Dose estimation after a mixed field exposure: Radium-223 and intensity modulated radiotherapy

Isabella Bastiani*, Stephen J. McMahon, Philip Turner, Kelly M. Redmond, Conor K. McGarry, Aidan Cole, Joe M. O'Sullivan, Kevin M. Prise, Liz Ainsbury, Rhona Anderson

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

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Introduction: Radium-223 dichloride ([223Ra]RaCl2), a radiopharmaceutical that delivers α-particles to regions of bone metastatic disease, has been proven to improve overall survival of men with metastatic castration resistant prostate cancer (mCRPC). mCRPC patients enrolled on the ADRRAD clinical trial are treated with a mixed field exposure comprising radium-223 (223Ra) and intensity modulated radiotherapy (IMRT). While absorbed dose estimation is an important step in the characterisation of wider systemic radiation risks in nuclear medicine, uncertainties remain for novel radiopharmaceuticals such as 223Ra. 

Methods: 24-Colour karyotyping was used to quantify the spectrum of chromosome aberrations in peripheral blood lymphocytes of ADRRAD patients at incremental times during their treatment. Dicentric equivalent frequencies were used in standard models for estimation of absorbed blood dose. To account for the mixed field nature of the treatment, existing models were used to determine the ratio of the component radiation types. Additionally, a new approach (M-FISHLET), based on the ratio of cells containing damage consistent with high-LET exposure (complex chromosomal exchanges) and low-LET exposure (simple exchanges), was used as a pseudo ratio for 223Ra:IMRT dose. 

Results: Total IMRT estimated doses delivered to the blood after completion of mixed radiotherapy (after 37 IMRT fractions and two [223Ra]RaCl2 injections) were in the range of 1.167 ± 0.092 and 2.148 ± 0.096 Gy (dose range across all models applied). By the last treatment cycle analysed in this study (four [223Ra]RaCl2 injections), the total absorbed 223Ra dose to the blood was estimated to be between 0.024 ± 0.027 and 0.665 ± 0.080 Gy, depending on the model used. Differences between the models were observed, with the observed dose variance coming from inter-model as opposed to inter-patient differences. The M-FISHLET model potentially overestimates the 223Ra absorbed blood dose by accounting for further PBL exposure in the vicinity of metastatic sites. 

Conclusions: The models presented provide initial estimations of cumulative dose received during incremental IMRT fractions and [223Ra]RaCl2 injections, which will enable improved understanding of the doses received by individual patients. While the M-FISHLET method builds on a well-established technique for external exposures, further consideration is needed to evaluate this method and its use in assessing non-targeted exposure by 223Ra after its localization at bone metastatic sites.

Original languageEnglish
Pages (from-to)10-20
Number of pages11
JournalNuclear Medicine and Biology
Publication statusPublished - 1 Mar 2022

Bibliographical note

Funding Information:
This project received funding from Public Health England, as part of the PHE PhD studentship scheme. This work was supported by the Movember Prostate Cancer UK Centre of Excellence (CEO13_2-004) and the Research and Development Division of the Public Health Agency of NI (COM/4965/14).

Open Access: . This is an open access article under the CC BY license (

Publisher Copyright: Crown Copyright © 2021 Published by Elsevier Inc.

Citation: Bastiani, Isabella, et al. "Dose estimation after a mixed field exposure: Radium-223 and intensity modulated radiotherapy." Nuclear Medicine and Biology 106 (2022): 10-20.



  • Biodosimetry
  • Chromosome exchanges
  • Prostate cancer
  • Radium-223
  • Targeted alpha-particle therapy


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