Dose escalated intensity modulated radiotherapy in the treatment of cervical cancer.

PURPOSE Standard dose of external beam radiotherapy seems to be insufficient for satisfactory control of loco-regionally advanced cervical cancer. Aim of our study is to evaluate the outcome as well as early and chronic toxicities in patients with loco-regionally advanced cervical cancer, treated with dose escalated intensity modulated radiotherapy (IMRT) combined with cisplatin chemotherapy. MATERIAL AND METHODS Thirty-nine patients with cervical carcinoma FIGO stage IB2 - IVA were treated with curative intent between 2006 and 2010. The dose of 50.4 Gy was prescribed to the elective pelvic nodal volume. Primary tumors < 4 cm in diameter (n = 6; 15.4 %) received an external beam radiotherapy (EBRT) boost of 5.4 Gy, primary tumors > 4 cm in diameter (n = 33; 84.6 %) received an EBRT boost of 9 Gy. Patients with positive lymph nodes detected with (18)FDG-PET/CT (n = 22; 56.4 %) received a boost to a total dose of 59.4 - 64.8 Gy. The para-aortic region was included in the radiation volume in 8 (20.5 %) patients and in 5 (12.8 %) patients the para-aortic macroscopic lymph nodes received an EBRT boost. IMRT was followed with a 3D planned high dose rate intrauterine brachytherapy given to 36 (92.3 %) patients with a total dose ranging between 15-18 Gy in three fractions (single fraction: 4-6.5 Gy). Patients without contraindications (n = 31/79.5 %) received concomitantly a cisplatin-based chemotherapy (40 mg/kg) weekly. Toxicities were graded according to the common terminology criteria for adverse events (CTCAE v 4.0). RESULTS Mean overall survival for the entire cohort was 61.1 months (±3.5 months). Mean disease free survival was 47.2 months (±4.9 months) and loco-regional disease free survival was 55.2 months (±4.4 months). 65 % of patients developed radiotherapy associated acute toxicities grade 1, ca. 30 % developed toxicities grade 2 and just two (5.2 %) patients developed grade 3 toxicities, one acute diarrhea and one acute cystitis. 16 % of patients had chronic toxicities grade 1, 9 % grade 2 and one patient (2.6 %) toxicities grade 3 in the form of vaginal dryness. CONCLUSION Dose escalated IMRT appears to have a satisfactory outcome with regards to mean overall survival, disease free and loco-regional disease free survival, whereas the treatment-related toxicities remain reasonably low.

Dose-painting intensity-modulated proton therapy for intermediate- and high-risk meningioma.

BACKGROUND Newly diagnosed WHO grade II-III or any WHO grade recurrent meningioma exhibit an aggressive behavior and thus are considered as high- or intermediate risk tumors. Given the unsatisfactory rates of disease control and survival after primary or adjuvant radiation therapy, optimization of treatment strategies is needed. We investigated the potential of dose-painting intensity-modulated proton beam-therapy (IMPT) for intermediate- and high-risk meningioma. MATERIAL AND METHODS Imaging data from five patients undergoing proton beam-therapy were used. The dose-painting target was defined using [68]Ga-[1,4,7,10-tetraazacyclododecane tetraacetic acid]- d-Phe(1),Tyr(3)-octreotate ([68]Ga-DOTATATE)-positron emission tomography (PET) in target delineation. IMPT and photon intensity-modulated radiation therapy (IMRT) treatment plans were generated for each patient using an in-house developed treatment planning system (TPS) supporting spot-scanning technology and a commercial TPS, respectively. Doses of 66 Gy (2.2 Gy/fraction) and 54 Gy (1.8 Gy/fraction) were prescribed to the PET-based planning target volume (PTVPET) and the union of PET- and anatomical imaging-based PTV, respectively, in 30 fractions, using simultaneous integrated boost. RESULTS Dose coverage of the PTVsPET was equally good or slightly better in IMPT plans: dose inhomogeneity was 10 ± 3% in the IMPT plans vs. 13 ± 1% in the IMRT plans (p = 0.33). The brain Dmean and brainstem D50 were small in the IMPT plans: 26.5 ± 1.5 Gy(RBE) and 0.002 ± 0.0 Gy(RBE), respectively, vs. 29.5 ± 1.5 Gy (p = 0.001) and 7.5 ± 11.1 Gy (p = 0.02) for the IMRT plans, respectively. The doses delivered to the optic structures were also decreased with IMPT. CONCLUSIONS Dose-painting IMPT is technically feasible using currently available planning tools and resulted in dose conformity of the dose-painted target comparable to IMRT with a significant reduction of radiation dose delivered to the brain, brainstem and optic apparatus. Dose escalation with IMPT may improve tumor control and decrease radiation-induced toxicity.

Verification of intensity modulated stereotactic radiotherapy using Monte Carlo calculations and EPID dosimetry

The purpose of this work was to develop a comprehensive IMSRT QA procedure that examined, using EPID dosimetry and Monte Carlo (MC) calculations, each step in the treatment planning and delivery process. These steps included verification of the field shaping, treatment planning system (RTPS) dose calculations, and patient dose delivery. Verification of each step in the treatment process is assumed to result in correct dose delivery to the patient. ^ The accelerator MC model was verified against commissioning data for field sizes from 0.8 × 0.8 cm 2 to 10 × 10 cm 2. Depth doses were within 2% local percent difference (LPD) in low gradient regions and 1 mm distance to agreement (DTA) in high gradient regions. Lateral profiles were within 2% LPD in low gradient regions and 1 mm DTA in high gradient regions. Calculated output factors were within 1% of measurement for field sizes ≥1 × 1 cm2. ^ The measured and calculated pretreatment EPID dose patterns were compared using criteria of 5% LPD, 1 mm DTA, or 2% of central axis pixel value with ≥95% of compared points required to pass for successful verification. Pretreatment field verification resulted in 97% percent of the points passing. ^ The RTPS and Monte Carlo phantom dose calculations were compared using 5% LPD, 2 mm DTA, or 2% of the maximum dose with ≥95% of compared points required passing for successful verification. RTPS calculation verification resulted in 97% percent of the points passing. ^ The measured and calculated EPID exit dose patterns were compared using criteria of 5% LPD, 1 mm DTA, or 2% of central axis pixel value with ≥95% of compared points required to pass for successful verification. Exit dose verification resulted in 97% percent of the points passing. ^ Each of the processes above verified an individual step in the treatment planning and delivery process. The combination of these verification steps ensures accurate treatment delivery to the patient. This work shows that Monte Carlo calculations and EPID dosimetry can be used to quantitatively verify IMSRT treatments resulting in improved patient care and, potentially, improved clinical outcome. ^

The design and evaluation of a 2D dose verification system for intensity modulated radiotherapy

The usage of intensity modulated radiotherapy (IMRT) treatments necessitates a significant amount of patient-specific quality assurance (QA). This research has investigated the precision and accuracy of Kodak EDR2 film measurements for IMRT verifications, the use of comparisons between 2D dose calculations and measurements to improve treatment plan beam models, and the dosimetric impact of delivery errors. New measurement techniques and software were developed and used clinically at M. D. Anderson Cancer Center. The software implemented two new dose comparison parameters, the 2D normalized agreement test (NAT) and the scalar NAT index. A single-film calibration technique using multileaf collimator (MLC) delivery was developed. EDR2 film's optical density response was found to be sensitive to several factors: radiation time, length of time between exposure and processing, and phantom material. Precision of EDR2 film measurements was found to be better than 1%. For IMRT verification, EDR2 film measurements agreed with ion chamber results to 2%/2mm accuracy for single-beam fluence map verifications and to 5%/2mm for transverse plane measurements of complete plan dose distributions. The same system was used to quantitatively optimize the radiation field offset and MLC transmission beam modeling parameters for Varian MLCs. While scalar dose comparison metrics can work well for optimization purposes, the influence of external parameters on the dose discrepancies must be minimized. The ability of 2D verifications to detect delivery errors was tested with simulated data. The dosimetric characteristics of delivery errors were compared to patient-specific clinical IMRT verifications. For the clinical verifications, the NAT index and percent of pixels failing the gamma index were exponentially distributed and dependent upon the measurement phantom but not the treatment site. Delivery errors affecting all beams in the treatment plan were flagged by the NAT index, although delivery errors impacting only one beam could not be differentiated from routine clinical verification discrepancies. Clinical use of this system will flag outliers, allow physicists to examine their causes, and perhaps improve the level of agreement between radiation dose distribution measurements and calculations. The principles used to design and evaluate this system are extensible to future multidimensional dose measurements and comparisons. ^

Proton therapy versus intensity modulated x-ray therapy in the treatment of prostate cancer: Estimating secondary cancer risks

External beam radiation therapy is used to treat nearly half of the more than 200,000 new cases of prostate cancer diagnosed in the United States each year. During a radiation therapy treatment, healthy tissues in the path of the therapeutic beam are exposed to high doses. In addition, the whole body is exposed to a low-dose bath of unwanted scatter radiation from the pelvis and leakage radiation from the treatment unit. As a result, survivors of radiation therapy for prostate cancer face an elevated risk of developing a radiogenic second cancer. Recently, proton therapy has been shown to reduce the dose delivered by the therapeutic beam to normal tissues during treatment compared to intensity modulated x-ray therapy (IMXT, the current standard of care). However, the magnitude of stray radiation doses from proton therapy, and their impact on this incidence of radiogenic second cancers, was not known. ^ The risk of a radiogenic second cancer following proton therapy for prostate cancer relative to IMXT was determined for 3 patients of large, median, and small anatomical stature. Doses delivered to healthy tissues from the therapeutic beam were obtained from treatment planning system calculations. Stray doses from IMXT were taken from the literature, while stray doses from proton therapy were simulated using a Monte Carlo model of a passive scattering treatment unit and an anthropomorphic phantom. Baseline risk models were taken from the Biological Effects of Ionizing Radiation VII report. A sensitivity analysis was conducted to characterize the uncertainty of risk calculations to uncertainties in the risk model, the relative biological effectiveness (RBE) of neutrons for carcinogenesis, and inter-patient anatomical variations. ^ The risk projections revealed that proton therapy carries a lower risk for radiogenic second cancer incidence following prostate irradiation compared to IMXT. The sensitivity analysis revealed that the results of the risk analysis depended only weakly on uncertainties in the risk model and inter-patient variations. Second cancer risks were sensitive to changes in the RBE of neutrons. However, the findings of the study were qualitatively consistent for all patient sizes and risk models considered, and for all neutron RBE values less than 100. ^

Volumetric Modulated Arc Therapy Evaluation with the Radiological Physics Center Head and Neck Phantom

Validation of treatment plan quality and dose calculation accuracy is essential for new radiotherapy techniques, including volumetric modulated arc therapy (VMAT). VMAT delivers intensity modulated radiotherapy treatments while simultaneously rotating the gantry, adding an additional level of complexity to both the dose calculation and delivery of VMAT treatments compared to static gantry IMRT. The purpose of this project was to compare two VMAT systems, Elekta VMAT and Varian RapidArc, to the current standard of care, IMRT, in terms of both treatment plan quality and dosimetric delivery accuracy using the Radiological Physics Center (RPC) head and neck (H&N) phantom. Clinically relevant treatment plans were created for the phantom using typical prescription and dose constraints for Elekta VMAT (planned with Pinnacle3 Smart Arc) and RapidArc and IMRT (both planned with Eclipse). The treatment plans were evaluated to determine if they were clinically comparable using several dosimetric criteria, including ability to meet dose objectives, hot spots, conformity index, and homogeneity index. The planned treatments were delivered to the phantom and absolute doses and relative dose distributions were measured with thermoluminescent dosimeters (TLDs) and radiochromic film, respectively. The measured and calculated doses of each treatment were compared to determine if they were clinically acceptable based upon RPC criteria of ±7% dose difference and 4 mm distance-to-agreement. Gamma analysis was used to assess dosimetric accuracy, as well. All treatment plans were able to meet the dosimetric objectives set by the RPC and had similar hot spots in the normal tissue. The Elekta VMAT plan was more homogenous but less conformal than the RapidArc and IMRT plans. When comparing the measured and calculated doses, all plans met the RPC ±7%/4 mm criteria. The percent of points passing the gamma analysis for each treatment delivery was acceptable. Treatment plan quality of the Elekta VMAT, RapidArc and IMRT treatments were comparable for consistent dose prescriptions and constraints. Additionally, the dosimetric accuracy of the Elekta VMAT and RapidArc treatments was verified to be within acceptable tolerances.

Constitutive expression of interleukin-6 in renal cell carcinoma is modulated by p53

Several studies indicate that interleukin-6 (IL-6) production is elevated in renal cell carcinoma (RCC) cells, and that IL-6 can serve as an autocrine growth factor in this malignancy. Wild type (wt) p53 represses transcription from the IL-6 promoter in an inducible system. The objective of this study was to determine the role of p53 in regulating constitutive IL-6 production in RCC cells. RCC cell lines containing mutant (mut) p53 produced significantly higher levels of IL-6 than those containing wt p53 (p < 0.05). Transfection of wt p53 into RCC cell lines resulted in significant repression of IL-6 promoter CAT activity p < 0.05). Mutant p53 was less effective at repressing IL-6 promoter activity in ACHN cells, and actually enhanced IL-6 promoter activity in the A498 cell line. A498 cells stably transfected with mutant p53 produced significantly higher levels of IL-6 than A498 cells transfected with an empty expression vector (p < 0.05). Electrophoretic mobility shift assay showed a significant decrease in binding of C/EBP, CREB, and NF-kB transcription factors to the IL-6 promoter in A498 cells transfected with wt p53. Mut p53 was unable to inhibit transcription factor binding to the IL-6 promoter in these cells. Mutant p53-expressing UOK 121LN cells showed decreased binding of C/EBP and CREB, but not NF-kB, following wt p53 transfection. These data suggest that (i) mutation of p53 contributes to the over-expression of IL-6 in RCC; and (ii) wt p53 represses IL-6 expression at least in part by interfering with the binding of C/EBP, CREB, and in some cases, NF-kB transcription factors to the IL-6 promoter. ^

Light-modulated responses of growth and photosynthetic performance to ocean acidification in the model diatom Phaeodactylum tricornutum

Ocean acidification (OA) due to atmospheric CO2 rise is expected to influence marine primary productivity. In order to investigate the interactive effects of OA and light changes on diatoms, we grew Phaeodactylum tricornutum, under ambient (390 ppmv; LC) and elevated CO2 (1000 ppmv; HC) conditions for 80 generations, and measured its physiological performance under different light levels (60 µmol/m**2/s, LL; 200 µmol/m**2/s, ML; 460 µmol/m**2/s, HL) for another 25 generations. The specific growth rate of the HC-grown cells was higher (about 12-18%) than that of the LC-grown ones, with the highest under the ML level. With increasing light levels, the effective photochemical yield of PSII (Fv'/Fm') decreased, but was enhanced by the elevated CO2, especially under the HL level. The cells acclimated to the HC condition showed a higher recovery rate of their photochemical yield of PSII compared to the LC-grown cells. For the HC-grown cells, dissolved inorganic carbon or CO2 levels for half saturation of photosynthesis (K1/2 DIC or K1/2 CO2) increased by 11, 55 and 32%, under the LL, ML and HL levels, reflecting a light dependent down-regulation of carbon concentrating mechanisms (CCMs). The linkage between higher level of the CCMs down-regulation and higher growth rate at ML under OA supports the theory that the saved energy from CCMs down-regulation adds on to enhance the growth of the diatom.

Astronomically modulated Neogene sediment records of ODP Site 184-1148

General global cooling over the Neogene has been modulated by changes in Earth's orbital parameters. Investigations of deep-sea sediment sequences show that various orbital cycles can dominate climate records for different latitudes or for different time intervals. However, a comprehensive understanding of astronomical imprints over the entire Neogene has been elusive because of the general absence of long, continuous records extending beyond the Pliocene. We present benthic foraminiferal d18O and d13C records over the past 23 Ma at Ocean Drilling Program Site 1148 in the northern South China Sea and construct an astronomically tuned timescale (TJ08) for these records based on natural gamma radiation and color reflectance data at this site. Our results show that a 41 ka cycle has dominated sediment records at this location over the Neogene, displaying a linear response to orbital forcing. A 100 ka cycle has also been significant. However, it is correlated nonlinearly with Earth's orbital variations at the 100 ka band. The sediment records also display a prominent 405 ka cycle. Although this cycle was coherent with orbital forcing during the Oligocene and the early Miocene, it was not coherent with Earth's orbital variations at the 405 ka band over the whole Neogene. Amplification of Northern Hemisphere and Southern Hemisphere glaciation since the middle Miocene may be responsible for this change in sedimentary response. Our benthic foraminifera d18O and d13C records further exhibit amplitude variations with longer periods of 600, 1000, 1200, and 2400 ka. Apparently, these cycles are nonlinear responses to insolation forcing.

Influence of Current Pulse Shape on Directly Modulated Systems Performance in Metro Area Optical Networks

Due to the fact that a metro network market is very cost sensitive, direct modulated schemes appear attractive. In this paper a CWDM (Coarse Wavelength Division Multiplexing) system is studied in detail by means of an Optical Communication System Design Software; a detailed study of the modulated current shape (exponential, sine and gaussian) for 2.5 Gb/s CWDM Metropolitan Area Networks is performed to evaluate its tolerance to linear impairments such as signal-to-noise-ratio degradation and dispersion. Point-to-point links are investigated and optimum design parameters are obtained. Through extensive sets of simulation results, it is shown that some of these shape pulses are more tolerant to dispersion when compared with conventional gaussian shape pulses. In order to achieve a low Bit Error Rate (BER), different types of optical transmitters are considered including strongly adiabatic and transient chirp dominated Directly Modulated Lasers (DMLs). We have used fibers with different dispersion characteristics, showing that the system performance depends, strongly, on the chosen DML?fiber couple.

Mixing effect on volume growth of Fagus sylvatica and Pinus sylvestris is modulated by stand density

Despite the increasing relevance of mixed stands due to their potential benefits; little information is available with regard to the effect of mixtures on yield in forest systems. Hence, it is necessary to study inter-specific relationships, and the resulting yield in mixed stands, which may vary with stand development, site or stand density, etc. In Spain, the province of Navarra is considered one of the biodiversity reservoirs; however, mixed forests occupy only a small area, probably as a consequence of management plans, in which there is an excessive focus on the productivity aspect, favoring the presence of pure stands of the most marketable species. The aim of this paper is to study how growth efficiencies of beech (Fagus sylvatica) and pine (Pinus sylvestris) are modified by the admixture of the other species and to determine whether stand density modifies interspecific relationships and to what extent. Two models were fitted from Spanish National Forest Inventory data, for P. sylvestris and F. sylvatica respectively, which relate the growth efficiency of the species, i.e. the volume increment of the species divided by the species proportion by area, with dominant height, quadratic mean diameter, stocking degree, and the species proportions by area of each species. Growth efficiency of pine increased with the admixture of beech, decreasing this positive effect when stocking degree increased. However, the positive effect of pine admixture on beech growth was greater at higher stocking degrees. Growth efficiency of beech was also dependent on stand dominant height, resulting in a net negative mixing effect when stand dominant heights and stocking degrees were simultaneously low. There is a relatively large range of species proportions and stocking degrees which results in transgressive overyielding: higher volume increments in mixed stands than that of the most productive pure pine stands. We concluded that stocking degree is a key factor in between-species interactions, being the effects of mixing not always greater at higher stand densities, but it depends on species composition.

Age-Related Effects in Working Memory Recognition Modulated by Retroactive Interference

One of the main causes for age-related declines in working memory is a higher vulnerability to retroactive interference due to a reduced ability to suppress irrelevant information. However, the underlying neural correlates remain to be established. Magnetoencephalography was used to investigate differential neural patterns in young and older adults performing an interference-based memory task with two experimental conditions, interrupting and distracting, during successful recognition. Behaviorally, both types of retroactive interference significantly impaired accuracy at recognition more in older adults than in young adults with the latter exhibiting greater disruptions by interrupters. Magnetoencephalography revealed the presence of differential age-related neural patterns. Specifically, time-modulated activations in temporo-occipital and superior parietal regions were higher in young adults compared with older adults for the interrupting condition. These results suggest that age-related deficits in inhibitory mechanisms that increase vulnerability to retroactive interference may be associated with neural under-recruitments in a high-interference task.

Fast magnetosonic wave excitation by an array of wires with time-modulated currents

The excitation of Fast Magnetosonic (FMS)waves by a cylindrical array of parallel tethers carrying timemodulated current is discussed. The tethers would fly vertical in the equatorial plane, which is perpendicular to the geomagnetic field when its tilt is ignored, and would be stabilized by the gravity gradient. The tether array would radiate a single FMS wave. In the time-dependent background made of geomagnetic field plus radiated wave, plasma FMS perturbations are excited in the array vicinity through a parametric instability. The growth rate is estimated by truncating the evolution equation for FMS perturbations to the two azimuthal modes of lowest order. Design parameters such as tether length and number, required power and mass are discussed for Low Earth Orbit conditions. The array-attached wave structure would have the radiated wave controlled by the intensity and modulation frequency of the currents, making an active experiment on non-linear low frequency waves possible in real space plasma conditions.

Temporal self-imaging effect for periodically modulated trains of pulses

In this paper, the mathematical description of the temporal selfimaging effect is studied, focusing on the situation in which the train of pulses to be dispersed has been previously periodically modulated in phase and amplitude. It is demonstrated that, for each input pulse and for some specific values of the chromatic dispersion, a subtrain of optical pulses is generated whose envelope is determined by the Discrete Fourier Transform of the modulating coefficients. The mathematical results are confirmed by simulations of various examples and some limits on the realization of the theory are commented.