Significance: The ability to measure the micro-mechanical properties of biological tissues and biomaterials is crucial for numerous fields of cancer research, including tumor mechanobiology, tumor-targeting drug delivery, and therapeutic development.

Aim: Our goal is to provide a renewed perspective on the mainstream techniques used for micro-mechanical evaluation of biological tissues and biomimetic scaffoldings. We specifically focus on portraying the outlook of laser speckle micro-rheology (LSM), a technology that quantifies the mechanical properties of biomaterials and tissues in a rapid, non-contact manner.

Approach: First, we briefly explain the motivation and significance of evaluating the tissue micro-mechanics in various fields of basic and translational cancer research and introduce the key concepts and quantitative metrics used to explain the mechanical properties of tissue. This is followed by reviewing the general active and passive themes of measuring micro-mechanics. Next, we focus on LSM and elaborate on the theoretical grounds and working principles of this technique. Then, the perspective for measuring the micro-mechanical properties via LSM is outlined. Finally, we draw an overview picture of LSM in cancer mechanobiology research.

Results: With the continued emergence of new approaches for measuring the mechanical attributes of biological tissues, the field of micro-mechanical imaging is at its boom. As one of these competent innovations, LSM presents a tremendous potential for both technical maturation and prospective applications in cancer biomechanics and mechanobiology research.

Conclusion: By elaborating the current viewpoint of LSM, we expect to accelerate the expansion of this approach to new territories in both technological domains and applied fields. This renewed perspective on LSM may also serve as a road map for other micro-mechanical measurement concepts to be applied for answering mechanobiological questions.

Significance: Photoacoustic imaging (PAI) is a powerful emerging technology with broad clinical applications, but consensus test methods are needed to standardize performance evaluation and accelerate translation.

Aim: To review consensus image quality test methods for mature imaging modalities [ultrasound, magnetic resonance imaging (MRI), x-ray CT, and x-ray mammography], identify best practices in phantom design and testing procedures, and compare against current practices in PAI phantom testing.

Approach: We reviewed scientific papers, international standards, clinical accreditation guidelines, and professional society recommendations describing medical image quality test methods. Observations are organized by image quality characteristics (IQCs), including spatial resolution, geometric accuracy, imaging depth, uniformity, sensitivity, low-contrast detectability, and artifacts.

Results: Consensus documents typically prescribed phantom geometry and material property requirements, as well as specific data acquisition and analysis protocols to optimize test consistency and reproducibility. While these documents considered a wide array of IQCs, reported PAI phantom testing focused heavily on in-plane resolution, depth of visualization, and sensitivity. Understudied IQCs that merit further consideration include out-of-plane resolution, geometric accuracy, uniformity, low-contrast detectability, and co-registration accuracy.

Conclusions: Available medical image quality standards provide a blueprint for establishing consensus best practices for photoacoustic image quality assessment and thus hastening PAI technology advancement, translation, and clinical adoption.

Significance: An increasing interest in the area of biological effects at exposure of tissues and cells to the terahertz (THz) radiation is driven by a rapid progress in THz biophotonics, observed during the past decades. Despite the attractiveness of THz technology for medical diagnosis and therapy, there is still quite limited knowledge about safe limits of THz exposure. Different modes of THz exposure of tissues and cells, including continuous-wave versus pulsed radiation, various powers, and number and duration of exposure cycles, ought to be systematically studied.

Aim: We provide an overview of recent research results in the area of biological effects at exposure of tissues and cells to THz waves.

Approach: We start with a brief overview of general features of the THz-wave–tissue interactions, as well as modern THz emitters, with an emphasis on those that are reliable for studying the biological effects of THz waves. Then, we consider three levels of biological system organization, at which the exposure effects are considered: (i) solutions of biological molecules; (ii) cultures of cells, individual cells, and cell structures; and (iii) entire organs or organisms; special attention is devoted to the cellular level. We distinguish thermal and nonthermal mechanisms of THz-wave–cell interactions and discuss a problem of adequate estimation of the THz biological effects’ specificity. The problem of experimental data reproducibility, caused by rareness of the THz experimental setups and an absence of unitary protocols, is also considered.

Results: The summarized data demonstrate the current stage of the research activity and knowledge about the THz exposure on living objects.

Conclusions: This review helps the biomedical optics community to summarize up-to-date knowledge in the area of cell exposure to THz radiation, and paves the ways for the development of THz safety standards and THz therapeutic applications.

Significance: Artificial skin (AS) is widely used in dermatology, pharmacology, and toxicology, and has great potential in transplant medicine, burn wound care, and chronic wound treatment. There is a great demand for high-quality AS product and a non-invasive detection method is highly desirable.

Aim: To quantify the constructure parameters (i.e., thickness and surface roughness) of AS samples in the culture cycle and explore the growth regularities using optical coherent tomography (OCT).

Approach: An adaptive interface detection algorithm is developed to recognize surface points in each A-scan, offering a rapid method to calculate parameters without constructing OCT B-scan pictures and further achieving realizing real-time quantification of AS thickness and surface roughness. Experiments on standard roughness plates and H&E-staining microscopy were performed as a verification.

Results: As applied on the whole cycle of AS culture, our method’s results show that during the air–liquid culture, the surface roughness of the skin first decreases and then exhibits an increase, which implies coincidence with the degree of keratinization under a microscope. And normal and typical abnormal samples can be differentiated by thickness and roughness parameters during the culture cycle.

Conclusions: The adaptive interface detection algorithm is suitable for high-sensitivity, fast detection, and quantification of the interface with layered characteristic tissues, and can be used for non-destructive detection of the growth regularity of AS sample thickness and roughness during the culture cycle.

Significance: The highest absorption peaks of the main components of bone are in the mid-infrared region, making Er:YAG and CO₂ lasers the most efficient lasers for cutting bone. Yet, studies of deep bone ablation in minimally invasive settings are very limited, as finding suitable materials for coupling high-power laser light with low attenuation beyond 2  μm is not trivial.

Aim: The first aim of this study was to compare the performance of different optical fibers in terms of transmitting Er:YAG laser light with a 2.94-μm wavelength at high pulse energy close to 1 J. The second aim was to achieve deep bone ablation using the best-performing fiber, as determined by our experiments.

Approach: In our study, various optical fibers with low attenuation (λ  =  2.94  μm) were used to couple the Er:YAG laser. The fibers were made of germanium oxide, sapphire, zirconium fluoride, and hollow-core silica, respectively. We compared the fibers in terms of transmission efficiency, resistance to high Er:YAG laser energy, and bending flexibility. The best-performing fiber was used to achieve deep bone ablation in a minimally invasive setting. To do this, we adapted the optimal settings for free-space deep bone ablation with an Er:YAG laser found in a previous study.

Results: Three of the fibers endured energy per pulse as high as 820 mJ at a repetition rate of 10 Hz. The best-performing fiber, made of germanium oxide, provided higher transmission efficiency and greater bending flexibility than the other fibers. With an output energy of 370 mJ per pulse at 10 Hz repetition rate, we reached a cutting depth of 6.82  ±  0.99  mm in sheep bone. Histology image analysis was performed on the bone tissue adjacent to the laser ablation crater; the images did not show any structural damage.

Conclusions: The findings suggest that our prototype could be used in future generations of endoscopic devices for minimally invasive laserosteotomy.

Significance: Performance of an acousto-optic imaging system is limited by light fluence rate and acoustic pressure field distributions characteristics. In optically scattering media, the former determines the achievable contrast, whereas the latter the imaging resolution. The system parameters can be shaped by changing relative positions of ultrasound (US) transducer array and optodes. However, in the case of many potential clinical applications, optimization possibilities in this regard are limited, as a sample is accessible from one side only and using a water tank for coupling is not feasible.

Aim: We investigate the possibilities of improving performance of an acousto-optic imaging system operating in reflection mode geometry with linear US array in direct contact with a sample using plane wave instead of focused US pulses.

Approach: Differences in acoustic pressure field distributions for various transducer excitation patterns were determined numerically and experimentally. Acousto-optic images of phantoms with and without optically absorbing inclusions were acquired by measuring laser speckle contrast decrease due to the light modulation by plane wave and focused US pulses with different apodization patterns.

Results: The residual acoustic pressure field components occupy relatively large volume and contribute to light modulation. Using nonsteered plane wave US pulses instead of focused ones allows one to mitigate their influence. It also allows one to obtain clear two-dimensional reconstructions of light fluence rate maps by shifting transducer apodization along the lateral direction.

Conclusions: Using nonsteered plane wave US pulses allows one to achieve better imaging performance than with focused pulses in the assumed system geometry.

Significance: Polyp size is important for selecting the surveillance interval or treatment policy. Nevertheless, it is challenging to accurately estimate the polyp size during endoscopy. An easy and cost-effective function to assist in polyp size estimation is required.

Aim: To propose a virtual scale function for endoscopy and evaluate its performance and expected accuracy.

Approach: An adaptive virtual scale behavior was demonstrated. The measurement error of the virtual scale along the distance between the tip of the endoscope and the object plane was evaluated using graph paper. The accuracy of polyp size estimation by an expert endoscopist was compared with the accuracy of the biopsy forceps method using phantom images.

Results: The measurement errors of the virtual scale were   ≤  0.7  mm when the distance to the graph paper, which faced the tip of the endoscope, varied from 4 to 30 mm. The accuracy with the virtual scale was significantly higher than that obtained with biopsy forceps (5.3  ±  5.5  %   versus 11.9  ±  9.4  %  , P  <  0.001).

Conclusions: The virtual scale function, which operates in real-time without any additional device, can be used to estimate polyp sizes easily and accurately with endoscopy.

Significance: Hyperspectral imaging (HSI) has emerged as a promising optical technique. Besides optical properties of a sample, other sample physical properties also affect the recorded images. They are significantly affected by the sample curvature and sample surface to camera distance. A correction method to reduce the artifacts is necessary to reliably extract sample properties.

Aim: Our aim is to correct hyperspectral images using the three-dimensional (3D) surface data and assess how the correction affects the extracted sample properties.

Approach: We propose the combination of HSI and 3D profilometry to correct the images using the Lambert cosine law. The feasibility of the correction method is presented first on hemispherical tissue phantoms and next on human hands before, during, and after the vascular occlusion test (VOT).

Results: Seven different phantoms with known optical properties were created and imaged with a hyperspectral system. The correction method worked up to 60 deg inclination angle, whereas for uncorrected images the maximum angles were 20 deg. Imaging hands before, during, and after VOT shows good agreement between the expected and extracted skin physiological parameters.

Conclusions: The correction method was successfully applied on the images of tissue phantoms of known optical properties and geometry and VOT. The proposed method could be applied to any reflectance optical imaging technique and should be used whenever the sample parameters need to be extracted from a curved surface sample.

Significance: Optical microscopy is characterized by the ability to get high resolution, below 1  μm, high contrast, functional and quantitative images. The use of shaped illumination, such as with lightsheet microscopy, has led to greater three-dimensional isotropic resolution with low phototoxicity. However, in most complex samples and tissues, optical imaging is limited by scattering. Many solutions to this issue have been proposed, from using passive approaches such as Bessel beam illumination to active methods incorporating aberration correction, but making fair comparisons between different approaches has proven to be challenging.

Aim: We present a phase-encoded Monte Carlo radiation transfer algorithm (φMC) capable of comparing the merits of different illumination strategies or predicting the performance of an individual approach.

Approach: We show that φMC is capable of modeling interference phenomena such as Gaussian or Bessel beams and compare the model with experiment.

Results: Using this verified model, we show that, for a sample with homogeneously distributed scatterers, there is no inherent advantage to illuminating a sample with a conical wave (Bessel beam) instead of a spherical wave (Gaussian beam), except for maintaining a greater depth of focus.

Conclusion: φMC is adaptable to any illumination geometry, sample property, or beam type (such as fractal or layered scatterer distribution) and as such provides a powerful predictive tool for optical imaging in thick samples.

Significance: Imaging biofluid flow under physiologic conditions aids in understanding disease processes and health complications. We present a method employing a microparallel plate strain induction chamber (MPPSIC) amenable to optical coherence tomography to track depth-resolved lateral displacement in fluids in real time while under constant and sinusoidal shear.

Aim: Our objective is to track biofluid motion under shearing conditions found in the respiratory epithelium, first validating methods in Newtonian fluids and subsequently assessing the capability of motion-tracking in bronchial mucus.

Approach: The motion of polystyrene microspheres in aqueous glycerol is tracked under constant and sinusoidal applied shear rates in the MPPSIC and is compared with theory. Then 1.5 wt. % bronchial mucus samples considered to be in a normal hydrated state are studied under sinusoidal shear rates of amplitudes 0.7 to 3.2  s^−  1.

Results: Newtonian fluids under low Reynolds conditions (Re  ∼  10^−  4) exhibit velocity decreases directly proportional to the distance from the plate driven at both constant and oscillating velocities, consistent with Navier–Stokes’s first and second problems at finite depths. A 1.5 wt. % mucus sample also exhibits a uniform shear strain profile.

Conclusions: The MPPSIC provides a new capability for studying biofluids, such as mucus, to assess potentially non-linear or strain-rate-dependent properties in a regime that is relevant to the mucus layer in the lung epithelium.

Significance: Effective vein visualization is critically important for several clinical procedures, such as venous blood sampling and intravenous injection. Existing technologies using infrared device or ultrasound rely on professional equipment and are not suitable for daily medical care. A regression-based vein visualization method is proposed.

Aim: We visualize veins from conventional RGB images to provide assistance in venipuncture procedures as well as clinical diagnosis of some venous insufficiency.

Approach: The RGB images taken by digital cameras are first transformed to spectral reflectance images using Wiener estimation. Multiple regression analysis is then applied to derive the relationship between spectral reflectance and the concentrations of pigments. Monte Carlo simulation is adopted to get prior information. Finally, vein patterns are visualized from the spatial distribution of pigments. To minimize the effect of illumination on skin color, light correction and shading removal operations are performed in advance.

Results: Experimental results from inner forearms of 60 subjects show the effectiveness of the regression-based method. Subjective and objective evaluations demonstrate that the clarity and completeness of vein patterns can be improved by light correction and shading removal.

Conclusions: Vein patterns can be successfully visualized from RGB images without any professional equipment. The proposed method can assist in venipuncture procedures. It also shows promising potential to be used in clinical diagnosis and treatment of some venous insufficiency.

Significance: Sub-diffuse optical properties may serve as useful cancer biomarkers, and wide-field heatmaps of these properties could aid physicians in identifying cancerous tissue. Sub-diffuse spatial frequency domain imaging (sd-SFDI) can reveal such wide-field maps, but the current time cost of experimentally validated methods for rendering these heatmaps precludes this technology from potential real-time applications.

Aim: Our study renders heatmaps of sub-diffuse optical properties from experimental sd-SFDI images in real time and reports these properties for cancerous and normal skin tissue subtypes.

Approach: A phase function sampling method was used to simulate sd-SFDI spectra over a wide range of optical properties. A machine learning model trained on these simulations and tested on tissue phantoms was used to render sub-diffuse optical property heatmaps from sd-SFDI images of cancerous and normal skin tissue.

Results: The model accurately rendered heatmaps from experimental sd-SFDI images in real time. In addition, heatmaps of a small number of tissue samples are presented to inform hypotheses on sub-diffuse optical property differences across skin tissue subtypes.

Conclusion: These results bring the overall process of sd-SFDI a fundamental step closer to real-time speeds and set a foundation for future real-time medical applications of sd-SFDI such as image guided surgery.

Significance: The current gold standard for monitoring small intestinal transplant (IT) rejection is endoscopic visual assessment and biopsy of suspicious lesions; however, these lesions are only superficially visualized by endoscopy. Invasive biopsies provide a coarse sampling of tissue health without depicting the true presence and extent of any pathology. Optical coherence tomography (OCT) presents a potential alternative approach with significant advantages over traditional white-light endoscopy.

Aim: The aim of our investigation was to evaluate OCT performance in distinguishing clinically relevant morphological features associated with IT graft failure.

Approach: OCT was applied to evaluate the small bowel tissues of two rhesus macaques that had undergone IT of the ileum. The traditional assessment from routine histological observation was compared with OCT captured using a handheld surgical probe during the days post-transplant and subsequently was compared with histophaology.

Results: The reported OCT system was capable of identifying major biological landmarks in healthy intestinal tissue. Following IT, one nonhuman primate (NHP) model suffered a severe graft ischemia, and the second NHP graft failed due to acute cellular rejection. OCT images show visual evidence of correspondence with histological signs of IT rejection.

Conclusions: Results suggest that OCT imaging has significant potential to reveal morphological changes associated with IT rejection and to improve patient outcomes overall.

Significance: As linear array transducers are widely used in clinical ultrasound imaging, photoacoustic tomography (PAT) with linear arrays is similarly suitable for clinical applications. However, due to the limited-view problem, a linear array has limited performance and leads to artifacts and blurring, which has hindered its broader application. There is a need to address the limited-view problem in PAT imaging with linear arrays.

Aim: We investigate potential approaches for improving PAT reconstruction from linear array, by optimizing the detection geometry and implementing iterative reconstruction.

Approach: PAT imaging with a single-array, dual-probe configurations in parallel-shape and L-shape, and square-shape configuration are compared in simulations and phantom experiments. An iterative model-based algorithm based on the variance-reduced stochastic gradient descent (VR-SGD) method is implemented. The optimum configuration found in simulation is validated on phantom experiments.

Results: PAT imaging with dual-probe detection and VR-SGD algorithm is found to improve the limited-view problem compared to a single probe and provide comparable performance as full-view geometry in simulation. This configuration is validated in experiments where more complete structure is obtained with reduced artifacts compared with a single array.

Conclusions: PAT with dual-probe detection and iterative reconstruction is a promising solution to the limited-view problem of linear arrays.

Significance: Complementary absorption and fluorescence contrast could prove useful for a wide range of biomedical applications. However, current absorption-based photoacoustic microscopy systems require the ultrasound transducers to physically touch the samples, thereby increasing contamination and limiting strong optical focusing in reflection mode.

Aim: We sought to develop an all-optical system for imaging cells and tissues using the three combined imaging modalities: photoacoustic remote sensing (PARS), epifluorescence, and confocal laser scanning microscopy (CLSM).

Approach: A PARS subsystem with ultraviolet excitation was used to obtain label-free absorption-contrast images of nucleic acids in ex vivo tissue samples. Co-integrated epifluorescence and CLSM subsystems were used to verify the 2D and 3D nuclei distribution.

Results: Complementary absorption and fluorescence contrast were demonstrated in phantom imaging experiments and subsequent cell and tissue imaging experiments. Lateral and axial resolution of ultraviolet-PARS (UV-PARS) is shown to be 0.39 and 1.6  μm, respectively, with 266-nm light. CLSM lateral and axial resolution was measured as 0.97 and 2.0  μm, respectively. This resolution is sufficient to image individual cell layers with fine optical sectioning. UV-PARS images of cell nuclei are validated in thick tissue using CLSM.

Conclusions: Multimodal absorption and fluorescence contrast are obtained with a non-contact all-optical microscopy system for the first time and utilized to obtain images of cells and tissues with subcellular resolution.

Significance: We introduce a model for better calibration of the trapping force using an equal but oppositely directed drag force acting on a trapped red blood cell (RBC). We demonstrate this approach by studying RBCs’ elastic properties from deidentified sickle cell anemia (SCA) and sickle cell trait (SCT) blood samples.

Aim: A laser trapping (LT) force was formulated and analytically calculated in a cylindrical model. Using this trapping force relative percent difference, the maximum (longitudinal) and minimum (transverse) radius rate and stiffness were used to study the elasticity.

Approach: The elastic property of SCA and SCT RBCs was analyzed using LT technique with computer controlled piezo-driven stage, in order to trap and stretch the RBCs.

Results: For all parameters, the results show that the SCT RBC samples have higher elastic property than the SCA RBCs. The higher rigidity in the SCA cell may be due to the lipid composition of the membrane, which was affected by the cholesterol concentration.

Conclusions: By developing a theoretical model for different trapping forces, we have also studied the elasticity of RBCs in SCT (with hemoglobin type HbAS) and in SCA (with hemoglobin type HbSS). The results for the quantities describing the elasticity of the cells consistently showed that the RBCs in the SCT display lower rigidity and higher deformability than the RBCs with SCA.

Significance: Personalized medicine requires the tracking of an individual’s metabolite levels over time to detect anomalies and evaluate the body’s response to medications. Implanted sensors offer effective means to continuously monitor specific metabolite levels, provided they are accurate, stable over long time periods, and do no harm.

Aim: Four types of hydrogel embedded with pH-sensitive sensors were evaluated for their accuracy, sensitivity, reversibility, longevity, dynamic response, and consistency in static versus dynamic conditions and long-term storage.

Approach: Raman spectroscopy was first used to calibrate the intensity of pH-sensitive peaks of the Raman-active hydrogel sensors in a static pH environment. The dynamic response was then assessed for hydrogels exposed to changing pH conditions within a flow cell. Finally, the static pH response after 5 months of storage was determined.

Results: All four types of hydrogels allowed the surface-enhanced Raman spectroscopy (SERS) sensors to respond to the pH level of the local environment without introducing interfering signals, resulting in consistent calibration curves. When the pH level changed, the probes in the gels were slow to reach steady-state, requiring several hours, and response times were found to vary among hydrogels. Only one type, poly(2-hydroxyethyl methacrylate) (pHEMA), lasted five months without significant degradation of dynamic range.

Conclusions: While all hydrogels appear to be viable candidates as biocompatible hosts for the SERS sensing chemistry, pHEMA was found to be most functionally stable over the long interval tested. Poly(ethylene glycol) hydrogels exhibit the most rapid response to changing pH. Since these two gel types are covalently cross-linked and do not generally degrade, they both offer advantages over sodium alginate for use as implants.

Significance: Optoacoustic stimulation offers an alternative stimulation strategy for the hearing organ. To serve as the base for a novel auditory prosthesis, the optoacoustic stimulation must be biocompatible and energy-saving.

Aim: Enhancing the efficiency of optoacoustic stimulation while reducing the energy input in a suited animal model.

Approach: Optoacoustically induced auditory brainstem responses (oABRs) were recorded after the pulsed laser irradiation of the tympanic membrane (TM) in mice. The results were compared with the ABRs induced through acoustic click stimulation. In addition, self-adhesive absorbing films were applied on the TM before the optoacoustic stimulation to investigate their effect on the resulting ABRs.

Results: Using an absorbing film on the TM during optical stimulation led to considerably enhanced oABR wave I amplitude values compared with the stimulation of the bare TM. When using our stimulation strategy, we induced oABR waves in the 50% to 60% range of the acoustical stimulation reached with 80-dB SPL click stimuli.

Conclusions: The mouse model can be used for certain developmental work for an optoacoustic auditory prosthesis. Using absorbing films on the TM during optical stimulation considerably enhances oABR wave I amplitude. Optimization of the stimulation strategy could further enhance the efficiency within biocompatibility margins.

Significance: We demonstrate that clinically used kinase inhibitors such as lapatinib can be used for enhancing aminolevulinic acid (ALA) for tumor fluorescence imaging and photodynamic therapy (PDT).

Aim: ALA is used as a prodrug for protoporphyrin IX (PpIX) fluorescence-guided tumor resection and PDT. Our previous studies indicate that tumors with high ABCG2 activity exhibit low PpIX fluorescence, which hampers the application of ALA. We aim to determine whether clinically used ABCG2-interacting kinase inhibitors increase ALA-PpIX fluorescence and PDT.

Approach: PpIX fluorescence was determined by spectrofluorometry, flow cytometry, and confocal microscopy after ALA alone or in combination with kinase inhibitors in triple negative breast cancer (TNBC) cell lines. Cytotoxicity was examined after ALA-PDT alone or in combination with kinase inhibitors. Effect of single and combination treatments on apoptosis was assessed by Western blot.

Results: Four kinase inhibitors (lapatinib, PD169316, sunitinib, gefitinib) significantly increased ALA-PpIX fluorescence and PDT response in TNBC cells with ABCG2 activity, but not in MCF10A nontumor breast epithelial cell line without ABCG2 activity. Confocal microscopic imaging showed that PpIX fluorescence was weak and diffuse after ALA alone, which was greatly enhanced by kinase inhibitors, particularly in the mitochondria. Lapatinib was the only inhibitor that significantly reduced PpIX efflux in cell culture medium and showed stronger enhancement of PDT response than other kinase inhibitors. Lapatinib, in combination with ALA, induced tumor cells to undergo apoptosis, whereas no apoptosis was detected after each individual treatment.

Conclusions: Although all four kinase inhibitors were able to enhance ALA-PpIX fluorescence and PDT, lapatinib exhibited the strongest enhancement effect. As an FDA-approved kinase inhibitor for breast cancer treatment, lapatinib is ready to be used in combination with ALA for therapeutic enhancement in tumors with elevated ABCG2 activity. This rational combination approach warrants further investigation in tumor models.

Significance: Optical imaging of Cherenkov emission during radiation therapy could be used to verify dose delivery in real-time if a more comprehensive quantitative understanding of the factors affecting emission intensity could be developed.

Aim: This study aims to explore the change in diffuse Cherenkov emission intensity with x-ray beam energy from irradiated tissue, both theoretically and experimentally.

Approach: Derivation of the emitted Cherenkov signal was achieved using diffusion theory, and experimental studies with 6 to 18 MV energy x-rays were performed in tissue phantoms to confirm the model predictions as related to the radiation build-up factor with depth into tissue.

Results: Irradiation at lower x-ray energies results in a greater surface dose and higher build-up slope, which results in a ∼46  %   greater diffusely emitted Cherenkov signal per unit dose at 6 MV relative to 18 MV x-rays. However, this phenomenon competes with a decrease in signal from less Cherenkov photons being generated at lower energies, a ∼44  %   reduction at 6 versus 18 MV. The result is an emitted Cherenkov signal that is nearly constant with beam energy.

Conclusions: This study explains why the observed Cherenkov emission from tissue is not a strong function of beam energy, despite the known strong correlation between Cherenkov intensity and particle energy in the absence of build-up and scattering effects.