Norman Albright

Five year results of linac radiosurgery for arteriovenous malformations: outcome for large AVMS

PURPOSE For radiosurgery of large arteriovenous malformations (AVMs), the optimal relationship of dose and volume to obliteration, complications, and hemorrhage is not well defined. Multivariate analysis was performed to assess the relationship of multiple AVM and treatment factors to the outcome of AVMs significantly larger than previously reported in the literature. METHODS AND MATERIALS 73 patients with intracranial AVMs underwent LINAC radiosurgery. Over 50% of the AVMs were larger than 3 cm in diameter and the median and mean treatment volumes were 8.4 cc and 15.3 cc, respectively (range 0.4-143.4 cc). Minimum AVM treatment doses varied between 1000-2200 cGy (median: 1600 cGy). RESULTS The obliteration rates for treatment volumes < 4 cc, 4-13.9 cc, and > or = 14 cc were 67%, 58%, and 23%, respectively. AVM obliteration was significantly associated with higher minimum treatment dose and negatively associated with a history of prior embolization with particulate materials. No AVM receiving < 1400 cGy was obliterated. The incidence of post-radiosurgical imaging abnormalities and clinical complications rose with increasing treatment volume. For treatment volumes > 14 cc receiving > or = 1600 cGy, the incidence of post-radiosurgical MRI T2 abnormalities was 72% and the incidence of radiation necrosis requiring resection was 22%. The rate of post-radiosurgical hemorrhage was 2.7% per person-year for AVMs with treatment volumes < 14 cc and 7.5% per person-year for AVMs > or = 14 cc. CONCLUSION As AVM size increases, the dose-volume range for the optimal balance between successful obliteration and the risk of complications and post-radiosurgical hemorrhage narrows.

Computerized video time lapse study of cell cycle delay and arrest, mitotic catastrophe, apoptosis and clonogenic survival in irradiated 14-3-3σ and CDKN1A (p21) knockout cell lines

Abstract Chu, K., Teele, N., Dewey, M. W., Albright, N. and Dewey, W. C. Computerized Video Time Lapse Study of Cell Cycle Delay and Arrest, Mitotic Catastrophe, Apoptosis and Clonogenic Survival in Irradiated 14-3-3σ and CDKN1A (p21) Knockout Cell Lines. Radiat. Res. 162, 270–286 (2004). Computerized video time lapse (CVTL) microscopy was used to observe cellular events induced by ionizing radiation (10–12 Gy) in nonclonogenic cells of the wild-type HCT116 colorectal carcinoma cell line and its three isogenic derivative lines in which p21 (CDKN1A), 14-3-3σ or both checkpoint genes (double-knockout) had been knocked out. Cells that fused after mitosis or failed to complete mitosis were classified together as cells that underwent mitotic catastrophe. Seventeen percent of the wild-type cells and 34–47% of the knockout cells underwent mitotic catastrophe to enter generation 1 with a 4N content of DNA, i.e., the same DNA content as irradiated cells arrested in G2 at the end of generation 0. Radiation caused a transient division delay in generation 0 before the cells divided or underwent mitotic catastrophe. Compared with the division delay for wild-type cells that express CDKN1A and 14-3-3σ, knocking out CDKN1A reduced the delay the most for cells irradiated in G1 (from ∼15 h to ∼3– 5 h), while knocking out 14-3-3σ reduced the delay the most for cells irradiated in late S and G2 (from ∼18 h to ∼3–4 h). However, 27% of wild-type cells and 17% of 14-3-3σ−/− cells were arrested at 96 h in generation 0 compared with less than 1% for CDKN1A−/− and double-knockout cells. Thus expression of CDKN1A is necessary for the prolonged delay or arrest in generation 0. Furthermore, CDKN1A plays a crucial role in generation 1, greatly inhibiting progression into subsequent generations of both diploid cells and polyploid cells produced by mitotic catastrophe. Thus, in CDKN1A-deficient cell lines, a series of mitotic catastrophe events occurred to produce highly polyploid progeny during generations 3 and 4. Most importantly, the polyploid progeny produced by mitotic catastrophe events did not die sooner than the progeny of dividing cells. Death was identified as loss of cell movement, i.e. metabolic activity. Thus mitotic catastrophe itself is not a direct mode of death. Instead, apoptosis during interphase of both uninucleated and polyploid cells was the primary mode of death observed in the four cell types. Knocking out either CDKN1A or 14-3-3σ increased the amount of cell death at 96 h, from 52% to ∼70%, with an even greater increase to 90% when both genes were knocked out. Thus, in addition to effects of CDKN1A and 14-3-3σ expression on transient cell cycle delay, CDKN1A has both an anti-proliferative and anti-apoptosis function, while 14-3-3σ has only an anti-apoptosis function. Finally, the large alterations in the amounts of cell death did not correlate overall with the small alterations in clonogenic survival (dose-modifying ratios of 1.05–1.13); however, knocking out CDKN1A resulted in a decrease in arrested cells and an increase in survival, while knocking out 14-3-3σ resulted in an increase in apoptosis and a decrease in survival.

Fetal dose estimates for radiotherapy of brain tumors during pregnancy

PURPOSE To determine clinically the fetal dose from irradiation of brain tumors during pregnancy and to quantitate the components of fetal dose using phantom measurements. METHODS AND MATERIALS Two patients received radiotherapy during pregnancy for malignant brain tumors. Case 1 was treated with opposed lateral blocked 10 x 15 cm fields and case 2 with 6 x 6 cm bicoronal wedged arcs, using 6 MV photons. Fetal dose was measured clinically and confirmed with phantom measurements using thermoluminescent dosimeters (TLDs). Further phantom measurements quantitated the components of scattered dose. RESULTS For case 1, both clinical and phantom measurements estimated fetal dose to be 0.09% of the tumor dose, corresponding to a total fetal dose of 0.06 Gy for a tumor dose of 68.0 Gy. Phantom measurements estimated that internal scatter contributed 20% of the fetal dose, leakage 20%, collimator scatter 33%, and block scatter 27%. For case 2, clinical and phantom measurements estimated fetal dose to be 0.04% of the tumor dose, corresponding to a total fetal dose of 0.03 Gy for a tumor dose of 78.0 Gy. Leakage contributed 74% of the fetal dose, internal scatter 13%, collimator scatter 9%, and wedge scatter 4%. CONCLUSIONS When indicated, brain tumors may be irradiated to high dose during pregnancy resulting in fetal exposure < 0.10 Gy, conferring an increased but acceptable risk of leukemia in the child, but no other deleterious effects to the fetus after the fourth week of gestation. For our particular field arrangements and linear accelerators, internal scatter contributed a small component of fetal dose compared to leakage and scatter from the collimators and blocks, and 18 MV photons resulted in a higher estimated fetal dose than 6 MV photons due to increased leakage and collimator scatter. These findings are not universal, but clinical and phantom TLD measurements estimate fetal dose accurately for energies < 10 MV and should be taken for each pregnant patient considered for treatment to confirm and document acceptable dose.

Computerized Video Time-Lapse Analysis of Apoptosis of REC:Myc Cells X-Irradiated in Different Phases of the Cell Cycle

Abstract Forrester, H. B., Albright, N., Ling, C. C. and Dewey, W. C. Computerized Video Time-Lapse Analysis of Apoptosis of REC:Myc Cells X-Irradiated in Different Phases of the Cell Cycle. Asynchronous rat embryo cells expressing Myc were followed in 50 fields by computerized video time lapse (CVTL) for three to four cycles before irradiation (4 Gy) and then for 6–7 days thereafter. Pedigrees were constructed for single cells that had been irradiated in different parts of the cycle, i.e. at different times after they were born. Over 95% of the cell death occurred by postmitotic apoptosis after the cells and their progeny had divided from one to six times. The duration of the process of apoptosis once it was initiated was independent of the phase in which the cell was irradiated. Cell death was defined as cessation of movement, typically 20–60 min after the cell rounded with membrane blebbing, but membrane rupture did not occur until 5 to 40 h later. The times to apoptosis and the number of divisions after irradiation were less for cells irradiated late in the cycle. Cells irradiated in G1 phase divided one to six times and survived 40–120 h before undergoing apoptosis compared to only one to two times and 5–40 h for cells irradiated in G2 phase. The only cells that died without dividing after irradiation were irradiated in mid to late S phase. Essentially the same results were observed for a dose of 9.5 Gy, although the progeny died sooner and after fewer divisions than after 4 Gy. Regardless of the phase in which they were irradiated, the cells underwent apoptosis from 2 to 150 h after their last division. Therefore, the postmitotic apoptosis did not occur in a predictable or programmed manner, although apoptosis was associated with lengthening of both the generation time and the duration of mitosis immediately prior to the death of the daughter cells. After the non-clonogenic cells divided and yielded progeny entering the first generation after irradiation with 4 Gy, 60% of the progeny either had micronuclei or were sisters of cells that had micronuclei, compared to none of the progeny of clonogenic cells having micronuclei in generation 1. However, another 20% of the non-clonogenic cells had progeny with micronuclei appearing first in generation 2 or 3. As a result, 80% of the non-clonogenic cells had progeny with micronuclei. Furthermore, cells with micronuclei were more likely to die during the generation in which the micronuclei were observed than cells not having micronuclei. Also, micronuclei were occasionally observed in the progeny from clonogenic cells in later generations at about the same time that lethal sectoring was observed. Thus cell death was associated with formation of micronuclei. Most importantly, cells irradiated in late S or G2 phase were more radiosensitive than cells irradiated in G1 phase for both loss of clonogenic survival and the time of death and number of divisions completed after irradiation. Finally, the cumulative percentage of apoptosis scored in whole populations of asynchronous or synchronous populations, without distinguishing between the progeny of individually irradiated cells, underestimates the true amount of apoptosis that occurs in cells that undergo postmitotic apoptosis after irradiation. Scoring cell death in whole populations of cells gives erroneous results since both clonogenic and non-clonogenic cells are dividing as non-clonogenic cells are undergoing apoptosis over a period of many days.

Precision radiation therapy for optic nerve sheath meningiomas

A more precise radiation therapy technique to treat unilateral optic nerve sheath meningioma is presented. It uses an immobilization device to align the ipsilateral optic nerve with a vertical axis and employs three small half-beam blocked fields to deliver radiation to a small conformal volume, thereby reducing the dose to the optic chiasm and the contralateral optic nerve. Three patients were successfully treated with this technique, and a fourth patient with optic nerve glioma was also treated in a similar fashion and was included in this study. The new technique irradiates a much smaller volume of tissue to high dose levels: 58 cm3 is irradiated to the 80% isodose level and only 18 cm3 to the 95% level. In contrast, the opposed lateral technique irradiates 171 and 73 cm3 to these levels, respectively. Thus, a considerable reduction in the volume of normal tissue irradiated was accomplished. Doses to the pituitary and contralateral optic nerve were 4% of the treatment dose for the new technique, whereas these doses were 40% and 100% for opposed laterals and 10% and 3% for wedged pair, respectively. The average setup error for this technique was very small, 50% of the setups measured were less than 1 mm off, and 92.5% were less than 3 mm off. However, for the conventional setups without a mask, only 21% of the setups were less than 1 mm off and 55% less than 3 mm off. We recommend this technique for localized unilateral optic nerve sheath meningioma and other optic nerve lesions that may require radiation therapy.

Reirradiation of pituitary adenoma

Fifteen patients initially irradiated for pituitary adenoma were subsequently treated with a second course of radiotherapy at the University of California at San Francisco between 1961 and 1989. The re-irradiation followed surgery in all but two cases. The median time to recurrence was 9 years (range 2-17) and median follow-up after the second course of radiotherapy was 10 years (range 1-30). The median initial radiation dose was 4084 cGy; that at recurrence was 4200 cGy. Local control has been maintained in 12 patients. One failed locally with a benign adenoma that was surgically salvaged. Two developed pituitary carcinomas which were poorly controlled. Of the patients who presented with visual abnormalities at the time of recurrence, 50% improved and the remainder stabilized after re-irradiation. There are no long-term visual complications. Hypopituitarism was present in nine patients prior to the second course of radiotherapy and developed in the remaining six patients after re-irradiation. Temporal lobe injury was seen in two patients. Careful analysis of each patients pituitary and temporal lobe doses, intervals between treatments, treatment volume, neurets, relative decay factors, absolute decay factors, TDF and modified LQF values, and dose-volume relationships, revealed no correlation with complication or likelihood of local control. Repeat radiotherapy for recurrent pituitary adenoma with the doses used in these patients appears to carry acceptable risk with good local control.

Computerized Video Time-Lapse (CVTL) Analysis of Cell Death Kinetics in Human Bladder Carcinoma Cells (EJ30) X-Irradiated in Different Phases of the Cell Cycle

Abstract Chu, K., Leonhardt, E. A., Trinh, M., Prieur-Carrillo, G., Lindqvist, J., Albright, N., Ling, C. C. and Dewey, W. C. Computerized Video Time-Lapse (CVTL) Analysis of Cell Death Kinetics in Human Bladder Carcinoma Cells (EJ30) X-Irradiated in Different Phases of the Cell Cycle. Radiat. Res. 158, 667–677 (2002). The purpose of this study was to quantify the modes and kinetics of cell death for EJ30 human bladder carcinoma cells irradiated in different phases of the cell cycle. Asynchronous human bladder carcinoma cells were observed in multiple fields by computerized video time-lapse (CVTL) microscopy for one to two cell divisions before irradiation (6 Gy) and for 6–11 days afterward. By analyzing time-lapse movies collected from these fields, pedigrees were constructed showing the behaviors of 231 cells irradiated in different phases of the cell cycle (i.e. at different times after mitosis). A total of 219 irradiated cells were determined to be non-colony-forming over the time spans of the experiments. In these nonclonogenic pedigrees, cells died primarily by necrosis either without entering mitosis or over 1 to 10 postirradiation generations. A total of 105 giant cells developed from the irradiated cells or their progeny, and 30% (31/105) divided successfully. Most nonclonogenic cells irradiated in mid-S phase (9–12 h after mitosis) died by the second generation, while those irradiated either before or after this short period in mid-S phase had cell deaths occurring over one to nine postirradiation generations. The nonclonogenic cells irradiated in mid-S phase also experienced the longest average delay before their first division. Clonogenic cells (11/12 cells) divided sooner after irradiation than the average nonclonogenic cells derived from the same phase of the cell cycle. The early death and long division delay observed for nonclonogenic cells irradiated in mid-S phase could possibly result from an increase in damage induced during the transition from the replication of euchromatin to the replication of heterochromatin.

Pulsed-field gel electrophoretic migration of DNA broken by X irradiation during DNA synthesis : Experimental results compared with Monte Carlo calculations

Synchronous CHO cells were X-irradiated in G1 or mid-S phase with 30-750 Gy, and then the size distribution of DNA molecules resulting from DNA double-strand breaks (DSBs) was studied by pulsed-field gel electrophoresis (PFGE). Cells irradiated in S phase also were pulse-labeled with [3H]dThd for 15 min to compare the migration patterns of replicating DNA with those of DNA mass, measured by imaging with a CCD camera. When cells were irradiated immediately after pulse labeling, a large amount of the 3H-labeled replicating DNA was trapped in the plug, i.e. > 90% for doses < 100 Gy. As the dose increased, the percentage trapped decreased, i.e. to approximately 50% for 750 Gy. The same results were observed for DNA mass when cells were irradiated in S phase, except that much less of the DNA was trapped, i.e. approximately 60% for 70-100 Gy, which produced approximately 2-Mbp molecules, compared to approximately 10% for 750 Gy, which produced approximately 0.3-Mbp molecules. These results and the migration patterns of DNA released into the lane indicated that large molecules are trapped more readily than small molecules because they contain more replicating regions (bands with bubbles) of DNA than small molecules. Our interpretation is that as the dose increases, a greater fraction of the breaks occur between the replicating bands, thus releasing linear molecules that are not replicating. The relatively small amount of 3H-labeled replicating DNA that is released from the PFGE plug migrates aberrantly, with a small amount migrating like linear G1-phase molecules and a large amount, depending on dose, migrating much more slowly than the DNA mass from cells irradiated in G1 or S phase. To explain these results, a Monte Carlo computer program was written to introduce DSBs randomly into DNA that is configured according to a model of DNA replication that is developed in a related study (Dewey and Albright, Radiat. Res. 148, 421-434, 1997). In relating the experimental observations to the results of the Monte Carlo calculations, we assumed that (a) molecules containing replication bubbles with and without forks are trapped in the PFGE plug, (b) linear molecules and molecules with replication forks only that are < or = 8 Mbp are released into the lane, and (c) molecules having replication forks migrate more slowly than linear molecules.

Modification of SR 2508 sensitization in hypoxic V79 cells by manipulation of glutathione levels.

This series of experiments employed the hypoxic cell sensitizer SR 2508 in concentrations ranging from 0.1 to 10 mM and V-79 cells irradiated in air or made hypoxic in glass syringes, then irradiated with 15 MV X rays. Using a series of survival curves measured at the various concentrations, K curves relating sensitizer enhancement ratio (SER) to SR 2508 concentration were calculated with normal GSH levels or with depletion of GSH to 0% using 1 mM buthionine sulfoximine (BSO) or elevation to 200% of normal using 1 mM oxothiazolidine carboxylate (OTZ). Survival curves were fitted by computer, allowing calculation of standard errors for the SER values. The depletion of GSH by BSO sensitized hypoxic and aerated cells significantly and caused more than additive enhancement of SR 2508 sensitization in hypoxic cells. Elevation of GSH with OTZ protects cells irradiated in air or hypoxia and reduces the SER obtained with SR 2508. The results further support the importance of GSH levels in influencing sensitization by nitroimidazoles.

Dosimetry of leakage doses from a mobile accelerator for IORT and legal issues for its clinical use in Japan

AbstractBackground. Despite the clinical usefulness of intraoperative radiotherapy, this treatment requires large staff numbers. A mobile linear accelerator unit dedicated for electron beam intraoperative radiation therapy (IORT) is now commercially available, but its use is not permitted by Japanese regulations on medical radiation. Methods. The mobile accelerator is now the subject of a clinical trial at the University of California, San Francisco (UCSF). Before the trial began, leakage doses around the facility were evaluated. Leakage doses around the accelerator were measured, and leakage doses arising from the operating room were monitored in the adjoining corridors, on the doors around the room and in the rooms on the floors above and below. Results. When the machine is used under the proper conditions, the leakage doses can be lower than the limit determined by the Japanese Radiation Safety Law. Conclusions. The mobile accelerator is a promising tool for IORT, and it is suggested that the Medical Treatment Law should be modified to permit the use of the machine in Japan.