Use of the FLUKA Monte Carlo code for 3D patient-specific dosimetry on PET-CT and SPECT-CT images.

Patient-specific absorbed dose calculation for nuclear medicine therapy is a topic of increasing interest. 3D dosimetry at the voxel level is one of the major improvements for the development of more accurate calculation techniques, as compared to the standard dosimetry at the organ level. This study aims to use the FLUKA Monte Carlo code to perform patient-specific 3D dosimetry through direct Monte Carlo simulation on PET-CT and SPECT-CT images. To this aim, dedicated routines were developed in the FLUKA environment. Two sets of simulations were performed on model and phantom images. Firstly, the correct handling of PET and SPECT images was tested under the assumption of homogeneous water medium by comparing FLUKA results with those obtained with the voxel kernel convolution method and with other Monte Carlo-based tools developed to the same purpose (the EGS-based 3D-RD software and the MCNP5-based MCID). Afterwards, the correct integration of the PET/SPECT and CT information was tested, performing direct simulations on PET/CT images for both homogeneous (water) and non-homogeneous (water with air, lung and bone inserts) phantoms. Comparison was performed with the other Monte Carlo tools performing direct simulation as well. The absorbed dose maps were compared at the voxel level. In the case of homogeneous water, by simulating 10(8) primary particles a 2% average difference with respect to the kernel convolution method was achieved; such difference was lower than the statistical uncertainty affecting the FLUKA results. The agreement with the other tools was within 3­4%, partially ascribable to the differences among the simulation algorithms. Including the CT-based density map, the average difference was always within 4% irrespective of the medium (water, air, bone), except for a maximum 6% value when comparing FLUKA and 3D-RD in air. The results confirmed that the routines were properly developed, opening the way for the use of FLUKA for patient-specific, image-based dosimetry in nuclear medicine.

Monte Carlo-based 3-dimensional dosimetry of salivary glands in radioiodine treatment of differentiated thyroid cancer estimated using 124I PET.

AIM: Salivary gland toxicity is of concern in radioiodine treatment of thyroid cancer. Toxicity is often observed while the estimated radiation absorbed dose (AD) values are below expected toxicity thresholds. Monte Carlo-based voxelized 3-dimensional radiobiological dosimetry (3D-RD) calculations of the salivary glands from eight metastatic thyroid cancer patients treated with 131I are presented with the objective of resolving this discrepancy. METHODS: GEANT4 Monte Carlo simulations were performed for 131I, based on pretherapeutic 124I PET/CT imaging corrected for partial volume effect, and the results scaled to the therapeutic administered activities. For patients with external regions of high uptake proximal to the salivary glands, such as thyroid remnants or lymph node metastases, separate simulations were run to quantify the AD contributions from both (A) the salivary glands themselves, and (B) the external proximal region of high uptake (present for five patients). The contribution from the whole body outside the field of view was also estimated using modeling. Voxelized and average ADs and biological effective doses (BEDs) were calculated. RESULTS: The estimated average therapeutic ADs were 2.26 Gy considering all contributions and 1.94 Gy from the self-dose component only. The average contribution from the external region of high uptake was 0.54 Gy. This difference was more pronounced for the submandibular glands (2.64 versus 2.10 Gy) compared to the parotid glands (1.88 Gy versus 1.78 Gy). The BED values were on average only 6.6 % higher than (2.41 Gy) the ADs. CONCLUSION: The external sources of activity contribute significantly to the salivary gland AD, however neither this contribution, nor the radiobiological effect quantified by the BED are in themselves sufficient to explain the clinically observed toxicity.

Spiritual perspectives and practices of family physicians with an expressed interest in spirituality.

BACKGROUND AND OBJECTIVES: Among a growing number of articles about spirituality and medicine, there are no open-ended empirical inquiries about family physicians' understanding of spirituality and what it might mean to incorporate spirituality into family practice. We used a qualitative methodology to investigate family physicians' perceptions of spirituality in clinical care, the roles of their own personal spirituality, and implications for medical education. METHODS: We used qualitative content analysis on transcripts of semi-structured interviews that had been conducted with 12 family physicians, in three regions of the country, with an expressed interest in spirituality. RESULTS: This group of physicians reported 1) taking a vital clinical role as encouragers of patients' spiritual resources, 2) a vital role of their personal spirituality as an underpinning of the vocation and practice of family medicine, and 3) the key roles of respectful dialogue and mentoring in medical education about spirituality. CONCLUSIONS: Results affirm the significance of spirituality in clinical family practice for the subjects interviewed and support a tripartite model that embraces clinical approaches to the spirituality of patients and families, the spirituality of caregivers, and the qualities of spirituality in health care organizations.