T staging esophageal tumors with x rays.

With histopathology results typically taking several days, the ability to stage tumors during interventions could provide a step change in various cancer interventions. X-ray technology has advanced significantly in recent years with the introduction of phase-based imaging methods. These have been adapted for use in standard labs rather than specialized facilities such as synchrotrons, and approaches that enable fast 3D scans with conventional x-ray sources have been developed. This opens the possibility to produce 3D images with enhanced soft tissue contrast at a level of detail comparable to histopathology, in times sufficiently short to be compatible with use during surgical interventions. In this paper we discuss the application of one such approach to human esophagi obtained from esophagectomy interventions. We demonstrate that the image quality is sufficiently high to enable tumor T staging based on the x-ray datasets alone. Alongside detection of involved margins with potentially life-saving implications, staging tumors intra-operatively has the potential to change patient pathways, facilitating optimization of therapeutic interventions during the procedure itself. Besides a prospective intra-operative use, the availability of high-quality 3D images of entire esophageal tumors can support histopathological characterization, from enabling "right slice first time" approaches to understanding the histopathology in the full 3D context of the surrounding tumor environment.

Medicine, material science and security: the versatility of the coded-aperture approach.

The principal limitation to the widespread deployment of X-ray phase imaging in a variety of applications is probably versatility. A versatile X-ray phase imaging system must be able to work with polychromatic and non-microfocus sources (for example, those currently used in medical and industrial applications), have physical dimensions sufficiently large to accommodate samples of interest, be insensitive to environmental disturbances (such as vibrations and temperature variations), require only simple system set-up and maintenance, and be able to perform quantitative imaging. The coded-aperture technique, based upon the edge illumination principle, satisfies each of these criteria. To date, we have applied the technique to mammography, materials science, small-animal imaging, non-destructive testing and security. In this paper, we outline the theory of coded-aperture phase imaging and show an example of how the technique may be applied to imaging samples with a practically important scale.

Low-dose phase contrast mammography with conventional x-ray sources.

PURPOSE: To provide an x-ray phase contrast imaging (XPCI) method working with conventional sources that could be readily translated into clinical practice. XPCI shows potential in synchrotron studies but attempts at translating it for use with conventional sources are subject to limitations in terms of field of view, stability, exposure time, and possibly most importantly, delivered dose. METHODS: Following the adaptation of our "edge-illumination" XPCI technique for use with conventional x-ray sources through the use of x-ray masks, the authors have further modified the design of such masks to allow further reducing the dose delivered to the sample without affecting the phase sensitivity of the method. RESULTS: The authors have built a prototype based on the new mask design and used it to image ex vivo breast tissue samples containing malignant lesions. The authors compared images acquired with this prototype to those obtained with a conventional system. The authors demonstrate and quantify image improvements, especially in terms of microcalcification detection. On calcifications detected also by the conventional system, the authors measure contrast increases from five to nine fold; calcifications and other features were also detected which are completely invisible in the conventional image. Dose measurements confirmed that the above enhancements were achieved while delivering doses compatible with clinical practice. CONCLUSIONS: The authors obtained phase-related image enhancements in mammography by means of a system built with components available off-the-shelf that operates under exposure time and dose conditions compatible with clinical practice. This opens the way to a straightforward translation of phase enhanced imaging methods into clinical practice.

X-ray phase-contrast imaging with nanoradian angular resolution.

We present a new quantitative x-ray phase-contrast imaging method based on the edge illumination principle, which allows achieving unprecedented nanoradian sensitivity. The extremely high angular resolution is demonstrated theoretically and through experimental images obtained at two different synchrotron radiation facilities. The results, achieved at both very high and very low x-ray energies, show that this highly sensitive technique can be efficiently exploited over a very broad range of experimental conditions. This method can open the way to new, previously inaccessible scientific applications in various fields including biology, medicine and materials science.

Targeting and retention of HPV16 E7 to the endoplasmic reticulum enhances immune tumour protection.

The endoplasmic reticulum (ER) is where the major histocompatibility complex (MHC) class I molecules are loaded with epitopes to cause an immune cellular response. Most of the protein antigens are degraded in the cytoplasm to amino acids and few epitopes reach the ER. Antigen targeting of this organelle by Calreticulin (CRT) fusion avoids this degradation and enhances the immune response. We constructed a recombinant adenovirus to express the E7 antigen with an ER-targeting signal peptide (SP) plus an ER retention signal (KDEL sequence). In cell-culture experiments we demonstrated that this new E7 antigen, SP-E7-KDEL, targeted the ER. Infection of mice with this recombinant adenovirus that expresses SP-E7-KDEL showed interferon induction and tumour-protection response, similar to that provided by an adenovirus expressing the E7 antigen fused to CRT. This work demonstrated that just by adding a SP and the KDEL sequence, antigens can be targeted and retained in the ER with a consequent enhancement of immune response and tumour protection. These results will have significant clinical applications.

Phase contrast imaging of breast tumours with synchrotron radiation.

Even though the potential of phase contrast (PC) imaging has been demonstrated in a number of biological tissue samples, the availability of free-space propagation phase contrast images of real breast tumours is still limited. The aim of this study was to obtain phase contrast images of two different pathological breast specimens containing tumours of differing morphological type at two synchrotron radiation (SR) facilities, and to assess any qualitative improvements in the evaluation and characterisation of the masses through the use of phase contrast imaging. A second aim was to assess the effects of parameters such as detector resolution, beam energy and sample-to-detector distance on image quality using the same breast specimens, as to date these effects have been modelled and discussed only for geometric phantoms. At each synchrotron radiation facility a range of images was acquired with different detectors and by varying the above parameters. Images of the same samples were also acquired with the absorption-based approach to allow a direct comparison and estimation of the advantages specifically ascribable to the PC technique.

High resolution Ca/P maps of bone architecture in 3D synchrotron radiation microtomographic images.

The Ca/P ratio was measured in cortical bone samples from the femoral neck and tibia of different animal species, using synchrotron radiation microtomography. Use of a monoenergetic X-ray beam, as provided by the synchrotron facility, generates accurate 3D maps of the linear attenuation coefficient within the sample and hence gives the ability to map different chemical components. Also, by comparing normal and abnormal bones, i.e. osteoporotic (induced by inflammation), changes in the Ca/P ratio brought about by bone diseases can be detected. MicroCT data sets were collected at 20 and 28 keV for each bone sample and two calibration phantoms. From the 3D data sets, multiple 2D slices were reconstructed with a slice thickness of approximately 30 microm. Regions of interest were defined around suitable sites and were converted to Ca/P ratios using the data collected from the test phantoms. A significant difference (p<0.001) between osteoporotics and age-matched normals at both energies was detected. Differences between different bone sites from the same animal are not significant (p>0.5) while those between the same bone sites from different animals are highly significant (p<0.001). Differences between estimates made at 20 and 28 keV are not significant (p>0.5). An important aspect is the ability to map the spatial distribution of the Ca/P ratio.

The effects of the imaging system on the validity limits of the ray-optical approach to phase contrast imaging.

A theoretical analysis of the x-ray phase contrast imaging and its validation via synchrotron radiation imaging is here presented. Two different mathematical models have been followed: the simpler ray-optical approach and the more rigorous Fresnel-Kirchoff diffraction theory. Subsequently, the conditions upon which the x-ray optical approximation can be used to describe the image formation mechanism have been analyzed, taking into account also the effects due to the finite source size and detector resolution. It is possible to demonstrate that the ray-optics results can also be obtained by opportunely developing the diffraction formalism only with some restrictions on the spatial frequencies present in the final image, without any limitation on the maximum phase shift. The conditions allowing the use of the simplified ray-optical approach to describe the phase contrast images have been here defined and their validation has been proved by means of computer simulations and phantom experiments.

Signal-to-noise ratio evaluation in dual-energy radiography with synchrotron radiation.

Dual-energy radiography is an effective technique that allows removal of contrast between pairs of materials in order to display details of interest on a uniform background. In mammographic images the detection of small nodules is often impeded by obscuring background 'clutter' resulting from the contrast between normal tissues (glandular and adipose) in their neighbourhood. We consider whether it could be possible to apply dual-energy radiography to the breast, which is hypothetically principally composed of three tissues, glandular, adipose and cancerous, in order to remove the contrast due to the distribution of normal tissues and, as a consequence, to enhance the intrinsic contrast of the pathology. The purpose of this work is to test the limitations of dual-energy radiography on a three-component phantom under optimum conditions of the source and detector. We use a synchrotron monochromatic beam, produced at the ELETTRA synchrotron facility (Trieste, Italy), and an imaging plate detector, in order to acquire two images at low and high energies of a phantom composed of polyethylene, plexiglas and water. For evaluation of the potential of this procedure we studied the signal-to-noise ratio (SNR) of polyethylene and water on a set of images obtained by applying the dual-energy procedure. We found that the SNR of polyethylene and water is around the detectability threshold (according to Rose's criteria) at the contrast cancellation angles. Finally we evaluated the air entrance dose required for this double exposure, resulting in 0.81 mGy for the low-energy image and 0.01 mGy for the high-energy image. To obtain the same image quality for a standard breast of 5.5 cm, mean glandular doses of 3.50 mGy and 0.03 mGy at 17 keV and at 34 keV, respectively, are required.

Preliminary study on extremely small angle x-ray scatter imaging with synchrotron radiation.

Among the medical physics community, there is nowadays a great interest in the possible implementation of scatter imaging techniques, especially in the field of breast imaging. It is well known that malignant lesions and normal tissue differ in their scattering signatures, and thus scattered radiation can provide a powerful tool to distinguish between the two cases. Up to now, most of the proposed techniques rely on the detection of radiation scattered at angles of the order of a few degrees, which in most cases results in very high contrast values. On the other hand, at those relatively large angles the scattered flux is relatively low with respect to the primary, which often implies the necessity of increasing the dose delivered to the sample in order to achieve sufficient statistics. Furthermore, most of these techniques are based on pencil beam set-ups, which results in an increase of the overall duration of the examination. We propose here an alternative approach based on the detection of radiation scattered at extremely small angles, of the order of approximately 100-200 microrad. This results in a relatively high scattered flux (5-10% of the primary) and in the possibility of utilizing a fan beam geometry, which reduces the acquisition times with respect to pencil beam set-ups. Images of several samples have been acquired, demonstrating that the proposed technique results in an increased contrast with respect to absorption imaging. Possible in vivo implementations of the technique at no dose expense are finally discussed.

An innovative digital imaging set-up allowing a low-dose approach to phase contrast applications in the medical field.

Recently, new imaging modalities based on the detection of weak phase perturbations effects, among which are phase contrast and diffraction imaging, have been developed by several researchers. Due to their high sensitivity to weakly absorbing details, these techniques seem to be very promising for applications in the medical field. On the other hand, digital radiology is undergoing a wide diffusion, and its benefits are presently very well understood. Up to now, however, the strong pixel size constraints associated with phase contrast pattern detection limited the possibility of exploiting the advantages of phase contrast in digital radiology applications. In this paper, an innovative setup capable of removing the pixel size constraints, and thus opening the way to low dose digital phase contrast imaging, is described. Furthermore, we introduce an imaging technique based on the detection of radiation scattered at small angles: the information extracted from the sample is increased at no dose expense. We believe that several radiological fields, mammography being the first important example, may benefit from the herein described innovative imaging techniques.

Experimental evaluation of a simple algorithm to enhance the spatial resolution in scanned radiographic systems.

In order to ensure an early diagnosis of breast cancer, an imaging system must fulfil extremely stringent requirements in terms of dynamic range, contrast resolution and spatial resolution. Furthermore, in order to reduce the dose delivered to the patient, a high efficiency of the detector device should be provided. In this paper the SYRMEP/FRONTRAD (SYnchrotron Radiation for MEdical Physics/FRONTier RADiology) mammography project, based on synchroton radiation and a novel solid state pixel detector, is briefly described. Particular relevance is given to the fact that the radiographic image is obtained by means of a scanning technique, which allows the possibility of utilizing a scanning step smaller than the pixel size. With this procedure, a convolution between the real image and the detector point spread function (PSF) is actually acquired: by carefully measuring the detector PSF, it is possible to apply a post-processing procedure (filtered deconvolution), which reconstructs images with enhanced spatial resolution. The image acquisition modality and the deconvolution algorithm are herein described, and some test object images, with spatial resolution enhanced by means of the filtered deconvolution procedure, are presented. As discussed in detail in this paper, this procedure allows us to obtain a spatial resolution determined by the scanning step, rather than by the pixel size.

Mammography with synchrotron radiation: phase-detection techniques.

The authors evaluated the effect on mammographic examinations of the use of synchrotron radiation to detect phase-perturbation effects, which are higher than absorption effects for soft tissue in the energy range of 15-25 keV. Detection of phase-perturbation effects was possible because of the high degree of coherence of synchrotron radiation sources. Synchrotron radiation images were obtained of a mammographic phantom and in vitro breast tissue specimens and compared with conventional mammographic studies. On the basis of grades assigned by three reviewers, image quality of the former was considerably higher, and the delivered dose was fully compatible.

HLA DOA1 and DOB1 loci in Honduran women with cervical dysplasia and invasive cervical carcinoma and their relationship to human papillomavirus infection.

Molecular and epidemiological studies have demonstrated that certain types of human papillomavirus (HPV), mainly HPV-16 and HPV-18, are the primary causes of cervical cancer and its precursor lesions; there is now evidence for a clear association with specific HLA class I and class II loci contributing independently to the expression of cervical cancer. Among Honduran women carcinoma of the cervix is the most common type of cancer, and infections with high-risk HPV types are highly prevalent. To study the interactive role of viral-host genetics, we performed PCR amplification of DNA and sequence-specific oligonucleotide probe typing on cervical scrapes from 49 women [24 with cervical intraepithelial neoplasia stage III or cervical cancer (severe cases) and 25 with stage I or II cervical intraepithelial neoplasia (mild cases)] and 75 control subjects to look for possible associations between HPV and HLA class II DQA1 and DQB1 alleles in the development of dysplasias and invasive cancer. This analysis revealed a predominance of HLA-DQA1*0301 among severe-case patients [relative risk (RR) = 3.45, p = 0.008), whereas DQA1*0501 was negatively associated (RR = 0.30, p = 0.03), suggesting a protective effect of this allele. HPV typing showed a decreased relative risk among the HPV-16 or HPV-18 carrying patients and other HPV-related positive patients in the presence of DQB1*0602 compared with positive control subjects (p = 0.04). No statistically significant allele frequency difference was observed between mild dysplasia cases and control subjects. The results suggest that DQA1*03011, which is in linkage desequilibrium with all HLA-DR4 alleles, confers an increased risk for severe cervical dysplasia and invasive cancer, whereas DQA1*0501, which is in several DR52 haplotypes, has a protective effect. Furthermore, specific HLA-DQB1 sequences may be important in determining the immune response to HPV peptides and may affect the risk for cervical cancer after HPV infection in mestizo Honduran women.

Low-dose phase contrast x-ray medical imaging.

Phase contrast x-ray imaging is a powerful technique for the detection of low-contrast details in weakly absorbing objects. This method is of possible relevance in the field of diagnostic radiology. In fact, imaging low-contrast details within soft tissue does not give satisfactory results in conventional x-ray absorption radiology, mammography being a typical example. Nevertheless, up to now all applications of the phase contrast technique, carried out on thin samples, have required radiation doses substantially higher than those delivered in conventional radiological examinations. To demonstrate the applicability of the method to mammography we produced phase contrast images of objects a few centimetres thick while delivering radiation doses lower than or comparable to doses needed in standard mammographic examinations (typically approximately 1 mGy mean glandular dose (MGD)). We show images of a custom mammographic phantom and of two specimens of human breast tissue obtained at the SYRMEP bending magnet beamline at Elettra, the Trieste synchrotron radiation facility. The introduction of an intensifier screen enabled us to obtain phase contrast images of these thick samples with radiation doses comparable to those used in mammography. Low absorbing details such as 50 microm thick nylon wires or thin calcium deposits (approximately 50 microm) within breast tissue, invisible with conventional techniques, are detected by means of the proposed method. We also find that the use of a bending magnet radiation source relaxes the previously reported requirements on source size for phase contrast imaging. Finally, the consistency of the results has been checked by theoretical simulations carried out for the purposes of this experiment.

Mammography of a phantom and breast tissue with synchrotron radiation and a linear-array silicon detector.

A linear-array, silicon pixel detector, capable of counting single photons, was applied to mammography by using a synchrotron radiation beam. Images were obtained of both a mammographic phantom and a breast-tissue sample. The phantom image was acquired with a mean glandular dose of 0.32 mGy. This detector combined with a synchrotron radiation beam allows acquisition of high-contrast, low-dose images of soft tissues.

A linear array silicon pixel detector: images of a mammographic test object and evaluation of delivered doses.

We present images of a mammographic test object obtained using a linear array silicon pixel detector capable of single-photon counting. The detector pixel size was 200 x 300 microns2 and images were acquired by scanning the test object between the laminar detector and the x-ray source with a scanning step of 100 microns. A molybdenum anode tube was used with two different filtrations: 2 mm aluminium and 25 microns molybdenum. Conventional film-screen images were also obtained in order to compare spatial and contrast resolution. In our digital images it is possible to recognize low-contrast details having dimensions smaller than or equal to the dimensions of details visible by means of a clinical mammographic unit. The detection of microcalcifications smaller than 150 microns was possible only when using the Mo filtration. However a copper wire of 50 microns diameter was detectable when embedded in a simulated tissue. We discuss in detail the mean glandular doses (MGDs) delivered during the image acquisition. The MGDs necessary to obtain good-quality images are always smaller than at a conventional mammographic unit. Since MGDs depend on the x-ray spectrum, the dose reduction becomes larger when the applied spectrum is harder than in film-screen acquisition (Al filtration and 35 kVp).