Reciprocal interactions between tumour cell populations enhance growth and reduce radiation sensitivity in prostate cancer.

Intratumoural heterogeneity (ITH) contributes to local recurrence following radiotherapy in prostate cancer. Recent studies also show that ecological interactions between heterogeneous tumour cell populations can lead to resistance in chemotherapy. Here, we evaluated whether interactions between heterogenous populations could impact growth and response to radiotherapy in prostate cancer. Using mixed 3D cultures of parental and radioresistant populations from two prostate cancer cell lines and a predator-prey mathematical model to investigate various types of ecological interactions, we show that reciprocal interactions between heterogeneous populations enhance overall growth and reduce radiation sensitivity. The type of interaction influences the time of regrowth after radiation, and, at the population level, alters the survival and cell cycle of each population without eliminating either one. These interactions can arise from oxygen constraints and from cellular cross-talk that alter the tumour microenvironment. These findings suggest that ecological-type interactions are important in radiation response and could be targeted to reduce local recurrence.

Imaging of normal lung, liver and parotid gland function for radiotherapy.

There is growing clinical evidence that functional imaging is useful for target volume definition and early assessment of tumour response to external beam radiotherapy. A subject that has perhaps received less attention, but is no less promising, is the application of functional imaging to the prediction or measurement of radiation adverse effects in normal tissues. In this manuscript, we review the current published literature describing the use of positron emission tomography (PET), four-dimensional computed tomography (4D-CT), single photon emission computed tomography (SPECT) and magnetic resonance imaging (MRI) to study normal tissue function in the context of radiotherapy to the lung, liver and head & neck. Published results to date demonstrate that functional imaging can be used to preferentially avoid normal tissues not easily identifiable on solely anatomical images. It is also a potentially very powerful tool for the early detection of radiotherapy-induced normal tissue adverse effects and could provide valuable data for building predictive models of outcome. However, one of the major challenges to building useful predictive models is that, to date, there are very little data available with combined images of normal function, 3D delivered radiation dose and clinical outcomes. Prospective data collection through well-constructed studies which use established morbidity scores is clearly a priority if significant progress is to be made in this area.

Optimization and assessment of quantitative 124I imaging on a Philips Gemini dual GS PET/CT system.

PURPOSE: Quantitative (124)I PET imaging is challenging as (124)I has a complex decay scheme. In this study the performance of a Philips Gemini dual GS PET/CT system was optimized and assessed for (124)I. METHODS: The energy window giving the maximum noise equivalent count rate (NECR) and NEMA 2001-NU2 image quality were measured. The activity concentration (AC) accuracy of images calibrated using factors from (18)F and (124)I decaying source measurements were investigated. RESULTS: The energy window 455-588 keV gave the maximum NECR of 9.67 kcps for 233 MBq. (124)I and (18)F image quality was comparable, although (124)I background variability was increased. The average underestimation in AC in (124)I images was 17.9 +/- 2.9% for nonuniform background and 14.7 +/- 2.9% for single scatter simulation (SSS) subtraction scatter correction. At 224 MBq the underestimation was 10.8 +/- 11.3%, which is comparable to 7.7 +/- 5.3% for (18)F, but increased with decreasing activity. CONCLUSIONS: The best (124)I PET quantitative accuracy was achieved for the optimized energy window, using SSS scatter correction and calibration factors from decaying (124)I source measurements. The quantitative accuracy for (124)I was comparable to that for (18)F at high activities of 224 MBq but diminishing with decreasing activity. Specific corrections for prompt gamma-photons may further improve the quantitative accuracy.

Using dose-surface maps to predict radiation-induced rectal bleeding: a neural network approach.

The incidence of late-toxicities after radiotherapy can be modelled based on the dose delivered to the organ under consideration. Most predictive models reduce the dose distribution to a set of dose-volume parameters and do not take the spatial distribution of the dose into account. The aim of this study was to develop a classifier predicting radiation-induced rectal bleeding using all available information on the dose to the rectal wall. The dose was projected on a two-dimensional dose-surface map (DSM) by virtual rectum-unfolding. These DSMs were used as inputs for a classification method based on locally connected neural networks. In contrast to fully connected conventional neural nets, locally connected nets take the topology of the input into account. In order to train the nets, data from 329 patients from the RT01 trial (ISRCTN 47772397) were split into ten roughly equal parts. By using nine of these parts as a training set and the remaining part as an independent test set, a ten-fold cross-validation was performed. Ensemble learning was used and 250 nets were built from randomly selected patients from the training set. Out of these 250 nets, an ensemble of expert nets was chosen. The performances of the full ensemble and of the expert ensemble were quantified by using receiver-operator-characteristic (ROC) curves. In order to quantify the predictive power of the shape, ensembles of fully connected conventional neural nets based on dose-surface histograms (DSHs) were generated and their performances were quantified. The expert ensembles performed better than or equally as well as the full ensembles. The area under the ROC curve for the DSM-based expert ensemble was 0.64. The area under the ROC curve for the DSH-based expert ensemble equalled 0.59. This difference in performance indicates that not only volumetric, but also morphological aspects of the dose distribution are correlated to rectal bleeding after radiotherapy. Thus, the shape of the dose distribution should be taken into account when a predictive model for radiation-induced rectal bleeding is developed.

Systematic review and meta-analysis of small bowel dose-volume and acute toxicity in conventionally-fractionated rectal cancer radiotherapy.

INTRODUCTION: The limited radiation tolerance of the small-bowel causes toxicity for patients receiving conventionally-fractionated radiotherapy for rectal cancer. Safe radiotherapy dose-escalation will require a better understanding of such toxicity. We conducted a systematic review and meta-analysis using published datasets of small bowel dose-volume and outcomes to analyse the relationship with acute toxicity. MATERIALS AND METHODS: SCOPUS, EMBASE & MEDLINE were searched to identify twelve publications reporting small-bowel dose-volumes and toxicity data or analysis. Where suitable data were available (mean absolute volume with parametric error measures), fixed-effects inverse-variance meta-analysis was used to compare cohorts of patients according to Grade ≥3 toxicity. For other data, non-parametric examinations of irradiated small-bowel dose-volume and incidence of toxicity were conducted, and a univariate logistic regression model was fitted. RESULTS: On fixed-effects meta-analysis of three studies (203 patients), each of the dose-volume measures V5Gy-V40Gy were significantly greater (p < 0.00001) for patients with Grade ≥3 toxicity than for those without. Absolute difference was largest for the lowest dose-volume parameter; however relative difference increases with increasing dose. On logistic regression multiple small-bowel DVH parameters were predictive of toxicity risk (V5Gy, V10Gy, V30Gy - V45Gy), with V10Gy the strongest (p = 0.004). CONCLUSIONS: Analysis of published clinical cohort dose-volume data provides evidence for a significant dose-volume-toxicity response effect for a wide range of clinically-relevant doses in the treatment of rectal cancer. Both low dose and high dose are shown to predict toxicity risk, which has important implications for radiotherapy planning and consideration of dose escalation for these patients.

Evaluation of the role of 18FDG-PET/CT in radiotherapy target definition in patients with head and neck cancer.

BACKGROUND AND PURPOSE: As techniques for radiotherapy delivery have developed, increasingly accurate localisation of disease is demanded. Functional imaging, particularly PET and its fusion with anatomical modalities, such as PET/CT, promises to improve detection and characterisation of disease. This study evaluated the impact of (18)FDG-PET/CT on radiotherapy target volume definition in head and neck cancer (HNC). MATERIALS AND METHODS: The PET/CT scans of patients with HNC were used in a radiotherapy planning (RTP) study. The gross tumour volume (GTV), clinical target volume (CTV) and planning target volume (PTV) were defined conventionally and compared to those defined using the PET/CT. Data were reported as the median value with 95% confidence intervals. RESULTS: Eighteen patients were consented, 9 had known primary tumour site, 9 presented as unknown primary. In nine cases where the primary site was known, the combined primary and nodal GTV (GTVp+n) increased by a median of 6.1cm(3) (2.6, 12.2) or 78% (18, 313), p=0.008 with CTV increasing by a median of 10.1cm(3) (1.3, 30.6) or 4% (0, 13) p=0.012. In 9 cases of unknown primary the GTVp+n increased by a median 6.3 cm(3) (0.2, 15.7) or 61% (4, 210), p=0.012, with CTV increasing by a median 155.4 cm(3) (2.7, 281.7) or 95% (1, 137), p=0.008. CONCLUSION: (18)FDG-PET revealed disease lying outside the conventional target volume, either extending a known area or highlighting a previously unknown area of disease, including the primary tumour in 5 cases. We recommend PET/CT in the RTP of all cases of unknown primary. In patients with a known primary, although the change in volume was statistically significant the clinical impact is less clear. (18)FDG-PET can also show areas within the conventional target volume that are hypermetabolic which may be possible biological target volumes for dose escalation studies in the future.

A radiation damage repair model for normal tissues.

A cellular Monte Carlo model describing radiation damage and repair in normal epithelial tissues is presented. The deliberately simplified model includes cell cycling, cell motility and radiation damage response (cell cycle arrest and cell death) only. Results demonstrate that the model produces a stable equilibrium system for mean cell cycle times in the range 24-96 h. Simulated irradiation of these stable equilibrium systems produced a range of responses that are shown to be consistent with experimental and clinical observation, including (i) re-epithelialization of radiation-induced lesions by a mixture of cell migration into the wound and repopulation at the periphery; (ii) observed radiosensitivity that is quantitatively consistent with both rate of induction of irreparable DNA lesions and, independently, with the observed acute oral and pharyngeal mucosal reactions to radiotherapy; (iii) an observed time between irradiation and maximum toxicity that is consistent with experimental data for skin; (iv) quantitatively accurate predictions of low-dose hyper-radiosensitivity; (v) Gomperzian repopulation for very small lesions ( approximately 2000 cells) and (vi) a linear rate of re-epithelialization of 5-10 microm h(-1) for large lesions (>15 000 cells).

Functional Parameters Derived from Magnetic Resonance Imaging Reflect Vascular Morphology in Preclinical Tumors and in Human Liver Metastases.

Purpose: Tumor vessels influence the growth and response of tumors to therapy. Imaging vascular changes in vivo using dynamic contrast-enhanced MRI (DCE-MRI) has shown potential to guide clinical decision making for treatment. However, quantitative MR imaging biomarkers of vascular function have not been widely adopted, partly because their relationship to structural changes in vessels remains unclear. We aimed to elucidate the relationships between vessel function and morphology in vivo Experimental Design: Untreated preclinical tumors with different levels of vascularization were imaged sequentially using DCE-MRI and CT. Relationships between functional parameters from MR (iAUC, K trans, and BATfrac) and structural parameters from CT (vessel volume, radius, and tortuosity) were assessed using linear models. Tumors treated with anti-VEGFR2 antibody were then imaged to determine whether antiangiogenic therapy altered these relationships. Finally, functional-structural relationships were measured in 10 patients with liver metastases from colorectal cancer.Results: Functional parameters iAUC and K trans primarily reflected vessel volume in untreated preclinical tumors. The relationships varied spatially and with tumor vascularity, and were altered by antiangiogenic treatment. In human liver metastases, all three structural parameters were linearly correlated with iAUC and K trans For iAUC, structural parameters also modified each other's effect.Conclusions: Our findings suggest that MR imaging biomarkers of vascular function are linked to structural changes in tumor vessels and that antiangiogenic therapy can affect this link. Our work also demonstrates the feasibility of three-dimensional functional-structural validation of MR biomarkers in vivo to improve their biological interpretation and clinical utility. Clin Cancer Res; 24(19); 4694-704. ©2018 AACR.

A potential to reduce pulmonary toxicity: the use of perfusion SPECT with IMRT for functional lung avoidance in radiotherapy of non-small cell lung cancer.

BACKGROUND AND PURPOSE: The study aimed to examine specific avoidance of functional lung (FL) defined by a single photon emission computerized tomography (SPECT) lung perfusion scan, using intensity modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3-DCRT) in patients with non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Patients with NSCLC underwent planning computerized tomography (CT) and lung perfusion SPECT scan in the treatment position using fiducial markers to allow co-registration in the treatment planning system. Radiotherapy (RT) volumes were delineated on the CT scan. FL was defined using co-registered SPECT images. Two inverse coplanar RT plans were generated for each patient: 4-field 3-DCRT and 5-field step-and-shoot IMRT. 3-DCRT plans were created using automated AutoPlan optimisation software, and IMRT plans were generated employing Pinnacle(3) treatment planning system (Philips Radiation Oncology Systems). All plans were prescribed to 64 Gy in 32 fractions using data for the 6 MV beam from an Elekta linear accelerator. The objectives for both plans were to minimize the volume of FL irradiated to 20 Gy (fV(20)) and dose variation within the planning target volume (PTV). A spinal cord dose was constrained to 46 Gy. Volume of PTV receiving 90% of the prescribed dose (PTV(90)), fV(20), and functional mean lung dose (fMLD) were recorded. The PTV(90)/fV(20) ratio was used to account for variations in both measures, where a higher value represented a better plan. RESULTS: Thirty-four RT plans of 17 patients with stage I-IIIB NSCLC suitable for radical RT were analysed. In 6 patients with stage I-II disease there was no improvement in PTV(90), fV(20), PTV/fV(20) ratio and fMLD using IMRT compared to 3-DCRT. In 11 patients with stage IIIA-B disease, the PTV was equally well covered with IMRT and 3-DCRT plans, with IMRT producing better PTV(90)/fV(20) ratio (mean ratio - 7.2 vs. 5.3, respectively, p=0.001) and reduced fMLD figures compared to 3-DCRT (mean value - 11.5 vs. 14.3 Gy, p=0.001). This was due to reduction in fV(20) while maintaining PTV coverage. CONCLUSION: The use of IMRT compared to 3-DCRT improves the avoidance of FL defined by perfusion SPECT scan in selected patients with locally advanced NSCLC. If the dose to FL is shown to be the primary determinant of lung toxicity, IMRT would allow for effective dose escalation by specific avoidance of FL.

Characterization of the ultrasonic attenuation coefficient and its frequency dependence in a polymer gel dosimeter.

Research on polymer-gel dosimetry has been driven by the need for three-dimensional dosimetry, and because alternative dosimeters are unsatisfactory or too slow for that task. Magnetic resonance tomography is currently the most well-developed technique for determining radiation-induced changes in polymer structure, but quick low-cost alternatives remain of significant interest. In previous work, ultrasound attenuation and speed of sound were found to change as a function of absorbed radiation dose in polymer-gel dosimeters, although the investigations were restricted to one ultrasound frequency. Here, the ultrasound attenuation coefficient mu in one polymer gel (MAGIC) was investigated as a function of radiation dose D and as a function of ultrasonic frequency f in a frequency range relevant for imaging dose distributions. The nonlinearity of the frequency dependence was characterized, fitting a power-law model mu = af(b); the fitting parameters were examined for potential use as additional dose readout parameters. In the observed relationship between the attenuation coefficient and dose, the slopes in a quasi-linear dose range from 0 to 30 Gy were found to vary with the gel batch but lie between 0.0222 and 0.0348 dB cm(-1) Gy(-1) at 2.3 MHz, between 0.0447 and 0.0608 dB cm(-1) Gy(-1) at 4.1 MHz and between 0.0663 and 0.0880 dB cm(-1) Gy(-1) at 6.0 MHz. The mean standard deviation of the slope for all samples and frequencies was 15.8%. The slope was greater at higher frequencies, but so were the intra-batch fluctuations and intra-sample standard deviations. Further investigations are required to overcome the observed variability, which was largely associated with the sample preparation technique, before it can be determined whether any frequency is superior to others in terms of accuracy and precision in dose determination. Nevertheless, lower frequencies will allow measurements through larger samples. The fit parameter a of the frequency dependence, describing the attenuation coefficient at 1 MHz, was found to be dose dependent, which is consistent with our expectations, as polymerization is known to be associated with increased absorption of ultrasound. No significant dose dependence was found for the fit parameter b, which describes the nonlinearity with frequency. This is consistent with the increased absorption being due to the introduction of new relaxation processes with characteristic frequencies similar to those of existing processes. The data presented here will help with optimizing the design of future 3D dose-imaging systems using ultrasound methods.

Optimization of energy-window settings for scatter correction in quantitative (111)In imaging: comparison of measurements and Monte Carlo simulations.

Activity quantification in nuclear medicine imaging is highly desirable, particularly for dosimetry and biodistribution studies of radiopharmaceuticals. Quantitative (111)In imaging is increasingly important with the current interest in therapy using (90)Y radiolabeled antibodies. One of the major problems in quantification is scatter in the images, which leads to degradation of image quality. The aim of this study was to optimize the energy-window settings for quantitative (111)In imaging with a camera that enabled acquisition in three energy windows. Experimental measurements and Monte Carlo simulations, using the SI-MIND code, were conducted to investigate parameters such as sensitivity, image contrast, and image resolution. Estimated scatter-to-total ratios and distributions, as obtained by the different window settings, were compared with corresponding simulations. Results showed positive agreement between experimental measurements and results from simulations, both quantitatively and qualitatively. We conclude that of the investigated methods, the optimal energy-window setting was two windows centered at 171 and 245 keV, together with a broad scatter window located between the photopeaks.

A quality-control method for SPECT-based dosimetry in targeted radionuclide therapy.

Dosimetry for targeted radionuclide therapy is necessary for treatment planning and radiation protection. Currently, there are no standard methods either for performing dosimetry or to evaluate the uncertainties inherent in the dosimetric calculations. In this paper, we present an experimental method using polymer gel dosimeters, whereby absorbed-dose distributions resulting from nonuniform distributions of activity may be determined directly from T(2) magnetic resonance imaging (MRI) as well as from scintigraphic images. A phantom containing a nonuniform distribution of I-131 was prepared by mixing 58 MBq of activity within the gel as it was solidifying. The resulting absorbed-dose distribution was determined directly from the MRI and from sequential single-photon emission computed tomography (SPECT) images using the Medical Internal Radiation Dose (MIRD) schema. The MRI data were quantified using 12 calibration vials uniformly irradiated by 0-12 MBq of I-131. The agreement between the two absorbed-dose maps was verified by convolving the MRI-based absorbed-dose map with the SPECT system point spread function, which gave a correlation coefficient of 0.96. It was seen that the absorbed-dose distribution, as imaged by the MRI, was misrepresented by the SPECT owing to its relatively poor spatial resolution, which included a shift of the voxel containing the maximum absorbed dose. This technique could provide an independent benchmark for assessing patient-specific dosimetry and, therefore, could be used as a basis for quality control for dosimetry.

Dosimetry for fractionated (131)I-mIBG therapies in patients with primary resistant high-risk neuroblastoma: preliminary results.

This paper describes the development of a protocol for SPECT-based tumor dosimetry for (131)I-mIBG therapy patients with high-risk neuroblastoma. The treatment aims to deliver a whole-body dose of 4 Gy in two fractions. Whole-body retention measurements taken during the first fraction are used to guide the second therapy administration. The tumor dose from 3 patients was assessed by acquiring a minimum of three SPECT scans. Dead-time and triple-energy window scatter corrections were applied. The images were reconstructed using filtered backprojection with a Chang attenuation correction, and a phantom-based calibration factor was used to convert to activity. A monoexponential fit was made to the data, and instantaneous uptake was assumed. Tumor absorbed-dose ratios were used to analyze intrapatient variations, and absolute tumor dosimetry was used to assess interpatient variation. The whole-body dose administered ranged from (3.7 +/- 0.1) Gy to (3.9 +/- 0.3) Gy. This method is more accurate than a weight-based administration method. Despite this, a variation in absorbed tumor dose of 10-103 Gy was observed. All repeat doses were in the same order of magnitude, although 2 patients received a lower tumor dose per MBq from the second therapy owing to a shorter biological half-life. The tumor dosimetry protocol was simple to apply and reproducible, but the errors in image quantitation needed to be evaluated.

An approximate analytical solution of the Bethe equation for charged particles in the radiotherapeutic energy range.

Charged particles such as protons and carbon ions are an increasingly important tool in radiotherapy. There are however unresolved physics issues impeding optimal implementation, including estimation of dose deposition in non-homogeneous tissue, an essential aspect of treatment optimization. Monte Carlo (MC) methods can be employed to estimate radiation profile, and whilst powerful, these are computationally expensive, limiting practicality. In this work, we start from fundamental physics in the form of the Bethe equation to yield a novel approximate analytical solution for particle range, energy and linear energy transfer (LET). The solution is given in terms of the exponential integral function with relativistic co-ordinate transform, allowing application at radiotherapeutic energy levels (50-350 MeV protons, 100-600 Mev/a.m.u carbon ions). Model results agreed closely for protons and carbon-ions (mean error within ≈1%) of literature values. Agreement was high along particle track, with some discrepancy manifesting at track-end. The model presented has applications within a charged particle radiotherapy optimization framework as a rapid method for dose and LET estimation, capable of accounting for heterogeneity in electron density and ionization potential.

Potential of Proton Therapy to Reduce Acute Hematologic Toxicity in Concurrent Chemoradiation Therapy for Esophageal Cancer.

PURPOSE: Radiation therapy dose escalation using a simultaneous integrated boost (SIB) is predicted to improve local tumor control in esophageal cancer; however, any increase in acute hematologic toxicity (HT) could limit the predicted improvement in patient outcomes. Proton therapy has been shown to significantly reduce HT in lung cancer patients receiving concurrent chemotherapy. Therefore, we investigated the potential of bone marrow sparing with protons for esophageal tumors. METHODS AND MATERIALS: Twenty-one patients with mid-esophageal cancer who had undergone conformal radiation therapy (3D50) were selected. Two surrogates for bone marrow were created by outlining the thoracic bones (bone) and only the body of the thoracic vertebrae (TV) in Eclipse. The percentage of overlap of the TV with the planning treatment volume was recorded for each patient. Additional plans were created retrospectively, including a volumetric modulated arc therapy (VMAT) plan with the same dose as for 3D50; a VMAT SIB plan with a dose prescription of 62.5 Gy to the high-risk subregion within the planning treatment volume; a reoptimized TV-sparing VMAT plan; and a proton therapy plan with the same SIB dose prescription. The bone and TV dose metrics were recorded and compared across all plans and variations with respect to PTV and percentage of overlap for each patient. RESULTS: The 3D50 plans showed the highest bone mean dose and TV percentage of volume receiving ≥30 Gy (V30Gy) for each patient. The VMAT plans irradiated a larger bone V10Gy than did the 3D50 plans. The reoptimized VMAT62.5 VT plans showed improved sparing of the TV volume, but only the proton plans showed significant sparing for bone V10Gy and bone mean dose, especially for patients with a larger PTV. CONCLUSIONS: The results of the present study have shown that proton therapy can reduced bone marrow toxicity.

Modelling duodenum radiotherapy toxicity using cohort dose-volume-histogram data.

BACKGROUND AND PURPOSE: Gastro-intestinal toxicity is dose-limiting in abdominal radiotherapy and correlated with duodenum dose-volume parameters. We aimed to derive updated NTCP model parameters using published data and prospective radiotherapy quality-assured cohort data. MATERIAL AND METHODS: A systematic search identified publications providing duodenum dose-volume histogram (DVH) statistics for clinical studies of conventionally-fractionated radiotherapy. Values for the Lyman-Kutcher-Burman (LKB) NTCP model were derived through sum-squared-error minimisation and using leave-one-out cross-validation. Data were corrected for fraction size and weighted according to patient numbers, and the model refined using individual patient DVH data for two further cohorts from prospective clinical trials. RESULTS: Six studies with published DVH data were utilised, and with individual patient data included outcomes for 531 patients in total (median follow-up 16months). Observed gastro-intestinal toxicity rates ranged from 0% to 14% (median 8%). LKB parameter values for unconstrained fit to published data were: n=0.070, m=0.46, TD50(1) [Gy]=183.8, while the values for the model incorporating the individual patient data were n=0.193, m=0.51, TD50(1) [Gy]=299.1. CONCLUSIONS: LKB parameters derived using published data are shown to be consistent to those previously obtained using individual patient data, supporting a small volume-effect and dependence on exposure to high threshold dose.

[18F]Fluoromisonidazole PET in rectal cancer.

BACKGROUND: There is an increasing interest in developing predictive biomarkers of tissue hypoxia using functional imaging for personalised radiotherapy in patients with rectal cancer that are considered for neoadjuvant chemoradiotherapy (CRT). The study explores [18F]fluoromisonidazole ([18F]FMISO) positron emission tomography (PET) scans for predicting clinical response in rectal cancer patients receiving neoadjuvant CRT. METHODS: Patients with biopsy-proven rectal adenocarcinoma were imaged at 0-45 min, 2 and 4 h, at baseline and after 8-10 fractions of CRT (week 2). The first 6 patients did not receive an enema (the non-enema group) and the last 4 patients received an enema before PET-CT scan (the enema group). [18F]FMISO production failed on 2 occasions. Static PET images at 4 h were analysed using tumour-to-muscle (T:M) SUVmax and tumour-to-blood (T:B) SUVmax. The 0-45 min dynamic PET scans were analysed using Casciari model to report hypoxia and perfusion. Akaike information criteria (AIC) were used to compare data fittings for different pharmacokinetic models. Pathological tumour regression grade was scored using American Joint Committee on Cancer (AJCC) 7.0. Shapiro-Wilk test was used to evaluate the normality of the data. RESULTS: Five out of eleven (5/11) patients were classed as good responders (AJCC 0/1 or good clinical response) and 6/11 as poor responders (AJCC 2/3 or poor clinical response). The median T:M SUVmax was 2.14 (IQR 0.58) at baseline and 1.30 (IQR 0.19) at week 2, and the corresponding median tumour hypoxia volume was 1.08 (IQR 1.31) cm3 and 0 (IQR 0.15) cm3, respectively. The median T:B SUVmax was 2.46 (IQR 1.50) at baseline and 1.61 (IQR 0.14) at week 2, and the corresponding median tumour hypoxia volume was 5.68 (IQR 5.86) cm3 and 0.76 (IQR 0.78) cm3, respectively. For 0-45 min tumour modelling, the median hypoxia was 0.92 (IQR 0.41) min-1 at baseline and 0.70 (IQR 0.10) min-1 at week 2. The median perfusion was 4.10 (IQR 1.71) ml g-1 min-1 at baseline and 2.48 (IQR 3.62) ml g-1 min-1 at week 2. In 9/11 patients with both PET scans, tumour perfusion decreased in non-responders and increased in responders except in one patient. None of the changes in other PET parameters showed any clear trend with clinical outcome. CONCLUSIONS: This pilot study with small number of datasets revealed significant challenges in delivery and interpretation of [18F]FMISO PET scans of rectal cancer. There are two principal problems namely spill-in from non-tumour tracer activity from rectal and bladder contents. Emphasis should be made on reducing spill-in effects from the bladder to improve data quality. This preliminary study has shown fundamental difficulties in the interpretation of [18F]FMISO PET scans for rectal cancer, limiting its clinical applicability.

The role of necrosis, acute hypoxia and chronic hypoxia in 18F-FMISO PET image contrast: a computational modelling study.

Positron emission tomography (PET) using 18F-fluoromisonidazole (FMISO) is a promising technique for imaging tumour hypoxia, and a potential target for radiotherapy dose-painting. However, the relationship between FMISO uptake and oxygen partial pressure ([Formula: see text]) is yet to be quantified fully. Tissue oxygenation varies over distances much smaller than clinical PET resolution (<100 µm versus ∼4 mm), and cyclic variations in tumour perfusion have been observed on timescales shorter than typical FMISO PET studies (∼20 min versus a few hours). Furthermore, tracer uptake may be decreased in voxels containing some degree of necrosis. This work develops a computational model of FMISO uptake in millimetre-scale tumour regions. Coupled partial differential equations govern the evolution of oxygen and FMISO distributions, and a dynamic vascular source map represents temporal variations in perfusion. Local FMISO binding capacity is modulated by the necrotic fraction. Outputs include spatiotemporal maps of [Formula: see text] and tracer accumulation, enabling calculation of tissue-to-blood ratios (TBRs) and time-activity curves (TACs) as a function of mean tissue oxygenation. The model is characterised using experimental data, finding half-maximal FMISO binding at local [Formula: see text] of 1.4 mmHg (95% CI: 0.3-2.6 mmHg) and half-maximal necrosis at 1.2 mmHg (0.1-4.9 mmHg). Simulations predict a non-linear non-monotonic relationship between FMISO activity (4 hr post-injection) and mean tissue [Formula: see text] : tracer uptake rises sharply from negligible levels in avascular tissue, peaking at ∼5 mmHg and declining towards blood activity in well-oxygenated conditions. Greater temporal variation in perfusion increases peak TBRs (range 2.20-5.27) as a result of smaller predicted necrotic fraction, rather than fundamental differences in FMISO accumulation under acute hypoxia. Identical late FMISO uptake can occur in regions with differing [Formula: see text] and necrotic fraction, but simulated TACs indicate that additional early-phase information may allow discrimination of hypoxic and necrotic signals. We conclude that a robust approach to FMISO interpretation (and dose-painting prescription) is likely to be based on dynamic PET analysis.

Estimating oxygen distribution from vasculature in three-dimensional tumour tissue.

Regions of tissue which are well oxygenated respond better to radiotherapy than hypoxic regions by up to a factor of three. If these volumes could be accurately estimated, then it might be possible to selectively boost dose to radio-resistant regions, a concept known as dose-painting. While imaging modalities such as 18F-fluoromisonidazole positron emission tomography (PET) allow identification of hypoxic regions, they are intrinsically limited by the physics of such systems to the millimetre domain, whereas tumour oxygenation is known to vary over a micrometre scale. Mathematical modelling of microscopic tumour oxygen distribution therefore has the potential to complement and enhance macroscopic information derived from PET. In this work, we develop a general method of estimating oxygen distribution in three dimensions from a source vessel map. The method is applied analytically to line sources and quasi-linear idealized line source maps, and also applied to full three-dimensional vessel distributions through a kernel method and compared with oxygen distribution in tumour sections. The model outlined is flexible and stable, and can readily be applied to estimating likely microscopic oxygen distribution from any source geometry. We also investigate the problem of reconstructing three-dimensional oxygen maps from histological and confocal two-dimensional sections, concluding that two-dimensional histological sections are generally inadequate representations of the three-dimensional oxygen distribution.