents the use of intraoperative microelectrode recording as a method for accurate target definition. The need to have accurate noninvasive localization of the target motivated our previous work on atlas-based identification; the aim of this present work is to provide additional validation of this approach based on the identification of the red nuclei (RN), which are located near the subthalamic nucleus (STN). Coordinates of RN were obtained from the Talairach and Tournoux (TT) atlas and transformed into the coordinates of the Montreal Neurological Institute (MNI) atlas, creating a mask representation of RN. The MNI atlas volume was nonrigidly registered onto the patient magnetic resonance imaging (MRI). This deformation field was then applied to the RN mask, providing its location on the patient MRI. Because RN are easily identifiable on 1.5 T T2-MRI images, they were manually delineated; the coordinates of the centers of mass of the manually and automatically identified structures were compared. Additionally, volumetric overlapping indices were calculated. Ten patients were examined by this technique. All indices indicated a high level of agreement between manually and automatically identified structures. These results not only confirm the accuracy of the method but also allow fine tuning of the automatic identification method to be performed.