Introduction of a surgical Black Box system in a hybrid angiosuite: Challenges and opportunities

PurposeIn laparoscopy, the Operating Room Black Box® (ORBB) provides insights into operative performance to improve patient safety. This technology may also enhance endovascular surgical practice; however, the use of a C-arm and X-rays pose important challenges, hindering transferability to an endovascular context. We describe the first implementation of ORBB technology in a hybrid angiosuite and illustrate its value in evaluating surgeons’ radiation safety, technical and non-technical performance.MethodsTeam members (surgeons, nurses, anaesthesiologists) and stakeholders were informed during several information sessions. Together with teams from Surgical Safety Technologies (Toronto, Canada), an implementation plan was developed, and video-evaluation frameworks were chosen.Radiation safety was assessed using dose measurements and video-evaluation of safety-related behaviours. Technical performance was assessed using ‘global’ (GRS) and ‘procedure-specific’ (PRS) rating scales and the ‘EndoVascular Aortic Repair Assessment of Technical Expertise’ (EVARATE) framework. Surgeons’ non-technical skills were assessed with the NOTSS framework.ResultsThe system captures Audio-visual data from four ceiling-mounted cameras, three ceiling-array microphones, the fluoroscopy screen and anaesthesia monitor. After patient and team consent, an elective endovascular aneurysm repair was successfully analysed. Dose-Area-Product and Air Kerma were 71094 mGy.cm² and 270 mGy, respectively. Behavioural analysis revealed deficiencies in stepping back and radiation safety communication. Technical skill assessment was feasible: GRS: 29/40; ‘PRS’: 27/35; EVARATE: 29/35. Non-technical analysis highlighted surgeons’ leadership qualities.ConclusionAn innovative data capture platform has been successfully installed to evaluate overall performance during endovascular procedures. This technology may facilitate identification of (radiation) safety-related errors and instigate educational interventions based on real-world issues.     

Affordable compensator for IMRT delivery designed for low-and-middle income countries,a Monte Carlo study

We propose a novel cost-effective compensator that can be used to facilitate access to IMRT in low-and-middle income countries. The compensator has the advantages of simplicity, less downtime, increased reliability and less impact on treatment quality from patient motion during treatment. Moreover, the system can be used with either a cobalt-60 unit or linear accelerator. In this Monte Carlo study, the dosimetric properties of the new compensator design have been evaluated. Results were obtained for different field sizes of cobalt teletherapy machine, and the dose was scored at 0.5 cm depth in a water phantom. The effects of compensator thickness, filling material type and shape, and field size were identified. Furthermore, the percentage depth dose and beam profiles for various field sizes and at different depths were obtained. Beam profiles show no significant signature of the beads relative to a solid compensator; in addition, they exhibit a better flatness while preserving symmetry for all field sizes. A reusable bead-based compensator appears to be feasible, and provides dose distribution similar to a solid compensator with low cost and no hazards. Our results avail the ongoing efforts to expand the reach to IMRT in low- and middle-income countries.     

Differential mutagenic response in selected lines of Drosophila melanogaster

Summary The mutagenic efficiency of ionizing radiations has been tested on different lines of Drosophila melanogaster. It has been shown that differential lethal effects are obtained when irradiated females from different lines are mated to flies carrying heterozygous lethal genes. The results seem not to be attributable to differential expression of the lethality in the various crosses performed with the irradiated flies. This might suggest that gene activity is involved in the expression of the mutagenic effects of radiations.     

Electron radiotherapy (IOERT) for applications outside of the breast: Dosimetry and influence of tissue inhomogeneities

PurposeThe purpose of study is to investigate the dosimetry of electron intraoperative radiotherapy (IOERT) of the Intraop Mobetron 2000 mobile LINAC in treatments outside of the breast. After commissioning and external validation of dosimetry, we report in vivo results of measurements for treatments outside the breast in a large patient cohort, and investigate if the presence of inhomogeneities can affect in vivo measurements.Methods and materialsApplicator factors and profile curves were measured with a stereotactic diode. The applicators factors of the 6 cm flat and beveled applicators were also confirmed with radiochromic films, parallel-plate ion chamber and by an external audit performed with ThermoLuminescent Dosimeters (TLDs). The influence of bone on dose was investigated by using radiochromic films attached to an insert equivalent to cortical bone, immersed in the water phantom. In vivo dosimetry was performed on 126 patients treated with IOERT using metal oxide-silicon semiconductor field effect transistors (MOSFETs) placed on the tumor bed.ResultsRelatively small differences were found among different detectors for measurements of applicator factors. In the external audit, the agreement with the TLD was mostly within ±0.2%. The largest increase of dose due to the presence of cortical bone insert was +6.0% with energy 12 MeV and 3 cm applicator. On average, in vivo dose was significantly (+3.1%) larger than prescribed dose.ConclusionIOERT in applications outside the breast results in low discrepancies between in vivo and prescribed doses, which can be also explained with the presence of tissue inhomogeneity.     

Isolation and initial characterization of a Schizosaccharomyces pombe mutant exhibiting temperature-dependent radiation sensitivity due to a mutation in a previously unidentified rad locus

Summary We have isolated a mutant of the yeast Schizosaccharomyces pombe which exhibits sensitivity to UV light when grown at either 30° or 37°C, as compared to the parental wild-type strain. This increased sensitivity is more pronounced when cells are grown at 37°C. The mutant is also sensitive to 18 MeV electrons at the high temperature. Tetrad analysis of spores generated by crossing the mutant and a Rad⁺ strain revealed that sensitivity to both types of radiation cosegregate 2:2, relative to wild-type resistance, indicating that a single altered chromosomal locus is responsible for the radiation sensitivities observed. In addition, analysis of spores resulting from crosses between the mutant and all other known S. pombe rad mutants indicates that the temperature-dependent sensitivity described in this report is mediated by a mutation in a previously unidentified rad locus.     

Comparison of the extent of hippocampal sparing according to the tilt of a patient’s head during WBRT using linear accelerator-based IMRT and VMAT

In this paper, we report the results of our investigation into whole brain radiotherapy (WBRT) using linear accelerator-based intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT) in lung cancer patients with a high risk of metastasis to the brain. Specifically, we assessed the absorbed dose and the rate of adverse effects for several organs at risk (OAR), including the hippocampus, according to the tilt of a patient’s head. We arbitrarily selected five cases where measurements were made with the patients’ heads tilted forward and five cases without such tilt. We set the entire brain as the planning target volume (PTV), and the hippocampi, the lenses, the eyes, and the cochleae as the main OAR, and formulated new plans for IMRT (coplanar, non-coplanar) and VMAT (coplanar, non-coplanar). Using the dose-volume histogram (DVH), we calculated and compared the effective uniform dose (EUD), normal tissue complication probability (NTCP) of the OAR and the mean and the maximum doses of hippocampus. As a result, if the patient tilted the head forward when receiving the Linac-based treatment, for the same treatment effect in the PTV, we confirmed that a lower dose entered the OAR, such as the hippocampus, eye, lens, and cochlea. Moreover, the damage to the hippocampus was expected to be the least when receiving coplanar VMAT with the head tilted forward. Accordingly, if patients tilt their heads forward when undergoing Linac-based WBRT, we anticipate that a smaller dose would be transmitted to the OAR, resulting in better quality of life following treatment.     

The metabolic state of cancer stem cells—a valid target for cancer therapy?

In the 1920s Otto Warburg first described high glucose uptake, aerobic glycolysis, and high lactate production in tumors. Since then high glucose uptake has been utilized in the development of PET imaging for cancer. However, despite a deepened understanding of the molecular underpinnings of glucose metabolism in cancer, this fundamental difference between normal and malignant tissue has yet to be employed in targeted cancer therapy in the clinic. In this review, we highlight attempts in the recent literature to target cancer cell metabolism and elaborate on the challenges and controversies of these strategies in general and in the context of tumor cell heterogeneity in cancer.     

A systematic quality assurance framework for the upgrade of radiation oncology information systems

In spite of its importance, no systematic and comprehensive quality assurance (QA) program for radiation oncology information systems (ROIS) to verify clinical and treatment data integrity and mitigate against data errors/corruption and/or data loss risks is available. Based on data organization, format and purpose, data in ROISs falls into five different categories: (1) the ROIS relational database and associated files; (2) the ROIS DICOM data stream; (3) treatment machine beam data and machine configuration data; (4) electronic medical record (EMR) documents; and (5) user-generated clinical and treatment reports from the ROIS. For each data category, this framework proposes a corresponding data QA strategy to very data integrity. This approach verified every bit of data in the ROIS, including billions of data records in the ROIS SQL database, tens of millions of ROIS database-associated files, tens of thousands of DICOM data files for a group of selected patients, almost half a million EMR documents, and tens of thousands of machine configuration files and beam data files. The framework has been validated through intentional modifications with test patient data. Despite the ‘big data’ nature of ROIS, the multiprocess and multithread nature of our QA tools enabled the whole ROIS data QA process to be completed within hours without clinical interruptions. The QA framework suggested in this study proved to be robust, efficient and comprehensive without labor-intensive manual checks and has been implemented for our routine ROIS QA and ROIS upgrades.     

An investigation of the reaction kinetics of luciferase and the effect of ionizing radiation on the reaction rate

The bioluminescence produced by luciferase, a firefly enzyme, requires three substrates: luciferin, ATP and oxygen. We find that ionizing radiation, in the form of a proton beam from a cyclotron, will eliminate dissolved oxygen prior to any damage to other substrates or to the protein. The dose constant for removal of oxygen is 70 ± 20 Gy, a much smaller dose than required to cause damage to protein. Removal of oxygen, which is initially in excess, leads to a sigmoidal response of bioluminescence to radiation dose, consistent with a Michaelis–Menten relationship to substrate concentration. When excess oxygen is exhausted, the response becomes exponential. Following the irradiation, bioluminescence recovers due to a slow leak of oxygen into the solution. This may also explain previous observations on the response of bioluminescent bacteria to radiation. We have studied the dependence of the reaction rate on enzyme and substrate concentration and propose a model for the reaction pathway consistent with this data. The light output from unirradiated samples decreases significantly with time due to product inhibition. We observe that this inhibition rate changes dramatically immediately after a sample is exposed to the beam. This sudden change of the inhibition rate is unexplained but shows that enzyme regulatory function responds to ionizing radiation at a dose level less than 0.6 Gy.