Single-center, retrospective study on changes in pain-relieving therapy after bone metastasis detection by bone scintigraphy in prostate cancer patients

Abstract Whole-body bone scintigraphy (WB-BS) is used for detecting and monitoring metastatic spread of prostate cancer (PCa) and to investigate bone pain episodes. To investigate the impact of a positive WB-BS on pain-relieving medicine prescription in PCa patients, a single-center, retrospective cohort study with PCa patients classified as positive for bone metastases (BM) by WB-BS was conducted. Demographic, clinical, and ambulatory pain-relieving medicine prescription data were evaluated. Pain-relieving medicines were categorized according to the WHO 'Analgesic Ladder'. Regimens adopted before and after WB-BS were compared. Differences were considered significant at p<0.05. A total of 180 PCa patients were diagnosed with BM, 64.4% of whom were ≥65 years of age. Thirty-three patients were prescribed analgesics only after WB-BS, mostly including NSAIDs and weak opioids. Pain-relieving prescription changed after WB-BS in patients with prescriptions before and after WB-BS, with a reduction in NSAIDs and adjuvants and an increase in weak and strong opioids. In addition, 40% of patients with WHO analgesic step 1 drugs and 21.7% of patients with WHO step 2 drugs before WB-BS changed to other WHO steps after WB-BS. Pain-relieving prescriptions changed after a positive WB-BS, providing evidence that it could contribute to clinical management of painful metastatic PCa patients.

SiPM-based gamma detector with a central GRIN lens for a visible/NIRF/gamma multi-modal laparoscope.

Intraoperative imaging has been studied using conventional devices such as near infrared (NIR) optical probes and gamma probes. However, these devices have limited depth penetration and spatial resolution. In a previous study, we realized a multi-modal endoscopic system. However, charge-coupled device (CCD)-based gamma imaging required long acquisition times and lacked gamma energy information. A silicon photomultiplier (SiPM)-based gamma detector is implemented in a multi-modal laparoscope herein. A gradient index (GRIN) lens and CCD are used to transfer and readout visible and NIR photons. The feasibility of in-vivo sentinel lymph node (SLN) mapping was successfully performed with the proposed system.

Stereoscopic portable hybrid gamma imaging for source depth estimation.

Advances in gamma imaging technology mean that is now technologically feasible to conduct stereoscopic gamma imaging in a hand-held unit. This paper derives an analytical model for stereoscopic pinhole imaging which can be used to predict performance for a wide range of camera configurations. Investigation of this concept through Monte Carlo and benchtop studies, for an example configuration, shows camera-source distance measurements with a mean deviation between calculated and actual distances of <5 mm for imaging distances of 50-250 mm. By combining this technique with stereoscopic optical imaging, we are then able to calculate the depth of a radioisotope source beneath a surface without any external positional tracking. This new hybrid technique has the potential to improve surgical localisation in procedures such as sentinel lymph node biopsy.

Energy and electron drift time measurements in a pixel CCI TlBr detector with 1.3 MeV prompt-gammas.

Assessing the position of the Bragg peak (BP) in hadron radiotherapy utilizing prompt-gamma imaging (PGI) presents many challenges in terms of detector physics. Gamma detectors with the capability of extracting the best energy, timing, and spatial information from each gamma interaction, as well as with high detection efficiency and count rate performance, are needed for this application. In this work we present the characterization of a pixel Cerenkov charge induction (CCI) thallium bromide (TlBr) detector in terms of energy and and electron drift time for its potential use in PGI. The CCI TlBr detector had dimensions of 4 × 4 × 5 mm3 and one of its electrodes was segmented in pixels with 1.7 mm pitch. A silicon photomultiplier (SiPM) was optically coupled to one of the faces of the TlBr slab to read out the Cerenkov light promptly emitted after the interaction of a gamma ray. The detector was operated stand-alone and the 1.275 prompt gammas from a 22Na radioactive source were used for the study. The electron drift time was obtained by combining the Cerenkov and charge induction signals and then used as a measure of the depth of interaction. The electron mobility in TlBr was estimated as ∼27 cm2 V-1 s-1. Energy resolutions between 3.4% and 4.0% at 1.275 MeV were obtained after depth-correction. These values improved to 3.0%-3.3% when events with drift times of 3-6 µs were selected. These results show the potential of pixel CCI TlBr detectors to resolve gamma interactions in the detector with mm-like accuracy in 3D and with excellent energy resolution. Previous studies with CCI TlBr devices have shown a timing resolution of <400 ps full width at half maximum when detecting 511 keV gamma rays, therefore, the timing accuracy is expected to improve with the increased energy of the gamma rays in PGI. While other important detector characteristics such as count rate capability remain to be studied, results from this work combined with other preliminary data show pixel CCI detectors can simultaneously provide excellent energy, timing, and spatial resolution performance and are a very promising option for PGI in hadron therapy.

Selective Neck Dissection Guided by a Radioactive I125 Seed for Papillary Thyroid Carcinoma Recurrence. / Disección cervical radioguiada con semillas de I125 como tratamiento de la recurrencia de cáncer papilar de tiroides.

Lymph nodes are the most common place of recurrence of papillary thyroid cancer, and surgery can be considered a therapeutic option. The risks of surgery increase with every intervention. We present 3 cases of cervical non palpable thyroid cancer recurrence managed with I125 seed radioguided cervical dissection from 2017 to 2019. Two of the cases had already a thyroidectomy and central compartment lymphadenectomy performed. The seed was placed guided by US on the lesion and its position was confirmed afterwards. The target was successfully localized in 100% of cases. There was no post surgery complications. There was no evidence of recurrence with a mean follow up of 15 months. Radioguided surgery using I125 seed it is a save technique and it offers a precise localization of the non palpable thyroid cancer recurrence.

Computational model for detector timing effects in Compton-camera based prompt-gamma imaging for proton radiotherapy.

This paper describes a realistic simulation of a Compton-camera (CC) based prompt-gamma (PG) imaging system for proton range verification for a range of clinical dose rates, and its comparison to PG measured data with a pre-clinical CC. We used a Monte Carlo plus Detector Effects (MCDE) model to simulate the production of prompt gamma-rays (PG) and their energy depositions in the CC. With Monte Carlo, we simulated PG emission resulting from irradiation of a high density polyethylene phantom with a 150 MeV proton pencil beam at dose rates of 5.0 × 108, 2.6 × 109, and 4.6 × 109 p+ s-1. Realistic detector timing effects (e.g. delayed triggering time, event-coincidence, dead time, etc,) were added in post-processing to allow for flexible count rate variations. We acquired PG emission measurements with our pre-clinical CC during irradiation with a clinical 150 MeV proton pencil beam at the same dose rates. For simulations and measurements, three primary changes could be seen in the PG emission data as the dose rate increased: (1) reduction in the total number of detected events due to increased dead-time percentage; (2) increase in false-coincidence events (i.e. multiple PGs interacting, rather than a single PG scatter); and (3) loss of distinct PG emission peaks in the energy spectrum. We used the MCDE model to estimate the quality of our measured PG data, primarily with regards to true and false double-scatters and triple-scatters recorded by the CC. The simulation results showed that of the recorded double-scatter PG interactions 22%, 57%, and 70% were false double-scatters and for triple-scatter interactions 3%, 21%, and 35% were false events at 5.0 × 108, 2.6 × 109, and 4.6 × 109 p+ s-1, respectively. These false scatter events represent noise in the data, and the high percentage of these events in the data represents a major limitation in our ability to produce usable PG images with our prototype CC.

Comparison of Radio-guided Occult Lesion Localization (ROLL) and Magnetic Occult Lesion Localization (MOLL) for Non-palpable Lesions: A Phantom Model Study.

BACKGROUND: Localization of nonpalpable breast cancers can be achieved with several techniques. We sought to compare radio-guided localization (ROLL) and magnetic tracer localization (MOLL) techniques by using a phantom model we previously developed, which can provide an accurate simulation for excision of nonpalpable breast lesions. MATERIALS AND METHODS: We designed 20 phantom models (10 MOLL, 10 ROLL group) for localization. A handheld gamma probe for the ROLL group and a manual magnetometer (SentiMag) for the MOLL group were used to test the ability of the modality to detect olives in turkey breasts. The excision time for each procedure, specimen size, and weight of the specimens removed from the turkey breasts were recorded. RESULTS: Both techniques resulted in 100% retrieval of the lesions. There was no difference between the groups in the duration of operative excision, specimen weight, or specimen volume. CONCLUSION: This experimental trial found similar success rates for ROLL and MOLL in localization of occult lesions using the turkey breast phantom model. MOLL can be performed in clinics without the need for a nuclear medicine team and radiation safety procedures.

Utilização de radiofármacos marcados com tecnécio 99m como potenciais marcadores na obtenção de imagens de perfusão miocárdica / Using technetium-99m-marked radiopharmaceuticals as potential markers in obtaining myocardial perfusion images

A Organização Mundial de Saúde (OMS) aponta as doenças cardiovasculares como a principal causa de morte no mundo, caracterizando um grave problema na saúde pública. Os três tipos de doenças que mais acarretam em óbito são: acidente vascular cerebral, seguido de infarto agudo do miocárdio e outras doenças isquêmicas do coração.Apesar dos avanços terapêuticos das últimas décadas, o infarto ainda apresenta altas taxas de mortalidade. Para as pessoas com doenças cardiovasculares ou com alto risco cardiovascular é fundamental o diagnóstico precoce da doença. A cintilografia de perfusão miocárdica é um método de investigação diagnóstica e prognóstico não invasivo de várias doenças cardiovasculares. Esse exame consiste na administração de um radiofármaco para obtenção de imagens de perfusão cardíaca. Dois traçadores marcados com Tecnécio-99m são amplamente utilizados na clínica, porém, esses dois radiofármacos não atendem aos requisitos de um agente de perfusão ideal, por sofrerem significativa excreção biliar, produzindo artefatos na imagem, o que pode inteferir um diagnóstico preciso, já que a qualidade é comprometida, e prolongando o tempo de obtenção da imagem após a administração do radiotraçador. Para superar essa lacuna, pesquisadores vêm estudando novos complexos catiônicos marcados com o Tecnécio. O objetivo desse artigo é fazer uma revisão, abordando a literatura sobre os radiofármacos que estão sendo estudados, suas vantagens e desvantagens sobre os traçadores já utilizados, e sobre sua potencial utilização na obtenção de imagem de perfusão cardíaca.

The World Health Organization (WHO) acknowledges cardiovascular diseases as the leading cause of death in the world, being regarded as a serious public health issue. The three types of diseases with the greatest mortality are: stroke, followed by acute myocardial infarction (AMI) and other ischemic heart diseases. Despite the therapeutic advances of the last decades, AMI still presents high mortality rates. Early diagnosis is essential for people with cardiovascular diseases or with a high cardiovascular risk. Myocardial perfusion scintigraphy is a method of diagnostic investigation and noninvasive prognosis of various cardiovascular diseases. This examination consists in the administration of a radiopharmaceutical drug to obtain images of cardiac perfusion. Two tracers labeled with Technetium-99m are widely used, however, these two radiopharmaceuticals do not meet the requirements of an ideal perfusion agent, because they have a high liver absorption, producing artifacts in the image, which can disrupt a precise diagnosis, since the quality is compromised, and prolonging the imaging time after administration of the radioisotope. To overcome this gap, researchers have been studying new cationic complexes marked with technetium. The objective of this article is to review the literature on the radiopharmaceuticals being studied, their advantages and disadvantages on the tracers already used, and their potential use in obtaining a cardiac perfusion image.

Effect of iterative reconstruction techniques on image quality in low radiation dose chest CT: a phantom study.

PURPOSE: We aimed to evaluate the quality of chest computed tomography (CT) images obtained with low-dose CT using three iterative reconstruction (IR) algorithms. METHODS: Two 64-detector spiral CT scanners (HDCT and iCT) were used to scan a chest phantom containing 6 ground-glass nodules (GGNs) at 11 radiation dose levels. CT images were reconstructed by filtered back projection or three IR algorithms. Reconstructed images were analyzed for CT values, average noise, contrast-to-noise ratio (CNR) values, subjective image noise, and diagnostic acceptability of the GGNs. Repeated-measures analysis of variance was used for statistical analyses. RESULTS: Average noise decreased and CNR increased with increasing radiation dose when the same reconstruction algorithm was applied. Average image noise was significantly lower when reconstructed with MBIR than with iDOSE4 at the same low radiation doses. The two radiologists showed good interobserver consistency in image quality with kappa 0.83. A significant relationship was found between image noise and diagnostic acceptability of the GGNs. CONCLUSION: Three IR algorithms are able to reduce the image noise and improve the image quality of low-dose CT. In the same radiation dose, the low-dose CT image quality reconstructed with MBIR algorithms is better than that of other IR algorithms.

Sentinel lymph node fingerprinting.

BACKGROUND: When locating the sentinel lymph node (SLN), surgeons use state-of-the-art imaging devices, such as a 1D gamma probe or less widely spread a 2D gamma camera. These devices project the 3D subspace onto a 1D respectively 2D space, hence loosing accuracy and the depth of the SLN which is very important, especially in the head and neck area with many critical structures in close vicinity. Recent methods which use a multi-pinhole collimator and a single gamma detector image try to gain a depth estimation of the SLN. The low intensity of the sources together with the computational cost of the optimization process make the reconstruction in real-time, however, very challenging. RESULTS: In this paper, we use an optimal design approach to improve the classical pinhole design, resulting in a non-symmetric distribution of the pinholes of the collimator. This new design shows a great improvement of the accuracy when reconstructing the position and depth of the radioactive tracer. Then, we introduce our Sentinel lymph node fingerprinting (SLNF) algorithm, inspired by MR-fingerprinting, for fast and accurate reconstruction of the tracer distribution in 3D space using a single gamma detector image. As a further advantage, the method requires no pre-processing, i.e. filtering of the detector image. The method is very stable in its performance even for low exposure times. In our ex vivo experiments, we successfully located multiple Technetium 99m (Tc-99m) sources with an exposure time of only one second and still, with a very small L 2-error. CONCLUSION: These promising results under short exposure time are very encouraging for SLN biopsy. Although, this device has not been tested on patients yet, we believe: that this approach will give the surgeon accurate 3D positions of the SLN and hence, can potentially reduce the trauma for the patient.

Impact of short-term low-dose tamoxifen on molecular breast imaging background parenchymal uptake: a pilot study.

BACKGROUND: High background parenchymal uptake (BPU) on molecular breast imaging (MBI) has been identified as a breast cancer risk factor. We explored the feasibility of offering a short-term intervention of low-dose oral tamoxifen to women with high BPU and examined whether this intervention would reduce BPU. METHODS: Women with a history of high BPU and no breast cancer history were invited to the study. Participants had an MBI exam, followed by 30 days of low-dose oral tamoxifen at either 5 mg or 10 mg/day, and a post-tamoxifen MBI exam. BPU on pre- and post-tamoxifen MBI exams was quantitatively assessed as the ratio of average counts in breast fibroglandular tissue vs. average counts in subcutaneous fat. Pre-tamoxifen and post-tamoxifen BPU were compared with paired t tests. RESULTS: Of 47 women invited, 22 enrolled and 21 completed the study (10 taking 5 mg tamoxifen, 11 taking 10 mg tamoxifen). Mean age was 47.7 years (range 41-56 years). After 30 days low-dose tamoxifen, 8 of 21 women (38%) showed a decline in BPU, defined as a decrease from the pre-tamoxifen MBI of at least 15%; 11 of 21 (52%) had no change in BPU (within ± 15%); 2 of 21 (10%) had an increase in BPU of greater than 15%. Overall, the average post-tamoxifen BPU was not significantly different from pre-tamoxifen BPU (1.34 post vs. 1.43 pre, p = 0.11). However, among women taking 10 mg tamoxifen, 5 of 11 (45%) showed a decline in BPU; average BPU was 1.19 post-tamoxifen vs. 1.34 pre-tamoxifen (p = 0.005). In women taking 5 mg tamoxifen, 2 of 10 (20%) showed a decline in BPU; average BPU was 1.51 post-tamoxifen vs.1.53 pre-tamoxifen (p = 0.99). CONCLUSIONS: Short-term intervention with low-dose tamoxifen may reduce high BPU on MBI for some patients. Our preliminary findings suggest that 10 mg tamoxifen per day may be more effective than 5 mg for inducing declines in BPU within 30 days. Given the variability in BPU response to tamoxifen observed among study participants, future study is warranted to determine if BPU response could predict the effectiveness of tamoxifen for breast cancer risk reduction within an individual. TRIAL REGISTRATION: ClinicalTrials.gov NCT02979301 . Registered 01 December 2016.

CHARACTERIZATION OF A SMALL FOV PORTABLE GC: MediPROBE.

In this work, we evaluated the performance of the prototype SFOV MediPROBE developed at the University of Naples Federico II through the protocol proposed by (Bhatia B.S., Bugby S.L., Lees J.E., Perkins A.C. A scheme for assessing the performance characteristics of a small field of-view gamma cameras. Physica. Medica., 31 (1), pp. 98-103. (2015) doi: 10.1016/j.ejmp.2014.08.004). We extensively investigated a new device configuration where the pinhole collimator was placed outside the housing of the probe, in order to increase the system spatial resolution, and the pixel size was doubled, in order to reduce the charge sharing effect. The experimental measurements show that the spatial resolution is enhanced by only about 10%, but the sensitivity decreases strongly. Therefore, the trade-off between these two features does not seem to be advantageous. In addition, our experiments suggest that the charge sharing effect is not completely canceled. Despite these results, the features of this device appear suitable for intraoperative surgical survey. We aim to use this device in the clinical practice for the intraoperative imaging of lymph nodes, breast, thyroid and parathyroid tumors.

Simulation of proton range monitoring in an anthropomorphic phantom using multi-slat collimators and time-of-flight detection of prompt-gamma quanta.

Prompt-gamma (PG) imaging has the potential for monitoring proton therapy in real time. Different approaches are investigated. We focus on developing multi-slat collimators to image PG quanta, aiming at optimizing collimator performance to detect deviations in treatment delivery. We investigated six different multi-slat configurations, which have either optimal (analytical) intrinsic spatial resolution at fixed efficiency, or otherwise; at different distances from the proton pencil-beam axis (15 cm-35 cm). We used Geant4 to simulate irradiations of the head (energy: 130 MeV) and pelvis (200 MeV) of an anthropomorphic phantom, with and without physiologic/morphologic or setup changes of clinical dosimetric relevance. The particles escaping the phantom were transported through each of these multi-slat configurations and the gamma counts profiles were recorded at the collimator exit. Median filtering was applied to the registered PG-profiles to mitigate the effects of septa shadowing and statistical fluctuations. Time-of-flight discrimination was used to enhance the signal-to-background ratio, which appeared crucial for 200 MeV irradiations. Visual detection of the artificially introduced changes was possible by comparing the PG to the depth-dose profiles. Moreover, 2 mm range shifts could be detected in the head irradiation case using a simple linear regression fit to the falloff of the PG-profile. The influence of changes in complex, patient-like dose distributions on the PG-profiles obtained with multi-slat collimation is first studied in this work, which further gives insight on collimator design optimization and highlights its potential and simplicity for detecting proton treatment deviations over a wide range of Bragg peak positions.

Performance evaluation of the LightPath imaging system for intra-operative Cerenkov luminescence imaging.

The performances of an intra-operative optical imaging system for Cerenkov luminescence imaging of resected tumor specimens were evaluated with phantom studies. The spatial resolution, the linearity of the measured signal with the activity concentration and the minimum detectable activity concentration were considered. A high linearity was observed over a broad range of activity concentration (R2⩾0.99 down to ∼40 kBq/ml of 18F-FDG). For 18F-FDG activity distributions 2 mm deep in biological tissue, the measured detection limit was 8 kBq/ml and a spatial resolution of 2.5 mm was obtained. The detection limit of the imaging system is comparable with clinical activity concentrations in tumor specimens, and the spatial resolution is compatible with clinical requirements.

Assessment of collimators in radium-223 imaging with channelized Hotelling observer: a simulation study.

OBJECTIVE: Radium-223 (223Ra) is used in unsealed radionuclide therapy for metastatic bone tumors. The aim of this study is to apply a computational model observer to 223Ra planar images, and to assess the performance of collimators in 223Ra imaging. METHODS: The 223Ra planar images were created via an in-house Monte Carlo simulation code using HEXAGON and NAI modules. The phantom was a National Electrical Manufacturers Association body phantom with a hot sphere. The concentration of the background was 55 Bq/mL, and the sphere was approximately 1.5-20 times that of the background concentration. The acquisition time was 10 min. The photopeaks (and the energy window) were 84 (full width of energy window: 20%), 154 (15%), and 270 keV (10%). Each 40 images, with and without hot concentration, were applied to a three-channel difference-of-Gaussian channelized Hotelling observer (CHO), and the signal-to-noise ratio (SNR) of the hot region was calculated. The images were examined using five different collimators: two low-energy general-purpose (LEGP), two medium-energy general-purpose (MEGP), and one high-energy general-purpose (HEGP) collimators. RESULTS: The SNR value was linearly proportional to the contrast of the hot region for all collimators and energy windows. The images of the 84-keV energy window with the MEGP collimator that have thicker septa and larger holes produced the highest SNR value. The SNR values of two LEGP collimators were approximately half of the MEGP collimators. The HEGP collimator was halfway between the MEGP and LEGP. Similar characteristics were observed for other energy windows (154, 270 keV). The SNR value of images captured via the 270-keV energy window was larger than 154-keV, although the sensitivity of the 270-keV energy window is lower than 154-keV. The results suggested a positive correlation between the SNR value and the fraction of unscattered photons. CONCLUSIONS: The SNR value of CHO reflected the performance of collimators and was available to assess and quantitatively evaluate the collimator performance in 223Ra imaging. The SNR value depends on the magnitudes of unscattered photon count and the fraction of unscattered photon count. Consequently, in this study, MEGP collimators performed better than LEGP and HEGP collimators for 223Ra imaging.

Astatine-211 imaging by a Compton camera for targeted radiotherapy.

Astatine-211 is a promising radionuclide for targeted radiotherapy. It is required to image the distribution of targeted radiotherapeutic agents in a patient's body for optimization of treatment strategies. We proposed to image 211At with high-energy photons to overcome some problems in conventional planar or single-photon emission computed tomography imaging. We performed an imaging experiment of a point-like 211At source using a Compton camera, and demonstrated the capability of imaging 211At with the high-energy photons for the first time.

A novel verification method using a plastic scintillator imagining system for assessment of gantry sag in radiotherapy.

PURPOSE: High accuracy of the beam-irradiated position is required for high-precision radiation therapy such as stereotactic body radiation therapy (SBRT), volumetric modulated arc therapy (VMAT), and intensity modulated radiation therapy (IMRT). Users generally perform the verification of the mechanical and radiation isocenters using the star shot test and the Winston Lutz test that allow evaluation of the displacement at the isocenter. However, these methods are unable to evaluate directly and quantitatively the sagging angle that is caused by the weight of the gantry itself along the gantry rotation axis. In addition, the verification of the central axis of the irradiated beam that is not dependent at the isocenter is needed for the mechanical quality assurance of a nonisocentric irradiation technique. In this study, we have developed a prototype system for the verification of three-dimensional (3D) beam alignment and we have verified the system concept for 3D isocentricity. Our system allows detection of the central axis in 3D coordinates and evaluation of the irradiated oblique angle to the gantry rotation axis, i.e., the sagging angle. MATERIALS & METHODS: In order to measure the central axis of the irradiated beam in 3D coordinates, we constructed the prototype verification system consisting of a column-shaped plastic scintillator (CoPS), a truncated cone-shaped mirror (TCsM), and a cooled charged-coupled device (CCD) camera. This verification system was irradiated with 6-MV photon beams and the scintillation light was measured using the CCD camera. The central axis on the axial plane (two-dimensional (2D) central axis) was acquired from the integration of the scintillation light along the major axis of the CoPS, and the central axis in 3D coordinates (3D central axis) was acquired from two curve-shaped profiles which were reflected by the TCsM. We verified the calculation accuracy of the gantry rotation axis, θz . Additionally, we calculated the 3D central axis and the sagging angle at each gantry angle. RESULTS: We acquired the measurement images composed of the 2D central axis and the two curve-shaped profiles. The relationship between the irradiated and measured angles with respect to the gantry rotation axis had good linearity. The mean and standard deviation of the difference between the irradiated and measured angles were 0.012 and 0.078 degrees, respectively. The size of the 2D and 3D radiation isocenters were 0.470 and 0.652 mm on the axial plane and in 3D coordinates, respectively. The sagging angles were -0.31, 0.39, and 0.38 degrees at the gantry angles of 0, 180, and 180E degrees, respectively. CONCLUSION: We developed a novel verification system, designated as the "kompeito shot test system," to verify the 3D beam alignment. This system concept works for both verification of the 3D isocentricity and the direct evaluation of the sagging angle. Next, we want to improve the aspects of this system, such as the shape and the type of scintillator, to increase the system accuracy and nonisocentric beam alignment performance.

High-Energy Collimator Is Preferable to Medium-Energy Collimator for Evaluating 223Ra Uptake in Bone Metastasis at 2 Weeks Postinjection.

An 80-year-old man with castration-resistant prostate cancer received Ra injection to treat bone metastases. Two weeks after the injection, the patient underwent static Ra scan of the chest with medium-energy and high-energy collimators for 30 minutes each. Images obtained with the 2 collimators showed that uptake in metastatic lesions was visually clearer and semiquantitatively higher with the high-energy collimator. The use of HE collimator for Ra imaging in the early phase has been reported, and the present case suggests that in the late phase HE collimator would also be preferable to medium-energy collimator in terms of lesion-based evaluation.

Prompt Gamma Imaging for In Vivo Range Verification of Pencil Beam Scanning Proton Therapy.

PURPOSE: To report the first clinical results and value assessment of prompt gamma imaging for in vivo proton range verification in pencil beam scanning mode. METHODS AND MATERIALS: A stand-alone, trolley-mounted, prototype prompt gamma camera utilizing a knife-edge slit collimator design was used to record the prompt gamma signal emitted along the proton tracks during delivery of proton therapy for a brain cancer patient. The recorded prompt gamma depth detection profiles of individual pencil beam spots were compared with the expected profiles simulated from the treatment plan. RESULTS: In 6 treatment fractions recorded over 3 weeks, the mean (± standard deviation) range shifts aggregated over all spots in 9 energy layers were -0.8 ± 1.3 mm for the lateral field, 1.7 ± 0.7 mm for the right-superior-oblique field, and -0.4 ± 0.9 mm for the vertex field. CONCLUSIONS: This study demonstrates the feasibility and illustrates the distinctive benefits of prompt gamma imaging in pencil beam scanning treatment mode. Accuracy in range verification was found in this first clinical case to be better than the range uncertainty margin applied in the treatment plan. These first results lay the foundation for additional work toward tighter integration of the system for in vivo proton range verification and quantification of range uncertainties.

A beam monitoring and validation system for continuous line scanning in proton therapy.

Line scanning represents a faster and potentially more flexible form of pencil beam scanning than conventional step-and-shoot irradiations. It seeks to minimize dead times in beam delivery whilst preserving the possibility of modulating the dose at any point in the target volume. Our second generation proton gantry features irradiations in line scanning mode, but it still lacks a dedicated monitoring and validation system that guarantees patient safety throughout the irradiation. We report on its design and implementation in this paper. In line scanning, we steer the proton beam continuously along straight lines while adapting the speed and/or current frequently to modulate the delivered dose. We intend to prevent delivery errors that could be clinically relevant through a two-stage system: safety level 1 monitors the beam current and position every 10 µs. We demonstrate that direct readings from ionization chambers in the gantry nozzle and Hall probes in the scanner magnets provide required information on current and position, respectively. Interlocks will be raised when measured signals exceed their predefined tolerance bands. Even in case of an erroneous delivery, safety level 1 restricts hot and cold spots of the physically delivered fraction dose to ±[Formula: see text] (±[Formula: see text] of [Formula: see text] biologically). In safety level 2-an additional, partly redundant validation step-we compare the integral line profile measured with a strip monitor in the nozzle to a forward-calculated prediction. The comparison is performed between two line applications to detect amplifying inaccuracies in speed and current modulation. This level can be regarded as an online quality assurance of the machine. Both safety levels use devices and functionalities already installed along the beamline. Hence, the presented monitoring and validation system preserves full compatibility of discrete and continuous delivery mode on a single gantry, with the possibility of switching between modes during the application of a single field.