Trigeminal neuralgia (TN) is treated in CyberKnife (Accuray Inc, Sunnyvale, USA) with the 5 mm collimator whose dosimetric inaccuracy is higher than the other available collimators. The 7.5 mm collimator which is having less dosimetric uncertainty can be an alternative for 5 mm collimator provided the dose distribution with 7.5 mm collimator is acceptable. Aim of this study is to analyze the role of 7.5 mm collimator in CyberKnife treatment plans of TN. The treatment plans with 5 mm collimators were re-optimized with 7.5 mm collimator and a bi-collimator system (5 mm and 7.5 mm). The treatment plans were compared for target coverage, brainstem doses, and the dose to normal tissues. The target and brainstem doses were comparable. However, the conformity indices were 2.31 ± 0.52, 2.40 ± 0.87 and 2.82 ± 0.51 for 5 mm, bi-collimator (5mm and 7.5 mm), 7.5 mm collimator plans respectively. This shows the level of dose spillage in 7.5 mm collimator plans. The 6 Gy dose volumes in 7.5 mm plans were 1.53 and 1.34 times higher than the 5 mm plan and the bi-collimator plans respectively. The treatment time parameters were lesser for 7.5 mm collimators. Since, the normal tissue dose is pretty high in 7.5 mm collimator plans, the use of it in TN plans can be ruled out though the treatment time is lesser for these 7.5 mm collimator plans.
Collimators; CyberKnife; stereotactic radiosurgery; trigeminal neuralgia
The objective of this study is to check the feasibility of in vivo rectal dose measurement in intensity-modulated radiotherapy (IMRT) and CyberKnife treatments for carcinoma prostate. An in-house pelvis phantom made with bee's wax was used in this study. Two cylindrical bone equivalent materials were used to simulate the femur. Target and other critical structures associated with carcinoma prostate were delineated on the treatment planning images by the radiation oncologist. IMRT treatment plan was generated in Oncentra Master Plan treatment planning system and CyberKnife treatment plan was generated in Multiplan treatment planning system. Dose measurements were carried out in phantom and in patient using Gafchromic EBT3 films. RIT software was used to analyze the dose measured by EBT3 films. The measured doses using EBT3 films were compared with the TPS-calculated dose along the anterior rectal wall at multiple points. From the in-phantom measurements, it is observed that the difference between calculated and measured dose was mostly within 5%, except for a few measurement points. The difference between calculated and measured dose in the in-patient measurements was higher than 5% in regions which were away from the target. Gafchromic EBT3 film is a suitable detector for in vivo rectal dose measurements as it offers the possibility of analyzing the dose at multiple points. In addition, the method of extending this in vivo rectal dose measurement technique as a tool for patient-specific quality assurance check is also analyzed.
Gafchromic EBT3; in vivo dosimetry; rectal dose measurement
Total body irradiation (TBI) is a special radiotherapy technique, administered prior to bone marrow transplantation. Due to the complex nature of the treatment setup, in vivo dosimetry for TBI is mandatory to ensure proper delivery of the intended radiation dose throughout the body. Lithium fluoride (LiF) TLD-100 chips are used for the TBI in vivo dosimetry. Results obtained from the in vivo dosimetry of 20 patients are analyzed. Results obtained from forehead, abdomen, pelvis, and mediastinum showed a similar pattern with the average measured dose from 96 to 97% of the prescription dose. Extremities and chest received a dose greater than the prescription dose in many instances (more than 20% of measurements). Homogeneous dose delivery to the whole body is checked by calculating the mean dose with standard deviation for each fraction. Reasons for the difference between prescription dose and measured dose for each site are discussed. Dose homogeneity within ±10% is achieved using our in-house TBI protocol.
In vivo dosimetry; lithium fluoride; total body irradiation; TLD-100
Prostate cancer in men has a high mortality and morbidity due to metastatic disease. The pathobiology of prostate cancer metastasis is not well understood and cell lines and animal models that recapitulate the complex nature of the disease are needed. Therefore, the goal of the study was to establish and characterize a new prostate cancer line derived from a dog with spontaneous prostate cancer.
A new cell line (Leo) was derived from a dog with spontaneous prostate cancer. Immunohistochemistry and PCR were used to characterize the primary prostate cancer and xenografts in nude mice. Subcutaneous tumor growth and metastases in nude mice were evaluated by bioluminescent imaging, radiography and histopathology. In vitro chemosensitivity of Leo cells to therapeutic agents was measured.
Leo cells expressed the secretory epithelial cytokeratins (CK) 8, 18 and ductal cell marker, CK7. The cell line grew in vitro (over 75 passages) and was tumorigenic in the subcutis of nude mice. Following intracardiac injection, Leo cells metastasized to the brain, spinal cord, bone, and adrenal gland. The incidence of metastases was greatest to the central nervous system (80%) with a lower incidence to bone (20%) and the adrenal glands (16%). In vitro chemosensitivity assays demonstrated that Leo cells were sensitive to velcade and an HDAC-42 inhibitor with IC50 concentrations of 1.9 nM and 0.95 μM respectively.
The new prostate cancer cell line (Leo) will be a valuable model to investigate the mechanisms of the brain and bone metastases.
Prostate cancer; Brain metastasis; spinal cord metastasis; dog; canine; bone metastasis
CyberKnife radiosurgery treatment of Trigeminal neuralgia (TN) is performed as a non-invasive image guided procedure. The prescription dose for TN is very high. The brainstem is the adjacent critical organ at risk (OAR) which is prone to receive the very high target dose of TN. The present study is to analyze the dose distribution inside the tiny trigeminal nerve target and also to analyze the dose fall off in the brain stem. Seven TN cases treated between November 2010 and January 2012 were taken for this study retrospectively. The treatment plans were analyzed for target dose conformity, homogeneity and dose coverage. In the brainstem the volume doses D1%, D2% were taken for analyzing the higher doses in the brain stem. The dose fall off was analyzed in terms of D5% and D10%. The mean value of maximum dose within the trigeminal nerve target was 73.5±2.1Gy (P=0.0007) and the minimum dose was 50.0±4.1Gy (P=0.1315). The mean conformity index was 2.19 and the probable reason could be the smallest CyberKnife collimator of 5mm used in the treatment plan. The mean D1%, of the brainstem was 10.5± 2.1Gy (P=0.5316) and the mean value of the maximum point dose within the brainstem was 35.6±3.8Gy. This shows the degree of dose fall off within the brainstem. Though the results of the present study are showing superior sparing of brain stem and reasonable of target coverage, it is necessary to execute the treatment plan with greater accuracy in CyberKnife as the immobilization is noninvasive and frameless.
Brainstem dose; cyberknife; stereotactic radiosurgery; trigeminal neuralgia
As the α/β value of prostate is very small and lower than the surrounding critical organs, hypofractionated radiotherapy became a vital mode of treatment of prostate cancer. Cyberknife (Accuray Inc., Sunnyvale, CA, USA) treatment for localized prostate cancer is performed in hypofractionated dose regimen alone. Effective dose escalation in the hypofractionated regimen can be estimated if the corresponding conventional 2 Gy per fraction equivalent normalized total dose (NTD) distribution is known. The present study aims to analyze the hypofractionated dose distribution of localized prostate cancer in terms of equivalent NTD. Randomly selected 12 localized prostate cases treated in cyberknife with a dose regimen of 36.25 Gy in 5 fractions were considered. The 2 Gy per fraction equivalent NTDs were calculated using the formula derived from the linear quadratic (LQ) model. Dose distributions were analyzed with the corresponding NTDs. The conformity index for the prescribed target dose of 36.25 Gy equivalent to the NTD dose of 90.63 Gy (α/β = 1.5) or 74.31 Gy (α/β = 3) was ranging between 1.15 and 1.73 with a mean value of 1.32 ± 0.15. The D5% of the target was 111.41 ± 8.66 Gy for α/β = 1.5 and 90.15 ± 6.57 Gy for α/β = 3. Similarly, the D95% was 91.98 ± 3.77 Gy for α/β = 1.5 and 75.35 ± 2.88 Gy for α/β = 3. The mean values of bladder and rectal volume receiving the prescribed dose of 36.25 Gy were 0.83 cm3 and 0.086 cm3, respectively. NTD dose analysis shows an escalated dose distribution within the target for low α/β (1.5 Gy) with reasonable sparing of organs at risk. However, the higher α/β of prostate (3 Gy) is not encouraging the fact of dose escalation in cyberknife hypofractionated dose regimen of localized prostate cancer.
Cyberknife; hypofractionation; localized prostate; low α/β; normalized total dose
Jak1/2 inhibition suppresses STAT3 phosphorylation that is characteristic of many cancers. Activated STAT3 promotes the transcription of factors that enhance tumor growth, survival, and angiogenesis. AZD1480 is a novel small molecule inhibitor of Jak1/2, which is a key mediator of STAT3 activation. This study examined the use of diffusion-weighted (DW) and dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) biomarkers in assessing early tumor response to AZD1480. Cediranib (AZD2171), a vascular endothelial growth factor signaling inhibitor, was used as a comparator. Thirty mice were injected with Calu-6 lung cancer cells and randomized into the three treatment groups: AZD1480, cediranib, and sham. DW-MRI and DCE-MRI protocols were performed at baseline and at days 3 and 5 after treatment. The percent change from baseline measurements for Ktrans, ADC, and ve were calculated and compared with hematoxylin and eosin (H&E), CD31, cParp, and Ki-67 histology data. Decreases in Ktrans of 29% (P < .05) and 53% (P < .05) were observed at days 3 and 5, respectively, for the cediranib group. No significant changes in Ktrans occurred for the AZD1480 group, but a significant increase in ADC was demonstrated at days 3 (63%, P < .05) and 5 (49%, P < .05). CD31 staining indicated diminished vasculature in the cediranib group, whereas significantly increased cParp staining for apoptotic activity and extracellular space by image analysis of H&E were present in the AZD1480 group. These imaging biomarker changes, and corresponding histopathology, support the use of ADC, but not Ktrans, as a pharmacodynamic biomarker of response to AZD1480 at these time points.
Dose linearity studies on conventional linear accelerators show a linearity error at low monitor units (MUs). The purpose of this study was to establish the dose linearity and MU stability characteristics of a cyberknife (Accuray Inc., USA) stereotactic radiosurgery system. Measurements were done at a depth of 5 cm in a stereotactic dose verification phantom with a source to surface distance of 75 cm in a Generation 4 (G4) type cyberknife system. All the 12 fixed-type collimators starting from 5 to 60 mm were used for the dose linearity study. The dose linearity was examined in small (1–10), medium (15–100) and large (125–1000) MU ranges. The MU stability test was performed with 60 mm collimator for 10 MU and 20 MU with different combinations. The maximum dose linearity error of –38.8% was observed for 1 MU with 5 mm collimator. Dose linearity error in the small MU range was considerably higher than in the medium and large MU ranges. The maximum error in the medium range was –2.4%. In the large MU range, the linearity error varied between –0.7% and 1.2%. The maximum deviation in the MU stability was –3.03%.
Cyberknife; dose linearity; monitor unit stability; small monitor units
Radical radiotherapy is one of the options for the management of prostate cancer. In external beam therapy, 3D conformal radiotherapy (3DCRT) and intensity modulated radiotherapy (IMRT) are the options for delivery of increased radiation dose, as vital organs are very close to the prostate and a higher dose to these structures leads to an increased toxicity. In brachytherapy, low dose rate brachytherapy with permanent implant of radioactive seeds and high dose rate brachytherapy (HDR) with remote after loaders are available. A dosimetric analysis has been made on IMRT and HDR brachytherapy plans. Ten cases from each IMRT and HDR brachytherapy have been taken for the study. The analysis includes comparison of conformity and homogeneity indices, D100, D95, D90, D80, D50, D10 and D5 of the target. For the organs at risk (OAR), namely rectum and bladder, V100, V90 and V50 are compared. In HDR brachytherapy, the doses to 1 cc and 0.1 cc of urethra have also been studied. Since a very high dose surrounds the source, the 300% dose volumes in the target and within the catheters are also studied in two plans, to estimate the actual volume of target receiving dose over 300%. This study shows that the prescribed dose covers 93 and 92% of the target volume in IMRT and HDR brachytherapy respectively. HDR brachytherapy delivers a much lesser dose to OAR, compared to the IMRT. For rectum, the V50 in IMRT is 34.0cc whilst it is 7.5cc in HDR brachytherapy. With the graphic optimization tool in HDR brachytherapy planning, the dose to urethra could be kept within 120% of the target dose. Hence it is concluded that HDR brachytherapy may be the choice of treatment for cancer of prostate in the early stage.
Brachytherapy; conformity; intensity modulated radiotherapy; prostate
Bone metastasis is the most common cause of morbidity and mortality in patients with advanced prostate cancer and is manifested primarily as mixed osteoblastic and osteolytic lesions. However, the mechanisms responsible for bone metastases in prostate cancer are not clearly understood, in part due to the lack of relevant in vivo models that mimic the clinical presentation of the disease in humans. We previously established a nude mouse model with mixed bone metastases using intracardiac injection of canine prostate cancer cells (Ace-1). In this study, we hypothesized that tumor-induced osteolysis promoted the incidence of bone metastases and osteoblastic activity.
We studied the effect of inhibition of osteolysis with zoledronic acid (ZA) on the prevention and progression of Ace-1 bone metastases in nude mice using prophylactic and delayed treatment protocols. Bioluminescent imaging, radiography, and histopathological evaluation were performed to monitor the effect of ZA on the incidence, progression and nature of bone metastases.
Unexpectedly, there was no significant difference in tumor burden and the incidence of metastasis between control and treatment groups as detected by bioluminescent imaging and bone histomorphometry. However, radiographic and histopathological analysis showed a significant treatment-related decrease in osteolysis, but no effect on tumor-induced trabecular bone thickness in both treatment groups compared to controls.
Our results demonstrated that the incidence of prostate cancer bone metastases in vivo was not reduced by zoledronic acid even though zoledronic acid inhibited bone resorption and bone loss associated with the mixed osteoblastic/osteolytic bone metastases in the Ace-1 model.
prostate cancer; bioluminescent imaging; bone metastases; zoledronic acid; osteoblastic metastases; osteolysis
Adult T-cell /lymphomaleukemia (ATLL) is caused by human T-cell lymphotropic virus type 1 (HTLV-1). Approximately 80% of ATLL patients develop humoral hypercalcemia of malignancy (HHM), a life-threatening complication leading to a poor prognosis. Parathyroid hormone–related protein (PTHrP) and macrophage inflammatory protein-1α (MIP-1α) are important factors in the pathogenesis of HHM in ATLL and the expression of PTHrP can be activated by nuclear factor κB (NF-κB). NF-κB is constitutively activated in ATLL cells and is essential for leukemogenesis including transformation of lymphocytes infected by HTLV-1. Our goal was to evaluate the effects of NF-κB disruption by a proteasomal inhibitor (PS-341) and osteoclastic inhibition by zoledronic acid (Zol) on the development of ATLL and HHM using a novel bioluminescent mouse model. We found that PS-341 decreased cell viability, increased apoptosis, and down-regulated PTHrP expression in ATLL cells in vitro. To investigate the in vivo efficacy, nonobese diabetic/severe combined immunodeficient (NOD/SCID) mice were xenografted with ATLL cells and treated with vehicle control, PS-341, Zol, or a combination of PS-341 and Zol. Bioluminescent imaging and tumor cell count showed a significant reduction in tumor burden in mice from all treatment groups. All treatments also significantly reduced the plasma calcium concentrations. Zol treatment increased trabecular bone volume and decreased osteoclast parameters. PS-341 reduced PTHrP and MIP-1A expression in tumor cells in vivo. Our results indicate that both PS-341 and Zol are effective treatments for ATLL and HHM, which are refractory to conventional therapy.
Over the past few decades, cones of different diameter (12.5 mm to 40 mm) were used for treatment of intracranial lesions. These give very focused dose delivery to the target with minimum dose to outside normal brain tissues. This study is intended to compare the older method of arc-based stereotactic treatments using cones with the new mini-multileaf collimator (mMLC). Treatment plans are made for various sites of intracranial lesions with the cones and mMLC. In case of nonspherical lesions, more than one isocenter is used to get an optimum dose distribution with cones, while a single isocenter is sufficient with mMLC. Treatment plans are compared for irregular lesions using cones with multiple isocenters and mMLC. It is observed that conformity index and dose heterogeneity are better for mMLC based treatments.
Dose-volume histograms; mini-multileaf collimator; stereotactic radiosurgery
This work was undertaken with the intention of investigating the possibility of clinical use of commercially available self-developing radiochromic film – Gafchromic EBT film – for IMRT dose verification. The dose response curves were generated for the films using VXR-16 film scanner. The results obtained with EBT films were compared with the results of Kodak EDR2 films. It was found that the EBT film has a linear response between the dose ranges of 0 and 600 cGy. The dose-related characteristics of the EBT film, like post-irradiation color growth with time, film uniformity and effect of scanning orientation, were studied. There is up to 8.6% increase in the color density between 2 and 40 h after irradiation. There was a considerable variation, up to 8.5%, in the film uniformity over its sensitive region. The quantitative difference between calculated and measured dose distributions was analyzed using Gamma index with the tolerance of 3% dose difference and 3 mm distance agreement. EDR2 films showed good and consistent results with the calculated dose distribution, whereas the results obtained using EBT were inconsistent. The variation in the film uniformity limits the use of EBT film for conventional large field IMRT verification. For IMRT of smaller field size (4.5 × 4.5 cm), the results obtained with EBT were comparable with results of EDR2 films.
EDR2 film; intensity modulated radiotherapy; radiochromic film