Marc R. Sontag

MANAGEMENT OF RADIATION ONCOLOGY PATIENTS WITH IMPLANTED CARDIAC PACEMAKERS : REPORT OF AAPM TASK GROUP NO.34

Contemporary cardiac pacemakers can fail from radiation damage at doses as low as 10 gray and can exhibit functional changes at doses as low as 2 gray. A review and discussion of this potential problem is presented and a protocol is offered that suggests that radiation therapy patients with implanted pacemakers be planned so as to limit accumulated dose to the pacemaker to 2 gray. Although certain levels and types of electromagnetic interference can cause pacemaker malfunction, there is evidence that this is not a serious problem around most contemporary radiation therapy equipment.

Induction of micronuclei by X-radiation in human, mouse and rat peripheral blood lymphocytes.

We compared the radiosensitivity of human, rat and mouse peripheral blood lymphocytes (PBLs) by analyzing micronuclei (MN) in cytochalasin B-induced binucleated (BN) cells. For each species and dose 4-ml aliquots of whole blood were X-irradiated to obtain doses of 38, 75, 150 or 300 cGy. Controls were sham-irradiated. After exposure to X-rays, mononuclear leukocytes were isolated using density gradients and cultured in RPMI 1640 medium containing phytohemagglutinin to stimulate mitogenesis. At 21 h cytochalasin B was added to produce BN PBLs, and all cultures were harvested at 52 h post-initiation using a cytocentrifuge. Significant dose-dependent increases in the percentage of micronucleated cells and the number of MN per BN cell were observed in all three species. The linear-quadratic regression curves for the total percentage of micronucleated cells for the three species were similar; however, the curve for the mouse PBLs had a larger quadratic component than either of the curves for the rat or human PBLs. Although the correlation between the percentage of cells with MN and those with chromosome aberrations was high (r2 greater than 0.95), the mouse and rat PBLs were over twice as efficient as human PBLs in forming MN from presumed acentric fragments. These data indicate that the induction of MN in BN cells following ionizing radiation is similar in human, rat and mouse PBLs, but care must be taken in using the MN results to predict frequencies of cells with chromosomal aberrations.

FOUR-DIMENSIONAL COMPUTED TOMOGRAPHY-BASED INTERFRACTIONAL REPRODUCIBILITY STUDY OF LUNG TUMOR INTRAFRACTIONAL MOTION

PURPOSE To evaluate the interfractional reproducibility of respiration-induced lung tumors motion, defined by their centroids and the intrafractional target motion range. METHODS AND MATERIALS Twentythree pairs of four-dimensional/computed tomography scans were acquired for 22 patients. Gross tumor volumes were contoured, Clinical target volumes (CTVs) were generated. Geometric data for CTVs and lung volumes were extracted. The motion tracks of CTV centroids, and CTV edges along the cranio-caudal, anterior-posterior, and lateral directions were evaluated. The Pearson correlation coefficient for motion tracks along the cranio-caudal direction was determined for the entire respiratory cycle and for five phases about the end of expiration. RESULTS The largest motion extent was along the cranio-caudal direction. The intrafractional motion extent for five CTVs was <0.5 cm, the largest motion range was 3.59 cm. Three CTVs with respiration-induced displacement >0.5 cm did not exhibit the similarity of motion, and for 16 CTVs with motion >0.5 cm the correlation coefficient was >0.8. The lung volumes in corresponding phases for cases that demonstrated CTVs motion similarity were reproducible. No correlation between tumor size and mobility was found. CONCLUSION Target motion reproducibility seems to be present in 87% of cases in our dataset. Three cases with dissimilar motion indicate that it is advisable to verify target motion during treatment. The adaptive adjustment to compensate the possible interfractional shifts in a target position should be incorporated as a routine policy for lung cancer radiotherapy.

Dose measurements in the build-up region for cobalt-60 therapy units.

The dose in the build-up region for four different Cobalt-60 therapy units was measured. It was found that, for large collimator openings and relatively short SSDs, a new dose peak occurs at a depth very much smaller than 0.5 cm. The dose at this peak is a function of collimator openings and SSDs and, in some extreme case, could be 15% or more higher than the dose at the conventional peak dose of 0.5 cm. The new dose peak is probably due to electrons produced in the source capsule and the part of the collimator close to the source; it can be almost eliminated by a filter placed just below the collimator.

The radiation dose-response relationship in a human glioma xenograft and an evaluation of the influence of glutathione depletion by buthionine sulfoximine

We have used an extensively characterized human glioma cell line in an athymic mouse model to evaluate new therapeutic approaches for human supratentorial high grade gliomas. The tumor, D-54MG, is a subline of a human anaplastic glioma. Eight days after homozygous nu/nu BALB/c athymic mice received intracranial (IC) injections of a tumor homogenate, the whole brain was irradiated with either single fractions of 4, 8, 9, and 12 Gy or twice daily fractions, separated by least 6 hr, of 2.28 Gy x 2 or 7.53 Gy x 2. To evaluate whether or not glutathione depletion influenced animal survival, animals at each dose level received either intraperitoneal (IP) buthionine sulfoximine (BSO) alone or I.P. BSO plus BSO in the drinking water. There was a stepwise prolongation of animal survival with increasing doses of external beam radiation. Mean survival in 9 of the 10 control groups (8-12 animals per group) ranged from 14.1 to 18.8 days. Mean survival ranged from 15.3 to 22.5 days at 4 Gy, 25 to 30 days at 8 Gy, 22.3 to 29.7 days at 9 Gy, and 32.9 to 33.6 days at 12 Gy single dose irradiation. At 2.28 Gy x 2 split dose irradiation mean survival was 29.3 days, for 7.53 Gy x 2 mean survival was over 47 days. The data for single fraction irradiation fit a linear regression line (r = 0.908) of mean animal survival = (1.22 [dose in Gy] + 16.7) days. Tumor GSH levels were decreased with all BSO dosing regimens tested. The most aggressive regimen (I.P. BSO+oral BSO for 5 days), reduced tumor GSH to 6.2% of control. Increased survival in irradiated glutathione depleted mice versus mice receiving radiation alone was not seen.

Irradiation for xenogeneic transplantation

Xenogeneic transplantation (XT) is the transplantation of organs or tissues from a member of one species to a member of another. Mammalian species frequently have circulating antibody which is directed against the foreign organ irrespective of known prior antigen exposure. This antibody may lead to hyperacute rejection. There is no reliable means to avert hyperacute rejection once it ensues so efforts must be directed towards eliminating the pre-existing antibody. In those species in which hyperacute rejection of xenografts does not occur, cell-mediated rejection, similar to allograft rejection, may occur. It is in the prevention of this latter form of rejection that radiation is most likely to be beneficial in XT. Both total lymphoid irradiation (TLI) and selective lymphoid irradiation (SLI) have been investigated for use in conjunction with XT. TLI has contributed to the prolongation of pancreatic islet-cell xenografts from hamsters to rats. TLI has also markedly prolonged the survival of cardiac transplants from hamsters to rats. A more modest prolongation of graft survival has been seen with the use of TLI in rabbit-to-rat exchanges. Therapy with TLI, cyclosporine, and splenectomy has markedly prolonged the survival of liver transplants from hamsters to rats, and preliminary data suggest that TLI may contribute to the prolongation of graft survival in the transplantation of hearts from monkeys to baboons. SLI appears to have prolonged graft survival, when used in conjunction with anti-lymphocyte globulin, in hamster-to-rat cardiac graft exchanges. The current state of knowledge of the use of irradiation in experimental XT is reviewed.

Clinical use of a concomitant boost technique using a gypsum compensator

PURPOSE To develop a clinical procedure to treat field within a field (concomitant boost) portals with a single compensated field. METHODS AND MATERIALS An ordinary manual cerrobend block former was used to produce styrofoam molds from simulator film data. A special gypsum compound was poured into the molds. The compensator block is independently mounted to the treatment machine via a custom-made compensator holder. RESULTS Measurements confirm that the inhomogeneous dose distribution has been reliably delivered via this technique. The accuracy of placement of the high dose region is sufficient for clinical use. CONCLUSION The procedure enables the concomitant boost effect to be easily implemented in the clinic without increasing clinical setup time.

Determination of differential scatter-air ratios (dSAR) for three-dimensional scatter integration.

Scatter dose may be calculated by summing the scatter contribution from individual volume elements. These contributions may be represented by differential scatter-air ratios (dSAR). Determination of dSAR from measured data is only approximately correct for second and higher orders of scatter and yields values often limited to one significant figure. Monte Carlo calculation, on the other hand, is time intensive, requires some knowledge of the beams x-ray spectrum, and mastering the complexities of a program such as EGS4. Total scatter dose at a point may be determined by measuring depth dose or tissue-air ratios and partitioning the dose into its primary and scatter components. Scatter may be represented by scatter-air ratios, which can be characterized by the sum of first, second, and higher orders of scatter. The first scatter dose may be computed exactly by summing the first scatter contribution from individual elements, determined from the first principle. Separation of dSAR into primary attenuation and depth-independent terms allows the latter to be precomputed once for a given energy and stored in tabular form. Second scatter may be treated in a similar manner. The higher orders of scatter are computed by subtracting the sum of calculated first and second scatter doses from the total scatter dose. Elements close to and approximately 1 cm above the point of calculation contribute most heavily to the first scatter dose. Compared to the first scatter dose, the second scatter dose contribution is lower, particularly for elements close to the point of calculation.(ABSTRACT TRUNCATED AT 250 WORDS)

Recent Advances In 3-d Treatment Planning Using A Graphics Supercomputer

The goal in the planning of radiation therapy treatments is to maximize the radiation dose to the target (tumor) volume while minimizing the dose to surrounding healthy tissues. Calculation and display of dose superimposed on patient anatomy in three dimensions is very time consuming. Graphics supercomputers, which combine computing speed with powerful graphics, can reduce this time dramatically. Automatic or semi-automatic outlining of patient contours are used instead of slower manual means. Beams-eye-view and physicians-eye-view display of radiation beam position allow rapid, interactive placement and shaping of radiation beams. Dose calculation algorithms optimized for the parallelizing and vectorizing nature of the graphics supercomputer architecture has reduced calculation times by 1-2 orders of magnitude compared to a standard mini-computer.