Yttrium-90 Radioembolization to the Prostate Gland: Proof of Concept in a Canine Model and Clinical Translation.

PURPOSE: To investigate the feasibility, safety, and absorbed-dose distribution of prostatic artery radioembolization (RE) in a canine model. MATERIALS AND METHODS: Fourteen male castrated beagles received dihydroandrosterone/estradiol to induce prostatic hyperplasia for the duration of the study. Each dog underwent fluoroscopic prostatic artery catheterization. Yttrium-90 (90Y) microspheres (TheraSphere; Boston Scientific, Marlborough, Massachusetts) were delivered to 1 prostatic hemigland (dose escalation from 60 to 200 Gy), with the contralateral side serving as a control. Assessments for adverse events were performed throughout the follow-up (Common Terminology Criteria for Adverse Events v5.0). Positron emission tomography/magnetic resonance (MR) imaging provided a confirmation after the delivery of absorbed-dose distribution. MR imaging was performed before and 3, 20, and 40 days after RE. Tissue harvest of the prostate, rectum, bladder, urethra, penis, and neurovascular bundles was performed 60 days after RE. RESULTS: All the animals successfully underwent RE. Positron emission tomography/MR imaging demonstrated localization to and good coverage of only the treated hemigland. No adverse events occurred. The MR imaging showed a significant dose-dependent decrease in the treated hemigland size at 40 days (25%-60%, P < .001). No extraprostatic radiographic changes were observed. Necropsy demonstrated no gross rectal, urethral, penile, or bladder changes. Histology revealed RE-induced changes in the treated prostatic tissues of the highest dose group, with gland atrophy and focal necrosis. No extraprostatic RE-related histologic findings were observed. CONCLUSIONS: Prostate 90Y RE is safe and feasible in a canine model and leads to focal dose-dependent changes in the gland without inducing unwanted extraprostatic effects. These results suggest that an investigation of nonoperative prostate cancer is warranted.

Correction to: Yttrium-90 radioembolization as a possible new treatment for brain cancer: proof of concept and safety analysis in a canine model.

An amendment to this paper has been published and can be accessed via the original article.

Yttrium-90 radioembolization as a possible new treatment for brain cancer: proof of concept and safety analysis in a canine model.

PURPOSE: To evaluate the safety, feasibility, and preliminary efficacy of yttrium-90 (90Y) radioembolization (RE) as a minimally invasive treatment in a canine model with presumed spontaneous brain cancers. MATERIALS: Three healthy research dogs (R1-R3) and five patient dogs with spontaneous intra-axial brain masses (P1-P5) underwent cerebral artery RE with 90Y glass microspheres (TheraSphere). 90Y-RE was performed on research dogs from the unilateral internal carotid artery (ICA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) while animals with brain masses were treated from the ICA. Post-treatment 90Y PET/CT was performed along with serial neurological exams by a veterinary neurologist. One month after treatment, research dogs were euthanized and the brains were extracted and sent for microdosimetric and histopathologic analyses. Patient dogs received post-treatment MRI at 1-, 3-, and 6-month intervals with long-term veterinary follow-up. RESULTS: The average absorbed dose to treated tissue in R1-R3 was 14.0, 30.9, and 73.2 Gy, respectively, with maximum doses exceeding 1000 Gy. One month after treatment, research dog pathologic analysis revealed no evidence of cortical atrophy and rare foci consistent with chronic infarcts, e.g., < 2-mm diameter. Absorbed doses to masses in P1-P5 were 45.5, 57.6, 58.1, 45.4, and 64.1 Gy while the dose to uninvolved brain tissue was 15.4, 27.6, 19.2, 16.7, and 33.3 G, respectively. Among both research and patient animals, 6 developed acute neurologic deficits following treatment. However, in all surviving dogs, the deficits were transient resolving between 7 and 33 days post-therapy. At 1 month post-therapy, patient animals showed a 24-94% reduction in mass volume with partial response in P1, P3, and P4 at 6 months post-treatment. While P2 initially showed a response, by 5 months, the mass had advanced beyond pre-treatment size, and the dog was euthanized. CONCLUSION: This proof of concept demonstrates the technical feasibility and safety of 90Y-RE in dogs, while preliminary, initial data on the efficacy of 90Y-RE as a potential treatment for brain cancer is encouraging.

The number of microspheres in Y90 radioembolization directly affects normal tissue radiation exposure.

PURPOSE: In Y90 radioembolization, the number of microspheres infused varies by more than a factor of 20 over the shelf-life of the glass radioembolization device. We investigated the effect of the number of Y90 microspheres on normal liver tissue. METHOD: Healthy pigs received lobar radioembolization with glass Y90 microspheres at 4, 8, 12, and 16 days post-calibration, representing a > 20× range in the number of microspheres deposited per milliliter in tissue. Animals were survived for 1-month post-treatment and the livers were explanted and scanned on a micro CT system to fully characterize the microscopic distribution of individual microspheres. A complete 3D microdosimetric evaluation of each liver was performed with a spatially correlated analysis of histopathologic effect. RESULTS: Through whole-lobe microscopic identification of each microsphere, a consistent number of microspheres per sphere cluster was found at 4, 8, and 12 days postcalibration, despite an 8-fold increase in total microspheres infused from days 4 to 12. The additional microspheres instead resulted in more clusters formed and, therefore, a more homogeneous microscopic absorbed dose. The increased absorbed-dose homogeneity resulted in a greater volume fraction of the liver receiving a potentially toxic absorbed dose based on radiobiologic models. Histopathologic findings in the animals support a possible increase in normal liver toxicity in later treatments with more spheres (i.e., ≥ day 12) compared to early treatments with less spheres (i.e., ≤ day 8). CONCLUSION: The microdosimetric evidence presented supports a recommendation of caution when treating large volumes (e.g., right lobe) using glass 90Y microspheres at more than 8 days post-calibration, i.e., after "2nd week" Monday. The favorable normal tissue microscopic distribution and associated low toxicity of first week therapies may encourage opportunities for dose escalation with glass microspheres and could also be considered for patients with decreased hepatic reserve.

Verification of a method to detect glass microspheres via micro-CT.

INTRODUCTION: The ability to determine the microscopic distribution of glass microspheres in 90 Y radioembolization has important applications in post-treatment microdosimetry and cluster analysis. Current methods are time-intensive and labor-intensive and thus are typically only applied to small samples. MATERIALS AND METHODS: A high-resolution micro-CT image with a voxel size of 8.74 µm was acquired of phantoms containing ~25 µm-diameter glass microspheres embedded in tissue-equivalent materials that were optically transparent, which allowed true microsphere locations to be determined using transmission light microscopy. A 3-stage algorithm was developed to estimate the number and locations of microspheres in tissue regions. The stages are thresholding the CT image and discarding regions with insufficient voxels, estimating the number of microspheres in each region using the values of the detected and neighboring region voxels and estimating locations for each microsphere using the outputs of the previous two stages. Two different methods for estimating the number of microspheres in each region were derived, as were five methods for localizing microspheres. Metrics for each stage were computed, and the mean absolute error (MAE) between the dose to 72 µm voxels of the true and estimated dose maps created from the microsphere locations was used as the figure of merit for overall algorithm performance. Microsphere locations identified in the optical micrograph were used as the gold standard for the metrics of all stages. The method's utility was then demonstrated using a specimen from a human neuroendocrine tumor (NET) treated with glass 90 Y microspheres. RESULTS: The stage detecting regions containing microspheres found 100% of microspheres inside regions. The number of incorrectly detected regions without microspheres was 1.5% of the total number of regions. In stage 2, with these parameters, nearly 94% of the actual number of spheres in each region was correctly counted, and only 5% of the estimated sphere quantities in each region were false positives. The MAE between the true dose maps and dose maps estimated using the full algorithm with optimal parameter and method choices was 4.2%. A total of 5,713 glass microspheres were identified as being distributed heterogeneously in the NET specimen with a maximum tumor dose of >2500 Gy and 46% of the specimen receiving <20 Gy. CONCLUSIONS: This work developed and evaluated a method to detect and estimate the three-dimensional locations of glass microspheres in whole tissue samples that require less manual effort than traditional methods. This method could be used to gain important insights into the heterogeneity of microsphere distributions that would be useful for improving radioembolization treatment planning.

Impact of using scatter-mimicking beams instead of standard beams to measure penetration when assessing the protective value of radiation-protective garments.

PURPOSE: Use standardized methods to determine how assessment of protective value of radiation-protective garments changes under conditions employing standard beam qualities, scatter-mimicking primary beams, and a modified Hp (10) measurement. METHODS: The shielding properties of radiation-protective garments depend on the spectrum of beam energies striking the garment and the attenuation properties of materials used to construct the garment, including x-ray fluorescence produced by these materials. In this study the primary beam spectra employed during clinical interventional radiology and cardiology procedures (clinical primary beams, CPB) were identified using radiation dose structured reports (RDSR) and fluoroscope log data. Monte Carlo simulation was used to determine the scattered radiation spectra produced by these CPB during typical clinical application. For these scattered spectra, scatter-mimicking primary beams (SMPB) were determined using numerical optimization-based spectral reconstruction that adjusted kV and filtration to produce the SMPB that optimally matched the scattered spectrum for each CPB. The penetration of a subset of SMPB through four radiation-protective garments of varying compositions and nominal thicknesses was measured using a geometry specified by the International Electrotechnical Commission (IEC). The diagnostic radiological index of protection (DRIP), which increases with increasing penetration through a garment, was calculated using these measurements. Penetration through the same garments was measured for standard beams specified by the American Society of Testing and Materials (ASTM). Finally, 10 mm of PMMA was affixed to the inside of each garment and the DRIP remeasured in this configuration to simulate Hp (10). RESULTS: The SMPB based on actual CPB were in general characterized by lower kV (range 60-76) and higher half-value layer (HVL, range 3.44-4.89 mm Al) than standard beam qualities specified by ASTM (kV range 70-85; HVL range 3.4-4.0 mm Al). A lead garment of nominal thickness 0.5 mm (D) had a DRIP of 0.8%, two lead-free garments of 0.5 mm nominal thickness had DRIPs of 1.2% (A) and 2.2% (B), and a lead-free bilayer (C) had a DRIP of 1.4%. When standard beam qualities specified by the ASTM were used, the DRIP for D was 2.2%, 175% higher than the DRIP measured using SMPB, and for A, B, and C was 2.8%, 3.2%, and 2.9%, respectively. This was 133%, 45%, and 107% higher than the DRIP measured using SMPB. Differences between the DRIP of lead-alternative garments and the lead garment were reduced when measured with 10 mm of PMMA. Using this method, the measured DRIPs were 2.2% (A), 3.1% (B), 2.5% (C), and 2.3% (D). CONCLUSIONS: Penetration of radiation through radiation-protective garments depended strongly on the methods and X-ray spectra used for evaluation. The DRIP was higher (i.e., protective value was lower) for lead-alternative garments than for lead garments in this evaluation. The DRIP was lower for all garments when SMPB based on actual clinical beam quality data were used to measure penetration compared to ASTM standard beams. Differences in penetration between lead-alternative and lead garments were less when the DRIP was measured with 10 mm of PMMA between the garment and the chamber.

Safety and efficacy of combined micropuncture and shallow angle femoral artery access for neurovascular angiography.

INTRODUCTION: The AXERA 2 low-angle vascular access device utilizes a dual arteriotomy mechanism in which the standard access tract is compressed by a vascular sheath inserted over the second, low-angle tract. It is unknown whether this device could be effectively used with 21-gauge micropuncture access, as the micropuncture introducer makes a larger arteriotomy than the 19-gauge needle provided with the AXERA 2 system. MATERIALS AND METHODS: A retrospective review was performed on 189 patients who underwent common femoral artery access for diagnostic cerebrovascular angiography using either combined micropuncture and AXERA 2 access or standard access with manual pressure hemostasis. Demographic and procedural data were reviewed along with complications related to vascular access and times to bed elevation, ambulation and discharge. RESULTS: Combined micropuncture and AXERA 2 access was performed on 110 patients and 79 patients had standard access. The AXERA device was successfully used in 91.8% of the cases. Demographic data, anticoagulant use and sheath sizes were similar between both subsets. Use of the AXERA 2 was associated with two bleeding complications (1.8%) compared with 10 (12.7%) with manual pressure hemostasis alone. Institution-specific protocol allowed shorter mean manual compression time, as well as shorter times to ambulation and discharge with the AXERA 2. CONCLUSIONS: Use of the AXERA 2 device with micropuncture access did not infer increased bleeding risk than standard arterial access in this patient series. The considerable incidence of device use failures suggests a learning curve associated with its use.

Computational simulation of the predicted dosimetric impact of adjuvant yttrium-90 PET/CT-guided percutaneous ablation following radioembolization.

BACKGROUND: 90Y PET/CT post-radioembolization imaging has demonstrated that the distribution of 90Y in a tumor can be non-uniform. Using computational modeling, we predicted the dosimetric impact of post-treatment 90Y PET/CT-guided percutaneous ablation of the portions of a tumor receiving the lowest absorbed dose. A cohort of fourteen patients with non-resectable liver cancer previously treated using 90Y radioembolization were included in this retrospective study. Each patient exhibited potentially under-treated areas of tumor following treatment based on quantitative 90Y PET/CT. 90Y PET/CT was used to guide electrode placement for simulated adjuvant radiofrequency ablation in areas of tumor receiving the lowest dose. The finite element method was used to solve Penne's bioheat transport equation, coupled with the Arrhenius thermal cell-death model to determine 3D thermal ablation zones. Tumor and unablated tumor absorbed-dose metrics (average dose, D50, D70, D90, V100) following ablation were compared, where D70 is the minimum dose to 70% of tumor and V100 is the fractional tumor volume receiving more than 100 Gy. RESULTS: Compared to radioembolization alone, 90Y radioembolization with adjuvant ablation was associated with predicted increases in all tumor dose metrics evaluated. The mean average absorbed dose increased by 11.2 ± 6.9 Gy. Increases in D50, D70, and D90 were 11.0 ± 6.9 Gy, 13.3 ± 10.9 Gy, and 11.8 ± 10.8 Gy, respectively. The mean increase in V100 was 7.2 ± 4.2%. All changes were statistically significant (P < 0.01). A negative correlation between pre-ablation tumor volume and D50, average dose, and V100 was identified (ρ < - 0.5, P < 0.05) suggesting that adjuvant radiofrequency ablation may be less beneficial to patients with large tumor burdens. CONCLUSIONS: This study has demonstrated that adjuvant 90Y PET/CT-guided radiofrequency ablation may improve tumor absorbed-dose metrics. These data may justify a prospective clinical trial to further evaluate this hybrid approach.

Bariatric Radioembolization: A Pilot Study on Technical Feasibility and Safety in a Porcine Model.

PURPOSE: To evaluate feasibility of left gastric artery (LGA) yttrium-90 ((90)Y) radioembolization as potential treatment for obesity in a porcine model. MATERIALS AND METHODS: This study included 8 young female pigs (12-13 weeks, 21.8-28.1 kg). Six animals received infusions of (90)Y resin microspheres (46.3-105.1 MBq) into the main LGA and the gastric artery arising from the splenic artery. Animal weight and serum ghrelin were measured before treatment and weekly thereafter. Animals were euthanized 69-74 days after treatment, and histologic analyses of mucosal integrity and ghrelin immunoreactive cell density were performed. RESULTS: Superficial mucosal ulcerations < 3.0 cm(2) were noted in 5 of 6 treated animals. Ghrelin immunoreactive cell density was significantly lower in treated versus untreated animals in the stomach fundus (13.5 vs 34.8, P < .05) and stomach body (11.2 vs 19.8, P < .05). Treated animals gained less weight than untreated animals over the study duration (40.2 kg ± 5.4 vs 54.7 kg ± 6.5, P = .053). Average fundic parietal area (165 cm(2) vs 282 cm(2), P = .067) and average stomach weight (297.2 g vs 397.0 g, P = .067) were decreased in treated versus untreated animals. Trichrome staining revealed significantly more fibrosis in treatment animals compared with control animals (13.0 vs 8.6, P < .05). No significant differences were identified in plasma ghrelin concentrations (P = .24). CONCLUSIONS: LGA (90)Y radioembolization is promising as a potential treatment for obesity. A larger preclinical study is needed to evaluate the safety and efficacy of this procedure further.

Sensitivity of the diagnostic radiological index of protection to procedural factors in fluoroscopy.

PURPOSE: To evaluate the sensitivity of the diagnostic radiological index of protection (DRIP), used to quantify the protective value of radioprotective garments, to procedural factors in fluoroscopy in an effort to determine an appropriate set of scatter-mimicking primary beams to be used in measuring the DRIP. METHODS: Monte Carlo simulations were performed to determine the shape of the scattered x-ray spectra incident on the operator in different clinical fluoroscopy scenarios, including interventional radiology and interventional cardiology (IC). Two clinical simulations studied the sensitivity of the scattered spectrum to gantry angle and patient size, while technical factors were varied according to measured automatic dose rate control (ADRC) data. Factorial simulations studied the sensitivity of the scattered spectrum to gantry angle, field of view, patient size, and beam quality for constant technical factors. Average energy (Eavg) was the figure of merit used to condense fluence in each energy bin to a single numerical index. RESULTS: Beam quality had the strongest influence on the scattered spectrum in fluoroscopy. Many procedural factors affect the scattered spectrum indirectly through their effect on primary beam quality through ADRC, e.g., gantry angle and patient size. Lateral C-arm rotation, common in IC, increased the energy of the scattered spectrum, regardless of the direction of rotation. The effect of patient size on scattered radiation depended on ADRC characteristics, patient size, and procedure type. CONCLUSIONS: The scattered spectrum striking the operator in fluoroscopy is most strongly influenced by primary beam quality, particularly kV. Use cases for protective garments should be classified by typical procedural primary beam qualities, which are governed by the ADRC according to the impacts of patient size, anatomical location, and gantry angle.

How Sensitive Is the Upper Gastrointestinal Tract to 90Y Radioembolization? A Histologic and Dosimetric Analysis in a Porcine Model.

In 90Y radioembolization, nontarget embolization to the stomach or small bowel can result in gastrointestinal injury, a rare but difficult to manage clinical complication. However, dosimetric thresholds for toxicity to these tissues from radioembolization have never been evaluated in a controlled setting. We performed an analysis of the effect of 90Y radioembolization in a porcine model at different absorbed-dose endpoints. METHODS: Six female pigs underwent transfemoral angiography and infusion of 90Y-resin microspheres into arteries supplying part of the gastric wall. Esophagogastroduodenoscopy was performed after 4 wk to assess interim gastrointestinal health. Animals were monitored for side effects for 9 wk after 90Y infusion, after which they were euthanized and their upper gastrointestinal tracts were excised for analysis. Histologic sections were used to map microsphere location, and a microdosimetric evaluation was performed to determine the absorbed-dose profile within the gastrointestinal wall. RESULTS: 90Y radioembolization dosages from 46.3 to 105.1 MBq were infused, resulting in average absorbed doses of between 35.5 and 91.9 Gy to the gastric wall. No animal exhibited any signs of pain or gastrointestinal distress through the duration of the study. Excised tissue showed 1-2 small (<3.0 cm2) healed or healing superficial gastric lesions in 5 of 6 animals. Histologic analysis demonstrated that lesion location was superficial to areas of abnormally high microsphere deposition. An analysis of microsphere deposition patterns within the gastrointestinal wall indicated a high preference for submucosal deposition. Dosimetric evaluation at the luminal mucosa performed on the basis of microscopic microsphere distribution confirmed that 90Y dosimetry techniques conventionally used in hepatic dosimetry provide a first-order estimate of absorbed dose. CONCLUSION: The upper gastrointestinal tract may be less sensitive to 90Y radioembolization than previously thought. Lack of charged-particle equilibrium at the luminal mucosa may contribute to decreased toxicity of 90Y radioembolization compared with external-beam radiation therapy in gastrointestinal tissue. Clinical examples of injury from 90Y nontarget embolization have likely resulted from relatively large 90Y activities being deposited in small tissue volumes, resulting in absorbed doses in excess of 100 Gy.

A Microdosimetric Analysis of Absorbed Dose to Tumor as a Function of Number of Microspheres per Unit Volume in 90Y Radioembolization.

UNLABELLED: Differences in maximum tolerable absorbed dose to normal liver between (90)Y radioembolization and external-beam radiation therapy have been explained by citing differences in absorbed-dose heterogeneity at the microscopic level. We investigated microscopic absorbed-dose heterogeneity in radioembolization as a function of the number of microspheres per unit volume in tumor. The goal was to determine what effect the number of microspheres may have, if any, on tumor control in (90)Y radioembolization. METHODS: (90)Y PET/CT data were combined with microscopic probability-density functions describing microsphere clustering to provide realistic simulation using Monte Carlo modeling on both a macroscopic and a microscopic level. A complete microdosimetric analysis using 100-µm voxels was performed on the basis of (90)Y PET/CT data from 19 tumors treated using radioembolization. Simulations were performed with average tumor microsphere-number densities from 200 to 70,000 spheres/mL. Monte Carlo simulations of each tumor and number density were repeated 20 times to establish SE. A 2-way balanced ANOVA was used to determine whether differences in microsphere-number density affected common tumor-dose metrics. RESULTS: Decreasing the microsphere-number density resulted in a decrease in D70, the minimum dose to 70% of the tumor. The slope of the dose-volume histogram also decreased with decreasing microsphere-number density in all tumors. Compared with a density of 50,000 spheres/mL, decreases in D70 were statistically significant below 20,000 spheres/mL. However, these differences are unlikely to have clinical significance until the density decreases to below 5,000 spheres/mL. Although D70 was decreased at a low microsphere-number density, one can compensate for decreases by an increase in the average tumor-absorbed dose, that is, by increasing the radioembolization treatment dose. CONCLUSION: Differences in microsphere-number density may have an effect on microscopic tumor absorbed-dose inhomogeneity. These results begin to explain differences in treatment planning strategies between glass and resin radioembolization devices.

The evolution of image-guided lumbosacral spine surgery.

Techniques and approaches of spinal fusion have considerably evolved since their first description in the early 1900s. The incorporation of pedicle screw constructs into lumbosacral spine surgery is among the most significant advances in the field, offering immediate stability and decreased rates of pseudarthrosis compared to previously described methods. However, early studies describing pedicle screw fixation and numerous studies thereafter have demonstrated clinically significant sequelae of inaccurate surgical fusion hardware placement. A number of image guidance systems have been developed to reduce morbidity from hardware malposition in increasingly complex spine surgeries. Advanced image guidance systems such as intraoperative stereotaxis improve the accuracy of pedicle screw placement using a variety of surgical approaches, however their clinical indications and clinical impact remain debated. Beginning with intraoperative fluoroscopy, this article describes the evolution of image guided lumbosacral spinal fusion, emphasizing two-dimensional (2D) and three-dimensional (3D) navigational methods.

Simulation-based educational curriculum for fluoroscopically guided lumbar puncture improves operator confidence and reduces patient dose.

RATIONALE AND OBJECTIVES: Fluoroscopically guided lumbar puncture (FGLP) is a commonly performed procedure with increased success rates relative to bedside technique. However, FGLP also exposes both patient and staff to ionizing radiation. The purpose of this study was to determine if the use of a simulation-based FGLP training program using an original, inexpensive lumbar spine phantom could improve operator confidence and efficiency, while also reducing patient dose. MATERIALS AND METHODS: A didactic and simulation-based FGLP curriculum was designed, including a 1-hour lecture and hands-on training with a lumbar spine phantom prototype developed at our institution. Six incoming post-graduate year 2 (PGY-2) radiology residents completed a short survey before taking the course, and each resident practiced 20 simulated FGLPs using the phantom before their first clinical procedure. Data from the 114 lumbar punctures (LPs) performed by the six trained residents (prospective cohort) were compared to data from 514 LPs performed by 17 residents who did not receive simulation-based training (retrospective cohort). Fluoroscopy time (FT), FGLP success rate, and indication were compared. RESULTS: There was a statistically significant reduction in average FT for the 114 procedures performed by the prospective study cohort compared to the 514 procedures performed by the retrospective cohort. This held true for all procedures in aggregate, LPs for myelography, and all procedures performed for a diagnostic indication. Aggregate FT for the prospective group (0.87 ± 0.68 minutes) was significantly lower compared to the retrospective group (1.09 ± 0.65 minutes) and resulted in a 25% reduction in average FT (P = .002). There was no statistically significant difference in the number of failed FGLPs between the two groups. CONCLUSIONS: Our simulation-based FGLP curriculum resulted in improved operator confidence and reduced FT. These changes suggest that resident procedure efficiency was improved, whereas patient dose was reduced. The FGLP training program was implemented by radiology residents and required a minimal investment of time and resources. The LP spine phantom used during training was inexpensive, durable, and effective. In addition, the phantom is compatible with multiple modalities including fluoroscopy, computed tomography, and ultrasound and could be easily adapted to other applications such as facet injections or joint arthrograms.

The impact of an antireflux catheter on target volume particulate distribution in liver-directed embolotherapy: a pilot study.

PURPOSE: To determine if there are differences in hepatic distribution of embolic particles following infusion with a standard end-hole catheter versus an antireflux microcatheter. MATERIALS AND METHODS: This prospective study included nine patients (age, 48-86 y) enrolled for treatment of hepatocellular carcinoma (n = 6), liver-dominant metastatic disease (n = 2), or intrahepatic cholangiocarcinoma (n = 1) with resin yttrium-90 ((90)Y) microspheres. Before (90)Y treatment, each patient received two same-day sequential lobar infusions of technetium 99m ((99m)Tc) macroaggregated albumin (MAA) via a conventional end-hole catheter and an antireflux microcatheter positioned at the same location. Differences in technetium 99m-MAA distribution within tumor and nontarget sites were evaluated by single-photon emission computed tomography (SPECT) on a qualitative and semiquantitative basis. The antireflux microcatheter was used for the ensuing (90)Y treatment, with posttreatment (90)Y positron emission tomography/computed tomography to assess distribution of (90)Y microspheres. RESULTS: Decreases in hepatic nontarget embolization were found in all patients when the antireflux catheter was used. These decreases ranged from a factor of 0.11 to a factor of 0.76 (mean, 0.42; σ = 0.19), representing a 24%-89% reduction. Increased tumor deposition was also noted in all patients, ranging from a factor of 1.33 to a factor of 1.90 (mean, 1.68; σ = 0.20), representing a relative increase of 33%-90%. Both findings were statistically significant (P < .05). CONCLUSIONS: Although this pilot study identified differences in the downstream distribution of embolic particles when the antireflux catheter was used, further investigation is needed to determine if these findings are reproducible in a larger patient cohort and, if so, whether they are associated with any clinical impact.

Application of the diagnostic radiological index of protection to protective garments.

PURPOSE: Previously, the diagnostic radiological index of protection (DRIP) was proposed as a metric for quantifying the protective value of radioprotective garments. The DRIP is a weighted sum of the percent transmissions of different radiation beams through a garment. Ideally, the beams would represent the anticipated stray radiation encountered during clinical use. However, it is impractical to expect a medical physicist to possess the equipment necessary to accurately measure transmission of scatteredradiation. Therefore, as a proof of concept, the authors tested a method that applied the DRIP to clinical practice. METHODS: Primary beam qualities used in interventional cardiology and radiology were observed and catalogued. Based on the observed range of beam qualities, five representative clinical primary beam qualities, specified by kV and added filtration, were selected for this evaluation. Monte Carlo simulations were performed using these primary beams as source definitions to generate scatteredspectra from the clinical primary beams. Using numerical optimization, ideal scatter mimicking primary beams, specified by kV and added aluminum filtration, were matched to the scatteredspectra according to half- and quarter-value layers and spectral shape. To within reasonable approximation, these theoretical scatter-mimicking primary beams were reproduced experimentally in laboratory x ray beams and used to measure transmission through pure lead and protective garments. For this proof of concept, the DRIP for pure lead and the garments was calculated by assigning equal weighting to percent transmission measurements for each of the five beams. Finally, the areal density of lead and garments was measured for consideration alongside the DRIP to assess the protective value of each material for a given weight. RESULTS: The authors identified ideal scatter mimicking primary beams that matched scatteredspectra to within 0.01 mm for half- and quarter-value layers in copper and within 5% for the shape function. The corresponding experimental scatter-mimicking primary beams matched the Monte Carlo generated scatteredspectra with maximum deviations of 6.8% and 6.6% for half- and quarter-value layers. The measured DRIP for 0.50 mm lead sheet was 2.0, indicating that it transmitted, on average, 2% of incident radiation. The measured DRIP for a lead garment and one lead-alternative garment closely matched that for pure lead of 0.50 mm thickness. The DRIP for other garments was substantially higher than 0.50 mm lead (3.9­5.4), indicating they transmitted about twice as much radiation. When the DRIP was plotted versus areal density, it was clear that, of the garments tested, none were better than lead on a weight-by-weight basis. CONCLUSIONS: A method for measuring the DRIP for protective garments using scatter-mimicking primary beams was developed. There was little discernable advantage in protective value per unit weight for lead-alternative versus lead-only garments. Careful consideration must be given to the balance of protection and weight when choosing a lead-alternative protective garment with a lower specified "lead equivalence," e.g., 0.35 mm. The DRIP has the potential to resolve this dilemma. Reporting the DRIP relative to areal density is an ideal metric for objective comparisons of protective garment performance, considering both protective value in terms of transmission of radiation and garment weight.

A robust and inexpensive phantom for fluoroscopically guided lumbar puncture training.

INTRODUCTION: This report describes the creation process for an inexpensive, durable, lumbar spine phantom for use in fluoroscopically guided lumbar puncture (LP) training. METHODS: The LP phantom prototype was made from a polyvinyl chloride lumbar spine model embedded in a translucent rectangular block of commercially available thermoplastic polymer gel. Radiology residents with limited previous experience performing LP used the phantom for 20 simulated procedures to gain confidence before starting patient procedures. The residents completed surveys detailing their experiences with the phantom. RESULTS: Quantitative evaluation of the phantom using fluoroscopy and computed tomography suggested good physical agreement with human anatomy. Six board-certified radiologists viewed the phantom under live fluoroscopy and indicated that the phantom represented human anatomy with sufficient accuracy. Furthermore, surveys from resident trainees indicated that the thermoplastic tissue substitute simulated the texture and resistance of human soft tissue reasonably well for the purposes of clinical training. The total material cost of the LP phantom prototype was approximately US $148.00. CONCLUSIONS: This novel spine phantom can be produced with relatively low cost when compared with similar commercially available products. The phantom offers reasonable visual and tactile agreement to human anatomy and may be useful for improving the confidence of physician trainees. The LP phantom is durable and can easily be repaired by reheating the polymer tissue substitute.