Technological Advances in Charged-Particle Therapy

Charted-particle therapy (CPT) benefits cancer patients by localizing doses in the tumor volume while minimizing the doses delivered to normal tissue through its unique physical and biological characteristics. The world's first CPT applied on humans was proton beam therapy (PBT), which was performed in the mid-1950s. Among heavy ions, carbon ions showed the most favorable biological characteristics for the treatment of cancer patients. Carbon ions show coincidence between the Bragg peak and maximum value of relative biological effectiveness. In addition, they show low oxygen enhancement ratios. Therefore, carbon-ion radiotherapy (CIRT) has become mainstream in the treatment of cancer patients using heavy ions. CIRT was first performed in 1977 at the Lawrence Berkeley Laboratory. The CPT technology has advanced in the intervening decades, enabling the use of rotating gantry, beam delivery with fast pencil-beam scanning, image-guided particle therapy, and intensity-modulated particle therapy. As a result, as of 2019, a total of 222,425 and 34,138 patients with cancer had been treated globally with PBT and CIRT, respectively. For more effective and efficient CPT, many groups are currently conducting further studies worldwide. This review summarizes recent technological advances that facilitate clinical use of CPT.

Intense carbon beams production with an all permanent magnet electron cyclotron resonance ion source for heavy ion medical machine

LAPECR3 (Lanzhou All Permanent magnet Electron cyclotron Resonance ion source No. 3) had been developed as an ion injector of Heavy Ion Medical Machine (HIMM) accelerator facility since 2009. The first HIMM accelerator facility was built in Wuwei city in 2015, and the LAPCER3 ion source has delivered C⁵⁺ ion beam to HIMM for more than 1000 days in the past four years. In order to improve the performance of the LAPECR3 ion source for intense carbon beams production, continuous research and development work has been made. The recently developed LAPECR3 ion source together with the new low-energy beam transportation can provide better performance in terms of both beam intensity and quality. This paper will generally review the LAPECR3 ion source operation status for HIMM, and the recent improvement will be presented, especially the stable beams production of C⁴⁺ and C⁵⁺.

OPTIMIZATION OF AN ADDITIONAL COLLIMATOR IN A BEAM DELIVERY SYSTEM FOR REDUCTION OF THE SECONDARY NEUTRON EXPOSURE IN PASSIVE CARBON-ION THERAPY

The aim of this work is to optimize an additional collimator in a beam delivery system to reduce neutron exposure to patients in passive carbon-ion therapy. All studies were performed by Monte Carlo simulation assuming the beam delivery system at Heavy-Ion Medical Accelerator in Chiba. We calculated the neutron ambient dose equivalent at patient positions with an additional collimator, and optimized the position, aperture size and material of the collimator to reduce the neutron ambient dose equivalent. The collimator located 125 and 470 cm upstream from the isocenter could reduce the dose equivalent near the isocenter by 35%, while the collimator located 813 cm upstream from the isocenter was ineffective. As for the material of the collimator, iron and nickel could conduct reduction slightly better than aluminum and polymethyl methacrylate. The additional collimator is an effective method for the reduction of the neutron ambient dose equivalent near the isocenter.

Commissioning of a respiratory gating system involving a pressure sensor in carbon-ion scanning radiotherapy

This study reports the commissioning methodology and results of a respiratory gating system [AZ - 733 V/733 VI (Anzai Medical Co., Japan)] using a pressure sensor in carbon-ion scanning radiotherapy. Commissioning includes choosing a location and method for pressure sensor installation, delay time measurement of the system, and the final flow test. Additionally, we proposed a methodology for the determination of a threshold level of generating an on/off gate for the beam to the respiratory waveform, which is important for clinical application. Regarding the location and method for installation of the pressure sensor, the actual person's abdomen, back of the body position, and supine/prone positioning were checked. By comparing the motion between the pressure sensor output and the reference LED sensor motion, the chest rear surface was shown to be unsuitable for the sensor installation, due to noise in the signal caused by the cardiac beat. Regarding delay time measurement of the system, measurements were performed for the following four steps: (a). Actual motion to wave signal generation; (b). Wave signal to gate signal generation; (c). Gate signal to beam on/off signal generation; (d). Beam on/off signal to the beam irradiation. The total delay time measured was 46 ms (beam on)/33 ms (beam off); these were within the prescribed tolerance time (<100 ms). Regarding the final flow test, an end-to-end test was performed with a patient verification system using an actual carbon-ion beam; the respiratory gating irradiation was successfully performed, in accordance with the intended timing. Finally, regarding the method for determining the threshold level of the gate generation of the respiration waveform, the target motion obtained from 4D-CT was assumed to be correlated with the waveform obtained from the pressure sensor; it was used to determine the threshold value in amplitude direction.

Opportunistic dose amplification for proton and carbon ion therapy via capture of internally generated thermal neutrons

This paper presents Neutron Capture Enhanced Particle Therapy (NCEPT), a method for enhancing the radiation dose delivered to a tumour relative to surrounding healthy tissues during proton and carbon ion therapy by capturing thermal neutrons produced inside the treatment volume during irradiation. NCEPT utilises extant and in-development boron-10 and gadolinium-157-based drugs from the related field of neutron capture therapy. Using Monte Carlo simulations, we demonstrate that a typical proton or carbon ion therapy treatment plan generates an approximately uniform thermal neutron field within the target volume, centred around the beam path. The tissue concentrations of neutron capture agents required to obtain an arbitrary 10% increase in biological effective dose are estimated for realistic treatment plans, and compared to concentrations previously reported in the literature. We conclude that the proposed method is theoretically feasible, and can provide a worthwhile improvement in the dose delivered to the tumour relative to healthy tissue with readily achievable concentrations of neutron capture enhancement drugs.

Treatment of arrhythmias by external charged particle beams: a Langendorff feasibility study

Hadron therapy has already proven to be successful in cancer therapy, and might be a noninvasive alternative for the ablation of cardiac arrhythmias in humans. We present a pilot experiment investigating acute effects of a 12C irradiation on the AV nodes of porcine hearts in a Langendorff setup. This setup was adapted to the requirements of charged particle therapy. Treatment plans were computed on calibrated CTs of the hearts. Irradiation was applied in units of 5 and 10 Gy over a period of about 3 h until a total dose of up to 160 Gy was reached. Repeated application of the same irradiation field helped to mitigate motion artifacts in the resulting dose distribution. After irradiation, PET scans were performed to verify accurate dose application. Acute AV blocks were identified. No other acute effects were observed. Hearts were kept in sinus rhythm for up to 6 h in the Langendorff setup. We demonstrated that 12C ions can be used to select a small target in the heart and, thereby, influence the electrical conduction system. Second, our pilot study seems to suggest that no adverse effects have to be expected immediately during heavy ion irradiation in performing subsequent experiments with doses of 30-60 Gy and intact pigs.

Ion therapy for uveal melanoma in new human eye phantom based on GEANT4 toolkit

Radiotherapy with ion beams like proton and carbon has been used for treatment of eye uveal melanoma for many years. In this research, we have developed a new phantom of human eye for Monte Carlo simulation of tumors treatment to use in GEANT4 toolkit. Total depth-dose profiles for the proton, alpha, and carbon incident beams with the same ranges have been calculated in the phantom. Moreover, the deposited energy of the secondary particles for each of the primary beams is calculated. The dose curves are compared for 47.8MeV proton, 190.1MeV alpha, and 1060MeV carbon ions that have the same range in the target region reaching to the center of tumor. The passively scattered spread-out Bragg peak (SOBP) for each incident beam as well as the flux curves of the secondary particles including neutron, gamma, and positron has been calculated and compared for the primary beams. The high sharpness of carbon beam׳s Bragg peak with low lateral broadening is the benefit of this beam in hadrontherapy but it has disadvantages of dose leakage in the tail after its Bragg peak and high intensity of neutron production. However, proton beam, which has a good conformation with tumor shape owing to the beam broadening caused by scattering, can be a good choice for the large-size tumors.

[The Impact of Gadolinium-based Contrast Agent for Carbon Ion Radiotherapy]

PURPOSE

The contrast agent used in the diagnostic department has high atomic numbers and might influence dose deposition in the particle therapy. In particular, the influence of gadolinium-based (Gd) contrast agent on range in carbon ion radiotherapy has not yet been evaluated. For this reason, we avoid carbon treatment and planning computed tomography (CT) acquisition on days when the contrast-enhanced magnetic resonance image (MRI) is performed. In this study, we evaluated the time required for this beam range effect to vanish by evaluating the temporal changes in the CT values after an enhanced MRI as well as the stopping power of Gd solution.

MATERIALS AND METHODS

Two types of diluted solutions with Gd contrast agent were used for comparing their transferred stopping power (TSP) and measured stopping power (MSP). The TSP was calculated with a CT value to stopping power ratio table that was created previously. Additionally, to evaluate in vivo attenuation, we measured the CT values in the renal pelvis from the CT images with and without contrast agent for 73 patients.

RESULTS

The maximum difference between the TSP and MSP was 85%. The difference between the TSP after 4 hours and the TSP with non-enhanced cases was less than 1%. Moreover, the difference between the MSP after 1 hour and the MSP with non-enhanced cases was less than 0.1%.

CONCLUSION

It was found that the impact of Gd contrast agent can be neglected 1 hour after administration for carbon beam irradiation and 4 hours after for planning the CT image acquisition.

Electron string ion sources for carbon ion cancer therapy accelerators

The type of the Electron String Ion Sources (ESIS) is considered to be the appropriate one to produce pulsed C(4+) and C(6+) ion beams for cancer therapy accelerators. In fact, the new test ESIS Krion-6T already now provides more than 10(10) C(4+) ions per pulse and about 5 × 10(9) C(6+) ions per pulse. Such ion sources could be suitable to apply at synchrotrons. It has also been found that Krion-6T can provide more than 10(11) C(6+) ions per second at the 100 Hz repetition rate, and the repetition rate can be increased at the same or larger ion output per second. This makes ESIS applicable at cyclotrons as well. ESIS can be also a suitable type of ion source to produce the (11)C radioactive ion beams. A specialized cryogenic cell was experimentally tested at the Krion-2M ESIS for pulse injection of gaseous species into the electron string. It has been shown in experiments with stable methane that the total conversion efficiency of methane molecules to C(4+) ions reached 5%÷10%. For cancer therapy with simultaneous irradiation and precise dose control (positron emission tomography) by means of (11)C, transporting to the tumor with the primary accelerated (11)C(4+) beam, this efficiency is preliminarily considered to be large enough to produce the (11)C(4+) beam from radioactive methane and to inject this beam into synchrotrons.

[Particle beam radiotherapy]

Recently, particle beam radiotherapy with protons or carbon ions has been used in cancer treatment. Energy deposition with particle beams increases as depth increases. Furthermore, carbon ion beams have stronger biological effects than X-rays or proton beams, because carbon beams generate denser ionization along the pathway of the particles. In Japan, clinical study with carbon ions for cancer therapy was initiated in 1994 at the National Institute of Radiological Science(NIRS). Four treatment facilities are now in operation, including Gunma University Heavy Ion Medical Center. The experience with carbon ion radiotherapy at NIRS has demonstrated advantages for the following types of cancer. In terms of histological type, adenocarcinomas, sarcomas, and melanomas that are relatively radioresistant to conventional X-ray radiotherapy may be sensitive to carbon ion radiotherapy. Primary sites that may be sensitive include the head and neck region, lung, liver, prostate, bone and soft tissue, and pelvis(for recurrence of rectal cancer). Combined with surgery, cytotoxic drugs, molecular targeted drugs, and immunotherapy, carbon ion radiotherapy promises to be an important modality in the future.

ICRP Publication 127: Radiological Protection in Ion Beam Radiotherapy

The goal of external-beam radiotherapy is to provide precise dose localisation in the treatment volume of the target with minimal damage to the surrounding normal tissue. Ion beams, such as protons and carbon ions, provide excellent dose distributions due primarily to their finite range, allowing a significant reduction of undesired exposure of normal tissue. Careful treatment planning is required for the given type and localisation of the tumour to be treated in order to maximise treatment efficiency and minimise the dose to normal tissue. Radiation exposure in out-of-field volumes arises from secondary neutrons and photons, particle fragments, and photons from activated materials. These unavoidable doses should be considered from the standpoint of radiological protection of the patient. Radiological protection of medical staff at ion beam radiotherapy facilities requires special attention. Appropriate management and control are required for the therapeutic equipment and the air in the treatment room that can be activated by the particle beam and its secondaries. Radiological protection and safety management should always conform with regulatory requirements. The current regulations for occupational exposures in photon radiotherapy are applicable to ion beam radiotherapy with protons or carbon ions. However, ion beam radiotherapy requires a more complex treatment system than conventional radiotherapy, and appropriate training of staff and suitable quality assurance programmes are recommended to avoid possible accidental exposure of patients, to minimise unnecessary doses to normal tissue, and to minimise radiation exposure of staff.

[The basic structure of heavy-ion tumor therapy facility]

Heavy-ions have the similar characteristic of depth-dose distribution with protons, but exhibit enhanced physical and radiobiological benefits. With increasing development in technical and clinical research, more facilities are being installed in the world. At the same time, many critical techniques of heavy-ion therapy facility were optimized and completed. This paper classified and reviewed the basic structure of heavy-ion system equipments, especially the accelerator, gantry, nozzle , TPS.

Measurement of neutron ambient dose equivalent in carbon-ion radiotherapy with an active scanned delivery system

In ion beam radiotherapy, secondary neutrons contribute to an undesired dose outside the target volume, and consequently the increase of secondary cancer risk is a growing concern. In this study, neutron ambient dose equivalents in carbon-ion radiotherapy (CIRT) with an active beam delivery system were measured with a rem meter, WENDI-II, at National Institute of Radiological Sciences. When the same irradiation target was assumed, the measured neutron dose with an active beam was at most ∼15 % of that with a passive beam. This percentage became smaller as larger distances from the iso-centre. Also, when using an active beam delivery system, the neutron dose per treatment dose in CIRT was comparable with that in proton radiotherapy. Finally, it was experimentally demonstrated that the use of an active scanned beam in CIRT can greatly reduce the secondary neutron dose.

An all permanent magnet electron cyclotron resonance ion source for heavy ion therapy

A high charge state all permanent Electron Cyclotron Resonance ion source, Lanzhou All Permanent ECR ion source no. 3-LAPECR3, has been successfully built at IMP in 2012, which will serve as the ion injector of the Heavy Ion Medical Machine (HIMM) project. As a commercial device, LAPECR3 features a compact structure, small size, and low cost. According to HIMM scenario more than 100 eμA of C(5+) ion beam should be extracted from the ion source, and the beam emittance better than 75 π*mm*mrad. In recent commissioning, about 120 eμA of C(5+) ion beam was got when work gas was CH4 while about 262 eμA of C(5+) ion beam was obtained when work gas was C2H2 gas. The design and construction of the ion source and its low-energy transportation beam line, and the preliminary commissioning results will be presented in detail in this paper.

Design study of electron cyclotron resonance-ion plasma accelerator for heavy ion cancer therapy

Electron Cyclotron Resonance-Ion Plasma Accelerator (ECR-IPAC) device, which theoretically can accelerate multiple charged ions to several hundred MeV with short acceleration length, has been proposed. The acceleration mechanism is based on the combination of two physical principles, plasma electron ion adiabatic ejection (PLEIADE) and Gyromagnetic Autoresonance (GYRAC). In this study, we have designed the proof of principle machine ECR-IPAC device and simulated the electromagnetic field distribution generating in the resonance cavity. ECR-IPAC device consisted of three parts, ECR ion source section, GYRAC section, and PLEIADE section. ECR ion source section and PLEIADE section were designed using several multi-turn solenoid coils and sextupole magnets, and GYRAC section was designed using 10 turns coil. The structure of ECR-IPAC device was the cylindrical shape, and the total length was 1024 mm and the maximum diameter was 580 mm. The magnetic field distribution, which maintains the stable acceleration of plasma, was generated on the acceleration center axis throughout three sections. In addition, the electric field for efficient acceleration of electrons was generated in the resonance cavity by supplying microwave of 2.45 GHz.

A study on prevention of an electric discharge at an extraction electrode of an electron cyclotron resonance ion source for cancer therapy

A compact ECR ion source has utilized for carbon radiotherapy. In order to increase beam intensity with higher electric field at the extraction electrode and be better ion supply stability for long periods, electric geometry and surface conditions of an extraction electrode have been studied. Focusing attention on black deposited substances on the extraction electrode, which were observed around the extraction electrode after long-term use, the relation between black deposited substances and the electrical insulation property is investigated. The black deposited substances were inspected for the thickness of deposit, surface roughness, structural arrangement examined using Raman spectroscopy, and characteristics of electric discharge in a test bench, which was set up to simulate the ECR ion source.

Electron beam ion sources for use in second generation synchrotrons for medical particle therapy

Cyclotrons and first generation synchrotrons are the commonly applied accelerators in medical particle therapy nowadays. Next generation accelerators such as Rapid Cycling Medical Synchrotrons (RCMS), direct drive accelerators, or dielectric wall accelerators have the potential to improve the existing accelerator techniques in this field. Innovative accelerator concepts for medical particle therapy can benefit from ion sources which meet their special requirements. In the present paper we report on measurements with a superconducting Electron Beam Ion Source, the Dresden EBIS-SC, under the aspect of application in combination with RCMS as a well proven technology. The measurements indicate that this ion source can offer significant advantages for medical particle therapy. We show that a superconducting EBIS can deliver ion pulses of medically relevant ions such as protons, C(4 +) and C(6 +) ions with intensities and frequencies required for RCMS [S. Peggs and T. Satogata, "A survey of Hadron therapy accelerator technology," in Proceedings of PAC07, BNL-79826- 2008-CP, Albuquerque, New Mexico, USA, 2007; A. Garonna, U. Amaldi et al., "Cyclinac medical accelerators using pulsed C(6 +)/H2(+) ion sources," in Proceedings of EBIST 2010, Stockholm, Sweden, July 2010]. Ion extraction spectra as well as individual ion pulses have been measured. For example, we report on the generation of proton pulses with up to 3 × 10(9) protons per pulse and with frequencies of up to 1000 Hz at electron beam currents of 600 mA.

CABOTO, a high-gradient linac for hadrontherapy

The field of hadrontherapy has grown rapidly in recent years. At present the therapeutic beam is provided by a cyclotron or a synchrotron, but neither cyclotrons nor synchrotrons present the best performances for hadrontherapy. The new generation of accelerators for hadrontherapy should allow fast active energy modulation and have a high repetition rate, so that moving organs can be appropriately treated in a reasonable time. In addition, a reduction of the dimensions and cost of the accelerators for hadrontherapy would make the acquisition and operation of a hadrontherapy facility more affordable, which would translate into great benefits for the potential hadrontherapy patients. The 'cyclinac', an accelerator concept that combines a cyclotron with a high-frequency linear accelerator (linac), is a fast-cycling machine specifically conceived to allow for fast active energy modulation. The present paper focuses on CABOTO (CArbon BOoster for Therapy in Oncology), a compact, efficient high-frequency linac that can accelerate C(6+) ions and H2 molecules from 150-410 MeV/u in ∼24 m. The paper presents the latest design of CABOTO and discusses its performances.

Evaluation of different fiducial markers for image-guided radiotherapy and particle therapy

Modern radiotherapy (RT) techniques are widely used in the irradiation of moving organs. A crucial step in ensuring the correct position of a target structure directly before or during treatment is daily image guidance by computed tomography (CT) or X-ray radiography (image-guided radiotherapy, IGRT). Therefore, combinations of modern irradiation devices and imaging, such as on-board imaging (OBI) with X-rays, or in-room CT such as the tomotherapy system, have been developed. Moreover, combinations of linear accelerators and in-room CT-scanners have been designed. IGRT is of special interest in hypofractionated and radiosurgical treatments where high single doses are applied in the proximity of critical organs at risk. Radiographically visible markers in or in close proximity to the target structure may help to reproduce the position during RT and could therefore be used as external surrogates for motion monitoring. Criteria sought for fiducial markers are (i) visibility in the radiologic modalities involved in radiotherapeutic treatment planning and image guidance, such as CT and kilovoltage (kV) OBI), (ii) low production of imaging artifacts, and (iii) low perturbation of the therapeutic dose to the target volume. Photon interaction with interstitial markers has been shown to be not as important as in particle therapy, where interaction of the particle beam, especially with metal markers, can have a significant impact on treatment. This applies especially with a scanned ion beam. Recently we commenced patient recruitment at our institution within the PROMETHEUS trial, which evaluates a hypofractionation regime, starting with 4 x 10 Gy (RBE), for patients with hepatocellular carcinoma. The aim of this work is, therefore, to evaluate potential implantable fiducial markers for enabling precise patient and thus organ positioning in scanned ion beams. To transfer existing knowledge of marker application from photon to particle therapy, we used a range of commercially available markers of different forms and sizes, consisting of carbon and gold materials, and evaluated them for their potential use in the clinical setup with scanned ion beams at our institution. All markers were implanted in a standardized Alderson phantom and were examined using CT scans and orthogonal kV OBI in our clinical routine protocol. Impact on beam perturbation downstream of the markers in the plateau region of a spread-out Bragg peak (SOBP) was estimated by using radiographic films for clinical proton and carbon ion beams of high and low energies. All tested markers achieved good visibility in CT and kV OBI. Disturbances due to artifacts and dose perturbation were highest in the arbitrarily folded gold and the thickest gold marker, but especially low in the carbon marker. Dose perturbation was highest in the arbitrarily folded gold marker. In summary, the analyzed markers offer promising potential for identifying target structures in our treatment setup at HIT and will soon be used in clinical routine. However, a careful choice of marker, depending on the tumor localization and irradiation strategy, will need to be made.

Study of the magnets used for a mobile isocenter carbon ion gantry

A conceptual design of a mobile isocenter carbon ion gantry was carried out in the framework of the Particle Training Network for European Radiotherapy (PARTNER) and Union of Light Ion Centres in Europe (ULICE) projects. To validate the magnets used in this gantry, Finite Element Method (FEM) simulations were performed with COMSOL multiphysics; the purpose was to evaluate the magnetic field quality and the influence of additional support structures for correctors, 90° bending dipole and quadrupoles, both in dynamic and static regimes. Due to the low ramp rates, the dynamic effects do not disturb the homogeneity and the magnetic field level. The differences between the stationary field and the corresponding dynamic field after the end of the ramps are in the order of 10(-4); it implies that the magnets can be operated without significant field lag at the nominal ramp rate. However, even in static regime the magnetic length of corrector magnet decreases by 5% when the rotator mechanical structure is considered. The simulations suggest an optimization phase of the correctors in the rotator.

First clinical experience in carbon ion scanning beam therapy: retrospective analysis of patient positional accuracy

Our institute has constructed a new treatment facility for carbon ion scanning beam therapy. The first clinical trials were successfully completed at the end of November 2011. To evaluate patient setup accuracy, positional errors between the reference Computed Tomography (CT) scan and final patient setup images were calculated using 2D-3D registration software. Eleven patients with tumors of the head and neck, prostate and pelvis receiving carbon ion scanning beam treatment participated. The patient setup process takes orthogonal X-ray flat panel detector (FPD) images and the therapists adjust the patient table position in six degrees of freedom to register the reference position by manual or auto- (or both) registration functions. We calculated residual positional errors with the 2D-3D auto-registration function using the final patient setup orthogonal FPD images and treatment planning CT data. Residual error averaged over all patients in each fraction decreased from the initial to the last treatment fraction [1.09 mm/0.76° (averaged in the 1st and 2nd fractions) to 0.77 mm/0.61° (averaged in the 15th and 16th fractions)]. 2D-3D registration calculation time was 8.0 s on average throughout the treatment course. Residual errors in translation and rotation averaged over all patients as a function of date decreased with the passage of time (1.6 mm/1.2° in May 2011 to 0.4 mm/0.2° in December 2011). This retrospective residual positional error analysis shows that the accuracy of patient setup during the first clinical trials of carbon ion beam scanning therapy was good and improved with increasing therapist experience.

[Research and development for next generation PET instrumentations]

Positron emission tomography (PET) plays important roles in cancer diagnosis and molecular imaging research; but potential points remain for which big improvements could be made, including resolution, sensitivity and costs. For example, the sensitivity of present PET scanners does not exceed 10%. This means that more than 90% of the gamma-rays emitted from a subject are not utilized for imaging. Therefore, research on next generation PET technologies remains a hot topic worldwide. In this paper, we introduce some research trends by describing PET physics research in the National Institute of Radiological Sciences (NIRS). A depth-of-interaction (DOI) detector, for which various methods have been studied, will be a key device to get any significant improvement in sensitivity while maintaining high spatial resolution. DOI measurement also has a potential to expand PET application fields because it allows for more flexible detector arrangement. As an example, we are developing the world's first, open-type PET geometry "OpenPET", which is expected to lead to PET imaging during treatment. The DOI detector itself continues to evolve with the help of recently developed semiconductor photodetectors, often referred to as silicon photomultipliers (SiPMs). We are developing a SiPM-based DOI detector to achieve sub-mm spatial resolution, which is reaching the theoretical limitation of PET imaging.