Model-Based Selection for Proton Therapy in Breast Cancer: Development of the National Indication Protocol for Proton Therapy and First Clinical Experiences.

AIMS: Proton therapy is a radiation technique that yields less dose in normal tissues than photon therapy. In the Netherlands, proton therapy is reimbursed if the reduced dose to normal tissues is predicted to translate into a prespecified reduction in toxicity, based on nationally approved validated models. The aim of this paper is to present the development of a national indication protocol for proton therapy (NIPP) for model-based selection of breast cancer patients and to report on first clinical experiences. MATERIALS AND METHODS: A national proton therapy working group for breast cancer (PWG-BC) screened the literature for prognostic models able to estimate the individual risk of specific radiation-induced side-effects. After critical appraisal and selection of suitable models, a NIPP for breast cancer was written and subjected to comments by all stakeholders. The approved NIPP was subsequently introduced to select breast cancer patients who would benefit most from proton therapy. RESULTS: The model of Darby et al. (N Engl J Med 2013; 368:987-82) was the only model fulfilling the criteria prespecified by the PWG-BC. The model estimates the relative risk of an acute coronary event (ACE) based on the mean heart dose. The absolute lifetime risk of ACE <80 years was calculated by applying this model to the Dutch absolute incidence of ACE for female and male patients, between 40 and 70 years at breast cancer radiotherapy, with/without cardiovascular risk factors. The NIPP was approved for reimbursement in January 2019. Based on a threshold value of a 2% absolute lower risk on ACE for proton therapy compared with photons, 268 breast cancer patients have been treated in the Netherlands with proton therapy between February 2019 and January 2021. CONCLUSION: The NIPP includes a model that allows the estimation of the absolute risk on ACE <80 years based on mean heart dose. In the first 2 years, 268 breast cancer patients have been treated with proton therapy in The Netherlands.

A generic curriculum development model for the biomedical physics component of the educational and training programmes of the non-physics healthcare professions.

The objective of the study was the construction of a generic curriculum development model for the use of biomedical physics (BMP) educators teaching the non-physics healthcare professions (HCP) in Europe. A comprehensive, qualitative cross-sectional Europe-wide survey of the curricula delivered by BMP in Faculties of Medicine and Health Sciences (FMHS) was carried out. Curricular content was collected from faculty web-sites, curricular documents and textbooks. The survey data was supplemented with semi-structured interviews and direct observation during onsite visits. The number of faculties studied was 118 from 67 universities spread all over Europe, whilst the number of onsite visits/interviews was 15 (geographically distributed as follows: Eastern Europe 6, North Western Europe 5, and South Western Europe 4). EU legislation, recommendations by European national medical councils, educational benchmark statements by higher education quality assurance agencies, research journals concerning HCP education and other documents relevant to standards in clinical practice and undergraduate education were also analyzed. Best practices and BMP learning outcomes were elicited from the curricular materials, interviews and documentation and these were subsequently used to construct the curriculum development model. A structured, comprehensive BMP learning outcomes inventory was designed in the format required by the European Qualifications Framework (EQF). The structures of the inventory and curriculum development model make them ideally suited for use by BMP involved in European curriculum development initiatives for the HCP.

The influence of simultaneous integrated boost, hypofractionation and oncoplastic surgery on cosmetic outcome and PROMs after breast conserving therapy.

INTRODUCTION: We retrospectively investigated the possible influence of a simultaneous integrated boost (SIB), hypofractionation and oncoplastic surgery on cosmetic outcome in 125 patients with stage I-II breast cancer treated with breast conserving therapy (BCT). PATIENTS AND METHODS: The boost was given sequentially (55%) or by SIB (45%); fractionation was conventional (83%) or hypofractionated (17%); the surgical technique was a conventional lumpectomy (74%) or an oncoplastic technique (26%). We compared cosmetic results subjectively using a questionnaire independently completed by the patient and by the physician and objectively with the BCCT.core software. Independent-samples T-tests were used to compare outcome in different groups. Patients also completed the EORTC QLQ C30 and BR23. RESULTS: Univariate analyses indicated no significant differences of the cosmetic results (P ≤ 0.05) for the type of boost or fractionation. However, the conventional lumpectomy group scored significantly better than the oncoplastic group in the BCCT.core evaluation, without a significant difference in the subjective cosmetic evaluation. Quality of life outcome was in favour of SIB, hypofractionation and conventional surgery. CONCLUSION: Our study indicates that the current RT techniques seem to be safe for cosmetic outcome and quality of life. Further investigation is needed to verify the possible negative influence of oncoplastic surgery on the cosmetic outcome and the quality of life as this technique is especially indicated for patients with an unfavourable tumour/breast volume ratio.

The traditional Chinese medical compound Rocaglamide protects nonmalignant primary cells from DNA damage-induced toxicity by inhibition of p53 expression.

One of the main obstacles of conventional anticancer therapy is the toxicity of chemotherapeutics to normal tissues. So far, clinical approaches that aim to specifically reduce chemotherapy-mediated toxicities are rare. Recently, a number of studies have demonstrated that herbal extracts derived from traditional Chinese medicine (TCM) may reduce chemotherapy-induced side effects. Thus, we screened a panel of published cancer-inhibiting TCM compounds for their chemoprotective potential and identified the phytochemical Rocaglamide (Roc-A) as a candidate. We show that Roc-A significantly reduces apoptotic cell death induced by DNA-damaging anticancer drugs in primary human and murine cells. Investigation of the molecular mechanism of Roc-A-mediated protection revealed that Roc-A specifically blocks DNA damage-induced upregulation of the transcription factor p53 by inhibiting its protein synthesis. The essential role of p53 in Roc-A-mediated protection was confirmed by siRNA knockdown of p53 and by comparison of the effects of Roc-A on chemoprotection of splenocytes isolated from wild-type and p53-deficient mice. Importantly, Roc-A did not protect p53-deficient or -mutated cancer cells. Our data suggest that Roc-A may be used as an adjuvant to reduce the side effects of chemotherapy in patients with p53-deficient or -mutated tumors.

Therapy of chronic myeloid leukaemia can benefit from the activation of stem cells: simulation studies of different treatment combinations.

BACKGROUND: Newly diagnosed patients with chronic myeloid leukaemia (CML) are currently treated with tyrosine kinase inhibitors (TKIs) such as imatinib, nilotinib or dasatinib. However, incomplete eradication of residual disease is a general problem of long-term TKI therapy. Activation of mouse haematopoietic stem cells by interferon-α (IFNα) stimulated the discussion of whether a combination treatment leads to accelerated eradication of the CML clone. METHODS: We base our simulation approach on a mathematical model describing human CML as a competition phenomenon between normal and malignant cells. We amend this model to incorporate the description of IFNα activity and simulate different scenarios for potential treatment combinations. RESULTS: We demonstrate that the overall sensitivity of CML stem cells to IFNα activation is a crucial determinant for the benefit of a potential combination therapy. We furthermore show that pulsed IFNα together with continuous TKI administration is the most promising strategy for a combination treatment in which the therapeutic benefit prevails adverse side effects. CONCLUSION: Our modelling approach is a highly beneficial tool to quantitatively address the competition between normal and leukaemic haematopoiesis in treated CML patients. We derive testable predictions for different experimental settings that are suggested before the clinical implementation of the combination treatment.

Leukemic spleen cells are more potent than bone marrow-derived cells in a transgenic mouse model of CML.

Spleen size ranks among the most important risk factors in chronic myeloid leukemia (CML), but the pathogenic mechanisms of splenic hematopoiesis in CML remain poorly defined. Here, we studied the biology of Bcr-Abl positive leukemia-initiating cells in the spleen, using an inducible transgenic mouse model of CML. Disease kinetics showed greater increases of immature leukemic cells in spleen vs bone marrow (BM). To assess how Bcr-Abl alters the behavior of spleen-derived CML cells, we transplanted these cells either before ('pre-uninduced') or 44 days after ('pre-induced') expression of the oncogene. Mice transplanted with pre-induced spleen cells showed significantly increased neutrophilia and splenomegaly compared with mice receiving pre-uninduced spleen cells, suggesting that Bcr-Abl expression in the donors had increased splenic tumor burden. However, pre-induction also altered the biology of these cells, as shown by a striking increase in erythropoietic potential. These results differ from those of BM-derived CML stem cells where pre-induction of Bcr-Abl had previously been shown to decrease disease transplantability. Moreover, splenic cells were less sensitive to imatinib than BM cells. In conclusion, Bcr-Abl alters the biology of splenic leukemic stem cells by a cell-autonomous mechanism, but the disease phenotype is also influenced by the microenvironment of these cells.

Multiresidue analysis of beta-agonists in bovine and porcine urine, feed and hair using liquid chromatography electrospray ionisation tandem mass spectrometry.

The use of beta-agonists as growth promoters in cattle breeding is forbidden in many countries for reasons of fair trade and consumer protection. In recent years the use of liquid chromatography (LC) tandem mass spectrometry (MS/MS) has been shown to be the method of choice for the control of beta-agonists. In this study an LC-MS/MS multiresidue analysis method is presented for trace analysis of 22 beta-agonists. A truly generic concept has been designed based on mixed-mode solid-phase extraction and positive electrospray ionisation LC-MS/MS operated in the multiple reaction monitoring mode. This method allows application to a wide variety of sample matrices such as urine, feed and hair, following minor modifications to the analysis procedure only. The method features fit-for-purpose sensitivity in urine as shown by CCalpha and CCbeta values of less than 0.2 and less than 0.5 microg/l respectively, for all beta-agonists studied (terbutaline and reproterol, less than 0.3 and less than 1.0 respectively). Similar but semiquantitative application to feed and hair showed CCbeta values of less than 10.0 and less than 5.0 microg/kg, respectively. A further simplification and improvement is demonstrated using Ultra Performance LC (UPLC) and fast-switching MS/MS. The successful validation of this method following the latest EU requirements and its application to real samples demonstrate that a new versatile tool has been achieved for veterinary control of beta-agonists.

UV radiation and cancer prevention: what is the evidence?

The health benefits of sunlight and the risk of skin cancer from UV exposure are still controversial. The literature was analyzed in terms of reviews, controlled and epidemiological studies for the relationships between sunshine exposure and overall cancer mortality, as well as mortality from cancer of the prostate, colon and breast. The residential and/or occupational sun exposure rate seemed to be positively correlated with a lower risk of overall morality due to organ cancer. A normal vitamin D status appeared to be an important precondition, via the local and autocrine synthesis of 1,25(OH)2D3 in the target tissues. The vitamin D hormone system is necessary for cell proliferation and differentiation; different types of vitamin D receptor gene polymorphism seemed to be associated with cancer cell growth. The health benefits of sunlight appear to outweigh the risk of skin cancer. However, the optimal UV exposure, the target level of circulating vitamin D, and whether vitamin D is the only pathway are still undetermined.

Stereotactic arc therapy for small elongated tumors using cones and collimator jaws; dosimetric and planning aspects.

Stereotactic arc treatment of small intracranial tumors is usually performed with arcs collimated by circular cones, resulting in treatment volumes which are basically spherical. For nonspherical lesions this results in a suboptimal dose distribution. Multiple isocenters may improve the dose conformity for these lesions, at the cost of large overdosages in the target volume. To achieve improved dose conformity as well as dose homogeneity, the linac jaws (with a minimum distance of 1.0 cm to the central beam axis) can routinely be used to block part of the circular beams. The purpose of this study was to investigate the feasibility of blocking cones with diameters as small as 1.0 cm and a minimum distance between the jaw and the central beam axis of 0.3 cm. First, the reproducibility in jaw positioning and resulting dose delivery on the treatment unit were assessed. Second, the accuracy of the TPS dose calculation for these small fields was established. Finally, clinically applied treatment plans using nonblocked cones were compared with plans using the partially blocked cones for several treatment sites. The reproducibility in dose delivery on our Varian Clinac 2300 C/D machines on the central beam axis is 0.8% (1 SD). The accuracy of the treatment planning system dose calculation algorithm is critically dependent on the used fits for the penumbra and the phantom scatter. The average deviation of calculated from measured dose on the central beam axis is -1.0%+/-1.4% (1 SD), which is clinically acceptable. Partial cone blocking results in improved dose distributions for elongated tumors, such as vestibular schwannoma and uveal melanoma. Multiple isocenters may be avoided. The technique is easy to implement and requires no additional workload.

Identification of an unknown beta-agonist in feed by liquid chromatography/bioassay/quadrupole time-of-flight tandem mass spectrometry with accurate mass measurement.

A new approach to the search for residues of unknown growth promoting agents such as anabolic steroids and beta-agonists in feed is presented. Following primary extraction and clean-up, samples are separated using gradient liquid chromatography (LC). The effluent is split towards two identical 96-well fraction collectors and an optional electrospray quadrupole time-of-flight mass spectrometry (QTOFMS) system for accurate mass measurement. One 96-well plate is used for a bioassay (enzyme-immuno assay, receptor assay) and will detect the bioactivity and position of the relevant peak in the chromatogram. The positive well in the second 96-well plate is used for identification by LC/QTOFMS/MS. The value of this LC/bioassay/QTOFMS/MS methodology is highlighted by the finding and structure elucidation of a new beta-agonist in a feed extract.

Conversion of measured percentage depth dose to tissue maximum ratio values in stereotactic radiotherapy.

For many treatment planning systems tissue maximum ratios (TMR) are required as input. These tissue maximum ratios can be measured with a 3D computer-controlled water phantom; however, a TMR measurement option is not always available on such a system. Alternatively TMR values can be measured 'manually' by lowering the detector and raising the water phantom with the same distance, but this makes TMR measurements time consuming. Therefore we have derived TMR values from percentage depth dose (PDD) curves. Existing conversion methods express TMR values in terms of PDD, phantom scatter factor (Sp), and inverse square law. For stereotactic treatments circular fields ranging from 5-50 mm (19 cones) are used with the treatment planning system XKnife (Radionics). The calculation of TMR curves for this range is not possible with existing methods. This is because PDD curves of field sizes smaller than 5 mm (smallest cone size) are needed, but these cones are not provided. Besides, for field sizes smaller than 40 mm, the phantom scatter factor is difficult to determine and will introduce significant errors. To overcome these uncertainties, an alternative method has been developed to obtain TMR values from PDD data, where absolute doses are expressed in terms of PDD, total scatter factor and inverse square law. For each depth, the dose as a function of field size is fitted to a double exponential function. Then the TMR is calculated by taking the ratio of this function at the depth of interest and the reference depth, for the correct field size. For all 19 cones the total scatter factor and PDDs have been measured with a shielded diode in water for a 6 MV photon beam. Calculated TMR curves are compared with TMR values measured with a diode. The agreement is within 2%. Therefore this relatively simple conversion method meets the required accuracy for daily dose calculation in stereotactic radiotherapy. In principle this method could also be applied for other small field sizes such as those formed with a mini multileaf collimator.

A linear diode array (JFD-5) for match line in vivo dosimetry in photon and electron beams; evaluation for a chest wall irradiation technique.

BACKGROUND AND PURPOSE: In vivo dosimetry using thermoluminiscence detectors (TLD) is routinely performed in our institution to determine dose inhomogeneities in the match line region during chest wall irradiation. However, TLDs have some drawbacks: online in vivo dosimetry cannot be performed; generally, doses delivered by the contributing fields are not measured separately; measurement analysis is time consuming. To overcome these problems, the Joined Field Detector (JFD-5), a detector for match line in vivo dosimetry based on diodes, has been developed. This detector and its characteristics are presented. MATERIALS AND METHODS: The JFD-5 is a linear array of 5 p-type diodes. The middle three diodes, used to measure the dose in the match line region, are positioned at 5-mm intervals. The outer two diodes, positioned at 3-cm distance from the central diode, are used to measure the dose in the two contributing fields. For three JFD-5 detectors, calibration factors for different energies, and sensitivity correction factors for non-standard field sizes, patient skin temperature, and oblique incidence have been determined. The accuracy of penumbra and match line dose measurements has been determined in phantom studies and in vivo. RESULTS: Calibration factors differ significantly between diodes and between photon and electron beams. However, conversion factors between energies can be applied. The correction factor for temperature is 0.35%/ degrees C, and for oblique incidence 2% at maximum. The penumbra measured with the JFD-5 agrees well with film and linear diode array measurements. JFD-5 in vivo match line dosimetry reproducibility was 2.0% (1 SD) while the agreement with TLD was 0.999+/-0.023 (1 SD). CONCLUSION: The JFD-5 can be used for accurate, reproducible, and fast on-line match line in vivo dosimetry.

Commissioning of a commercially available system for intensity-modulated radiotherapy dose delivery with dynamic multileaf collimation.

PURPOSE: To commission commercially available equipment for intensity-modulated radiotherapy (IMRT) using dynamic multileaf collimation (DMLC). MATERIALS AND METHODS: First, the stability in leaf positioning and in realized IMRT profiles on a Varian 2300 C/D machine were determined as a function of time and gantry angle, and as a result of treatment interrupts. Second, dose distributions calculated with the CadPlan (Varian) treatment planning system, using leaf trajectories calculated with the leaf motion calculator (LMC) algorithm, were compared with distributions realized at the 2300 C/D unit. RESULTS: Day-to-day and gantry angle variations in leaf positioning and dose delivery were very small (less than 0.1-0.2 mm and 2%). The effect of treatment interrupts on measured dose distributions was less than 2%. The agreement between the final dose distribution calculated by CadPlan and the measured dose was generally within 2%, or 2 mm at steep dose gradients, using a leaf transmission value of 1.8% and a leaf separation value of 2 mm in LMC. For narrow peaks, deviations of up to 6% were observed. LMC does not synchronize adjacent leaf trajectories resulting in tongue-and-groove underdosages of up to 29% for extreme cases. CONCLUSIONS: The 2300 C/D machine is suitable for accurate and reproducible DMLC treatments. The agreement between dose predictions with LMC and CadPlan, and realized doses at this unit is clinically acceptable for most cases. However, differences between calculated and actual dose values may exist in peaked fluences or due to tongue-and-groove effects. Therefore, pretreatment dosimetric verification for each patient is recommended.

Both IgG and IgM anti-pig antibodies induce complement activation and cytotoxicity.

Hyperacute rejection of pig xenografts transplanted in humans is caused by endothelial cell binding of pre-formed xenoreactive antibodies (XAb) and activation of the classical pathway of complement. Human XAb mainly consist of anti-Galalpha1 3Gal antibodies, which occur in IgM, IgG and IgA classes. Whereas IgM anti-Galalpha1 3Gal antibodies have an established role in hyperacute rejection, the potential role of IgG XAb in this process is still controversial. The aim of the present study was to assess the specificity and functional properties of IgG and IgM XAb. Both classes were present in all human plasma samples tested, with a high inter-individual variability. Levels of IgG XAb did not correlate with levels of IgM XAb. Binding to Galalpha1 3Gal is strongly correlated with binding to the pig cell line PK15, both for IgG and for IgM, pointing to Galalpha1 3Gal as the major antigen recognized. Both purified IgM and IgG induced C3 deposition on PK15 cells and complement-dependent cytotoxicity in a dose-dependent way. The combination of IgG and IgM XAb resulted in an additive effect on cytotoxicity. Affinity-purified IgG anti-Galalpha1 3Gal antibodies were 22 times less potent than IgM in induction of cytotoxicity. These results indicate a quantitative, but not a qualitative, difference between IgM and IgG anti-pig antibodies concerning their complement-activating properties. Therefore, both classes of XAb are of importance in the pathogenesis of hyperacute rejection, and the relative importance of each class may differ considerably between individual patients, depending on the ratio of IgG and IgM XAb present in serum.

Chest wall irradiation with MLC-shaped photon and electron fields.

PURPOSE: To improve the treatment technique for chest wall irradiation, using the multileaf collimator (MLC) of the MM50 Racetrack Microtron to shape both photon and electron beams, and to check the dose delivery in the match-line region of these fields for the routine and improved technique. METHODS AND MATERIALS: Using diode and film phantom measurements, the optimal number of photon beam segments and their positions relative to the electron beam were determined. On phantoms, and during actual patient treatment using in vivo dosimetry, the dose homogeneity in the match-line region was determined for both the routine and improved techniques. RESULTS: Three photon beam segments (9-mm gap, perfect match, and 9-mm overlap) were used to match the electron beam, resulting in minimum-maximum dose values in the match-line region of 88-109%, compared to 80-115% for the routine technique (2 photon beam segments). During patient treatment, the average minimum and maximum dose values were 95% and 115%, respectively, compared to 78% and 127%, respectively, for the routine technique. The interfraction variation in dose delivery was reduced from 11.0% (1 SD) to 4.6% (1 SD). The actual treatment time was reduced from 10 to 4.5 min. CONCLUSION: Using the MLC of the MM50 to shape both photon and electron beams, an improved treatment technique for chest wall irradiation was developed, which is less labor intensive, faster, and yields a more homogeneous, and better reproducible dose delivery.

Negative growth regulation of SK-N-MC cells by bFGF defines a growth factor-sensitive point in G2.

Basic fibroblast growth factor (bFGF) has been shown to induce growth inhibition of the neuroepithelioma cell line SK-N-MC. Here we show that this growth inhibition occurs in G(2). We show that bFGF is active on these cells during S and early G(2) phase. Therefore, this constitutes a rather unusual mechanism of growth inhibition, because it is generally believed that cells become refractory to extracellular signals after passage through the restriction point. We show that bFGF treatment inhibits Tyr-15 dephosphorylation of cdc2 and prevents activation of Cdc25C, similar to what is seen upon activation of the G(2) DNA damage checkpoint. Interestingly, both DNA damage- and bFGF-induced effects on cdc2 phosphorylation are reverted by caffeine. To confirm the involvement of similar pathways induced by bFGF and DNA damage, we generated tetracycline-regulatable SK-N-MC clones expressing Cdc25C-S216A. Expression of this Cdc25C mutant can revert the bFGF-induced effects on cdc2 phosphorylation and can rescue cells from the block in G(2) imposed by bFGF. Taken together, these data define a growth factor-sensitive point in G(2) that most likely involves regulation of Cdc25C phosphorylation.

In vivo dosimetry during conformal radiotherapy: requirements for and findings of a routine procedure.

PURPOSE: Conformal radiotherapy requires accurate knowledge of the actual dose delivered to a patient. The impact of routine in vivo dosimetry, including its special requirements, clinical findings and resources, has been analysed for three conformal treatment techniques to evaluate its usefulness in daily clinical practice. MATERIALS AND METHODS: Based on pilot studies, routine in vivo dosimetry quality control (QC) protocols were implemented in the clinic. Entrance and exit diode dose measurements have been performed during two treatment sessions for 378 patients having prostate, bladder and parotid gland tumours. Dose calculations were performed with a CT-based three-dimensional treatment planning system. In our QC-protocol we applied action levels of 2.5% for the prostate and bladder tumour group and 4.0% for the parotid gland patients. When the difference between the measured dose at the dose specification point and the prescribed dose exceeded the action level the deviation was investigated and the number of monitor units (MUs) adjusted. Since an accurate dose measurement was necessary, some properties of the on-line high-precision diode measurement system and the long-term change in sensitivity of the diodes were investigated in detail. RESULTS: The sensitivity of all diodes decreased by approximately 7% after receiving an integrated dose of 10 kGy, for 4 and 8 MV beams. For 34 (9%) patients the difference between the measured and calculated dose was larger than the action level. Systematic errors in the use of a new software release of the monitor unit calculation program, limitations of the dose calculation algorithms, errors in the planning procedure and instability in the performance of the accelerator have been detected. CONCLUSIONS: Accurate in vivo dosimetry, using a diode measurement system, is a powerful tool to trace dosimetric errors during conformal radiotherapy in the range of 2.5-10%, provided that the system is carefully calibrated. The implementation of an intensive in vivo dosimetry programme requires additional staff for measurements and evaluation. The patient measurements add only a few minutes to the total treatment time per patient and guarantee an accurate dose delivery, which is a prerequisite for conformal radiotherapy.

Inhibition of cell proliferation by lithium is associated with interference in cdc2 activation.

Lithium can interfere with embryonal development in a variety of organisms. We investigated the effect of lithium on the proliferation of early embryonal cells. [3H]Thymidine incorporation of non-committed mouse P19 embryonal carcinoma cells was inhibited by lithium treatment. Similar effects were seen in a variety of other cells. This growth inhibition occurred in the G2 phase, since cells accumulated with a 4N DNA content, but the appearance of mitotic cells was blocked. Lithium could also prevent the activation of cdc2, thereby inhibiting cyclin B/cdc2 kinase activity. These data indicate that lithium might disturb embryonal development through interference in embryonal cell cycle regulation.

Potentiation of anti-cancer drug activity at low intratumoral pH induced by the mitochondrial inhibitor m-iodobenzylguanidine (MIBG) and its analogue benzylguanidine (BG).

Tumour-selective acidification is of potential interest for enhanced therapeutic gain of pH sensitive drugs. In this study, we investigated the feasibility of a tumour-selective reduction of the extracellular and intracellular pH and their effect on the tumour response of selected anti-cancer drugs. In an in vitro L1210 leukaemic cell model, we confirmed enhanced cytotoxicity of chlorambucil at low extracellular pH conditions. In contrast, the alkylating drugs melphalan and cisplatin, and bioreductive agents mitomycin C and its derivative EO9, required low intracellular pH conditions for enhanced activation. Furthermore, a strong and pH-independent synergism was observed between the pH-equilibrating drug nigericin and melphalan, of which the mechanism is unclear. In radiation-induced fibrosarcoma (RIF-1) tumour-bearing mice, the extracellular pH was reduced by the mitochondrial inhibitor m-iodobenzylguanidine (MIBG) or its analogue benzylguanidine (BG) plus glucose. To simultaneously reduce the intracellular pH, MIBG plus glucose were combined with the ionophore nigericin or the Na+/H+ exchanger inhibitor amiloride and the Na+-dependent HCO3-/Cl- exchanger inhibitor 4,4'-diisothiocyanostilbene-2,2'-disulphonic acid (DIDS). Biochemical studies confirmed an effective reduction of the extracellular pH to approximately 6.2, and anti-tumour responses to the interventions indicated a simultaneous reduction of the intracellular pH below 6.6 for at least 3 h. Combined reduction of extra- and intracellular tumour pH with melphalan increased the tumour regrowth time to 200% of the pretreatment volume from 5.7 +/- 0.6 days for melphalan alone to 8.1 +/- 0.7 days with pH manipulation (P < 0.05). Mitomycin C related tumour growth delay was enhanced by the combined interventions from 3.8 +/- 0.5 to 5.2 +/- 0.5 days (P < 0.05), but only in tumours of relatively large sizes. The interventions were non-toxic alone or in combination with the anti-cancer drugs and did not affect melphalan biodistribution. In conclusion, we have developed non-toxic interventions for sustained and selective reduction of extra- and intracellular tumour pH which potentiated the tumour responses to selected anti-cancer drugs.

An analysis of anatomic landmark mobility and setup deviations in radiotherapy for lung cancer.

PURPOSE: To identify thoracic structures that exhibit little internal motion during irradiation and to determine setup variations in patients with lung cancer. METHODS AND MATERIALS: Intrafractional images were generated with an electronic portal-imaging device from the AP fields of 10 patients, during several fractions. To determine the intrafractional mobility of thoracic structures, visible structures were contoured in every image and matched with a reference image by means of a cross-correlation algorithm. Setup variations were determined by comparing portal images with the digitized simulator films using the stable structures as landmarks. RESULTS: Mobility was limited in the lateral direction for the trachea, thoracic wall, paraspinal line, and aortic notch, and in the craniocaudal direction for the clavicle, aortic notch, and thoracic.wall. Analysis of patient setup revealed random deviations of 2.0 mm (1 SD) in the lateral direction and 2.8 mm in the craniocaudal direction, while the systematic deviations were 2.5 and 2.0 mm (1 SD) respectively. CONCLUSIONS: We have identified thoracic structures that exhibit little internal motion in the frontal plane, and recommend that these structures be used for verifying patient setup during radiotherapy. The daily variation in the setup of lung cancer patients at our center appears to be acceptable.