External beam radiation therapy with kilovoltage x-rays

Beam collimation and filtration optimization for a novel orthovoltage radiotherapy system

BACKGROUND

The inaccessibility of clinical linear accelerators in low- and middle-income countries creates a need for low-cost alternatives. Kilovoltage (kV) x-ray tubes have shown promise as a source that could meet this need. However, performing radiotherapy with a kV x-ray tube has numerous difficulties, including high skin dose, rapid dose fall-off, and low dose rates. These limitations create a need for highly effective beam collimation and filtration.

PURPOSE

To improve the treatment potential of a novel kV x-ray system by optimizing an iris collimator and beam filtration using Bayesian techniques and Monte Carlo (MC) simulations.

METHODS

The Kilovoltage Optimized AcceLerated Adaptive therapy system's current beam configuration consists of a 225 kVp x-ray tube, a 12-leaflet tungsten iris collimator, and a 0.1 mm copper filter. A Bayesian optimization was performed for the large and small focal spot sizes of the kV x-ray tube source at 220 kVp using TopasOpt, an open-source library for optimization in TOPAS. Collimator thickness, copper filter thickness, source-to-collimator distance (SCD), and source-to-surface distance (SSD) were the variables considered in the optimization. The objective function was designed to maximize the dose rate and the dose at a depth of 5 cm while minimizing the beam penumbra width and the out-of-field dose (OFD), all evaluated in a water phantom. Post-optimization, the optimal beam configuration was simulated and compared to the existing configuration.

RESULTS

The optimal collimation setup consisted of 2.5 mm thick tungsten leaflets for the iris collimator and a 350 mm SSD for both focal spot sizes. The optimal copper filtration was 0.22 mm for the large focal spot and 0.15 mm for the small focal spot, with a SCD of 148.5 mm for the large focal spot and 125.8 mm for the small focal spot. For the large focal spot, the surface dose rate decreased by 9.4%, while the PDD at 5cm depth (PDD 5 c m $\text{PDD}_{5\textnormal {cm}}$ ) increased by 7.7% compared to the existing iris collimator. Additionally, the surface beam penumbra width was reduced by 31.3%, and no significant changes in the OFD were observed. For the small focal spot, the surface dose rate for the new collimator increased by 3.7% and thePDD 5 c m $\text{PDD}_{5\textnormal {cm}}$ increased by 5.3%, with no statistically significant changes in the beam penumbra width or OFD.

CONCLUSION

The optimal beam collimation and filtration for both x-ray tube focal spot sizes of a kV radiotherapy system was determined using Bayesian optimization and MC simulations and resulted in improved dose distributions.

Initial characterization of a novel dual-robot orthovoltage radiotherapy system

Purpose:Adequate access to radiotherapy is a critical global concern affecting low-resource settings such as low- and middle-income countries and rural regions. We propose to reduce this disparity by developing a novel low-cost radiotherapy device that treats using non-coplanar techniques and a 225 kVp x-ray tube.Methods:This novel device has been preliminarily characterized spectrally, via spectrometer measurements, dosimetrically, via percent depth dose curves and 2D profiles, and geometrically, via a coplanar star-shot. Dosimetric and geometric evaluations were then combined by performing a proof of workflow of the KOALA system. Monte Carlo simulations were run in TOPAS to validate dosimetric measurements and the proof of workflow measurement.Results:Spectral results showed excellent agreement between measured and modelled spectra. Dose errors of  < 2% were achieved for PDD curves. Full width at half maximum values for the 2D profiles were, on average, 0.95 mm higher in simulation compared to film. A star-shot test demonstrated the high geometrical accuracy of the system with a 0.3 mm diameter wobble circle. Finally, a mean absolute percent error of 5  ±  5% (1σ) was measured for the proof of workflow test.Conclusions:This initial characterization showcased the strengths and weaknesses of the KOALA system, with excellent isocenter precision and depth dose accuracy while lacking dosimetric accuracy in the 2D profiles. Further improvements on the source-to-collimator distance and treatment couch material can be made to improve the accuracy of a Monte Carlo model of the KOALA system.

An Evaluation of the Potential Radiosensitization Effect of Spherical Gold Nanoparticles to Induce Cellular Damage Using Different Radiation Qualities

Global disparities in cancer prevention, detection, and treatment demand a unified international effort to reduce the disease's burden and improve outcomes. Despite advances in chemotherapy and radiotherapy, many tumors remain resistant to these treatments. Gold nanoparticles (AuNPs) have shown promise as radiosensitizers, enhancing the effectiveness of low-energy X-rays by emitting Auger electrons that cause localized cellular damage. In this study, spherical AuNPs of 5 nm and 10 nm were characterized and tested on various cell lines, including malignant breast cells (MCF-7), non-malignant cells (CHO-K1 and MCF-10A), and human lymphocytes. Cells were treated with AuNPs and irradiated with attenuated 6 megavoltage (MV) X-rays or p(66)/Be neutron radiation to assess DNA double-strand break (DSB) damage, cell viability, and cell cycle progression. The combination of AuNPs and neutron radiation induced higher levels of γ-H2AX foci and micronucleus formation compared to treatments with AuNPs or X-ray radiation alone. AuNPs alone reduced cellular kinetics and increased the accumulation of cells in the G2/M phase, suggesting a block of cell cycle progression. For cell proliferation, significant effects were only observed at the concentration of 50 μg/mL of AuNPs, while lower concentrations had no inhibitory effect. Further research is needed to quantify internalized AuNPs and correlate their concentration with the observed cellular effects to unravel the biological mechanisms of their radioenhancement.

Gold Nanoparticles Cause Radiosensitization in 4T1 Cells by Inhibiting DNA Double Strand Break Repair: Single Cell Comparisons of DSB Formation and γH2AX Expression

Metal nanoparticles sensitize cancers to radiotherapy however their mechanisms of action are complex. The conceptual inspiration arose from theories of physical dose deposition however various chemical and biological factors have also been identified. Interpretation of data has been limited by challenges in measuring true DNA damage compared to DNA damage repair factors. Here, we applied a new assay, STRIDE, for the first time to measure DNA double strand breaks (DSBs) in 4T1 cells as a model of triple negative breast cancer exposed to gold nanoparticles and radiation, and compared this to the common γH2AX assay for DSB repair. The STRIDE assay showed no increase in DSB detection 15 mins after irradiation for cells containing nanoparticles compared to cells without. Gold nanoparticles led to prolonged detection of DSBs after irradiation and delayed the DSB repair. The data show no evidence of increased radiation dose deposition with nanoparticles, but rather enhanced radiobiological effects resulting from nanoparticles which includes disruption of the recruitment of essential DDR machinery, thereby impairing DNA repair processes.

Electron radiation therapy: Back to the future?

Electron radiotherapy has long been preferred to photons for the treatment of superficial lesions because of its physical characteristics (high dose at the surface, rapid decrease in depth). Other characteristics (penumbra, heterogeneity on an oblique or irregular surface) make them difficult to use. In most indications (skin cancers, head and neck, medulloblastoma), with technical progress, in some cases they have been replaced by intensity-modulated conformal radiotherapy, brachytherapy and contact therapy. Other indications (drainage of mesotheliomas or irradiation of benign lesions) have disappeared. The low frequency of use leads to problems of safety and cost-effectiveness. However, modern photon radiotherapy techniques are still less effective than electrons in specific indications such as total skin irradiation (mycosis fungoides) or certain thin chest wall irradiations after total mastectomy, reirradiation or paediatric treatments without protons. Flash therapy, initiated by electrons, has been developed over the last 10 years, providing high-dose irradiation in an extremely short time. Initial results show good efficacy, with fewer side effects than with conventional radiotherapy. These results are leading to clinical technological developments on a larger scale. Although it has been replaced in most indications by more modern techniques, electron radiotherapy remains essential for targeted indications in specialised centres. The emergence of flash therapy will lead to new indications, on machines equipped with this new technology, which have yet to be defined and are currently the responsibility of specialised teams.

kV reference dosimetry in Australia and New Zealand: Survey results and trends

PURPOSE

To assess the number of radiotherapy kilovoltage (kV) units in service, their clinical utilization, and methodology and equipment used for absorbed dose determination across Australia and New Zealand.

METHODS

A survey was sent to 61 Australian and New Zealand radiotherapy providers in the second half of 2023.

RESULTS

Fifty-seven responses were received, with 43 departments having kV units and providing beam quality data for 185 therapeutic kV beams 20-300 kVp. Percentage depth dose curves were compared between five clinical beams with 100 kVp and 2.13-6.28 mm Aluminum half value layers (HVLs), demonstrating large differences that can occur between beams with the same kVp. Eighteen departments provided clinical utilization data for their kV units, with a total of 4458 treatment courses and their corresponding kVp reported. All departments complied with national and international recommendations with respect to the equipment used for reference dosimetry of kV beams; 77% of ionization chambers used for absorbed dose determination were of Farmer-type, with the remaining 23% being plane parallel soft x-ray chambers. Methods of derivation of air-kerma calibration factors varied, with 73% of respondents using a draft document disseminated by the Australian Primary Standards laboratory, 23% using HVL alone, and 6% using other methods.

CONCLUSIONS

The results of this survey provide a snapshot of kilovoltage radiation therapy use and the number of kV units across Australia and New Zealand. This data can be used as a point of reference for future investigations into clinical utilization and reference dosimetry methods across Australia and New Zealand or for comparisons with other countries, facilitating standardization of reference dosimetry practice for kilovoltage units.

Non-coplanar lung SABR treatments delivered with a gantry-mounted x-ray tube

Objective.To create two non-coplanar, stereotactic ablative radiotherapy (SABR) lung patient treatment plans compliant with the radiation therapy oncology group (RTOG) 0813 dosimetric criteria using a simple, isocentric, therapy with kilovoltage arcs (SITKA) system designed to provide low cost external radiotherapy treatments for low- and middle-income countries (LMICs).Approach.A treatment machine design has been proposed featuring a 320 kVp x-ray tube mounted on a gantry. A deep learning cone-beam CT (CBCT) to synthetic CT (sCT) method was employed to remove the additional cost of planning CTs. A novel inverse treatment planning approach using GPU backprojection was used to create a highly non-coplanar treatment plan with circular beam shapes generated by an iris collimator. Treatments were planned and simulated using the TOPAS Monte Carlo (MC) code for two lung patients. Dose distributions were compared to 6 MV volumetric modulated arc therapy (VMAT) planned in Eclipse on the same cases for a Truebeam linac as well as obeying the RTOG 0813 protocols for lung SABR treatments with a prescribed dose of 50 Gy.Main results.The low-cost SITKA treatments were compliant with all RTOG 0813 dosimetric criteria. SITKA treatments showed, on average, a 6.7 and 4.9 Gy reduction of the maximum dose in soft tissue organs at risk (OARs) as compared to VMAT, for the two patients respectively. This was accompanied by a small increase in the mean dose of 0.17 and 0.30 Gy in soft tissue OARs.Significance.The proposed SITKA system offers a maximally low-cost, effective alternative to conventional radiotherapy systems for lung cancer patients, particularly in low-income countries. The system's non-coplanar, isocentric approach, coupled with the deep learning CBCT to sCT and GPU backprojection-based inverse treatment planning, offers lower maximum doses in OARs and comparable conformity to VMAT plans at a fraction of the cost of conventional radiotherapy.

X-ray radiation-induced intestinal barrier dysfunction in human epithelial Caco-2 cell monolayers

Radiation therapy and unwanted radiological or nuclear exposure, such as nuclear plant accidents, terrorist attacks, and military conflicts, pose serious health issues to humans. Dysfunction of the intestinal epithelial barrier and the leakage of luminal antigens and bacteria across the barrier have been linked to various human diseases. Intestinal permeability is regulated by intercellular structures, termed tight junctions (TJs), which are disrupted after radiation exposure. In this study, we investigated radiation-induced alterations in TJ-related proteins in an intestinal epithelial cell model. Caco-2 cells were irradiated with 2, 5, and 10 Gy and harvested 1 and 24 h after X-ray exposure. The trypan blue assay revealed that cell viability was reduced in a dose-dependent manner 24 h after X-ray exposure compared to that of non-irradiated cells. However, the WST-8 assay revealed that cell proliferation was significantly reduced only 24 h after radiation exposure to 10 Gy compared to that of non-irradiated cells. In addition, a decreased growth rate and increased doubling time were observed in cells irradiated with X-rays. Intestinal permeability was significantly increased, and transepithelial electrical resistance values were remarkably reduced in Caco-2 cell monolayers irradiated with X-rays compared to non-irradiated cells. X-ray irradiation significantly decreased the mRNA and protein levels of ZO-1, occludin, claudin-3, and claudin-4, with ZO-1 and claudin-3 protein levels decreasing in a dose-dependent manner. Overall, the present study reveals that exposure to X-ray induces dysfunction of the human epithelial intestinal barrier and integrity via the downregulation of TJ-related genes, which may be a key factor contributing to intestinal barrier damage and increased intestinal permeability.

Radiotherapy plus immune checkpoint inhibitor in prostate cancer

The immune checkpoint inhibitor (ICI) is a promising strategy for treating cancer. However, the efficiency of ICI monotherapy is limited, which could be mainly attributed to the tumor microenvironment of the "cold" tumor. Prostate cancer, a type of "cold" cancer, is the most common cancer affecting men's health. Radiotherapy is regarded as one of the most effective prostate cancer treatments. In the era of immune therapy, the enhanced antigen presentation and immune cell infiltration caused by radiotherapy might boost the therapeutic efficacy of ICI. Here, the rationale of radiotherapy combined with ICI was reviewed. Also, the scheme of radiotherapy combined with immune checkpoint blockades was suggested as a potential option to improve the outcome of patients with prostate cancer.

Dosimetric characterization of a mobile accelerator dedicated for intraoperative radiation therapy: Monte Carlo simulations and experimental validation

PURPOSE

This Technical Note validates previously published data about the dosimetry of the electron beams produced by a mobile accelerator dedicated for intraoperative radiation therapy (IORT). The evaluation of the directional response of a PTW microDiamond detector is presented together with a detailed analysis of the output factors (OFs) for bevelled applicators.

METHODS

The OFs of the 6, 8, 10 and 12 MeV electron beams produced by a light intraoperative accelerator (LIAC, SIT, Italy) were measured in a commercial water phantom using the microDiamond. A set of flat and bevelled applicators with sizes ranging from 4 to 10 cm was characterized. For bevelled applicators, a correction for the angular dependence of the microDiamond was calculated using a home-made spherical phantom. Correction factors were obtained through measurements performed rotating the accelerator treatment head at 0°, 15°, 30° and 45°.

RESULTS

For flat applicators, the average deviation between measured and simulated OFs was (-1.1 ± 0.7)%. The microDiamond showed a higher angular dependence for the 6 MeV beam (∼8% for angles up to 45°, range 92 % ÷ 100 %), while the variations for 8, 10 and 12 MeV beams were ∼ 4 % (range 97 % ÷ 101 %). Correcting for this dependence, the average deviation of the OFs for bevelled applicators was (-0.9 ± 1.6)%.

CONCLUSIONS

The presented results were in very good agreement with those reported in literature. Very similar deviations were found between flat and bevelled applicators confirming the suitability of our method to determine the angular dependence correction factors of the microDiamond detector.

A potential revolution in cancer treatment: A topical review of FLASH radiotherapy

FLASH radiotherapy (RT) is a novel technique in which the ultrahigh dose rate (UHDR) (≥40 Gy/s) is delivered to the entire treatment volume. Recent outcomes of in vivo studies show that the UHDR RT has the potential to spare normal tissue without sacrificing tumor control. There is a growing interest in the application of FLASH RT, and the ultrahigh dose irradiation delivery has been achieved by a few experimental and modified linear accelerators. The underlying mechanism of FLASH effect is yet to be fully understood, but the oxygen depletion in normal tissue providing extra protection during FLASH irradiation is a hypothesis that attracts most attention currently. Monte Carlo simulation is playing an important role in FLASH, enabling the understanding of its dosimetry calculations and hardware design. More advanced Monte Carlo simulation tools are under development to fulfill the challenge of reproducing the radiolysis and radiobiology processes in FLASH irradiation. FLASH RT may become one of standard treatment modalities for tumor treatment in the future. This paper presents the history and status of FLASH RT studies with a focus on FLASH irradiation delivery modalities, underlying mechanism of FLASH effect, in vivo and vitro experiments, and simulation studies. Existing challenges and prospects of this novel technique are discussed in this manuscript.

Attenuation coefficient in the energy range 14–36 keV of 3D printing materials for physical breast phantoms

Objective. To measure the monoenergetic x-ray linear attenuation coefficient, μ, of fused deposition modeling (FDM) colored 3D printing materials (ABS, PLAwhite, PLAorange, PET and NYLON), used as adipose, glandular or skin tissue substitutes for manufacturing physical breast phantoms. Approach. Attenuation data (at 14, 18, 20, 24, 28, 30 and 36 keV) were acquired at Elettra synchrotron radiation facility, with step-wedge objects, using the Lambert–Beer law and a CCD imaging detector. Test objects were 3D printed using the Ultimaker 3 FDM printer. PMMA, Nylon-6 and high-density polyethylene step objects were also investigated for the validation of the proposed methodology. Printing uniformity was assessed via monoenergetic and polyenergetic imaging (32 kV, W/Rh). Main results. Maximum absolute deviation of μ for PMMA, Nylon-6 and HD-PE was 5.0%, with reference to literature data. For ABS and NYLON, μ differed by less than 6.1% and 7.1% from that of adipose tissue, respectively; for PET and PLAorange the difference was less than 11.3% and 6.3% from glandular tissue, respectively. PLAorange is a good substitute of skin (differences from −9.4% to +1.2%). Hence, ABS and NYLON filaments are suitable adipose tissue substitutes, while PET and PLAorange mimick the glandular tissue. PLAwhite could be printed at less than 100% infill density for matching the attenuation of glandular tissue, using the measured density calibration curve. The printing mesh was observed for sample thicknesses less than 60 mm, imaged in the direction normal to the printing layers. Printing dimensional repeatability and reproducibility was less 1%. Significance. For the first time an experimental determination was provided of the linear attenuation coefficient of common 3D printing filament materials with estimates of μ at all energies in the range 14–36 keV, for their use in mammography, breast tomosynthesis and breast computed tomography investigations.

Dosimetry of a novel converging X-ray source for kilovoltage radiotherapy

PURPOSE

The objective of this work was to evaluate phantom dosimetry of a novel kilovoltage (kV) X-ray source, which employs a stationary tungsten anode and a linearly swept scanning electron beam. The source utilizes converging X-ray collimation along with orthogonal mechanical rotation to distribute surface flux over large area. In this study, this was investigated as a potential solution to fast-falloff limitations expected with kV radiotherapy. This was done with the aim of future clinical development of a lower cost radiotherapy alternative to megavoltage (MV) linac systems.

METHODS

Radiochromic film was employed for dosimetry on the kV X-ray source of the linear-converging radiotherapy system (LCRS). The source utilizes charge particle optics to magnetically deflect and focus an electron beam along a stationary, reflection tungsten target in an ultra-high-vacuum stainless-steel chamber. Resulting X-rays were collimated into converging beamlets that span a large planar angle and converge at the system isocenter. In this study, radiochromic film dosimetry was done at 140 and 145 kVp for a designated planning treatment volume (PTV) of 4 cm diameter. An acrylic phantom was employed for dose distribution measurements of stationary and rotational delivery. Film dosimetry was evaluated in planes parallel to the source X-ray window at various depths, as well as in the plane of gantry rotation.

RESULTS

At 140 and 145 kVp and using a collimated 4 cm square field at depth, lesion-to-skin dose ratio was shown to improve with additional beams from different relative source positions, where the different beams are focused at the same isocenter and do not overlap at the phantom surface. It was only possible to achieve a 1:1 D_max -to-surface ratio with four delivery beams, but the ratio improved to 4:1 with 12 beams, focused at the same isocenter depth of 7.8 cm in an acrylic phantom. For the tests conducted, the following D_max -to-surface ratios were obtained: 0.4:1 lesion-to-skin ratio for stationary delivery from one entry beam, 0.71:1 lesion-to-skin ratio was obtained for two beams, 1.07:1 ratio for four beams, and 4:1 for 12 beams. Dose-depth profiles were evaluated for stationary and rotational dosimetry. Additionally, rotational dosimetry was measured for a case more analogous to a clinical scenario, where the isocenter was located at an off-center simulated lesion.

CONCLUSIONS

The results demonstrate potential dose-depth improvements with kV arc therapy by distributing the surface flux with a wide converging beam along with perpendicular mechanical source rotation of the LCRS. The system delivered tolerable dose to a large surface area when a threshold of multiple, separated beams was reached. The radiochromic film data support the feasibility of the construct of the LCRS kV radiotherapy system design.

Radiosensitization Effect of Gold Nanoparticles in Proton Therapy

The number of proton therapy facilities and the clinical usage of high energy proton beams for cancer treatment has substantially increased over the last decade. This is mainly due to the superior dose distribution of proton beams resulting in a reduction of side effects and a lower integral dose compared to conventional X-ray radiotherapy. More recently, the usage of metallic nanoparticles as radiosensitizers to enhance radiotherapy is receiving growing attention. While this strategy was originally intended for X-ray radiotherapy, there is currently a small number of experimental studies indicating promising results for proton therapy. However, most of these studies used low proton energies, which are less applicable to clinical practice; and very small gold nanoparticles (AuNPs). Therefore, this proof of principle study evaluates the radiosensitization effect of larger AuNPs in combination with a 200 MeV proton beam. CHO-K1 cells were exposed to a concentration of 10 μg/ml of 50 nm AuNPs for 4 hours before irradiation with a clinical proton beam at NRF iThemba LABS. AuNP internalization was confirmed by inductively coupled mass spectrometry and transmission electron microscopy, showing a random distribution of AuNPs throughout the cytoplasm of the cells and even some close localization to the nuclear membrane. The combined exposure to AuNPs and protons resulted in an increase in cell killing, which was 27.1% at 2 Gy and 43.8% at 6 Gy, compared to proton irradiation alone, illustrating the radiosensitizing potential of AuNPs. Additionally, cells were irradiated at different positions along the proton depth-dose curve to investigate the LET-dependence of AuNP radiosensitization. An increase in cytogenetic damage was observed at all depths for the combined treatment compared to protons alone, but no incremental increase with LET could be determined. In conclusion, this study confirms the potential of 50 nm AuNPs to increase the therapeutic efficacy of proton therapy.