Development and performance evaluation of a high-speed multileaf collimator.

Multileaf collimator (MLC) tracking represents a promising technique for motion management in radiotherapy. However, the conflict between limited leaf speed/acceleration and the demand for tracking fast target motion is now a prominent issue. Conventional MLCs typically have a maximum leaf speed of 3-4 cm/s and a maximum leaf acceleration of 50-70 cm/s2, which are inadequate to track fast target motion. To cope with this problem, we have recently developed a high-speed multileaf collimator (HS-MLC) prototype, which employs linear motors instead of rotary motors to drive leaves. Consequently, it inherits various benefits of linear motors, including direct drive and high dynamics. The primary aim of this paper was to introduce the development and performance evaluation of the HS-MLC. The evaluation includes Monte Carlo simulations of the basic dosimetric properties, camera-based measurements of the mechanical properties and tracking experiments for 25 sets of patient-measured motion data. The Monte Carlo simulation results show that the maximum leakage at 6MV is 1.29% and the average is 0.61%. The end-to-end leakage is 3.96% for 5 cm offset and is 1.75% for 10 cm offset. The penumbra for a standard 10 × 10 cm2 field ranges from 4.8 mm to 5.4 mm across the full range of leaf motion. The mechanical property measurements demonstrate that the maximum leaf speed is 40 cm/s, the maximum leaf acceleration is 1000 cm/s2, and the geometric accuracy can be kept within 0.5 mm. Regarding the tracking experiments for a wide range of motion patterns (fast breathing, irregular breathing, etc.), a root-mean-square error (RMSE) of less than 0.19 mm was achieved. In conclusion, the HS-MLC is able to well track fast target motion that is beyond the capability of conventional MLCs due to its superior mechanical properties. The new MLC design provides a feasible solution to make high-accuracy and high-efficiency motion management possible.

Mover Position Detection for PMTLM Based on Linear Hall Sensors through EKF Processing.

Accurate mover position is vital for a permanent magnet tubular linear motor (PMTLM) control system. In this paper, two linear Hall sensors are utilized to detect the mover position. However, Hall sensor signals contain third-order harmonics, creating errors in mover position detection. To filter out the third-order harmonics, a signal processing method based on the extended Kalman filter (EKF) is presented. The limitation of conventional processing method is first analyzed, and then EKF is adopted to detect the mover position. In the EKF model, the amplitude of the fundamental component and the percentage of the harmonic component are taken as state variables, and they can be estimated based solely on the measured sensor signals. Then, the harmonic component can be calculated and eliminated. The proposed method has the advantages of faster convergence, better stability and higher accuracy. Finally, experimental results validate the effectiveness and superiority of the proposed method.

Rounded leaf end effect of multileaf collimator on penumbra width and radiation field offset: an analytical and numerical study.

BACKGROUND: Penumbra characteristics play a significant role in dose delivery accuracy for radiation therapy. For treatment planning, penumbra width and radiation field offset strongly influence target dose conformity and organ at risk sparing. METHODS: In this study, we present an analytical and numerical approach for evaluation of the rounded leaf end effect on penumbra characteristics. Based on the rule of half-value layer, algorithms for leaf position calculation and radiation field offset correction were developed, which were advantageous particularly in dealing with large radius leaf end. Computer simulation was performed based on the Monte Carlo codes of EGSnrc/BEAMnrc, with groups of leaf end radii and source sizes. Data processing technique of curve fitting was employed for deriving penumbra width and radiation field offset. RESULTS: Results showed that penumbra width increased with source size. Penumbra width curves for large radius leaf end were U-shaped. This observation was probably related to the fact that radiation beams penetrated through the proximal and distal leaf sides. In contrast, source size had negligible impact on radiation field offset. Radiation field offsets were found to be constant both for analytical method and numerical simulation. However, the overall resulting values of radiation field offset obtained by analytical method were slightly smaller compared with Monte Carlo simulation. CONCLUSIONS: The method we proposed could provide insight into the investigation of rounded leaf end effects on penumbra characteristics. Penumbra width and radiation field offset calibration should be carefully performed to commission multileaf collimator for intensity modulated radiotherapy.

In vivo expansion of regulatory T cells with IL-2/IL-2 mAb complexes prevents anti-factor VIII immune responses in hemophilia A mice treated with factor VIII plasmid-mediated gene therapy.

Generation of transgene-specific immune responses can constitute a major complication following gene therapy treatment. An in vivo approach to inducing selective expansion of Regulatory T (Treg) cells by injecting interleukin-2 (IL-2) mixed with a specific IL-2 monoclonal antibody (JES6-1) was adopted to modulate anti-factor VIII (anti-FVIII) immune responses. Three consecutive IL-2 complexes treatments combined with FVIII plasmid injection prevented anti-FVIII formation and achieved persistent, therapeutic-level of FVIII expression in hemophilia A (HemA) mice. The IL-2 complexes treatment expanded CD4(+)CD25(+)Foxp3(+) Treg cells five- to sevenfold on peak day, and they gradually returned to normal levels within 7-14 days without changing other lymphocyte populations. The transiently expanded Treg cells are highly activated and display suppressive function in vitro. Adoptive transfer of the expanded Treg cells protected recipient mice from generation of high-titer antibodies following FVIII plasmid challenge. Repeated plasmid transfer is applicable in tolerized mice without eliciting immune responses. Mice treated with IL-2 complexes mounted immune responses against both T-dependent and T-independent neoantigens, indicating that IL-2 complexes did not hamper the immune system for long. These results demonstrate the important role of Treg cells in suppressing anti-FVIII immune responses and the potential of developing Treg cell expansion therapies that induce long-term tolerance to FVIII.

Anti-CD3 antibodies modulate anti-factor VIII immune responses in hemophilia A mice after factor VIII plasmid-mediated gene therapy.

One major obstacle in gene therapy is the generation of immune responses directed against transgene product. Five consecutive anti-CD3 treatments concomitant with factor VIII (FVIII) plasmid injection prevented the formation of inhibitory antibodies against FVIII and achieved persistent, therapeutic levels of FVIII gene expression in treated hemophilia A mice. Repeated plasmid gene transfer is applicable in tolerized mice without eliciting immune responses. Anti-CD3 treatment significantly depleted both CD4+ and CD8+ T cells, whereas increased transforming growth factor-beta levels in plasma and the frequency of both CD4+CD25+FoxP3+ and CD4+CD25-Foxp3+ regulatory T cells in the initial few weeks after treatment. Although prior depletion of CD4+CD25+ cells did not abrogate tolerance induction, adoptive transfer of CD4+ cells from tolerized mice at 6 weeks after treatment protected recipient mice from anti-FVIII immune responses. Anti-CD3-treated mice mounted immune responses against both T-dependent and T-independent neo-antigens, indicating that anti-CD3 did not hamper the immune systems in the long term. Concomitant FVIII plasmid + anti-CD3 treatment induced long-term tolerance specific to FVIII via a mechanism involving the increase in transforming growth factor-beta levels and the generation of adaptive FVIII-specific CD4+Foxp3+ regulatory T cells at the periphery. Furthermore, anti-CD3 can reduce the titers of preexisting anti-FVIII inhibitory antibodies in hemophilia A mice.

Transient blockade of the inducible costimulator pathway generates long-term tolerance to factor VIII after nonviral gene transfer into hemophilia A mice.

Formation of inhibitory antibodies is a common problem encountered in clinical treatment for hemophilia. Human factor VIII (hFVIII) plasmid gene therapy in hemophilia A mice also leads to strong humoral responses. We demonstrate that short-term therapy with an anti-ICOS monoclonal antibody to transiently block the inducible costimulator/inducible costimulator ligand (ICOS/ICOSL) signaling pathway led to sustained tolerance to hFVIII in hFVIII plasmid-treated hemophilia A mice and allowed persistent, high-level FVIII functional activity (100%-300% of normal). Anti-ICOS treatment resulted in depletion of ICOS(+)CD4(+) T cells and activation of CD25(+)Foxp3(+) Tregs in the peripheral blood, spleen, and lymph nodes. CD4(+) T cells from anti-ICOS-treated mice did not proliferate in response to hFVIII stimulation and produced high levels of regulatory cytokines, including interleukin-10 and transforming growth factor-beta. Moreover, CD4(+)CD25(+) Tregs from tolerized mice adoptively transferred dominant tolerance in syngeneic hFVIII plasmid-treated hemophilia A mice and reduced the production of antibodies against FVIII. Anti-ICOS-treated mice tolerized to hFVIII generated normal primary and secondary antibody responses after immunization with the T-dependent antigen, bacteriophage Phix 174, indicating maintenance of immune competency. Our data indicate that transient anti-ICOS monoclonal antibody treatment represents a novel single-agent immunomodulatory strategy to overcome the immune responses against transgene product after gene therapy.

Lateral Penumbra Modelling Based Leaf End Shape Optimization for Multileaf Collimator in Radiotherapy.

Lateral penumbra of multileaf collimator plays an important role in radiotherapy treatment planning. Growing evidence has revealed that, for a single-focused multileaf collimator, lateral penumbra width is leaf position dependent and largely attributed to the leaf end shape. In our study, an analytical method for leaf end induced lateral penumbra modelling is formulated using Tangent Secant Theory. Compared with Monte Carlo simulation and ray tracing algorithm, our model serves well the purpose of cost-efficient penumbra evaluation. Leaf ends represented in parametric forms of circular arc, elliptical arc, Bézier curve, and B-spline are implemented. With biobjective function of penumbra mean and variance introduced, genetic algorithm is carried out for approximating the Pareto frontier. Results show that for circular arc leaf end objective function is convex and convergence to optimal solution is guaranteed using gradient based iterative method. It is found that optimal leaf end in the shape of Bézier curve achieves minimal standard deviation, while using B-spline minimum of penumbra mean is obtained. For treatment modalities in clinical application, optimized leaf ends are in close agreement with actual shapes. Taken together, the method that we propose can provide insight into leaf end shape design of multileaf collimator.

Performance evaluation of a high-speed multileaf collimator in real-time IMRT delivery to moving targets.

PURPOSE: Multileaf collimator (MLC) tracking can be used for motion management. However, on account of mechanical constraints, it is a crucial challenge for conventional MLCs (3-4 cm/s in leaf speed) to track fast targets, especially moving in 2D in the beam's eye view (BEV). Our group has recently developed a "high-speed" MLC (HS-MLC) prototype with a maximum leaf speed of 40 cm/s, which makes it possible to track the vast majority of moving targets without violation of mechanical constraints. The major innovation of the HS-MLC design is that it employs linear motors instead of rotary motors to drive leaves. This paper mainly aims to evaluate the performance of the HS-MLC in real-time intensity-modulated radiation therapy delivery to targets moving in 2D in the BEV. METHODS: A 2D real-time tracking algorithm was proposed first based on a previous superimposing leaf sequencing method. Then, simulations were performed to evaluate the delivery performance including fluence accuracy, efficiency, delivery time, and number of monitor units under various settings of limiting coefficient and dose rate for four clinical fluence maps and two target speeds. The comparisons between the HS-MLC with a "medium-speed" MLC (MS-MLC, 10 cm/s) and a "low-speed" MLC (LS-MLC, 5 cm/s) were also made. For validation, experiments were carried out on the HS-MLC prototype in the lab environment. A camera-based measurement system was set up to detect actual leaf trajectories. RESULTS: Simulation results indicate that a limiting coefficient of 0.5 and a dose rate of 400 MU/min are "optimal" in the sense of getting best compromise between delivery time and number of monitor units. Under the optimal parameters, the HS-MLC achieved 100% in efficiency, 18.1 s in delivery time, and 121.2 MU in number of monitor units on average for the "fast" target speed, compared to 94%, 20.6 s, and 129.9 MU with the MS-MLC, and to 53%, 40.2 s, and 141.1 MU with the LS-MLC. The benefits of increased leaf speed were demonstrated. The experimental results agreed with the simulation ones, which further confirmed the efficacy of the HS-MLC. CONCLUSIONS: The HS-MLC is superior to conventional MLCs when used for tracking, benefiting from its high leaf speed. These results indicate that the novel HS-MLC is feasible for high-accuracy and high-efficiency motion management. It also offers guidance for future MLC design.

Ultrasound enhances gene delivery of human factor IX plasmid.

Delivery of plasmid DNA can be enhanced by treatment with ultrasound (US); acoustic cavitation appears to play an important role in the process. Ultrasound contrast agents (UCAs; stabilized microbubbles) nucleate acoustic cavitation, and lower the acoustic pressure threshold for inertial cavitation occurrence. Fifty micrograms of a liver-specific, high-expressing human factor IX plasmid, pBS-HCRHP-FIXIA, mixed with UCA or phosphate-buffered saline was delivered to mouse livers by intrahepatic injection, with simultaneous exposure to 1 MHz-pulsed US using various acoustic protocols. Variable pulse duration (PD) at constant treatment time, pulse repetition frequency, and an acoustic peak negative pressure amplitude of 1.8 MPa produced 2- to 13-fold enhancements in hFIX gene expression, but PD was not a strong determinant. In contrast, a dose-response relationship was demonstrated for the peak negative pressure (P-), with significant enhancement of gene transduction at P- >/= 2 MPa. Up to 63 ng/ml (approaching the therapeutic range for treating hemophilia patients) could be achieved by transducing one liver lobe at 4-MPa P-, corresponding to a 66- fold increment relative to treatment with naked DNA alone. Under the same conditions, mouse livers could also be transduced with a GFP plasmid. Histology showed transient liver damage caused by intrahepatic injection and US exposure at 4-MPa P-; however, the damage was repaired in a few days. We conclude that therapeutic US in combination with UCA has the potential to promote safe and efficient nonviral gene transfer of hFIX for the treatment of hemophilia.

A discrete time-varying internal model-based approach for high precision tracking of a multi-axis servo gantry.

In this paper, we consider the discrete time-varying internal model-based control design for high precision tracking of complicated reference trajectories generated by time-varying systems. Based on a novel parallel time-varying internal model structure, asymptotic tracking conditions for the design of internal model units are developed, and a low order robust time-varying stabilizer is further synthesized. In a discrete time setting, the high precision tracking control architecture is deployed on a Voice Coil Motor (VCM) actuated servo gantry system, where numerical simulations and real time experimental results are provided, achieving the tracking errors around 3.5‰ for frequency-varying signals.

Anti-CD20 as the B-Cell Targeting Agent in a Combined Therapy to Modulate Anti-Factor VIII Immune Responses in Hemophilia a Inhibitor Mice.

Neutralizing antibody formation against transgene products can represent a major complication following gene therapy with treatment of genetic diseases, such as hemophilia A. Although successful approaches have been developed to prevent the formation of anti-factor VIII (FVIII) antibodies, innovative strategies to overcome pre-existing anti-FVIII immune responses in FVIII-primed subjects are still lacking. Anti-FVIII neutralizing antibodies circulate for long periods in part due to persistence of memory B-cells. Anti-CD20 targets a variety of B-cells (pre-B-cells to mature/memory cells); therefore, we investigated the impact of B-cell depletion on anti-FVIII immune responses in hemophilia A mice using anti-CD20 combined with regulatory T (Treg) cell expansion using IL-2/IL-2mAb complexes plus rapamycin. We found that anti-CD20 alone can partially modulate anti-FVIII immune responses in both unprimed and FVIII-primed hemophilia A mice. Moreover, in mice treated with anti-CD20+IL-2/IL-2mAb complexes+rapamycin+FVIII, anti-FVIII antibody titers were significantly reduced in comparison to mice treated with regimens targeting only B or T cells. In addition, titers remained low after a second challenge with FVIII plasmid. Treg cells and activation markers were transiently and significantly increased in the groups treated with IL-2/IL-2mAb complexes; however, significant B-cell depletion was obtained in anti-CD20-treated groups. Importantly, both FVIII-specific antibody-secreting cells and memory B-cells were significantly reduced in mice treated with combination therapy. This study demonstrates that a combination regimen is highly promising as a treatment option for modulating anti-FVIII antibodies and facilitating induction of long-term tolerance to FVIII in hemophilia A mice.

Immunomodulation of transgene responses following naked DNA transfer of human factor VIII into hemophilia A mice.

A robust humoral immune response against human factor VIII (hFVIII) following naked DNA transfer into immunocompetent hemophilia A mice completely inhibits circulating FVIII activity despite initial high-level hFVIII gene expression. To prevent this undesirable response, we compared transient immunomodulation strategies. Eight groups of mice (n = 4-9 per group) were treated with naked DNA transfer of pBS-HCRHPI-hFVIIIA simultaneously with immunosuppressive reagents that included cyclosporine A (CSA), rapamycin (RAP), mycophenylate mofetil (MMF), a combination of CSA and MMF, a combination of RAP and MMF, a monoclonal antibody against murine CD40 ligand (MR1), recombinant murine Ctla4Ig, and a combination of MR1 and Ctla4Ig. All animals except those receiving only CSA exhibited delayed or absent immune responses against hFVIII. The most effective immunosuppressive regimen, the combination of Ctla4Ig and MR1, prevented inhibitor formation in 8 of 9 animals; the ninth had transient low-titer antibodies. All 9 mice of this group produced persistent, therapeutic levels of hFVIII for more than 6 months. When challenged with the T-dependent antigen bacteriophage Phix174, tolerized mice exhibited normal primary and secondary antibody responses, suggesting that transient immunomodulation to disrupt B/T-cell interaction at the time of plasmid injection effectively promoted long-term immune tolerance specific for hFVIII.

Naked DNA transfer of Factor VIII induced transgene-specific, species-independent immune response in hemophilia A mice.

The development of antibodies to a previously unexpressed protein product may limit the success of human gene therapy approaches. We inserted B-domain-deleted factor VIII (FVIII) cDNA of human, canine, or murine origin into the multiple cloning site of a liver-specific vector, pBS-HCRHPI-A, to yield plasmids pBS-HCRHPI-FVIIIA, pBS-HCRHPI-cFVIIIA, and pBS-HCRHPI-mFVIIIA, respectively. Fifty micrograms of each plasmid in 2 ml of solution was rapidly injected into the tail vein of three groups of hemophilia A mice. Factor VIII levels ranging from 3 to 12 IU/ml were obtained from all three groups (normal is 1 IU/ml in human plasma) 3 days after treatment. These initial very high levels of functional human, canine, or murine factor VIII, however, fell gradually to undetectable levels within 2-3 weeks, and their disappearance correlated with the generation of high-titer, inhibitory anti-FVIII antibodies. Notably, this immune response occurred independent of the species of origin of the exogenous factor VIII. Antibody titers to factor VIII were detected beginning at 2 weeks, reached a plateau and remained at high levels for over 6 months. The majority of anti-hFVIII IgG was IgG1 isotype specific, suggesting a humoral response mediated by Th2-induced signals. Consistent with this idea, in a separate group of mice treated with pBS-HCRHPI-FVIIIA, transient immunosuppression by cyclophosphamide significantly delayed (5/6) or abolished (1/6) inhibitory antibody formation against the transgene.