Structural basis of GPBAR activation and bile acid recognition.

The G-protein-coupled bile acid receptor (GPBAR) conveys the cross-membrane signalling of a vast variety of bile acids and is a signalling hub in the liver-bile acid-microbiota-metabolism axis1-3. Here we report the cryo-electron microscopy structures of GPBAR-Gs complexes stabilized by either the high-affinity P3954 or the semisynthesized bile acid derivative INT-7771,3 at 3 Å resolution. These structures revealed a large oval pocket that contains several polar groups positioned to accommodate the amphipathic cholic core of bile acids, a fingerprint of key residues to recognize diverse bile acids in the orthosteric site, a putative second bile acid-binding site with allosteric properties and structural features that contribute to bias properties. Moreover, GPBAR undertakes an atypical mode of activation and G protein coupling that features a different set of key residues connecting the ligand-binding pocket to the Gs-coupling site, and a specific interaction motif that is localized in intracellular loop 3. Overall, our study not only reveals unique structural features of GPBAR that are involved in bile acid recognition and allosteric effects, but also suggests the presence of distinct connecting mechanisms between the ligand-binding pocket and the G-protein-binding site in the G-protein-coupled receptor superfamily.

Impact of proton PBS machine operating parameters on the effectiveness of layer rescanning for interplay effect mitigation in lung SBRT treatment.

BACKGROUND: Rescanning is a common technique used in proton pencil beam scanning to mitigate the interplay effect. Advances in machine operating parameters across different generations of particle therapy systems have led to improvements in beam delivery time (BDT). However, the potential impact of these improvements on the effectiveness of rescanning remains an underexplored area in the existing research. METHODS: We systematically investigated the impact of proton machine operating parameters on the effectiveness of layer rescanning in mitigating interplay effect during lung SBRT treatment, using the CIRS phantom. Focused on the Hitachi synchrotron particle therapy system, we explored machine operating parameters from our institution's current (2015) and upcoming systems (2025A and 2025B). Accumulated dynamic 4D dose were reconstructed to assess the interplay effect and layer rescanning effectiveness. RESULTS: Achieving target coverage and dose homogeneity within 2% deviation required 6, 6, and 20 times layer rescanning for the 2015, 2025A, and 2025B machine parameters, respectively. Beyond this point, further increasing the number of layer rescanning did not further improve the dose distribution. BDTs without rescanning were 50.4, 24.4, and 11.4 s for 2015, 2025A, and 2025B, respectively. However, after incorporating proper number of layer rescanning (six for 2015 and 2025A, 20 for 2025B), BDTs increased to 67.0, 39.6, and 42.3 s for 2015, 2025A, and 2025B machine parameters. Our data also demonstrated the potential problem of false negative and false positive if the randomness of the respiratory phase at which the beam is initiated is not considered in the evaluation of interplay effect. CONCLUSION: The effectiveness of layer rescanning for mitigating interplay effect is affected by machine operating parameters. Therefore, past clinical experiences may not be applicable to modern machines.

Low Concentration of Peroxymonosulfate Triggers Dissolved Oxygen Conversion over Single Atomic Fe-N3 O1 Sites for Water Decontamination.

Achieving satisfactory organic pollutant oxidation with a low concentration of peroxymonosulfate (PMS) is vital for persulfate-involved advanced oxidation processes to reduce resource consumption and avoid excessive sulfate anion (SO4 2- ) production. Herein, efficient conversion of dissolved oxygen (DO) over single-atomic Fe-N3 O1 sites anchored on carbon nitride for efficient contaminant degradation is fulfilled, triggered by a low concentration of PMS (0.2 mm). Experimental and theoretical results reveal that the preferentially adsorbed PMS onto atomic Fe-N3 O1 center can deliver electrons toward the single Fe atom to increase its electron density to trigger DO reduction into superoxide radical (O2 • - ) and successive transformation into singlet oxygen (1 O2 ), which is quite different from the conventional PMS activation process mostly depending on PMS itself function for reactive oxygen species generation. On the other hand, PMS with high concentration could occupy active Fe-N3 O1 sites to hamper DO conversion and further produce massive SO4 2- . A couple of -Fe-CN0.05 -and slight PMS is effective for actual kitchen wastewater remediation and long-term bisphenol A degradation. This work elucidates the triggering role of low-concentration PMS in DO conversion over a single-atom Fe catalyst, which can inspire the development of resource-saving, cost-effective, and environmentally-friendly catalytic oxidation systems for environmental restoration.

A unique GCN5 histone acetyltransferase complex controls erythrocyte invasion and virulence in the malaria parasite Plasmodium falciparum.

The histone acetyltransferase GCN5-associated SAGA complex is evolutionarily conserved from yeast to human and functions as a general transcription co-activator in global gene regulation. In this study, we identified a divergent GCN5 complex in Plasmodium falciparum, which contains two plant homeodomain (PHD) proteins (PfPHD1 and PfPHD2) and a plant apetela2 (AP2)-domain transcription factor (PfAP2-LT). To dissect the functions of the PfGCN5 complex, we generated parasite lines with either the bromodomain in PfGCN5 or the PHD domain in PfPHD1 deleted. The two deletion mutants closely phenocopied each other, exhibiting significantly reduced merozoite invasion of erythrocytes and elevated sexual conversion. These domain deletions caused dramatic decreases not only in histone H3K9 acetylation but also in H3K4 trimethylation, indicating synergistic crosstalk between the two euchromatin marks. Domain deletion in either PfGCN5 or PfPHD1 profoundly disturbed the global transcription pattern, causing altered expression of more than 60% of the genes. At the schizont stage, these domain deletions were linked to specific down-regulation of merozoite genes involved in erythrocyte invasion, many of which contain the AP2-LT binding motif and are also regulated by AP2-I and BDP1, suggesting targeted recruitment of the PfGCN5 complex to the invasion genes by these specific factors. Conversely, at the ring stage, PfGCN5 or PfPHD1 domain deletions disrupted the mutually exclusive expression pattern of the entire var gene family, which encodes the virulent factor PfEMP1. Correlation analysis between the chromatin state and alteration of gene expression demonstrated that up- and down-regulated genes in these mutants are highly correlated with the silent and active chromatin states in the wild-type parasite, respectively. Collectively, the PfGCN5 complex represents a novel HAT complex with a unique subunit composition including an AP2 transcription factor, which signifies a new paradigm for targeting the co-activator complex to regulate general and parasite-specific cellular processes in this low-branching parasitic protist.

Turning the Inert Element Zinc into an Active Single-Atom Catalyst for Efficient Fenton-Like Chemistry.

Amongst various Fenton-like single-atom catalysts (SACs), the zinc (Zn)-related SACs have been barely reported due to the fully occupied 3d10 configuration of Zn2+ being inactive for the Fenton-like reaction. Herein, the inert element Zn is turned into an active single-atom catalyst (SA-Zn-NC) for Fenton-like chemistry by forming an atomic Zn-N4 coordination structure. The SA-Zn-NC shows admirable Fenton-like activity in organic pollutant remediation, including self-oxidation and catalytic degradation by superoxide radical (O2 ⋅- ) and singlet oxygen (1 O2 ). Experimental and theoretical results unveiled that the single-atomic Zn-N4 site with electron acquisition can transfer electrons donated by electron-rich pollutants and low-concentration PMS toward dissolved oxygen (DO) to actuate DO reduction into O2 ⋅- and successive conversion into 1 O2 . This work inspires an exploration of efficient and stable Fenton-like SACs for sustainable and resource-saving environmental applications.

Safety and tolerance assessment of milk fat globule membrane-enriched infant formulas in healthy term Chinese infants: a randomised multicenter controlled trial.

BACKGROUND: Milk fat globule membrane (MFGM), natural to breast milk, is essential for neonatal development, but lacking from standard infant formulas. OBJECTIVES: To evaluate the safety and tolerability of MFGM supplementation in formula for infants 0 to 12 months. METHODS: In a prospective, multicentre, double-blind, randomized trial, healthy term infants were randomized to a standard formula (SF, n = 104) or an MFGM-enriched formula (MF, n = 108) for 6 months and a corresponding follow-on formula until 12 months. Exclusively breast-fed infants (n = 206) were recruited as the reference group (BFR). Tolerance and safety events were recorded continuously. Anthropometric measurements were assessed at enrolment, 42 days and 4, 6, 8 and 12 months. RESULTS: Infants (n = 375) completed the study with average dropout of < 20%. Stool frequency, color, and consistency between SF and MF were not significantly different throughout, except the incidence of loose stools in MF at 6 months being lower than for SF (odds ratio 0.216, P < 0.05) and the frequency of green-colored stools at 12 months being higher in MF (CI 95%, odds ratio 8.92, P < 0.05). The BFR had a higher frequency of golden stools and lower rate of green stools (4-6 months) than the two formula-fed groups (P < 0.05). SF displayed more diarrhoea (4.8%) than MF (1%) and BFR (1%) at the 8-month visit (P < 0.05). BFR (0-1%) had significantly less (P < 0.05) lower respiratory infections than MF (4.6-6.5%) and SF (2.9-5.8%) at 6- and 8-months, respectively. Formula intake, frequency of spit-up/vomiting or poor sleep were similar between SF and MF. Growth rate (g/day) was similar at 4, 6, 8 and 12 months between the 3 groups, but growth rate for BFR was significantly higher than for SF and MF at 42 days (95% CI, P = 0.001). CONCLUSIONS: MFGM-enriched formula was safe and well-tolerated in healthy term infants between 0 and 12 months, and total incidences of adverse events were similar to that for the SF group. A few differences in formula tolerance were observed, however these differences were not in any way related to poor growth.

RBE-weighted dose and its impact on the risk of acute coronary event for breast cancer patients treated with intensity modulated proton therapy.

PURPOSE: To evaluate the relative biological effectiveness (RBE)-weighted dose to the heart and to estimate RBE uncertainties when assuming a constant RBE of 1.1, for breast cancer patients receiving intensity-modulated proton therapy (IMPT). Further, to study the impact of RBE uncertainties on the risk of an acute coronary event (ACE). MATERIAL AND METHODS: We analyzed 20 patients who received IMPT to either the left breast (n = 10) or left chest wall (n = 10) and regional lymph nodes. The Monte Carlo simulation engine, MCsquare, was used to simulate the dose-averaged linear energy transfer (LETd) map. The RBE-weighted dose to the heart and its substructures was calculated using three different RBE models. The risk of ACE was estimated per its linear relationship with mean heart dose (MHD) as established by Darby et al. RESULTS: The median MHD increased from 1.33 GyRBE assuming an RBE of 1.1 to 1.64, 1.87, and 1.99 GyRBE when using the RBE-weighted dose models. The median values (and ranges) of the excess absolute risk of ACE were 0.4% (0.1%-0.8%) when assuming an RBE of 1.1, and 0.6% (0.2%-1.0%), 0.6% (0.2%-1.1%), and 0.7% (0.2%-1.1%) with the RBE-weighted models. For our patient cohort, the maximum excess absolute risk of ACE increased by 0.3% with the RBE-weighted doses compared to the constant RBE of 1.1, reaching an excess absolute ACE risk of 1.1%. The interpatient LETd variation was small for the relevant high-dose regions of the heart. CONCLUSION: All three RBE models predicted a higher biological dose compared to the clinical standard dose assuming a constant RBE of 1.1. An underestimation of the biological dose results in underestimation of the ACE risk. Analyzing the voxel-by-voxel biological dose and the LET map alongside clinical outcomes is warranted in the development of a more accurate normal-tissue complication probability model.

Corilagin: A Novel Antivirulence Strategy to Alleviate Streptococcus pneumoniae Infection by Diminishing Pneumolysin Oligomers.

Pneumolysin (PLY) is a significant virulence factor of Streptococcus pneumoniae (S. pneumoniae), able to break through the defense system of a host and mediate the occurrence of a series of infections. Therefore, PLY as the most ideal target to prevent S. pneumoniae infection has received more and more attention and research. Corilagin is a tannic acid that exhibits excellent inhibition of PLY oligomers without bacteriostatic activity to S. pneumoniae. Herein, hemolytic activity assays, cell viability tests and western blot experiments are executed to evaluate the antivirulence efficacy of corilagin against PLY in vitro. Colony observation, hematoxylin and eosin (H&E) staining and cytokines of bronchoalveolar lavage fluid (BALF) are applied to assess the therapeutic effect of corilagin in mice infected by S. pneumoniae. The results indicate the related genes of corilagin act mainly via enrichment in pathways associated with pneumonia disease. Furthermore, molecular docking and molecular dynamics simulations show that corilagin might bind with domains 3 and 4 of PLY and interfere with its hemolytic activity, which is further confirmed by the site-directed mutagenesis of PLY. Additionally, corilagin limits PLY oligomer production without impacting PLY expression in S. pneumoniae cultures. Moreover, corilagin effectively relieves PLY-mediated cell injury without any cytotoxicity, even then reducing the colony count in the lung and the levels of pro-inflammatory factors in BALF and remarkably improving lung lesions. All the results demonstrate that corilagin may be a novel strategy to cope with S. pneumoniae infection by inhibiting PLY oligomerization.

Dryocrassin ABBA ameliorates Streptococcus pneumoniae-induced infection in vitro through inhibiting Streptococcus pneumoniae growth and neutralizing pneumolysin activity.

To explore the role of dryocrassin ABBA (ABBA) in the prevention and treatment of Streptococcus pneumoniae (S. pneumoniae) infections in vitro, a minimal inhibitory concentration test, growth curve assay, hemolysis assay, BacLight LIVE/DEAD staining experiments, oligomerization inhibition assay, time-killing test, LDH release detection assay and cytotoxicity test were performed to evaluate the efficacy of ABBA against S. pneumoniae infections in vitro. The results indicated that ABBA treatment exists bactericidal effect on S. pneumoniae at a concentration of less than 8 µg/ml. Furthermore, ABBA was effective at inhibiting the oligomerization of pneumolysin (PLY) from reducing its hemolytic activity. Meanwhile, ABBA could ameliorate cell injury by neutralizing the biological activity of PLY without cytotoxicity. In summary, ABBA was a leading compound against S. pneumoniae infections through bactericidal effect and neutralizing PLY activity.

Incorporation of the LETd-weighted biological dose in the evaluation of breast intensity-modulated proton therapy plans.

PURPOSE: To evaluate the LETd-weighted biological dose to OARs in proton therapy for breast cancer and to study the relationship of the LETd-weighted biological dose relative to the standard dose (RBE = 1.1) and thereby to provide estimations of the biological dose uncertainties with the standard dose calculations (RBE = 1.1) commonly used in clinical practice. METHOD: This study included 20 patients who received IMPT treatment to the whole breast/chest wall and regional lymph nodes. The LETd distributions were calculated along with the physical dose using an open-source Monte Carlo simulation package, MCsquare. Using the McMahon linear model, the LETd-weighted biological dose was computed from the physical dose and LETd. OAR doses were compared between the Dose (RBE = 1.1) and the LETd-weighted biological dose, on brachial plexus, rib, heart, esophagus, and Ipsilateral lung. RESULTS: On average, the LETd-weighted biological dose compared to the Dose (RBE = 1.1) was higher by 8% for the brachial plexus D0.1 cc, 13% for the ribs D0.5 cc, 24% for mean heart dose, and 10% for the esophagus D0.1 cc, respectively. The LETd-weighted doses to the Ipsilateral lung V5, V10, and V20 were comparable to the Dose (RBE = 1.1). No statistically significant difference in biological dose enhancement to OARs was observed between the intact breast group and the CW group, with the exception of the ribs: the CW group experienced slightly greater biological dose enhancement (13% vs. 12%, p = 0.04) to the ribs than the intact breast group. CONCLUSION: Enhanced biological dose was observed compared to standard dose with assumed RBE of 1.1 for the heart, ribs, esophagus, and brachial plexus in breast/CW and regional nodal IMPT plans. Variable RBE models should be considered in the evaluation of the IMPT breast plans, especially for OARs located near the end of range of a proton beam. Clinical outcome studies are needed to validate model predictions for clinical toxicities.

Unraveling the High-Activity Origin of Single-Atom Iron Catalysts for Organic Pollutant Oxidation via Peroxymonosulfate Activation.

Single-atom catalysts (SACs) have emerged as efficient materials in the elimination of aqueous organic contaminants; however, the origin of high activity of SACs still remains elusive. Herein, we identify an 8.1-fold catalytic specific activity (reaction rate constant normalized to catalyst's specific surface area and dosage) enhancement that can be fulfilled with a single-atom iron catalyst (SA-Fe-NC) prepared via a cascade anchoring method compared to the iron nanoparticle-loaded catalyst, resulting in one of the most active currently known catalysts in peroxymonosulfate (PMS) conversion for organic pollutant oxidation. Experimental data and theoretical results unraveled that the high-activity origin of the SA-Fe-NC stems from the Fe-pyridinic N4 moiety, which dramatically increases active sites by not only creating the electron-rich Fe single atom as the catalytic site but also producing electron-poor carbon atoms neighboring pyridinic N as binding sites for PMS activation including synchronous PMS reduction and oxidation together with dissolved oxygen reduction. Moreover, the SA-Fe-NC exhibits excellent stability and applicability to realistic industrial wastewater remediation. This work offers a novel yet reasonable interpretation for why a small amount of iron in the SA-Fe-NC can deliver extremely superior specific activity in PMS activation and develops a promising catalytic oxidation system toward actual environmental cleanup.

Non-Tuberculous Mycobacteria Caused Calcaneal Osteomyelitis after Ankle Local Injection Therapy.

BACKGROUND: Non-tuberculous mycobacteria (NTM) are ubiquitous, being found in water, soil, and animals. Al-though more than 170 species have been identified, the majority of human NTM diseases are caused by fewer than 20 species. Reported mycobacteria osteomyelitis cases are fewer than 200 worldwide, with patient age ranging from 6 - 88 years. Many underlying conditions, including immunocompromised patients, wounds, and physical exercise, are associated with the disease. When treating this infection, the first step to consider is an early diagnosis in the course of illness to prevent significant bone destruction and loss of function. To treat mycobacteria osteomyelitis, prolonged antibiotic administration, often in conjunction with surgical intervention, is typically required. METHODS AND RESULTS: A case of non-tuberculous mycobacteria infection leading to calcaneal osteomyelitis after ankle local injection therapy is diagnosed with magnetic resonance imaging (MRI), bacteria culture, and is further confirmed by the Next Generation Sequencing of the nucleotides. The patient recovered gradually after more than 8 months of treatment. CONCLUSIONS: Diagnosis of non-tuberculous mycobacteria infection could be challenging especially with osteomyelitis. Early diagnosis is critical to prevent prolonged treatment and adverse effects, as well as destruction of the bone and resulting dysfunction.

Non-Tuberculous Mycobacteria Pulmonary Infection Could Be Easily Misdiagnosed Leading to Serious Consequences.

BACKGROUND: Non-tuberculous mycobacteria (NTM) infection is on the rise worldwide. Chronic pulmonary infection can be difficult to diagnose, and thus easily misdiagnosed and mistreated in clinical practice, leading to serious complications. Case presentation, methods and results: A patient with NTM pulmonary infection, who had undergone a lengthy treatment course in two different hospitals, resulting in drug related multi-organ damage, was presented. The patient was ultimately diagnosed with NTM infection via a culture of lymph node biopsy, a diagnosis was further confirmed by MALDI-TOF mass spectrometry. The patient's condition improved gradually and was discharged from hospital. CONCLUSIONS: Clinicians are advised to be cautious of the likelihood of NTM pulmonary infection in febrile patients with patchy shadows in pulmonary imaging, especially after a failure to respond to a diagnostic anti-tuberculosis treatment. A lung biopsy for pathologic diagnosis and culture is necessary in order to avoid misdiagnosis and subsequent serious consequences.

Puf3 participates in ribosomal biogenesis in malaria parasites.

In this study, we characterized the Puf family gene member Puf3 in the malaria parasites Plasmodium falciparum and Plasmodium yoelii Secondary structure prediction suggested that the RNA-binding domains of the Puf3 proteins consisted of 11 pumilio repeats that were similar to those in the human Puf-A (also known as PUM3) and Saccharomyces cerevisiae Puf6 proteins, which are involved in ribosome biogenesis. Neither P. falciparum (Pf)Puf3 nor P. yoelii (Py)Puf3 could be genetically disrupted, suggesting they may be essential for the intraerythrocytic developmental cycle. Cellular fractionation of PfPuf3 in the asexual stages revealed preferential partitioning to the nuclear fraction, consistent with nuclear localization of PfPuf3::GFP and PyPuf3::GFP as detected by immunofluorescence. Furthermore, PfPuf3 colocalized with the nucleolar marker PfNop1, demonstrating that PfPuf3 is a nucleolar protein in the asexual stages. We found, however, that PyPuf3 changed its localization from being nucleolar to being present in cytosolic puncta in the mosquito and liver stages, which may reflect alternative functions in these stages. Affinity purification of molecules that associated with a PTP-tagged variant of PfPuf3 revealed 31 proteins associated with the 60S ribosome, and an enrichment of 28S rRNA and internal transcribed spacer 2 sequences. Taken together, these results suggest an essential function for PfPuf3 in ribosomal biogenesis.

Using flattening filter free beams in electronic tissue compensation whole breast irradiation with deep inspiration breath hold.

PURPOSE: In order to reduce heart dose, DIBH has become a common practice in left-sided whole breast irradiation. This technique involves a significant strain on patients due to the breath-hold requirements. We hereby investigate the dosimetric and delivery feasibility of using flattening filter free (FFF) energies with electronic tissue compensation (ECOMP) planning technique to reduce the required breath-hold lengths and increase patient compatibility. METHODS: Fifteen left-sided, postlumpectomy patients previously receiving DIBH whole-breast radiotherapy (266cGy x 16fx) were retrospectively planned using ECOMP for both 6X and 6X-FFF. A dosimetric comparison was made between the two plans for each patient using various dosimetric constraints. Delivery feasibility was analyzed by recalculating the 6X ECOMP plan with 6X-FFF without replanning (6X-FFF QA) and delivering both plans for a one-to-one comparison using Gamma analysis. Beam-on times for the 6X and 6X-FFF plans were measured. For all tests, Wilcoxon signed-rank test was used with P < 0.05 as significant. RESULTS: No statistical difference was observed between 6X and 6X-FFF plans for most dosimetric endpoints except contralateral breast Dmax (P = 0.0008) and skin Dmax (p = 0.03) and Dmin (P = 0.01) for which 6X-FFF showed favorable results when compared with 6X. 6X-FFF significantly reduced beam-on times for all patients by 22%-42% (average 32%). All plan QAs passed departmental gamma criteria (10% low-dose threshold, 3%/3mm, >95% passing). CONCLUSION: ECOMP planning with FFF was found feasible for left-sided breast patients with DIBH. Plan quality is comparable, if not better, than plans using flattened beams. FFF ECOMP could significantly reduce beam-on time and required breath-hold lengths thereby increasing patient compatibility for this treatment while offering satisfactory plan quality and delivery accuracy.

A comprehensive dosimetric study of Monte Carlo and pencil-beam algorithms on intensity-modulated proton therapy for breast cancer.

PB algorithms are commonly used for proton therapy. Previously reported limitations of the PB algorithm for proton therapy are mainly focused on high-density gradients and small-field dosimetry, the effect of PB algorithms on intensity-modulated proton therapy (IMPT) for breast cancer has yet to be illuminated. In this study, we examined 20 patients with breast cancer and systematically investigated the dosimetric impact of MC and PB algorithms on IMPT. Four plans were generated for each patient: (a) a PB plan that optimized and computed the final dose using a PB algorithm; (b) a MC-recomputed plan that recomputed the final dose of the PB plan using a MC algorithm; (c) a MC-renormalized plan that renormalized the MC-recomputed plan to restore the target coverage; and (d) a MC-optimized plan that optimized and computed the final dose using a MC algorithm. The DVH on CTVs and on organ-at-risks (OARs) from each plan were studied. The Mann-Whitney U-test was used for testing the differences between any two types of plans. We found that PB algorithms significantly overestimated the target dose in breast IMPT plans. The median value of the CTV D99% , D95% , and Dmean dropped by 3.7%, 3.4%, and 2.1%, respectively, of the prescription dose in the MC-recomputed plans compared with the PB plans. The magnitude of the target dose overestimation by the PB algorithm was higher for the breast CTV than for the chest wall CTV. In the MC-renormalized plans, the target dose coverage was comparable with the original PB plans, but renormalization led to a significant increase in target hot spots as well as skin dose. The MC-optimized plans led to sufficient target dose coverage, acceptable target hot spots, and good sparing of skin and other OARs. Utilizing the MC algorithm for both plan optimization and final dose computation in breast IMPT treatment planning is therefore desirable.

Does intensity modulation increase target dose calculation errors of conventional algorithms for lung SBRT?

PURPOSE: Conventional dose algorithms (Type A and Type B) for lung SBRT can display considerable target dose errors compared to Type-C algorithms. Intensity-modulated techniques (IMRT/VMAT) are increasingly being utilized for lung SBRT. Therefore, our study aimed to assess whether intensity modulation increased target dose calculation errors by conventional algorithms over conformal techniques. METHODS: Twenty lung SBRT patients were parallely planned with both IMRT and dynamic conformal arc (DCA) techniques using a Type-A algorithm, and another 20 patients were parallely planned with IMRT, VMAT, and DCA using a Type-B algorithm. All 100 plans were recalculated with Type-C algorithms using identical beam and monitor unit settings, with the Type-A/Type-B algorithm dose errors defined using Type-C recalculation as the ground truth. Target dose errors for PTV and GTV were calculated for a variety of dosimetric end points. Using Wilcoxon signed-rank tests (p < 0.05 for statistical significance), target dose errors were compared between corresponding IMRT/VMAT and DCA plans for the two conventional algorithms. The levels of intensity modulation were also evaluated using the ratios of MUs in the IMRT/VMAT plans to those in the corresponding DCA plans. Linear regression was used to study the correlation between intensity modulation and relative dose error magnitudes. RESULTS: Overall, larger errors were found for the Type-A algorithm than for the Type-B algorithm. However, the IMRT/VMAT plans were not found to have statistically larger dose errors from their corresponding DCA plans. Linear regression did not identify a significant correlation between the intensity modulation level and the relative dose error. CONCLUSION: Intensity modulation did not appear to increase target dose calculation errors for lung SBRT plans calculated with conventional algorithms.

Dosimetric and radiobiological comparison for quality assurance of IMRT and VMAT plans.

INTRODUCTION: The gamma analysis used for quality assurance of a complex radiotherapy plan examines the dosimetric equivalence between planned and measured dose distributions within some tolerance. This study explores whether the dosimetric difference is correlated with any radiobiological difference between delivered and planned dose. METHODS: VMAT or IMRT plans optimized for 14 cancer patients were calculated and delivered to a QA device. Measured dose was compared against planned dose using 2-D gamma analysis. Dose volume histograms (for various patient structures) obtained by interpolating measured data were compared against the planned ones using a 3-D gamma analysis. Dose volume histograms were used in the Poisson model to calculate tumor control probability for the treatment targets and in the Sigmoid dose-response model to calculate normal tissue complication probability for the organs at risk. RESULTS: Differences in measured and planned dosimetric data for the patient plans passing at ≥94.9% rate at 3%/3 mm criteria are not statistically significant. Average ± standard deviation tumor control probabilities based on measured and planned data are 65.8±4.0% and 67.8±4.1% for head and neck, and 71.9±2.7% and 73.3±3.1% for lung plans, respectively. The differences in tumor control probabilities obtained from measured and planned dose are statistically insignificant. However, the differences in normal tissue complication probabilities for larynx, lungs-GTV, heart, and cord are statistically significant for the patient plans meeting ≥94.9% passing criterion at 3%/3 mm. CONCLUSION: A ≥90% gamma passing criterion at 3%/3 mm cannot assure the radiobiological equivalence between planned and delivered dose. These results agree with the published literature demonstrating the inadequacy of the criterion for dosimetric QA and suggest for a tighter tolerance.

Effect of the normalized prescription isodose line on the magnitude of Monte Carlo vs. pencil beam target dose differences for lung stereotactic body radiotherapy.

In lung stereotactic body radiotherapy (SBRT) cases, the pencil beam (PB) dose calculation algorithm is known to overestimate target dose as compared to the more accurate Monte Carlo (MC) algorithm. We investigated whether changing the normalized prescription isodose line affected the magnitude of MC vs. PB target dose differences. Forty-eight patient plans and twenty virtual-tumor phantom plans were studied. For patient plans, four alternative plans prescribed to 60%, 70%, 80%, and 90% isodose lines were each created for 12 patients who previously received lung SBRT treatments. Using 6 MV dynamic conformal arcs, the plans were individually optimized to achieve similar dose coverage and conformity for all plans of the same patient, albeit at the different prescription levels. These plans, having used a PB algorithm, were all recalculated with MC to compare the target dose differences. The relative MC vs. PB target dose variations were investigated by comparing PTV D95, Dmean, and D5 loss at the four prescription levels. The MC-to-PB ratio of the plan heterogeneity index (HI) was also evaluated and compared among different isodose levels. To definitively demonstrate the cause of the isodose line dependence, a simulated phantom study was conducted using simple, spherical virtual tumors planned with uniform block margins. The tumor size and beam energy were also altered in the phantom study to investigate the interplay between these confounding factors and the isodose line effect. The magnitude of the target dose overestimation by PB was greater for higher prescription isodose levels. The MC vs. PB reduction in the target dose coverage indices, D95 and V100 of PTV, were found to monotonically increase with increasing isodose lines from 60% to 90%, resulting in more pronounced target dose coverage deficiency at higher isodose prescription levels. No isodose level-dependent trend was observed for the dose errors in the target mean or high dose indices, Dmean or D5. The phantom study demonstrated that the observed isodose level dependence was caused by different beam margins used for the different isodose levels: a higher prescription line required a larger beam margin, leading to more low-density lung tissues in the field and, therefore, larger dose errors at the target periphery (when calculated with PB). The phantom study also found that the observed isodose level dependence was greater for smaller targets and for higher beam energies. We hereby characterized the effect of normalized prescription isodose line on magnitude of PTV dose coverage as calculated by MC vs. PB. When comparing reported MC dose deficiency values for different patients, the selection of prescription isodose line should be considered in addition to other factors known to affect differences in calculated doses between various algorithms.

Spatially fractionated radiotherapy (GRID) using helical tomotherapy.

Spatially fractionated radiotherapy (GRID) was designed to treat large tumors while sparing skin, and it is usually delivered with a linear accelerator using a commercially available block or multileaf collimator (LINAC-GRID). For deep-seated (skin to tumor distance (> 8 cm)) tumors, it is always a challenge to achieve adequate tumor dose coverage. A novel method to perform GRID treatment using helical tomotherapy (HT-GRID) was developed at our institution. Our approach allows treating patients by generating a patient-specific virtual GRID block (software-generated) and using IMRT technique to optimize the treatment plan. Here, we report our initial clinical experience using HT-GRID, and dosimetric comparison results between HT-GRID and LINAC-GRID. This study evaluates 10 previously treated patients who had deep-seated bulky tumors with complex geometries. Five of these patients were treated with HT-GRID and replanned with LINAC-GRID for comparison. Similarly, five other patients were treated with LINAC-GRID and replanned with HT-GRID for comparison. The prescription was set such that the maximum dose to the GTV is 20 Gy in a single fraction. Dosimetric parameters compared included: mean GTV dose (DGTV mean), GTV dose inhomogeneity (valley-to-peak dose ratio (VPR)), normal tissue doses (DNmean), and other organs-at-risk (OARs) doses. In addition, equivalent uniform doses (EUD) for both GTV and normal tissue were evaluated. In summary, HT-GRID technique is patient-specific, and allows adjustment of the GRID pattern to match different tumor sizes and shapes when they are deep-seated and cannot be adequately treated with LINAC-GRID. HT-GRID delivers a higher DGTV mean, EUD, and VPR compared to LINAC-GRID. HT-GRID delivers a higher DNmean and lower EUD for normal tissue compared to LINAC-GRID. HT-GRID plans also have more options for tumors with complex anatomical relationships between the GTV and the avoidance OARs (abutment or close proximity).