BackgroundRecent developments enable to deliver rotational IMRT with standard C-arm gantry based linear accelerators. This upcoming treatment technique was benchmarked in a multi-center treatment planning study against static gantry IMRT and rotational IMRT based on a ring gantry for a complex parotid gland sparing head-and-neck technique.MethodsTreatment plans were created for 10 patients with head-and-neck tumours (oropharynx, hypopharynx, larynx) using the following treatment planning systems (TPS) for rotational IMRT: Monaco (ELEKTA VMAT solution), Eclipse (Varian RapidArc solution) and HiArt for the helical tomotherapy (Tomotherapy). Planning of static gantry IMRT was performed with KonRad, Pinnacle and Panther DAO based on step&shoot IMRT delivery and Eclipse for sliding window IMRT. The prescribed doses for the high dose PTVs were 65.1Gy or 60.9Gy and for the low dose PTVs 55.8Gy or 52.5Gy dependend on resection status. Plan evaluation was based on target coverage, conformity and homogeneity, DVHs of OARs and the volume of normal tissue receiving more than 5Gy (V5Gy). Additionally, the cumulative monitor units (MUs) and treatment times of the different technologies were compared. All evaluation parameters were averaged over all 10 patients for each technique and planning modality.ResultsDepending on IMRT technique and TPS, the mean CI values of all patients ranged from 1.17 to 2.82; and mean HI values varied from 0.05 to 0.10. The mean values of the median doses of the spared parotid were 26.5Gy for RapidArc and 23Gy for VMAT, 14.1Gy for Tomo. For fixed gantry techniques 21Gy was achieved for step&shoot+KonRad, 17.0Gy for step&shoot+Panther DAO, 23.3Gy for step&shoot+Pinnacle and 18.6Gy for sliding window.V5Gy values were lowest for the sliding window IMRT technique (3499 ccm) and largest for RapidArc (5480 ccm). The lowest mean MU value of 408 was achieved by Panther DAO, compared to 1140 for sliding window IMRT.ConclusionsAll IMRT delivery technologies with their associated TPS provide plans with satisfying target coverage while at the same time respecting the defined OAR criteria. Sliding window IMRT, RapidArc and Tomo techniques resulted in better target dose homogeneity compared to VMAT and step&shoot IMRT. Rotational IMRT based on C-arm linacs and Tomotherapy seem to be advantageous with respect to OAR sparing and treatment delivery efficiency, at the cost of higher dose delivered to normal tissues. The overall treatment plan quality using Tomo seems to be better than the other TPS technology combinations.

Commercial 2-D detectors have the potential to replace films as an "area detector" for field-related verification of IMRT. The on-line information provided by the respective systems can even improve the efficiency of the QA procedures.

Spontaneous calcium waves in enzymatically isolated rat cardiac myocytes were investigated by confocal laser scanning microscopy (CLSM) using the fluorescent Ca2+-indicator fluo-3 AM. As recently shown, a spreading wave of enhanced cytosolic calcium appears, most probably during Ca2+ overload, and is initiated by an elementary event called a "calcium spark." When measured by conventional fluorescence microscopy the propagation velocity of spontaneous calcium waves determined at several points along the cardiac myocyte was previously found to be constant. More precise measurements with a CLSM showed a nonlinear propagation. The wave velocity was low, close to the focus, and increased with increasing time and propagation length, approaching a maximum of 113 microns/s. This result was surprising, inasmuch as for geometrical reasons a decrease of the propagation velocity might be expected if the confocal plane is not identical with that plane where the focus of the wave was localized. It is suggested that the propagation velocity is essentially dependent on the curvature of the spreading wave. From the linear relationship of velocity versus curvature, a critical radius of 2.7 +/- 1.4 microns (mean +/- SD) was worked out, below which an outward propagation of the wave will not take place. Once released from a sufficiently extended cluster of sarcoplasmic reticulum release channels, calcium diffuses and will activate its neighbors. While traveling away, the volume into which calcium diffuses becomes effectively smaller than at low radii. This effect is the consequence of the summation of elementary events (Ca2+ sparks) and leads to a steeper increase of the cytosolic calcium concentration after a certain diffusion path length. Thus the time taken to reach a critical threshold of [Ca2+]i at the neighboring calcium release sites decreases with decreasing curvature and the wave will propagate faster.

BackgroundThe new TomoDirect™ modality offers a non-rotational option with discrete beam angles. We have investigated this mode for TBI with the intention to test the feasibility and to establish it as a clinical routine method. Special foci were directed onto treatment planning, dosimetric accuracy and practical aspects.Patients and methodsTBI plans were calculated with TomoDirect™ for a Rando™ phantom and all patients with an intended fractionated total body irradiation between November 2013 and May 2014 (n = 8). Finally, four of these patients were irradiated with TomoDirect™. Additionally we studied variations in the modulation factor, pitch, field width of Y-jaws and dose grid during optimization. Dose measurements were performed using thermoluminescent rods in the Rando™ phantom, with the Delta4® and with ionization chambers in a solid water phantom.ResultsFor all eight calculated plans with a prescribed dose of 12 Gy Dmean was 12.09-12.33 Gy (12,25 ± 0.08 Gy), D98 11.2-11.6 Gy (11.45 ± 0.12 Gy) and D2 12.6-13.1 Gy (12.94 ± 0.13 Gy). Dmean of inner lungs was 8.73 ± 0.22 Gy on the left side and 8.69 ± 0.27 Gy on the right side.When single planning parameters are varied with otherwise constant parameters, the modulation factor showed the greatest impact on dose homogeneity and treatment time. The impact of the pitch was marginally, and almost equal homogeneity can be obtained with field width of Y-jaws 5 cm and 2.5 cm.Measurements with thermoluminescent rods (n = 25) in the Rando™ phantom showed a mean dose deviation between measured and calculated dose of 0.66 ± 2.26%. 18 of 25 TLDs had a deviation below 3%, seven of 25 TLDs between 3% and 5%.ConclusionTBI with TomoDirect™ allows a superior homogeneity compared to conventional methods, where lung blocks are widely accepted. The treatment is performed only in supine position and is robust and comfortable for the patient.TomoDirect™ allows the implementation of organ-specific dose prescriptions. So the discussion about the balance between the need for aggressive treatment and limited toxicity can be renewed with the new potentials of TomoDirect™ - for children as well as for adults – and possibly yield a better clinical outcome in the future.

PD in IMRT can be minimized by proper selection of treatment delivery method and photon beam energy. When selecting the IMRT technique in centers where compensator IMRT and MLC IMRT is available, PD burden should be taken into account. The large amount of photon components and neutron components caused by leakage radiation from the treatment head leads to the recommendation that radiation protection aspects for patients undergoing IMRT should be considered in linac design. For further clarification, additional experiments have to be carried out on other types of linacs.