Lymphatic endothelial transcription factor Tbx1 promotes an immunosuppressive microenvironment to facilitate post-myocardial infarction repair.

The heart is an autoimmune-prone organ. It is crucial for the heart to keep injury-induced autoimmunity in check to avoid autoimmune-mediated inflammatory disease. However, little is known about how injury-induced autoimmunity is constrained in hearts. Here, we reveal an unknown intramyocardial immunosuppressive program driven by Tbx1, a DiGeorge syndrome disease gene that encodes a T-box transcription factor (TF). We found induced profound lymphangiogenic and immunomodulatory gene expression changes in lymphatic endothelial cells (LECs) after myocardial infarction (MI). The activated LECs penetrated the infarcted area and functioned as intramyocardial immune hubs to increase the numbers of tolerogenic dendritic cells (tDCs) and regulatory T (Treg) cells through the chemokine Ccl21 and integrin Icam1, thereby inhibiting the expansion of autoreactive CD8+ T cells and promoting reparative macrophage expansion to facilitate post-MI repair. Mimicking its timing and implementation may be an additional approach to treating autoimmunity-mediated cardiac diseases.

Identification of postnatal development dependent genes and proteins in porcine epididymis.

BACKGROUND: The epididymis is a highly regionalized tubular organ possesses vectorial functions of sperm concentration, maturation, transport, and storage. The epididymis-expressed genes and proteins are characterized by regional and developmental dependent pattern. However, a systematic and comprehensive insight into the postnatal development dependent changes in gene and protein expressions of porcine epididymis is still lacking. Here, the RNA and protein of epididymis of Duroc pigs at different postnatal development stages were extracted by using commercial RNeasy Midi kit and extraction buffer (7 M Urea, 2 M thiourea, 3% CHAPS, and 1 mM PMSF) combined with sonication, respectively, which were further subjected to transcriptomic and proteomic profiling. RESULTS: Transcriptome analysis indicated that 198 and 163 differentially expressed genes (DEGs) were continuously up-regulated and down-regulated along with postnatal development stage changes, respectively. Most of the up-regulated DEGs linked to functions of endoplasmic reticulum and lysosome, while the down-regulated DEGs mainly related to molecular process of extracellular matrix. Moreover, the following key genes INSIG1, PGRMC1, NPC2, GBA, MMP2, MMP14, SFRP1, ELN, WNT-2, COL3A1, and SPARC were highlighted. A total of 49 differentially expressed proteins (DEPs) corresponding to postnatal development stages changes were uncovered by the proteome analysis. Several key proteins ACSL3 and ACADM, VDAC1 and VDAC2, and KNG1, SERPINB1, C3, and TF implicated in fatty acid metabolism, voltage-gated ion channel assembly, and apoptotic and immune processes were emphasized. In the integrative network, the key genes and proteins formed different clusters and showed strong interactions. Additionally, NPC2, COL3A1, C3, and VDAC1 are located at the hub position in each cluster. CONCLUSIONS: The identified postnatal development dependent genes and proteins in the present study will pave the way for shedding light on the molecular basis of porcine epididymis functions and are useful for further studies on the specific regulation mechanisms responsible for epididymal sperm maturation.

Feasibility of using megavoltage computed tomography to reduce proton range uncertainty: A simulation study.

PURPOSE: To demonstrate that variation in chemical composition has a negligible effect on the mapping curve from relative electron density (RED) to proton stopping power ratio (SPR), and to establish the theoretical framework of using Megavoltage (MV) computed tomography (CT), instead of kilovoltage (kV) dual energy CT, to accurately estimate proton SPR. METHODS: A simulation study was performed to evaluate the effect of chemical composition variation on kVCT number and proton SPR. The simulation study involved both reference and simulated human tissues. The reference human tissues, together with their physical densities and chemical compositions, came from the ICRP publication 23. The simulated human tissues were created from the reference human tissues assuming that elemental percentage weight followed a Gaussian distribution. For all tissues, kVCT number and proton SPR were obtained through (a) theoretical calculation from tissue's physical density and chemical composition which served as the ground truth, and (b) estimation from RED using the calibration curves established from the stoichiometric method. Deviations of the estimated values from the calculated values were quantified as errors in using RED to estimate kVCT number and proton SPR. RESULTS: Given a chemical composition variation of 5% (1σ) of the nominal percentage weights, the total estimation error of using RED to estimate kVCT number was 0.34%, 0.62%, and 0.77% and the total estimation error of using RED to estimate proton SPR was 0.30%, 0.22%, and 0.16% for fat tissues, non-fat soft tissues and bone tissues, respectively. CONCLUSION: Chemical composition had a negligible effect on the method of using RED to determine proton SPR. RED itself is sufficient to accurately determine proton SPR. MVCT number maintains a superb linear relationship with RED because it is highly dominated by Compton scattering. Therefore, MVCT has great potential in reducing the proton range uncertainty.

Dosimetric comparison of distal esophageal carcinoma plans for patients treated with small-spot intensity-modulated proton versus volumetric-modulated arc therapies.

BACKGROUND: Esophageal carcinoma is the eighth most common cancer in the world. Volumetric-modulated arc therapy (VMAT) is widely used to treat distal esophageal carcinoma due to high conformality to the target and good sparing of organs at risk (OAR). It is not clear if small-spot intensity-modulated proton therapy (IMPT) demonstrates a dosimetric advantage over VMAT. In this study, we compared dosimetric performance of VMAT and small-spot IMPT for distal esophageal carcinoma in terms of plan quality, plan robustness, and interplay effects. METHODS: 35 distal esophageal carcinoma patients were retrospectively reviewed; 19 patients received small-spot IMPT and the remaining 16 of them received VMAT. Both plans were generated by delivering prescription doses to clinical target volumes (CTVs) on phase-averaged 4D-CT's. The dose-volume-histogram (DVH) band method was used to quantify plan robustness. Software was developed to evaluate interplay effects with randomized starting phases for each field per fraction. DVH indices were compared using Wilcoxon rank-sum test. For fair comparison, all the treatment plans were normalized to have the same CTVhigh D95% in the nominal scenario relative to the prescription dose. RESULTS: In the nominal scenario, small-spot IMPT delivered statistically significantly lower liver Dmean and V30Gy[RBE] , lung Dmean , heart Dmean compared with VMAT. CTVhigh dose homogeneity and protection of other OARs were comparable between the two treatments. In terms of plan robustness, the IMPT and VMAT plans were comparable for kidney V18Gy[RBE] , liver V30Gy[RBE] , stomach V45Gy[RBE] , lung Dmean , V5Gy[RBE] , and V20Gy[RBE] , cord Dmax and D 0.03 c m 3 , liver Dmean , heart V20Gy[RBE] , and V30Gy[RBE] , but IMPT was significantly worse for CTVhigh D95% , D 2 c m 3 , and D5% -D95% , CTVlow D95% , heart Dmean , and V40Gy[RBE] , requiring careful and experienced adjustments during the planning process and robustness considerations. The small-spot IMPT plans still met the standard clinical requirements after interplay effects were considered. CONCLUSIONS: Small-spot IMPT decreases doses to heart, liver, and total lung compared to VMAT as well as achieves clinically acceptable plan robustness. Our study supports the use of small-spot IMPT for the treatment of distal esophageal carcinoma.

Small-spot intensity-modulated proton therapy and volumetric-modulated arc therapies for patients with locally advanced non-small-cell lung cancer: A dosimetric comparative study.

PURPOSE: To compare dosimetric performance of volumetric-modulated arc therapy (VMAT) and small-spot intensity-modulated proton therapy for stage III non-small-cell lung cancer (NSCLC). METHODS AND MATERIALS: A total of 24 NSCLC patients were retrospectively reviewed; 12 patients received intensity-modulated proton therapy (IMPT) and the remaining 12 received VMAT. Both plans were generated by delivering prescription doses to clinical target volumes (CTV) on averaged 4D-CTs. The dose-volume-histograms (DVH) band method was used to quantify plan robustness. Software was developed to evaluate interplay effects with randomized starting phases of each field per fraction. DVH indices were compared using Wilcoxon rank sum test. RESULTS: Compared with VMAT, IMPT delivered significantly lower cord Dmax , heart Dmean , and lung V5 Gy[ RBE ] with comparable CTV dose homogeneity, and protection of other OARs. In terms of plan robustness, the IMPT plans were statistically better than VMAT plans in heart Dmean , but were statistically worse in CTV dose coverage, cord Dmax , lung Dmean , and V5 Gy[ RBE ] . Other DVH indices were comparable. The IMPT plans still met the standard clinical requirements with interplay effects considered. CONCLUSIONS: Small-spot IMPT improves cord, heart, and lung sparing compared to VMAT and achieves clinically acceptable plan robustness at least for the patients included in this study with motion amplitude less than 11 mm. Our study supports the usage of IMPT to treat some lung cancer patients.

Use of a radial projection to reduce the statistical uncertainty of spot lateral profiles generated by Monte Carlo simulation.

Monte Carlo (MC) simulation has been used to generate commissioning data for the beam modeling of treatment planning system (TPS). We have developed a method called radial projection (RP) for postprocessing of MC-simulation-generated data. We used the RP method to reduce the statistical uncertainty of the lateral profile of proton pencil beams with axial symmetry. The RP method takes advantage of the axial symmetry of dose distribution to use the mean value of multiple independent scores as the representative score. Using the mean as the representative value rather than any individual score results in substantial reduction in statistical uncertainty. Herein, we present the concept and step-by-step implementation of the RP method, as well as show the advantage of the RP method over conventional measurement methods for generating lateral profile. Lateral profiles generated by both methods were compared to demonstrate the uncertainty reduction qualitatively, and standard error comparison was performed to demonstrate the reduction quantitatively. The comparisons showed that statistical uncertainty was reduced substantially by the RP method. Using the RP method to postprocess MC data, the corresponding MC simulation time was reduced by a factor of 10 without quality reduction in the generated result from the MC data. We concluded that the RP method is an effective technique to increase MC simulation efficiency for generating lateral profiles for axially symmetric pencil beams.

Exploratory study of the association of volumetric modulated arc therapy (VMAT) plan robustness with local failure in head and neck cancer.

This work is to show which is more relevant to cause local failures (LFs) due to patient setup uncertainty between the planning target volume (PTV) underdosage and the potential target underdosage subject to patient setup uncertainties in head and neck (H&N) cancer treated with volumetric-modulated arc therapy (VMAT). Thirteen LFs in 10 H&N patients treated by VMAT were analyzed. Measures have been taken to minimize the chances of insufficient target delineation for these patients and the patients were clinically determined to have LF based on the PET/CT scan results by an experienced radiologist and then reviewed by a second experienced radiation oncologist. Two methods were used to identify the possible locations of LF due to underdosage: (a) examining the standard VMAT plan, in which the underdosed volume in the nominal dose distribution (UVN) was generated by subtracting the volumes receiving the prescription doses from PTVs, and (b) plan robustness analysis, in which in addition to the nominal dose distribution, six perturbed dose distributions were created by translating the CT iso-center in three cardinal directions by the PTV margin. The coldest dose distribution was represented by the minimum of the seven doses in each voxel. The underdosed volume in the coldest dose distribution (UVC) was generated by subtracting the volumes receiving the prescription doses in the coldest dose distribution from the volumes receiving the prescription doses in the nominal dose distribution. UVN and UVC were subsequently examined for spatial association with the locations of LF. The association was tested using the binominal distribution and the Fisher's exact test of independence. We found that of 13 LFs, 11 were associated with UVCs (P = 0.011), while three were associated with UVNs (P = 0.99). We concluded that the possible target underdosage due to patient setup uncertainties appeared to be a more relevant factor associated with LF in VMAT for H&N cancer than the compromised PTV coverage at least for the patients included in this study.

Daily QA in proton therapy using a single commercially available detector.

We present here a novel method for using a single device in the daily quality assur- ance (QA) of pencil beam scanning (PBS) proton beams and an improved method for uniform scanning (US). The device can be used to measure the spot position, spot sigma, range, output, collinearity of the X-ray system and proton beam, and to QA the first scatterers and a number of other imaging and mechanical checks. We have performed the daily QA according to this procedure for more than six months in both a PBS gantry and a US gantry. All of the tests were found to be sensitive and accurate enough to determine if the property being tested is within the tolerance. The output has remained within the ± 2% tolerance, with the majority of measurements within ± 1%, and the range was within ± 0.5 mm. The collinearity of the proton beam in both gantries is within the ± 1 mm tolerance in both X and Y directions for all measurements. A novel procedure to measure the functionality of the first scatterers in the US gantry is included in the QA procedure. It was found to be sensitive enough to pick up the thinnest scatterer of 0.6 mm in both possible failure methods - when it always remains in the beam or in the case when it never goes into the beam. The daily QA procedure presented here can be implemented at PBS or US proton therapy centers with a minimal outlay for equipment and setup time. The procedure can be performed in less than 30 min, and has been found to be accurate and reliable enough for the QA of a proton therapy gantry before patient treatment every day. 

A novel daily QA system for proton therapy.

We describe the design and use of a daily quality assurance (QA) system for proton therapy. The QA system is designed to check the overall readiness of proton therapy system consistently within certain reference tolerances by a home-made QA device (the QA device). The QA device is comprised of a commercially available QA device, rf-Daily QA 3, a home-made acrylic phantom, a set of acrylic compensators with various thicknesses, and a mechanical indexing jig. The indexing jig indexes the rf-Daily QA 3, as well as the acrylic phantom, onto the patient treatment couch. Embedded fiducial markers in the acrylic phantom are used to check X-ray image quality and positioning alignment accuracy of the imaging system. The rf-Daily QA 3 is used to check proton beam output, range and symmetry with one single beam delivery. We developed in-house software to calculate beam range and symmetry, based on various ion chambers' readings inside the rf-Daily QA 3. With a single setup and one beam irradiation, the QA system is employed to check couch movement, laser alignment, image registration, and reference proton beam characteristics. The simplicity and robustness of this QA system allows for a total QA time of less than 20 minutes per room. The system has been in use at three proton therapy centers since June 2009.

House ammonia exposure causes alterations in microbiota, transcriptome, and metabolome of rabbits.

Introduction: Pollutant gas emissions in the current production system of the livestock industry have negative influences on environment as well as the health of farm staffs and animals. Although ammonia (NH3) is considered as the primary and harmful gas pollutant in the rabbit farm, less investigation has performed to determine the toxic effects of house ammonia exposure on rabbit in the commercial confined barn. Methods: In this study, we performed multi-omics analysis on rabbits exposed to high and low concentration of house ammonia under similar environmental conditions to unravel the alterations in nasal and colonic microbiota, pulmonary and colonic gene expression, and muscular metabolic profile. Results and discussion: The results showed that house ammonia exposure notably affected microbial structure, composition, and functional capacity in both nasal and colon, which may impact on local immune responses and inflammatory processes. Transcriptome analysis indicated that genes related to cell death (MCL1, TMBIM6, HSPB1, and CD74) and immune response (CDC42, LAMTOR5, VAMP8, and CTSB) were differentially expressed in the lung, and colonic genes associated with redox state (CAT, SELENBP1, GLUD1, and ALDH1A1) were significantly up-regulated. Several key differentially abundant metabolites such as L-glutamic acid, L-glutamine, L-ornithine, oxoglutaric acid, and isocitric acid were identified in muscle metabolome, which could denote house ammonia exposure perturbed amino acids, nucleotides, and energy metabolism. In addition, the widespread and strong inter-system interplay were uncovered in the integrative correlation network, and central features were confirmed by in vitro experiments. Our findings disclose the comprehensive evidence for the deleterious effects of house ammonia exposure on rabbit and provide valuable information for understanding the underlying impairment mechanisms.

Seasonal Variations in Production Performance, Health Status, and Gut Microbiota of Meat Rabbit Reared in Semi-Confined Conditions.

In this study, we investigated the variations in production performance, health status, and gut microbiota of meat rabbits raised in the semi-confined barn during summer and winter. Compared to summer, rabbits reared in winter possessed significantly higher slaughter weight and carcass weight. Rabbits fed in the summer were more vulnerable to different stressors, which led to increased protein levels of HSP90, IL-1α, IL-1ß, IL-2, and concentrations of MDA, but declined GSH and SOD activities. Additionally, significant differences in gut microbial communities were observed. Compared to the winter, rabbits fed in the summer had significantly lower and higher alpha and beta diversity. Both Firmicutes and Verrucomicrobiota were the dominant phyla, and they accounted for greater proportions in the winter than in the summer. At lower microbial taxa levels, several seasonal differentially enriched microbes were identified, such as Akkermansia muciniphila, the Oscillospiraceae NK4A214 group, the Christensenellaceae R-7 group, Alistipes, and Muribaculaceae. Functional capacities linked to microbial proliferation, nutrient metabolism, and environmental adaptive responses exhibited significantly different abundances between summer and winter. Moreover, strong interactions among different indicators were presented. Based on our findings, we not only proposed several potential strategies to ameliorate the undesirable effects of seasonal changes on the productivity and health of meat rabbits but also underscored the directions for future mechanistic studies of adaptation physiology.

Identification and validation of hub genes involved in foam cell formation and atherosclerosis development via bioinformatics.

Background: Foam cells play crucial roles in all phases of atherosclerosis. However, until now, the specific mechanisms by which these foam cells contribute to atherosclerosis remain unclear. We aimed to identify novel foam cell biomarkers and interventional targets for atherosclerosis, characterizing their potential mechanisms in the progression of atherosclerosis. Methods: Microarray data of atherosclerosis and foam cells were downloaded from the Gene Expression Omnibus (GEO) database. Differentially expression genes (DEGs) were screened using the "LIMMA" package in R software. The Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis and Gene Ontology (GO) annotation were both carried out. Hub genes were found in Cytoscape after a protein-protein interaction (PPI) enrichment analysis was carried out. Validation of important genes in the GSE41571 dataset, cellular assays, and tissue samples. Results: A total of 407 DEGs in atherosclerosis and 219 DEGs in foam cells were identified, and the DEGs in atherosclerosis were mainly involved in cell proliferation and differentiation. CSF1R and PLAUR were identified as common hub genes and validated in GSE41571. In addition, we also found that the expression of CSF1R and PLAUR gradually increased with the accumulation of lipids and disease progression in cell and tissue experiments. Conclusion: CSF1R and PLAUR are key hub genes of foam cells and may play an important role in the biological process of atherosclerosis. These results advance our understanding of the mechanism behind atherosclerosis and potential therapeutic targets for future development.

Commissioning of output factors for uniform scanning proton beams.

PURPOSE: Current commercial treatment planning systems are not able to accurately predict output factors and calculate monitor units for proton fields. Patient-specific field output factors are thus determined by either measurements or empirical modeling based on commissioning data. The objective of this study is to commission output factors for uniform scanning beams utilized at the ProCure proton therapy centers. METHODS: Using water phantoms and a plane parallel ionization chamber, the authors first measured output factors with a fixed 10 cm diameter aperture as a function of proton range and modulation width for clinically available proton beams with ranges between 4 and 31.5 cm and modulation widths between 2 and 15 cm. The authors then measured the output factor as a function of collimated field size at various calibration depths for proton beams of various ranges and modulation widths. The authors further examined the dependence of the output factor on the scanning area (i.e., uncollimated proton field), snout position, and phantom material. An empirical model was developed to calculate the output factor for patient-specific fields and the model-predicted output factors were compared to measurements. RESULTS: The output factor increased with proton range and field size, and decreased with modulation width. The scanning area and snout position have a small but non-negligible effect on the output factors. The predicted output factors based on the empirical modeling agreed within 2% of measurements for all prostate treatment fields and within 3% for 98.5% of all treatment fields. CONCLUSIONS: Comprehensive measurements at a large subset of available beam conditions are needed to commission output factors for proton therapy beams. The empirical modeling agrees well with the measured output factor data. This investigation indicates that it is possible to accurately predict output factors and thus eliminate or reduce time-consuming patient-specific output measurements for proton treatments.

Technical Note: Clinical modeling and validation of breast tissue expander metallic ports in a commercial treatment planning system for proton therapy.

PURPOSE: To validate breast tissue expander metallic port (MP) models in a commercial treatment planning system (TPS) in proton pencil beam scanning (PBS) treatments for breast cancer patients with breast tissue expanders. METHODS AND MATERIALS: Three types of MPs taken out of a Mentor CPX4, a Natrelle 133, and a PMT Integra breast tissue expanders and a 650 cc saline filled Mentor CPX4 expander were placed on top of acrylic slabs, and scanned using a Siemens Somatom Definition AS Open RT CT scanner. Structure templates for each of the MPs were designed within Eclipse TPS. The CT numbers for the metallic parts were overridden to reflect measured or calculated relative proton stopping powers (RPSPs). Mock targets were contoured in acrylic to represent postmastectomy chest-wall radiation therapy (PMRT) targets. Plans with different beam incident angles were optimized using the Eclipse TPS to deliver uniform prescription dose to the target using Hitachi Probeat-V PBS beams. Eclipse calculated doses and an in-house Monte Carlo (MC) code calculated doses were compared to the measured Gafchromic EBT3 film doses in acrylic. RESULTS: TPS/MC and film dose comparison results showed that (1) 3%/2 mm/10% threshold Gamma pass rates were better than 90.8% in the acrylic target region for all plans; (2) comparing TPS and film doses for the individual beam plans in the MP dose shadow areas, the area with dose difference above 5% ([ΔA] 5%) ranged from 1.1 to 5.0 cm2 , and the maximum dose difference ([ΔD] 0.01 cm2 ) ranged from 12.5% to 25.0%; (3) comparing MC and film doses for the individual beam plans in the MP dose shadow areas, the (ΔA) 5% varied from 1.1 to 2.9 cm2 and (ΔD) 0.01 cm2 varied from 8.5% to 24.2%; (4) for a plan composed of three individual beams treating through the Mentor CPX4 expander, the TPS (ΔA) 5% was less than 0.13 cm2 , and the (ΔD) 0.01 cm2 was less than 6% in the MP dose shadow areas. CONCLUSIONS: It is feasible to treat patients with tissue expanders using multiple PBS beams using a structure template with CT number overridden to represent the measured/calculated RPSP for MPs for PBS treatment planning. MC dose was more accurate than analytical dose in the areas with high dose gradient caused by the density heterogeneity of the breast tissue expander MPs.

Technical Note: Long-term monitoring of diode sensitivity degradation induced by proton irradiation.

PURPOSE: To measure diode sensitivity degradation (DSD) induced by cumulative proton dose delivered to a commercial daily quality assurance (QA) device. METHODS: At our institution, six Daily QA 3 (DQA3, Sun Nuclear Corporation, Melbourne, FL, USA) devices have been used for daily proton pencil beam scanning QA in four proton gantry rooms over a span of 4 years. DQA3 diode counts were cross-calibrated using a homogenous field with a known dose of 1 Gy. The DSD rate (ΔR%/100 Gy) was calculated using linear regression on time-series plots of diode counts and an estimate of cumulative dose per year based on the cross-calibration. The effect of DSD on daily QA spot position measurements was quantified by converting DSD to baseline spot position shift. RESULTS: The average dose delivered to the four inner DQA3 diodes was 104 ± 5 Gy/year, and the rate of DSD was -5.1% ± 1.0/100 Gy with the exception of one DQA3 device that had a significantly higher rate of DSD (-12%/100 Gy). The R2 s of the linear fit to time-series plots were between 0.92 and 0.98. The DSD rates were not constant but decreases with accumulated doses. The four center diodes, which received 40% of the cumulative dose received by inner diodes, had a DSD rate of -7.2% ± 0.9/100 Gy. For our daily QA program, 1 year of DSD was equivalent to a 0.2 mm shift in spot position. CONCLUSIONS: The DSD rate of DQA3 diodes determined by long-term proton daily QA data was about -5%/100 Gy, which is more than 10 times greater than the reported DSD rate from photon irradiation. DQA3 diodes may be used for daily proton QA programs, provided that they are recalibrated at an appropriate frequency that should be determined specifically for different daily QA programs.

Technical Note: Multiple energy extraction techniques for synchrotron-based proton delivery systems may exacerbate motion interplay effects in lung cancer treatments.

PURPOSE: The multiple energy extraction (MEE) delivery technique for synchrotron-based proton delivery systems reduces beam delivery time by decelerating the beam multiple times during one accelerator spill, but this might cause additional plan quality degradation due to intrafractional motion. We seek to determine whether MEE causes significantly different plan quality degradation compared to single energy extraction (SEE) for lung cancer treatments due to the interplay effect. METHODS: Ten lung cancer patients treated with IMPT at our institution were nonrandomly sampled based on a representative range of tumor motion amplitudes, tumor volumes, and respiratory periods. Dose-volume histogram (DVH) indices from single-fraction SEE and MEE four-dimensional (4D) dynamic dose distributions were compared using the Wilcoxon signed-rank test. Distributions of monitor units (MU) to breathing phases were investigated for features associated with plan quality degradation. SEE and MEE DVH indices were compared in fractionated deliveries of the worst-case patient treatment scenario to evaluate the impact of fractionation. RESULTS: There were no clinically significant differences in target mean dose, target dose conformity, or dose to organs-at-risk between SEE and MEE in single-fraction delivery. Three patients had significantly worse dose homogeneity with MEE compared to SEE (single-fraction mean D5% -D95% increased by up to 9.6% of prescription dose), and plots of MU distribution to breathing phases showed synchronization patterns with MEE but not SEE. However, after 30 fractions the patient in the worst-case scenario had clinically acceptable target dose homogeneity and coverage with MEE (mean D5% -D95% increased by 1% compared to SEE). CONCLUSIONS: For some patients with breathing periods close to the mean spill duration, MEE resulted in significantly worse single-fraction target dose homogeneity compared to SEE due to the interplay effect. However, this was mitigated by fractionation, and target dose homogeneity and coverage were clinically acceptable after 30 fractions with MEE.

Neonatal Heart Responds to Pressure Overload With Differential Alterations in Various Cardiomyocyte Maturation Programs That Accommodate Simultaneous Hypertrophy and Hyperplasia.

Pressure overload is one of the pathophysiological conditions commonly associated with right-sided congenital heart disease (CHD). Patients suffer from this condition right after birth. However, little is known about how neonatal heart reacts to it. We have previously established a pulmonary artery banding (PAB) model in neonatal rat. Here we show that PAB accelerated transition of mononuclear cardiomyocytes into multinucleated cells to promote hypertrophic growth in neonatal heart. The elevated afterload significantly increased the mitotic activities of neonatal cardiomyocytes. Consistent with the proliferative potential, the elevated pressure overload also increased cytokinetic marker counts of cardiomyocytes. Using cardiomyocyte-specific lineage tracing, we noticed a clonal expansion of rare unlabeled cardiomyocytes in the PAB group, revealing a subgroup of cardiomyocytes with a strong capability of proliferation. In addition, PAB hearts at post-banding day 7 didn't have the accumulation of macrophages, which is an immune response essential for neonatal heart regeneration in injury models. Transcriptomic analyses revealed that neonatal PAB induced an expression profile featuring both cardiomyocyte hypertrophy, such as highly activated translation, oxidative phosphorylation, and mitochondrial biogenesis programs etc., and immature cardiomyocyte, such as enhanced cell cycle activities and glycolytic metabolism, down-regulated cytoskeleton and ion channel gene expression, and maintenance of fetal-specific sarcomeric isoforms etc. It indicates that pressure overload has differential impacts on various cardiomyocyte maturation (CM) programs that may contribute to the concurrent cardiomyocyte hypertrophy and hyperplasia. The bivalent status of transcriptional profile highlights the plasticity of neonatal cardiomyocytes that can be exploited to adapt the postnatal environment.

Hybrid 3D analytical linear energy transfer calculation algorithm based on precalculated data from Monte Carlo simulations.

PURPOSE: The dose-averaged linear energy transfer (LETd ) for intensity-modulated proton therapy (IMPT) calculated by one-dimensional (1D) analytical models deviates from more accurate but time-consuming Monte Carlo (MC) simulations. We developed a fast hybrid three-dimensional (3D) analytical LETd calculation that is more accurate than 1D analytical model. METHODS: We used the Geant4 MC code to generate 3D LETd distributions of monoenergetic proton beams in water for all energies and used a customized error function to fit the LETd lateral profiles at various depths to the MC simulation. The 3D LETd calculation kernel was a lookup table of these fitted coefficients, and LETd was determined directly from spot energies and voxel coordinates during analytical dose calculations. We validated our new method by comparing the calculated LETd distributions to MC results using 3D Gamma index analysis with 3%/2 mm criteria in 12 patient geometries. The significance of the improvement in Gamma index analysis passing rates over the 1D analytical model was determined using the Wilcoxon rank-sum test. RESULTS: The passing rate of 3D Gamma analysis comparing LETd distributions from the hybrid 3D method and the 1D method to MC simulations was significantly improved from 94.0% ± 2.5% to 98.0% ± 1.0% (P = 0.0003). The typical time to calculate dose and LETd simultaneously using an Intel Xeon E5-2680 2.50 GHz workstation was approximately 2.5 min. CONCLUSIONS: Our new method significantly improved the LETd calculation accuracy compared to the 1D method while maintaining significantly shorter calculation time even comparing with the GPU-based fast MC code.

Technical Note: Integrating an open source Monte Carlo code "MCsquare" for clinical use in intensity-modulated proton therapy.

PURPOSE: To commission an open source Monte Carlo (MC) dose engine, "MCsquare" for a synchrotron-based proton machine, integrate it into our in-house C++-based I/O user interface and our web-based software platform, expand its functionalities, and improve calculation efficiency for intensity-modulated proton therapy (IMPT). METHODS: We commissioned MCsquare using a double Gaussian beam model based on in-air lateral profiles, integrated depth dose of 97 beam energies, and measurements of various spread-out Bragg peaks (SOBPs). Then we integrated MCsquare into our C++-based dose calculation code and web-based second check platform "DOSeCHECK." We validated the commissioned MCsquare based on 12 different patient geometries and compared the dose calculation with a well-benchmarked GPU-accelerated MC (gMC) dose engine. We further improved the MCsquare efficiency by employing the computed tomography (CT) resampling approach. We also expanded its functionality by adding a linear energy transfer (LET)-related model-dependent biological dose calculation. RESULTS: Differences between MCsquare calculations and SOBP measurements were <2.5% (<1.5% for ~85% of measurements) in water. The dose distributions calculated using MCsquare agreed well with the results calculated using gMC in patient geometries. The average 3D gamma analysis (2%/2 mm) passing rates comparing MCsquare and gMC calculations in the 12 patient geometries were 98.0 ± 1.0%. The computation time to calculate one IMPT plan in patients' geometries using an inexpensive CPU workstation (Intel Xeon E5-2680 2.50 GHz) was 2.3 ± 1.8 min after the variable resolution technique was adopted. All calculations except for one craniospinal patient were finished within 3.5 min. CONCLUSIONS: MCsquare was successfully commissioned for a synchrotron-based proton beam therapy delivery system and integrated into our web-based second check platform. After adopting CT resampling and implementing LET model-dependent biological dose calculation capabilities, MCsquare will be sufficiently efficient and powerful to achieve Monte Carlo-based and LET-guided robust optimization in IMPT, which will be done in the future studies.

Robust Optimization for Intensity Modulated Proton Therapy to Redistribute High Linear Energy Transfer from Nearby Critical Organs to Tumors in Head and Neck Cancer.

PURPOSE: We propose linear energy transfer (LET)-guided robust optimization in intensity modulated proton therapy for head and neck cancer. This method simultaneously considers LET and physical dose distributions of tumors and organs at risk (OARs) with uncertainties. METHODS AND MATERIALS: Fourteen patients with head and neck cancer were included in this retrospective study. Cord, brain stem, brain, and oral cavity were considered. Two algorithms, voxel-wise worst-case robust optimization and LET-guided robust optimization (LETRO), were used to generate intensity modulated proton therapy plans for each patient. The latter method directly optimized LET distributions rather than indirectly as in previous methods. LET-volume histograms (LETVHs) were generated, and high LET was redistributed from nearby OARs to tumors in a user-defined way via LET-volume constraints. Dose-volume histogram indices, such as clinical target volume (CTV) D98% and D2%-D98%, cord Dmax, brain stem Dmax, brain Dmax, and oral cavity Dmean, were calculated. Plan robustness was quantified using the worst-case analysis method. LETVH indices analogous to dose-volume histogram indices were used to characterize LET distributions. The Wilcoxon signed rank test was performed to measure statistical significance. RESULTS: In the nominal scenario, LETRO provided higher LET distributions in the CTV (unit: keV/µm; CTV LET98%: 1.18 vs 1.08, LETRO vs RO, P = .0031) while preserving comparable physical dose and plan robustness. LETRO achieved significantly reduced LET distributions in the cord, brain stem, and oral cavity compared with RO (cord LETmax: 7.20 vs 8.20, P = .0010; brain stem LETmax: 10.95 vs 12.05, P = .0007; oral cavity LETmean: 2.11 vs 3.12, P = .0052) and had comparable physical dose and plan robustness in all OARs. In the worst-case scenario, LETRO achieved significantly higher LETmean in the CTV, reduced LETmax in the brain, and was comparable to other LETVH indices (CTV LETmean: 3.26 vs 3.35, P = .0012; brain LETmax: 24.80 vs 22.00, P = .0016). CONCLUSIONS: LETRO robustly optimized LET and physical dose distributions simultaneously. It redistributed high LET from OARs to targets with slightly modified physical dose and plan robustness.