The dosimetric impact of titanium implants in spinal SBRT using four commercial treatment planning algorithms.

To evaluate the dosimetric impact of titanium implants in spine SBRT using four dose calculation algorithms. Twenty patients with titanium implants in the spine treated with SBRT without density override (DO) were selected. The clinical plan for each patient was created in Pinnacle and subsequently imported into Eclipse (AAA and AcurosXB) and Raystation (CC) for dose evaluation with and without DO to the titanium implant. We renormalized all plans such that 90% of the tumor volume received the prescription dose and subsequently evaluated the following dose metrics: (1) the maximum dose to 0.03 cc (Dmax), dose to 99% (D99%) and 90% (D90%) of the tumor volume; (2) Dmax and volumetric metrics of the spinal cord. For the same algorithm, plans with and without DO had similar dose distributions. Differences in Dmax, D99% and D90% of the tumor were on average <2% with slightly larger variations up to 5.58% in Dmax using AcurosXB. Dmax of the spinal cord for plans calculated with DO increased but the differences were clinically insignificant for all algorithms (mean: 0.36% ± 0.7%). Comparing to the clinical plans, the relative differences for all algorithms had an average of 1.73% (-10.36%-13.21%) for the tumor metrics and -0.93% (-9.87%-10.95%) for Dmax of the spinal cord. A few cases with small tumor and spinal cord volumes, dose differences of >10% in both D99% and Dmax of the tumor, and Dmax of the spinal cord were observed. For all algorithms, the presence of titanium implants in the spine for most patients had minimal impact on dose distributions with and without DO. For the same plan calculated with different algorithms, larger differences in volumetric metrics of >10% could be observed, impacted by dose gradient at the plan normalization volume, tumor volumes, plan complexity, and partial voxel volume interpolation.

Physical analysis reveals distinct responses of human bronchial epithelial cells to guanidine and isothiazolinone biocides.

Changes in the physical state of the cells can serve as important indicators of stress responses because they are closely linked with the changes in the pathophysiological functions of the cells. Physical traits can be conveniently assessed by analyzing the morphological features and the stresses at the cell-matrix and cell-cell adhesions in both single-cell and monolayer model systems in 2D. In this study, we investigated the mechano-stress responses of human bronchial epithelial cells, BEAS-2B, to two functionally distinct groups of biocides identified during the humidifier disinfectant accident, namely, guanidine (PHMG) and isothiazolinone (CMIT/MIT). We analyzed the physical traits, including cell area, nuclear area, and nuclear shape. While the results showed inconsistent average responses to the biocides, the degree of dispersion in the data set, measured by standard deviation, was remarkably higher in CMIT/MIT treated cells for all traits. As mechano-stress endpoints, traction and intercellular stresses were also measured, and the cytoskeletal actin structures were analyzed using immunofluorescence. This study demonstrates the versatility of the real-time imaging-based biomechanical analysis, which will contribute to identifying the temporally sensitive cellular behaviors as well as the emergence of heterogeneity in response to exogenously imposed stress factors. This study will also shed light on a comparative understanding of less studied substance, CMIT/MIT, in relation to a more studied substance, PHMG, which will further contribute to more strategic planning for proper risk management of the ingredients involved in toxicological accidents.

Image-guided volumetric-modulated arc therapy of total body irradiation: An efficient workflow from simulation to delivery.

INTRODUCTION: Using multi-isocenter volumetric-modulated arc therapy (VMAT) for total body irradiation (TBI) may improve dose uniformity and vulnerable tissue protection compared with classical whole-body field technique. Two drawbacks limit its application: (1) VMAT-TBI planning is time consuming; (2) VMAT-TBI plans are sensitive to patient positioning uncertainties due to beam matching. This study presents a robust planning technique with image-guided delivery to improve dose delivery accuracy. In addition, a streamlined sim-to-treat workflow with automatic scripts is proposed to reduce planning time. MATERIALS: Twenty-five patients were included in this study. Patients were scanned in supine head-first and feet-first directions. An automatic workflow was used to (1) create a whole-body CT by registering two CT scans, (2) contour lungs, kidneys, and planning target volume (PTV), (3) divide PTV into multiple sub-targets for planning, and (4) place isocenters. Treatment planning included feathered AP/PA beams for legs/feet and VMAT for the body. VMAT-TBI was evaluated for plan quality, planning/delivery time, and setup accuracy using image guidance. RESULTS: VMAT-TBI planning time can be reduced to a day with automatic scripts. Treatment time took around an hour per fraction. VMAT-TBI improved dose coverage (PTV V100 increased from 76.8 ± 10.5 to 88.5 ± 2.6; p < 0.001) and reduced lung dose (lung mean dose reduced from 10.8 ± 0.7 Gy to 9.4 ± 0.8 Gy, p < 0.001) compared with classic AP/PA technique. CONCLUSION: A VMAT-TBI sim-to-treat workflow with robust planning and image-guided delivery was proposed. VMAT-TBI improved the plan quality compared with classical whole-body field techniques.

Enhancing PKA-dependent mesothelial barrier integrity reduces ovarian cancer transmesothelial migration via inhibition of contractility.

Cancer-mesothelial cell interactions are critical for multiple solid tumors to colonize the surface of peritoneal organs. Understanding mechanisms of mesothelial barrier dysfunction that impair its protective function is critical for discovering mesothelial-targeted therapies to combat metastatic spread. Here, we utilized a live cell imaging-based assay to elucidate the dynamics of ovarian cancer spheroid transmesothelial migration and mesothelial-generated mechanical forces. Treatment of mesothelial cells with the adenylyl cyclase agonist forskolin strengthens cell-cell junctions, reduces actomyosin fibers, contractility-driven matrix displacements, and cancer spheroid transmigration in a protein kinase A (PKA)-dependent mechanism. We also show that inhibition of the cytoskeletal regulator Rho-associated kinase in mesothelial cells phenocopies the anti-metastatic effects of forskolin. Conversely, upregulation of contractility in mesothelial cells disrupts cell-cell junctions and increases the clearance rates of ovarian cancer spheroids. Our findings demonstrate the critical role of mesothelial cell contractility and mesothelial barrier integrity in regulating metastatic dissemination within the peritoneal microenvironment.

CAR T cell infiltration and cytotoxic killing within the core of 3D breast cancer spheroids under control of antigen sensing in microwell arrays.

The success of chimeric antigen receptor (CAR) T cells in blood cancers has intensified efforts to develop CAR T therapies for solid cancers. In the solid tumor microenvironment, CAR T cell trafficking and suppression of cytotoxic killing represent limiting factors for therapeutic efficacy. Here, we present a microwell platform to study CAR T cell interactions with 3D tumor spheroids and determine predictors of anti-tumor CAR T cell function. To precisely control antigen sensing by CAR T cells, we utilized a switchable adaptor CAR system, that instead of directly binding to an antigen of interest, covalently attaches to co-administered antibody adaptors that mediate tumor antigen recognition. Following addition of an anti-HER2 adaptor antibody, primary human CAR T cells exhibited higher infiltration and clustering compared to the no adaptor control. By tracking CAR T cell killing at the individual spheroid level, we showed the suppressive effects of spheroid size and identified the initial CAR T cell : spheroid area ratio as a predictor of cytotoxicity. Spatiotemporal analysis revealed lower CAR T cell numbers and cytotoxicity in the spheroid core compared to the periphery. Finally, increasing CAR T cell seeding density, resulted in higher CAR T cell infiltration and cancer cell elimination in the spheroid core. Our findings provide new quantitative insights into CAR T cell-mediated killing of HER2+ breast tumor cells. Given the miniaturized nature and live imaging capabilities, our microfabricated system holds promise for discovering cell-cell interaction mechanisms that orchestrate antitumor CAR T cell functions and screening cellular immunotherapies in 3D tumor models.

Cancer-cell derived S100A11 promotes macrophage recruitment in ER+ breast cancer.

Macrophages are pivotal in driving breast tumor development, progression, and resistance to treatment, particularly in estrogen receptor-positive (ER+) tumors, where they infiltrate the tumor microenvironment (TME) influenced by cancer cell-secreted factors. By analyzing single-cell RNA-sequencing data from 25 ER+ tumors, we elucidated interactions between cancer cells and macrophages, correlating macrophage density with epithelial cancer cell density. We identified that S100A11, a previously unexplored factor in macrophage-cancer crosstalk, predicts high macrophage density and poor outcomes in ER+ tumors. We found that recombinant S100A11 enhances macrophage infiltration and migration in a dose-dependent manner. Additionally, in 3D models, we showed that S100A11 expression levels in ER+ cancer cells predict macrophage infiltration patterns. Neutralizing S100A11 decreased macrophage recruitment, both in cancer cell lines and in a clinically relevant patient-derived organoid model, underscoring its role as a paracrine regulator of cancer-macrophage interactions in the protumorigenic TME. This study offers novel insights into the interplay between macrophages and cancer cells in ER+ breast tumors, highlighting S100A11 as a potential therapeutic target to modulate the macrophage-rich tumor microenvironment.

Radio-immune response modelling for spatially fractionated radiotherapy.

Objective.Radiation-induced cell death is a complex process influenced by physical, chemical and biological phenomena. Although consensus on the nature and the mechanism of the bystander effect were not yet made, the immune process presumably plays an important role in many aspects of the radiotherapy including the bystander effect. A mathematical model of immune response during and after radiation therapy is presented.Approach.Immune response of host body and immune suppression of tumor cells are modelled with four compartments in this study; viable tumor cells, T cell lymphocytes, immune triggering cells, and doomed cells. The growth of tumor was analyzed in two distinctive modes of tumor status (immune limited and immune escape) and its bifurcation condition.Main results.Tumors in the immune limited mode can grow only up to a finite size, named as terminal tumor volume analytically calculated from the model. The dynamics of the tumor growth in the immune escape mode is much more complex than the tumors in the immune limited mode especially when the status of tumor is close to the bifurcation condition. Radiation can kill tumor cells not only by radiation damage but also by boosting immune reaction.Significance.The model demonstrated that the highly heterogeneous dose distribution in spatially fractionated radiotherapy (SFRT) can make a drastic difference in tumor cell killing compared to the homogeneous dose distribution. SFRT cannot only enhance but also moderate the cell killing depending on the immune response triggered by many factors such as dose prescription parameters, tumor volume at the time of treatment and tumor characteristics. The model was applied to the lifted data of 67NR tumors on mice and a sarcoma patient treated multiple times over 1200 days for the treatment of tumor recurrence as a demonstration.

Fibrous Matrix Architecture-Dependent Activation of Fibroblasts with a Cancer-Associated Fibroblast-like Phenotype.

Cancer-associated fibroblasts (CAFs) are one of the most prevalent cell types within the tumor microenvironment (TME). While several physicochemical cues from the TME, including growth factors, cytokines, and ECM specificity, have been identified as essential factors for CAF activation, the precise mechanism of how the ECM architecture regulates CAF initiation remains elusive. Using a gelatin-based electrospun fiber mesh, we examined the effect of matrix fiber density on CAF activation induced by MCF-7 conditioned media (CM). A less dense (3D) gelatin mesh matrix facilitated better activation of dermal fibroblasts into a CAF-like phenotype in the CM than a highly dense (3D) gelatin mesh matrix. In addition, it was discovered that CAF activation on the less dense (LD) matrix is dependent on the cell size-related AKT/mTOR signaling cascade, accompanied by an increase in intracellular tension within the well-spread fibroblasts.

Radio-Immune Response Modelling for Spatially Fractionated Radiotherapy.

Radiation-induced cell death is a complex process influenced by physical, chemical and biological phenomena. Strong dose gradient may intensify the complexity and reportedly creates significantly more cell death known as bystander effect. Although consensus on the nature and the mechanism of the bystander effect were not yet made, the immune process presumably plays an important role in many aspects of the radiotherapy including the bystander effect. Immune response of host body and immune suppression of tumor cells are modelled with four compartments in this study; viable tumor cells, T cell lymphocytes, immune triggering cells, and doomed cells. The growth of tumor was analyzed in two distinctive modes of tumor status (immune limited and immune escape) and its bifurcation condition. Tumors in the immune limited mode can grow only up to a finite size, named as terminal tumor volume analytically calculated from the model. The dynamics of the tumor growth in the immune escape mode is much more complex than the tumors in the immune limited mode especially when the status of tumor is close to the bifurcation condition. Radiation can kill tumor cells not only by radiation damage but also by boosting immune reaction. The model demonstrated that the highly heterogeneous dose distribution in spatially fractionated radiotherapy (SFRT) can make a drastic difference in tumor cell killing compared to the homogeneous dose distribution. SFRT can not only enhance but also moderate the cell killing depending on the immune response triggered by many factors such as dose prescription parameters, tumor volume at the time of treatment and tumor characteristics. The model was applied to the lifted data of 67NR tumors on mice and a sarcoma patient treated multiple times over 1200 days for the treatment of tumor recurrence as a demonstration.

ECM Architecture-Mediated Regulation of ß-Cell Differentiation from hESCs via Hippo-Independent YAP Activation.

Changes in the extracellular matrix (ECM) influence stem cell fate. When hESCs were differentiated on a thin layer of Matrigel coated onto PDMS (Matrigel_PDMS), they exhibited a substantial increase in focal adhesion and focal adhesion-associated proteins compared with those cultured on Matrigel coated onto TCPS (Matrigel_TCPS), resulting in YAP/TEF1 activation and ultimately promoting the transcriptional activities of pancreatic endoderm (PE)-associated genes. Interestingly, YAP activation in PE cells was mediated through integrin α3-FAK-CDC42-PP1A signaling rather than the typical Hippo signaling pathway. Furthermore, pancreatic islet-like organoids (PIOs) generated on Matrigel_PDMS secreted more insulin than those generated from Matrigel_TCPS. Electron micrographs revealed differential Matrigel architectures depending on the underlying substrate, resulting in varying cell-matrix anchorage resistance levels. Accordingly, the high apparent stiffness of the unique mucus-like network structure of Matrigel_PDMS was the critical factor that directly upregulated focal adhesion, thereby leading to better maturation of the pancreatic development of hESCs in vitro.

Dosimetric evaluation of adult and paediatric brain tumours planned using mask-based cobalt-60 fractionated stereotactic radiotherapy compared to linear accelerator-based volumetric modulated arc therapy.

INTRODUCTION: We conducted a study to evaluate the dosimetric feasibility of mask-based cobalt-60 fractionated stereotactic radiotherapy (mcfSRT) with the Leksell Gamma Knife® Icon™ device. METHODS: Eleven patients with intracranial tumours were selected for this dosimetry study. These patients, previously treated with volumetric arc therapy (VMAT), were re-planned using mcfSRT. Target volume coverage, conformity/gradient indices, doses to organs at risk and treatment times were compared between the mcfSRT and VMAT plans. Two-sided paired Wilcoxon signed-rank test was used to compare differences between the two plans. RESULTS: The V95 for PTV was similar between fractionated mcfSRT and VMAT (P = 0.47). The conformity index and gradient indices were 0.9 and 3.3, respectively, for mcfSRT compared to 0.7 and 4.2, respectively, for VMAT (P < 0.001 and 0.004, respectively). The radiation exposure to normal brain was lower for mcfSRT across V10, V25 and V50 compared with VMAT (P = 0.007, <0.001 and <0.001, respectively). The median D0.1cc for optic nerve and chiasm as well as the median D50 to the hippocampi were lower for mcfSRT compared to VMAT. Median beam-on time for mcfSRT was 9.7 min per fraction, compared to 0.9 min for VMAT (P = 0.002). CONCLUSION: mcfSRT plans achieve equivalent target volume coverage, improved conformity and gradient indices, and reduced radiation doses to organs at risk as compared with VMAT plans. These results suggest superior dosimetric parameters for mcfSRT plans and can form the basis for future prospective studies.

Implementing failure mode and effect analysis to improve the safety of volumetric modulated arc therapy for total body irradiation.

PURPOSE: Volumetric-modulated arc therapy for total body irradiation (VMAT-TBI) is a novel radiotherapy technique that has been implemented at our institution. The purpose of this work is to investigate possible failure modes (FMs) in the treatment process and to develop a quality control (QC) program for VMAT-TBI following TG-100 guidelines. METHODS: We formed a multidisciplinary team to map out the complete treatment process of VMAT-TBI following the AAPM TG-100 guidelines. This process map gives a visual representation of the VMAT-TBI workflow from the CT simulation, image processing, contouring, treatment planning, to treatment delivery. From the process map, potential FMs were identified. The occurrence (O), detectability (D), and severity of impact (S) of each FM were assigned according to scoring criteria (1-10) by the multidisciplinary team. A risk priority number (RPN) was calculated from average O, S, and D of each FM (RPN = O x S x D). High risk FMs were identified as 20% of the FMs having the highest RPN scores. After the FMEA analysis, fault-tree analysis (FTA) was performed for each major step of the treatment process to determine the effects of potential failures to the treatment outcome. Effective QC methods were identified to prevent the high risk failures and to improve the safety of the VMAT-TBI program. RESULTS: We identified a total of 55 sub-processes and 128 FMs from the VMAT-TBI workflow. The top five high-risk FMs were: (1) Prescription and/or OAR constraints changed during planning and not communicated to the planner, (2) Patient moves or breathes too heavily during the upper body CT scan (3) Patient moves during the lower body CT scan, (4) Treatment planning system not calculating total body DVH metrics correctly for TBI, (5) Improper optimization criteria used or not sufficient optimization, resulting in suboptimal dose coverage, OAR sparing or excessive hotspots during treatment planning. Two FMs have average severity scores ≥8: Incorrect PTV subdivision/isocenter placement and Prescription and/or OAR constraints changed during planning and not communicated to the planner. Quality assurance and QC interventions including staff training, standard operating procedures, and quality checklists were implemented based on the FMEA and FTA. CONCLUSION: FM and effect analysis was performed to identify high-risk FMs of our VMAT-TBI program. FMEA and FTA were effective in identifying potential FMs and determining the best quality management (QM) measures to implement in the VMAT-TBI program.

A total inverse planning paradigm: Prospective clinical trial evaluating the performance of a novel MR-based 3D-printed head immobilization device.

Background and purpose: Brain radiotherapy (cnsRT) requires reproducible positioning and immobilization, attained through redundant dedicated imaging studies and a bespoke moulding session to create a thermoplastic mask (T-mask). Innovative approaches may improve the value of care. We prospectively deployed and assessed the performance of a patient-specific 3D-printed mask (3Dp-mask), generated solely from MR imaging, to replicate a reproducible positioning and tolerable immobilization for patients undergoing cnsRT. Material and methods: Patients undergoing LINAC-based cnsRT (primary tumors or resected metastases) were enrolled into two arms: control (T-mask) and investigational (3Dp-mask). For the latter, an in-house designed 3Dp-mask was generated from MR images to recreate the head positioning during MR acquisition and allow coupling with the LINAC tabletop. Differences in inter-fraction motion were compared between both arms. Tolerability was assessed using patient-reported questionnaires at various time points. Results: Between January 2020 - July 2022, forty patients were enrolled (20 per arm). All participants completed the prescribed cnsRT and study evaluations. Average 3Dp-mask design and printing completion time was 36 h:50 min (range 12 h:56 min - 42 h:01 min). Inter-fraction motion analyses showed three-axis displacements comparable to the acceptable tolerance for the current standard-of-care. No differences in patient-reported tolerability were seen at baseline. During the last week of cnsRT, 3Dp-mask resulted in significantly lower facial and cervical discomfort and patients subjectively reported less pressure and confinement sensation when compared to the T-mask. No adverse events were observed. Conclusion: The proposed total inverse planning paradigm using a 3D-printed immobilization device is feasible and renders comparable inter-fraction performance while offering a better patient experience, potentially improving cnsRT workflows and its cost-effectiveness.

Fast transit portal dosimetry using density-scaled layer modeling of aSi-based electronic portal imaging device and Monte Carlo method.

PURPOSE: Fast and accurate transit portal dosimetry was investigated by developing a density-scaled layer model of electronic portal imaging device (EPID) and applying it to a clinical environment. METHODS: The model was developed for fast Monte Carlo dose calculation. The model was validated through comparison with measurements of dose on EPID using first open beams of varying field sizes under a 20-cm-thick flat phantom. After this basic validation, the model was further tested by applying it to transit dosimetry and dose reconstruction that employed our predetermined dose-response-based algorithm developed earlier. The application employed clinical intensity-modulated beams irradiated on a Rando phantom. The clinical beams were obtained through planning on pelvic regions of the Rando phantom simulating prostate and large pelvis intensity modulated radiation therapy. To enhance agreement between calculations and measurements of dose near penumbral regions, convolution conversion of acquired EPID images was alternatively used. In addition, thickness-dependent image-to-dose calibration factors were generated through measurements of image and calculations of dose in EPID through flat phantoms of various thicknesses. The factors were used to convert acquired images in EPID into dose. RESULTS: For open beam measurements, the model showed agreement with measurements in dose difference better than 2% across open fields. For tests with a Rando phantom, the transit dosimetry measurements were compared with forwardly calculated doses in EPID showing gamma pass rates between 90.8% and 98.8% given 4.5 mm distance-to-agreement (DTA) and 3% dose difference (DD) for all individual beams tried in this study. The reconstructed dose in the phantom was compared with forwardly calculated doses showing pass rates between 93.3% and 100% in isocentric perpendicular planes to the beam direction given 3 mm DTA and 3% DD for all beams. On isocentric axial planes, the pass rates varied between 95.8% and 99.9% for all individual beams and they were 98.2% and 99.9% for the composite beams of the small and large pelvis cases, respectively. Three-dimensional gamma pass rates were 99.0% and 96.4% for the small and large pelvis cases, respectively. CONCLUSIONS: The layer model of EPID built for Monte Carlo calculations offered fast (less than 1 min) and accurate calculation for transit dosimety and dose reconstruction.

A new conformity and dose gradient distance measure for stereotactic radiosurgery of brain metastasis.

Purpose: Competing radiosurgery plans are compared based on their conformity and gradient of dose distribution to the target volume (TV). Most widely used quality metrics such as new conformity index (NCI) and gradient index (GI) are known to have strong volume dependency on the TV of interest. A simple quality measure without the volume dependency is presented for evaluating stereotactic radiosurgery plans, expressed in distance dimension compared to the unit-less volume ratio used in NCI and GI. Methods and Materials: The conformity distance measure (CDM) is defined as the effective radius of the union volume subtracted by that of the intersection volume, where volume operations are on TV and prescription isodose volume (PIV). Gradient distance measure (GDM) is defined as the effective radius of 50% PIV (low dose volume of the plan) subtracted by that of corresponding ideal low dose volume (iLDV). Volume independency and consistent sensitivity of CDM and GDM on PIV displacement and dose spillage are analyzed using a simple two-sphere model. 2429 cases of Gamma Knife and 76 cases of Linac based radiosurgery plans for brain metastasis were retrospectively studied to demonstrate volume independency of the new measures and their implication on target coverage. Results: The sensitivity of NCI on PIV displacement and dose spillage was inversely proportional to the effective radius of the target volume, while the sensitivity of CDM on target motion and dose spillage was constant regardless the target volume. The iLDV for 50% PIV was approximately 2.4 times of PIV based on previous Linac based radiosurgery/IMRT/VMAT plans and single shot analysis from Gamma Knife (GK), ICON. Although NCI ranged from 1 to 14.7 for GK plans and from 1.2 to 20.8 for VMAT plans showing strong volume dependency, CDM showed negligible volume dependency of less than 2.1 mm for more than 90% cases and peak frequency was at 0.8 mm. CDM was correlated well with target coverage as a function of PIV displacement regardless of target volume. Target coverage, V100, was larger than 95% when PIV displacement is less than CDM. Conclusions: The new conformity and gradient measure, CDM and GDM are proposed in this paper. The new measures are volume independent which is preferred for reliable evaluation of the radiosurgery plan quality over wide range of radiosurgery targets. As represented by distance dimension similar to PTV margin, the new measures may be more adequate for image guided radiosurgery applications.

Pillar-Based Mechanical Induction of an Aggressive Tumorigenic Lung Cancer Cell Model.

Tissue microarchitecture imposes physical constraints to the migration of individual cells. Especially in cancer metastasis, three-dimensional structural barriers within the extracellular matrix are known to affect the migratory behavior of cells, regulating the pathological state of the cells. Here, we employed a culture platform with micropillar arrays of 2 µm diameter and 16 µm pitch (2.16 micropillar) as a mechanical stimulant. Using this platform, we investigated how a long-term culture of A549 human lung carcinoma cells on the (2.16) micropillar-embossed dishes would influence the pathological state of the cell. A549 cells grown on the (2.16) micropillar array with 10 µm height exhibited a significantly elongated morphology and enhanced migration even after the detachment and reattachment, as evidenced in the conventional wound-healing assay, single-cell tracking analysis, and in vivo tumor colonization assays. Moreover, the pillar-induced morphological deformation in nuclei was accompanied by cell-cycle arrest in the S phase, leading to suppressed proliferation. While these marked traits of morphology-migration-proliferation support more aggressive characteristics of metastatic cancer cells, typical indices of epithelial-mesenchymal transition were not found, but instead, remarkable traces of amoeboidal transition were confirmed. Our study also emphasizes the importance of mechanical stimuli from the microenvironment during pathogenesis and how gained traits can be passed onto subsequent generations, ultimately affecting their pathophysiological behavior. Furthermore, this study highlights the potential use of pillar-based mechanical stimuli as an in vitro cell culture strategy to induce more aggressive tumorigenic cancer cell models.

Engineering 3D Cortical Spheroids for an In Vitro Ischemic Stroke Model.

Three-dimensional (3D) spheroids composed of brain cells have shown great potential to mimic the pathophysiology of the brain. However, a 3D spheroidal brain-disease model for cerebral ischemia has not been reported. This study investigated an ultralow attachment (ULA) surface-mediated formation of 3D cortical spheroids using primary rat cortical cells to recapitulate the cerebral ischemic responses in stroke by oxygen-glucose deprivation-reoxygenation (OGD-R) treatment. Comparison between two-dimensional (2D) and 3D cell culture models confirmed the better performance of the 3D cortical spheroids as normal brain models. The cortical cells cultured in 3D maintained their healthy physiological morphology of a less activated state and suppressed mRNA expressions of pathological stroke markers, S100B, IL-1ß, and MBP, selected based on in vivo stroke model. Interestingly, the spheroids formed on the ULA surface exhibited striking aggregation dynamics involving active cell-substrate interactions, whereas those formed on the agarose surface aggregated passively by the convective flow of the media. Accordingly, ULA spheroids manifested a layered arrangement of neurons and astrocytes with higher expressions of integrin ß1, integrin α5, N-cadherin, and fibronectin than the agarose spheroids. OGD-R-induced stroke model of the ULA spheroids successfully mimicked the ischemic response as evidenced by the upregulated mRNA expressions of the key markers for stroke, S100B, IL-1ß, and MBP. Our study suggested that structurally and functionally distinct cortical spheroids could be generated by simply tuning the cell-substrate binding activities during dynamic spheroidal formation, which should be an essential factor to consider in establishing a brain-disease model.

Is there a volume threshold of brain metastases for Linac-based stereotactic radiotherapy?

PURPOSE: To investigate whether there is a volume threshold in target volume of brain metastases below which a small cone size and sharp penumbra in Gamma Knife (GK) may provide improved plan quality when compared to Volumetric Modulated Arc Therapy (VMAT)-based stereotactic radiosurgery (SRS). METHODS: For patients treated on GK SRS for brain metastases in 2018-2019 in our institution, 121 patients with two and three targets were identified. Twenty-six patients with two or three brain metastases (total of 76 lesions) were selected for this study. Two VMAT plans, SmartArc (Pinnacle) and HyperArc (Eclipse), were generated retrospectively for each patient. Plan quality was evaluated based on RTOG conformity index (CI), Paddick gradient index (GI), normal tissue (NT) V12Gy and V4.5Gy. By using the receiver operating characteristic (ROC) curve for both VMAT plans (SmartArc and HyperArc) and metrics of RTOG CI and NT V12Gy, we compared GK plans to SmartArc and HyperArc plans separately to determine the threshold volume. RESULTS: For SmartArc plans, both ROC curve analyses showed a threshold volume of 0.4 cc for both CI and NT V12Gy. For HyperArc plans, the threshold volumes were 0.2 cc for the CI and 0.5 cc for NT V12Gy. GK plans produced improved dose distribution compared to VMAT for targets ≤0.4 cc, but HyperArc was found to have competing results with GK in terms of CI and NT V12Gy. For targets > 0.4 cc, both SmartArc and HyperArc showed better plan quality when compared to the GK plans. CONCLUSIONS: Target volumes ≤0.4 cc may require a small cone size and sharp penumbra in GK while for target volumes >0.4 cc, VMAT-based SRS can provide improved overall plan quality and faster treatment delivery.

Verification of source and collimator configuration for Gamma Knife Perfexion using panoramic imaging.

PURPOSE: The new model of stereotactic radiosurgery system, Gamma Knife Perfexion, allows automatic selection of built-in collimation, eliminating the need for the time consuming manual collimator installation required with previous models. However, the configuration of sources and collimators inside the system does not permit easy access for the verification of the selected collimation. While the conventional method of exposing a film at the isocenter is useful for obtaining composite dose information, it is difficult to interpret the data in terms of the integrity of each individual source and corresponding collimation. The primary aim of this study was to develop a method of verifying the geometric configuration of the sources and collimator modules of the Gamma Knife Perfexion. In addition, the method was extended to make dose measurements and verify the accuracy of dose distributions calculated by the mathematical formalism used in the treatment planning system, Leksell Gamma Plan. METHODS: A panoramic view of all of 192 cobalt sources was simultaneously acquired by exposing a radiochromic film wrapped around the surface of a cylindrical phantom. The center of the phantom was mounted at the isocenter with its axis aligned along the longitudinal axis of the couch. The sizes and shapes of the source images projected on the phantom surface were compared to those calculated based on the manufacturer's design specifications. The measured dose at various points on the film was also compared to calculations using the algorithm of the planning system. RESULTS: The panoramic images allowed clear identification of each of the 192 sources, verifying source integrity and selected collimator sizes. Dose on the film surface is due to the primary beam as well as phantom scatter and leakage contributions. Therefore, the dose at a point away from the isocenter cannot be determined simply based on the proportionality of collimator output factors; the use of a dose computation algorithm is required. Scatter and leakage dose contributions from neighboring sources were calculated and found to be 6.3% (ranging from 4.5% to 7.4%), 16.7% (12.5%-19.3%), and 66.6% (38%-78%) for the 4, 8, and 16 mm collimators, respectively, at the centers of the source images. The measured average dose on films with 16 mm collimators agrees with the dose model of the treatment planning system to within 1.0%. The average doses on the film were 24.0, 60.8, and 186.2 cGy for 4, 8, and 16 mm diameter collimators, respectively, when the machine was set to deliver a reference dose of 100 Gy to the center of an 80 mm radius spherical dosimetry phantom. CONCLUSIONS: A method of simultaneously capturing and analyzing the panoramic images of 192 cobalt sources has been developed to verify the source and collimator configuration of GK systems. The method was extended to verify the dose calculation model of the treatment planning system by comparing the measured doses on the panoramic film images and the corresponding calculated doses. The method presented can play a significant role in comprehensive commissioning and routine quality assurance testing of the Gamma Knife systems.

An artificial neural network to model response of a radiotherapy beam monitoring system.

PURPOSE: The integral quality monitor (IQM) is a real-time radiotherapy beam monitoring system, which consists of a spatially sensitive large-area ion chamber, mounted at the collimator of the linear accelerator (linac), and a calculation algorithm to predict the detector signal for each beam segment. By comparing the measured and predicted signals the system validates the beam delivery. The current commercial version of IQM uses an analytic method to predict the signal, which requires a semi-empirical approach to determine and optimize various calculation parameters. The process of developing the calculation model is complex and time consuming, and moreover, the model cannot be easily generalized across various beam delivery platforms with different combinations of beam energy, beam flattening, beam shaping elements, and Linac models. Therefore, as an alternative solution, we investigated the feasibility of developing a machine learning (ML) method, using an artificial neural network (ANN), to predict the ion chamber signal. In developing an ANN, it is not necessary to explicitly account for each of the elements of beam interactions with various structures in the beam path to the ion chamber. METHODS: The ANN was designed with multilayer perceptron (MLP). The input layer consisted of multiple features, derived from the geometrical characteristics of beam segments. Gradient descent error backpropagation technique was used to train the ANN. The combined training dataset included 270 rectangular fields, and 801 clinical IMRT fields delivered using 6 MV beams on Varian TrueBeamTM and Elekta InfinityTM . Each of 12 different ANN configurations (3 different sets of input features × 4 different sets of number of hidden nodes) was simulated 10 times with randomly selected 80% of data for training and the remaining data for validation. RESULTS: Artificial neural networks with one hidden layer, consisting of 10 nodes, and 10 input features provided optimum results. Once the feature sets were extracted, the time required for the network training was on the order of a few minutes, and the time required to perform an output calculation per field was only fraction of a second. More than 95% of clinical intensity-modulated radiation therapy (IMRT) segments were calculated within ± 3.0% modeling error for Varian Truebeam (90% and ±3.3% for Elekta Infinity). A total of 3320 volumetric-modulated arc therapy (VMAT) segments from Truebeam were calculated using the ANN trained with IMRT fields. More than 95% of the cumulative VMAT beam segments were within 3.6% modeling error, similar to the performance for IMRT segments. In general the modeling error was found to be inversely proportional to the size and intensity of the beam segment. CONCLUSIONS: A prototype ANN has been developed for predicting the signals of the IQM system, with substantially less efforts compared to the analytic model. The performance of the ANN was found to be at least equivalent to that of the analytic method, in terms of average and maximum error, for 6 MV beams on both Varian TrueBeam and Elekta Infinity platforms.