Background: 90Y and 177Lu are two well-known radionuclides used in radionuclide therapy to treat neuroendocrine tumors.
Objective: This current study aims to evaluate, compare and optimize tumor therapy with 90Y and 177Lu for different volumes of the tumor using the criterion of self-absorbed dose, cross-absorbed dose, absorbed dose profile, absorbed dose uniformity, and dose-volume histogram (DVH) curve using Gate Monte Carlo simulation code.
Material and Methods: In our analytical study, Gate Monte Carlo simulation code has been used to model tumors and simulate particle transport. Spherical tumors were modeled from radius 0.5 to 20 mm. Tumors were uniformly designed from water (soft tissue reagent). The full energy spectrum of each radionuclide of 177Lu and 90Y was used in the total volume of tumors with isotropic radiation, homogeneously. Self-absorbed dose, cross-absorbed dose, absorbed dose profile, absorbed dose uniformity, and DVH curve parameters were evaluated.
Results: The absorbed dose for 90Y is higher than 177Lu in all tumors (p-value <5%). The uniformity of the absorbed dose for 177Lu is much greater than 90Y. As the tumor size increases, the DVH graph improves for 90Y.
Conclusion: Based on self-absorbed dose, cross-absorbed dose, absorbed dose uniformity, and DVH diagram, 177Lu and 90Y are appropriate for smaller and larger tumors, respectively. Next, we can evaluate the appropriate cocktail of these radionuclides, in terms of the type of composition, for the treatment of tumors with a specific size.
Radionuclide radiation therapy is an important method for treating the disseminated tumors and metastases [ 1 ]. A major advantage of radionuclide therapy is that it treats not only primary large tumors and macro-metastases but also small tumors and micro-metastases [ 1 , 2 ].
As tumor tissue absorbs radiopharmaceuticals, healthy tissue also absorbs them and irradiated, and radionuclide therapy planning thus aims is to deliver the highest absorbed dose to the tumor tissue and the least damage to the organ at risk [ 3 - 5 ].
90Y and 177Lu are two well-known radionuclides used in radionuclide therapy of neuroendocrine tumors. Based on the previous literature, 177Lu and 90Y have low and high energy beta particles, respectively, and also they are widely used for treating smaller and larger tumors [ 6 - 9 ].
In the clinical situation, the most serious part of treatment planning of radionuclide therapy is determining the measure of prescribed radioactive material for improving treatment, based on the maximum absorbed dose to the tumor tissues and the minimum absorbed dose to critical organs. Also, there are some limitations, including methods for estimating dose distribution in tumors and tissues around tumors. As a result, proper treatment planning is an accurate and fast method of dose estimation to optimize treatment planning. If the dosimetry technique adopted is not appropriate, we may experience an increase in the absorbed dose of around the tumor and an insufficient absorbed dose inside the tumor as a result of estimating the wrong dose, leading to cancer reversion and low utilization [ 4 , 8 , 10 ].
Evaluation of self-dose and cross-dose of tumors in radionuclide therapy is important to examine the treatment planning [ 9 ].
It is also important to study the tumor’s absorbed dose profile to evaluate the tumor absorbed dose’s flatness, which directly affects the optimal treatment [ 11 ].
Dose Volume Histogram (DVH) and external radiotherapy can be utilized to examine the treatment planning of radionuclide therapy [ 12 ].
It seems that the study of physical parameters can well evaluate treatment planning in radionuclide therapy. Therefore, the current study aims to evaluate, compare and optimize tumor therapy with 90Y and 177Lu for different sizes of tumors using the criteria of self-absorbed dose, cross-absorbed dose, absorbed dose profile, dose uniformity, and DVH curve, using Gate Monte Carlo simulation code.
Material and Methods
In this analytical study, Gate version 8.1 (based Geant4 package version 10.4) Monte Carlo simulation code has been used to model tumors and simulate particle transport. Spherical tumors were modeled from radius 0.5 to 20 mm (volume of 0.4 to 4000 mm3) [ 13 ]. The dimension of an area outside the tumor is greater than three times the maximum range of each radionuclide for calculating the cross dose. Tumors were uniformly designed from water (soft tissue reagent). The total energy spectrum of 177Lu and 90Y radionuclides were used in the total volume of tumors with isotropic radiation, homogeneously [ 14 ]. The characteristics of these radionuclides are shown in Table 1. To achieve more accuracy, “standard physical processes” were used to perform the simulation, which included Photoelectric, Compton, Rayleigh Scattering, Gamma Conversion, Electron Ionization, Bremsstrahlung, and Multiple Scattering processes [ 9 ]. The output files from the simulation include the dose and dose uncertainty files. The absorbed dose, Dm, is calculated by energy deposited by equation 1.
|Isotope||T1/2 (day)||Average energy (Kev)||Maximum range (mm)|
(1) Dm = Energy deposited/Volume
Dm finally divided by the number of primary particles, and then the absorbed dose is eventually reported in Gy/Bq.s. The absorbed dose uniformity (flatness) inside the tumor (given from dose profile)is defined based on equation 2 [ 11 , 15 ]:
(2) %flatness = Dosemax - Dosemin Dosemax + Dosemin × 100
We also plot the relative Dose Volume Histogram (DVH) for all tumors and radionuclides.
To achieve statistical uncertainty less than 5%, the number of primary particles for simulation was considered 109 and 108 for 177Lu and 90Y, respectively.
|Radionuclide radius of tumors (mm)||90Y||177Lu|
|Radionuclide radius of tumors (mm)||90Y||177Lu|
Using the Mann-Whitney test, we analyzed the absorbed doses for 177Lu and 90Y radionuclides in all tumor sizes and concluded a substantial difference between absorbed doses for 177Lu and 90Y in all tumor sizes.
The absorbed dose for 90Y is greater than 177Lu (p-value <5%) in all tumor sizes.
The self-absorbed dose according to the tumor’s dimension is presented in Figure 1, which is qualitatively observed that as the tumor size increases the difference of 177Lu and 90Y decreases. Figure 2 shows the ratio of cross absorbed dose to total-absorbed dose as a function of tumor size. By increasing tumor size, the delivered absorbed dose to the outside of the tumor increases for 177Lu and 90Y, but from one size onwards, this reduction is gradual, and the extra-tumor doses for 177Lu and 90Y are almost constant.
Absorbed dose profiles of 177Lu and 90Y for a special tumor are shown in Figure 3 as an example. The absorbed dose flatness, which is a function of tumor size, is presented in Table 4. As seen, the flatness of 177Lu is better than 90Y. In addition, Figures 4 and 5 show the flatness values according to distance.
|Radionuclide radius of tumors (mm)||90Y||177Lu|
Table 5 shows Pearson coefficient values (showing the graph’s slope) with the significant level for determining the amount of uniformity improvement with increasing tumor size. It is observed that as tumor size increases, the uniformity of the absorbed dose of 177Lu and 90Y improves. It is worth noting that the rate of 90Y absorbed dose uniformity improves greater than that of 177Lu (p-value= 0.05).
Dose Volume Histogram (DVH)
The relative volume as a function of relative dose diagrams for 177Lu and 90Y radionuclides and tumor with the sizes of 1, 10 and, 20 mm, as representatives of all tumor sizes, are shown in Figure 6. It is understandable that as the tumor size increases, the DVH graph improves for 90Y as well. In smaller tumors, for 90Y, energy is transferred to a smaller volume of tumor space than in larger ones.
For all tumors, the absorbed dose for 90Y is more than 177Lu, which because of the higher energy of beta particles in 90Y compared to 177Lu. This issue is in accordance with previous work such as Enger et al. [ 9 ] in 2008 and O. ‘Donoghue et al. [ 13 ] in 1995.
Given that the absorbed dose profile was studied in the past, it seems that this parameter and the absorbed dose uniformity of the tumor can help to improve the treatment planning of radionuclide therapy.
Our study examined the absorbed dose uniformity and concluded that the flatness of 177Lu is better than 90Y, i.e. the absorbed dose variation for 177Lu is less than 90Y, and 177Lu delivers a more uniform absorbed dose to the entire tumor volume and ultimately improves tumor treatment.
Figures 4 and 5 show the absorbed dose uniformity values inside the tumors for 177Lu and 90Y. Also, for determining the amount of uniformity improvement with increasing tumor size, Pearson coefficient values (showing the graph’s slope) with a significant value are shown in Table 5. It is observed that with increasing tumor size, the absorbed dose uniformity of 177Lu and 90Y radionuclides improves, and it is noteworthy that the rate of 90Y absorbed dose uniformity improves greater than that of 177Lu. DVH can also be used to examine treatment planning in radionuclide therapy [ 12 ].
In our study, we also have drawn DVH curves for 177Lu and 90Y in all tumors. By evaluating the DVH curves, it can be realized that 177Lu is more suitable than 90Y for smaller tumors because 177Lu transfers the energy of the beta particles to the larger space of the small tumors.
90Y transfers a higher dose to the tumor, while covers less volume of the tumor. Moreover, it seems that with increasing tumor size, the DVH curve improves for 90Y. Thus, 90Y can be used to treat larger tumors; however, it should be mentioned that using 90Y causes a non-uniform dose within the tumor and increases the dose to surrounding organs.
According to the obtained results, 177Lu has better dose uniformity and DVH than 90Y for smaller tumors, and also delivers lower absorbed dose to outside area of the tumors. The disadvantages of 177Lu are unfavorable DVH for larger tumors and delivers low absorbed dose in all tumors. The benefits of 90Y are more tumor dose, and more favorable DVH for larger tumors, and its disadvantage is less absorbed dose uniformity and a more dose outside of the tumor.
In terms of the impact of tumor size on physical parameters in tumor therapy, we can conclude that by increasing tumor size: 1- the absorbed dose difference between 177Lu and 90Y decreases, 2- the absorbed dose flatness improves, and 3- the DVH diagram for 177Lu and 90Y worsens and improves, respectively.
By examining the parameters of self-absorbed dose, cross-absorbed dose, absorbed dose uniformity, and DVH diagram, the results of our work support the strategy of using 177Lu and 90Y for treatment of small and large tumors, respectively, in order to use the advantages of each radionuclide for better tumor treatment [ 4 , 5 , 16 , 17 ].
In targeted radionuclide therapy, the physical parameters of self-absorbed dose, cross-absorbed dose, absorbed dose uniformity, and DVH diagram could be utilized to evaluate the treatment planning system. By examining these parameters, it can be concluded that 177Lu and 90Y are appropriate for smaller and larger tumors, respectively. In addition, we can evaluate the appropriate cocktail of these radionuclides, in terms of the type of composition, for the treatment of tumors with a specific size.
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