Index of content:
Volume 40, Issue 9, September 2013
Computed tomography (CT) imaging is the modality of choice for lung cancer diagnostics. With the increasing number of lung interventions on sublobar level in recent years, determining and visualizing pulmonary segments in CT images and, in oncological cases, reliable segment-related information about the location of tumors has become increasingly desirable. Computer-assisted identification of lung segments in CT images is subject of this work.Methods:
The authors present a new interactive approach for the segmentation of lung segments that uses the Euclidean distance of each point in the lung to the segmental branches of the pulmonary artery. The aim is to analyze the potential of the method. Detailed manual pulmonary artery segmentations are used to achieve the best possible segment approximation results. A detailed description of the method and its evaluation on 11 CT scans from clinical routine are given.Results:
An accuracy of 2–3 mm is measured for the segment boundaries computed by the pulmonary artery-based method. On average, maximum deviations of 8 mm are observed. 135 intersegmental pulmonary veins detected in the 11 test CT scans serve as reference data. Furthermore, a comparison of the presented pulmonary artery-based approach to a similar approach that uses the Euclidean distance to the segmental branches of the bronchial tree is presented. It shows a significantly higher accuracy for the pulmonary artery-based approach in lung regions at least 30 mm distal to the lung hilum.Conclusions:
A pulmonary artery-based determination of lung segments in CT images is promising. In the tests, the pulmonary artery-based determination has been shown to be superior to the bronchial tree-based determination. The suitability of the segment approximation method for application in the planning of segment resections in clinical practice has already been verified in experimental cases. However, automation of the method accompanied by an evaluation on a larger number of test cases is required before application in the daily clinical routine.
The more important heavy charged particle radiotherapy of the future is more likely to be with heavy ions rather than protons40(2013); http://dx.doi.org/10.1118/1.4798945View Description Hide Description
- MEDICAL PHYSICS LETTER
40(2013); http://dx.doi.org/10.1118/1.4817480View Description Hide DescriptionPurpose:
To provide an x-ray phase contrast imaging (XPCI) method working with conventional sources that could be readily translated into clinical practice. XPCI shows potential in synchrotron studies but attempts at translating it for use with conventional sources are subject to limitations in terms of field of view, stability, exposure time, and possibly most importantly, delivered dose.Methods:
Following the adaptation of our “edge-illumination” XPCI technique for use with conventional x-ray sources through the use of x-ray masks, the authors have further modified the design of such masks to allow further reducing the dose delivered to the sample without affecting the phase sensitivity of the method.Results:
The authors have built a prototype based on the new mask design and used it to image ex vivo breast tissue samples containing malignant lesions. The authors compared images acquired with this prototype to those obtained with a conventional system. The authors demonstrate and quantify image improvements, especially in terms of microcalcification detection. On calcifications detected also by the conventional system, the authors measure contrast increases from five to nine fold; calcifications and other features were also detected which are completely invisible in the conventional image. Dose measurements confirmed that the above enhancements were achieved while delivering doses compatible with clinical practice.Conclusions:
The authors obtained phase-related image enhancements in mammography by means of a system built with components available off-the-shelf that operates under exposure time and dose conditions compatible with clinical practice. This opens the way to a straightforward translation of phase enhanced imaging methods into clinical practice.
- RADIATION THERAPY PHYSICS
40(2013); http://dx.doi.org/10.1118/1.4816654View Description Hide DescriptionPurpose:
Automatic, atlas-based segmentation of medical images benefits from using multiple atlases, mainly in terms of robustness. However, a large disadvantage of using multiple atlases is the large computation time that is involved in registering atlas images to the target image. This paper aims to reduce the computation load of multiatlas-based segmentation by heuristically selecting atlases before registration.Methods:
To be able to select atlases, pairwise registrations are performed for all atlas combinations. Based on the results of these registrations, atlases are clustered, such that each cluster contains atlas that registers well to each other. This can all be done in a preprocessing step. Then, the representatives of each cluster are registered to the target image. The quality of the result of this registration is estimated for each of the representatives and used to decide which clusters to fully register to the target image. Finally, the segmentations of the registered images are combined into a single segmentation in a label fusion procedure.Results:
The authors perform multiatlas segmentation once with postregistration atlas selection and once with the proposed preregistration method, using a set of 182 segmented atlases of prostate cancer patients. The authors performed the full set of 182 leave-one-out experiments and in each experiment compared the result of the atlas-based segmentation procedure to the known segmentation of the atlas that was chosen as a target image. The results show that preregistration atlas selection is slightly less accurate than postregistration atlas selection, but this is not statistically significant.Conclusions:
Based on the results the authors conclude that the proposed method is able to reduce the number of atlases that have to be registered to the target image with 80% on average, without compromising segmentation accuracy.
40(2013); http://dx.doi.org/10.1118/1.4816658View Description Hide DescriptionPurpose:
The paper considers the fractionation problem in intensity modulated proton therapy (IMPT). Conventionally, IMPT fields are optimized independently of the fractionation scheme. In this work, we discuss the simultaneous optimization of fractionation scheme and pencil beam intensities.Methods:
This is performed by allowing for distinct pencil beam intensities in each fraction, which are optimized using objective and constraint functions based on biologically equivalent dose (BED). The paper presents a model that mimics an IMPT treatment with a single incident beam direction for which the optimal fractionation scheme can be determined despite the nonconvexity of the BED-based treatment planning problem.Results:
For this model, it is shown that a small α/β ratio in the tumor gives rise to a hypofractionated treatment, whereas a large α/β ratio gives rise to hyperfractionation. It is further demonstrated that, for intermediate α/β ratios in the tumor, a nonuniform fractionation scheme emerges, in which it is optimal to deliver different dose distributions in subsequent fractions. The intuitive explanation for this phenomenon is as follows: By varying the dose distribution in the tumor between fractions, the same total BED can be achieved with a lower physical dose. If it is possible to achieve this dose variation in the tumor without varying the dose in the normal tissue (which would have an adverse effect), the reduction in physical dose may lead to a net reduction of the normal tissue BED. For proton therapy, this is indeed possible to some degree because the entrance dose is mostly independent of the range of the proton pencil beam.Conclusions:
The paper provides conceptual insight into the interdependence of optimal fractionation schemes and the spatial optimization of dose distributions. It demonstrates the emergence of nonuniform fractionation schemes that arise from the standard BED model when IMPT fields and fractionation scheme are optimized simultaneously. Although the projected benefits are likely to be small, the approach may give rise to an improved therapeutic ratio for tumors treated with stereotactic techniques to high doses per fraction.
Joint surface reconstruction and 4D deformation estimation from sparse data and prior knowledge for marker-less Respiratory motion tracking40(2013); http://dx.doi.org/10.1118/1.4816675View Description Hide DescriptionPurpose:
The intraprocedural tracking of respiratory motion has the potential to substantially improve image-guided diagnosis and interventions. The authors have developed a sparse-to-dense registration approach that is capable of recovering the patient's external 3D body surface and estimating a 4D (3D + time) surface motion field from sparse sampling data and patient-specific prior shape knowledge.Methods:
The system utilizes an emerging marker-less and laser-based active triangulation (AT) sensor that delivers sparse but highly accurate 3D measurements in real-time. These sparse position measurements are registered with a dense reference surface extracted from planning data. Thereby a dense displacement field is recovered, which describes the spatio-temporal 4D deformation of the complete patient body surface, depending on the type and state of respiration. It yields both a reconstruction of the instantaneous patient shape and a high-dimensional respiratory surrogate for respiratory motion tracking. The method is validated on a 4D CT respiration phantom and evaluated on both real data from an AT prototype and synthetic data sampled from dense surface scans acquired with a structured-light scanner.Results:
In the experiments, the authors estimated surface motion fields with the proposed algorithm on 256 datasets from 16 subjects and in different respiration states, achieving a mean surface reconstruction accuracy of ±0.23 mm with respect to ground truth data—down from a mean initial surface mismatch of 5.66 mm. The 95th percentile of the local residual mesh-to-mesh distance after registration did not exceed 1.17 mm for any subject. On average, the total runtime of our proof of concept CPU implementation is 2.3 s per frame, outperforming related work substantially.Conclusions:
In external beam radiation therapy, the approach holds potential for patient monitoring during treatment using the reconstructed surface, and for motion-compensated dose delivery using the estimated 4D surface motion field in combination with external-internal correlation models.
40(2013); http://dx.doi.org/10.1118/1.4816677View Description Hide DescriptionPurpose:
The aim of this work was to design a novel high-dose rate (HDR) (192Ir) brachytherapy applicator for treatment of rectal carcinomas that uses tungsten shielding for possibly improved dosimetric results over commercial brachytherapy applicator(s).Methods:
A set of 15 single-depth applicators and one dual-depth applicator were designed and simulated using Monte Carlo (MCNPX). All applicators simulated were high-density tungsten alloy cylinders, 16-mm in diameter, and 60-mm long, with longitudinal grooves within which an192Ir source can be placed. The single-depth designs varied regarding the number and depth of these grooves, ranging from 8 to 16 and 1-mm to 3-mm, respectively. The dual-depth design had ten channels, each of which had two depths at which the source could be placed. Optimized treatment plans were generated for each design on data from 13 treated patients (36 fractions) with asymmetrical clinical target volumes (CTVs). All results were compared against the clinically treated plans which used intracavitary mold applicator (ICMA), as well as a recently designed, highly automated, and collimated intensity modulation device named dynamic modulated brachytherapy (DMBT) device.Results:
All applicator designs outperformed the ICMA in every calculated dosimetric criteria, except the total dwell times (∼30% increase). There were clear, but relative, tradeoffs regarding both the number of channels and the depth of each channel. Overall, the 12-channel, 1-mm depth, and 14-channel 2-mm depth designs had the best results of the simpler designs, sparing the healthy rectal tissues the most while achieving comparable CTV coverage with the dose heterogeneity index and lateral spill doses improving by over 10% and the contralateral healthy rectum dose dropping over 30% compared to ICMA. The ten-channel dual-depth design outperformed each single-depth design, yielding the best coverage and sparing.Conclusions:
New grooved tungsten HDR-brachytherapy devices have been designed and simulated. The results of this work attest to the capability of these new, highly anisotropic, intelligently shielded applicators to limit dose to healthy tissues while maintaining a conformal prescription dose to the CTV.
40(2013); http://dx.doi.org/10.1118/1.4817236View Description Hide DescriptionPurpose:
To quantify the predictive uncertainty in infrared (IR)-marker-based dynamic tumor tracking irradiation (IR Tracking) with Vero4DRT (MHI-TM2000) for lung cancer using logfiles.Methods:
A total of 110 logfiles for 10 patients with lung cancer who underwent IR Tracking were analyzed. Before beam delivery, external IR markers and implanted gold markers were monitored for 40 s with the IR camera every 16.7 ms and with an orthogonal kV x-ray imaging subsystem every 80 or 160 ms. A predictive model [four-dimensional (4D) model] was then created to correlate the positions of the IR markers (P IR) with the three-dimensional (3D) positions of the tumor indicated by the implanted gold markers (P detect). The sequence of these processes was defined as 4D modeling. During beam delivery, the 4D model predicted the future 3D target positions (P predict) from the P IR in real-time, and the gimbaled x-ray head then tracked the target continuously. In clinical practice, the authors updated the 4D model at least once during each treatment session to improve its predictive accuracy. This study evaluated the predictive errors in 4D modeling (E 4DM) and those resulting from the baseline drift of P IR and P detect during a treatment session (E BD). E 4DM was defined as the difference between P predict and P detect in 4D modeling, and E BD was defined as the mean difference between P predict calculated from P IR in updated 4D modeling using (a) a 4D model created from training data before the model update and (b) an updated 4D model created from new training data.Results:
The meanE 4DM was 0.0 mm with the exception of one logfile. Standard deviations of E 4DM ranged from 0.1 to 1.0, 0.1 to 1.6, and 0.2 to 1.3 mm in the left-right (LR), anterior–posterior (AP), and superior–inferior (SI) directions, respectively. The median elapsed time before updating the 4D model was 13 (range, 2–33) min, and the median frequency of 4D modeling was twice (range, 2–3 times) per treatment session. E BD ranged from −1.0 to 1.0, −2.1 to 3.3, and −2.0 to 3.5 mm in the LR, AP, and SI directions, respectively. E BD was highly correlated with BDdetect in the LR (R = −0.83) and AP directions (R = −0.88), but not in the SI direction (R = −0.40). Meanwhile, E BD was highly correlated with BDIR in the SI direction (R = −0.67), but not in the LR (R = 0.15) or AP (R = −0.11) direction. If the 4D model was not updated in the presence of intrafractional baseline drift, the predicted target position deviated from the detected target position systematically.Conclusions:
Application of IR Tracking substantially reduced the geometric error caused by respiratory motion; however, an intrafractional error due to baseline drift of >3 mm was occasionally observed. To compensate forE BD, the authors recommend checking the target and IR marker positions constantly and updating the 4D model several times during a treatment session.
Simulations using patient data to evaluate systematic errors that may occur in 4D treatment planning: A proof of concept study40(2013); http://dx.doi.org/10.1118/1.4817244View Description Hide DescriptionPurpose:
The purpose of this work is to present a framework to evaluate the accuracy of four-dimensional treatment planning in external beam radiation therapy using measured patient data and digital phantoms.Methods:
To accomplish this, 4D digital phantoms of two model patients were created using measured patient lung tumor positions. These phantoms were used to simulate a four-dimensional computed tomography image set, which in turn was used to create a 4D Monte Carlo (4DMC) treatment plan. The 4DMC plan was evaluated by simulating the delivery of the treatment plan over approximately 5 min of tumor motion measured from the same patient on a different day. Unique phantoms accounting for the patient position (tumor position and thorax position) at 2 s intervals were used to represent the model patients on the day of treatment delivery and the delivered dose to the tumor was determined using Monte Carlo simulations.Results:
For Patient 1, the tumor was adequately covered with 95.2% of the tumor receiving the prescribed dose. For Patient 2, the tumor was not adequately covered and only 74.3% of the tumor received the prescribed dose.Conclusions:
This study presents a framework to evaluate 4D treatment planning methods and demonstrates a potential limitation of 4D treatment planning methods. When systematic errors are present, including when the imaging study used for treatment planning does not represent all potential tumor locations during therapy, the treatment planning methods may not adequately predict the dose to the tumor. This is the first example of a simulation study based on patient tumor trajectories where systematic errors that occur due to an inaccurate estimate of tumor motion are evaluated.
40(2013); http://dx.doi.org/10.1118/1.4817482View Description Hide DescriptionPurpose:
In this study the Octavius detector 729 ionization chamber (IC) array with the Octavius 4D phantom was characterized for flattening filter (FF) and flattening filter free (FFF) static and rotational beams. The device was assessed for verification with FF and FFF RapidArc treatment plans.Methods:
The response of the detectors to field size, dose linearity, and dose rate were assessed for 6 MV FF beams and also 6 and 10 MV FFF beams. Dosimetric and mechanical accuracy of the detector array within the Octavius 4D rotational phantom was evaluated against measurements made using semiflex and pinpoint ionization chambers, and radiochromic film. Verification FF and FFF RapidArc plans were assessed using a gamma function with 3%/3 mm tolerances and 2%/2 mm tolerances and further analysis of these plans was undertaken using film and a second detector array with higher spatial resolution.Results:
A warm-up dose of >6 Gy was required for detector stability. Dose-rate measurements were stable across a range from 0.26 to 15 Gy/min and dose response was linear, although the device overestimated small doses compared with pinpoint ionization chamber measurements. Output factors agreed with ionization chamber measurements to within 0.6% for square fields of side between 3 and 25 cm and within 1.2% for 2 × 2 cm2 fields. The Octavius 4D phantom was found to be consistent with measurements made with radiochromic film, where the gantry angle was found to be within 0.4° of that expected during rotational deliveries. RapidArc FF and FFF beams were found to have an accuracy of >97.9% and >90% of pixels passing 3%/3 mm and 2%/2 mm, respectively. Detector spatial resolution was observed to be a factor in determining the accurate delivery of each plan, particularly at steep dose gradients. This was confirmed using data from a second detector array with higher spatial resolution and with radiochromic film.Conclusions:
The Octavius 4D phantom with associated Octavius detector 729 ionization chamber array is a dosimetrically and mechanically stable device for pretreatment verification of FF and FFF RapidArc treatments. Further improvements may be possible through use of a detector array with higher spatial resolution (detector size and/or detector spacing).
Measurements of lateral penumbra for uniform scanning proton beams under various beam delivery conditions and comparison to the XiO treatment planning system40(2013); http://dx.doi.org/10.1118/1.4818283View Description Hide DescriptionPurpose
: The main purposes of this study were to (1) investigate the dependency of lateral penumbra (80%–20% distance) of uniform scanning proton beams on various factors such as air gap, proton range, modulation width, compensator thickness, and depth, and (2) compare the lateral penumbra calculated by a treatment planning system (TPS) with measurements.Methods
: First, lateral penumbra was measured using solid–water phantom and radiographic films for (a) air gap, ranged from 0 to 35 cm, (b) proton range, ranged from 8 to 30 cm, (c) modulation, ranged from 2 to 10 cm, (d) compensator thickness, ranged from 0 to 20 cm, and (e) depth, ranged from 7 to 15 cm. Second, dose calculations were computed in a virtual water phantom using the XiO TPS with pencil beam algorithm for identical beam conditions and geometrical configurations that were used for the measurements. The calculated lateral penumbra was then compared with the measured one for both the horizontal and vertical scanning magnets of our uniform scanning proton beam delivery system.Results
: The results in the current study showed that the lateral penumbra of horizontal scanning magnet was larger (up to 1.4 mm for measurement and up to 1.0 mm for TPS) compared to that of vertical scanning magnet. Both the TPS and measurements showed an almost linear increase in lateral penumbra with increasing air gap as it produced the greatest effect on lateral penumbra. Lateral penumbra was dependent on the depth and proton range. Specifically, the width of lateral penumbra was found to be always lower at shallower depth than at deeper depth within the spread out Bragg peak (SOBP) region. The lateral penumbra results were less sensitive to the variation in the thickness of compensator, whereas lateral penumbra was independent of modulation. Overall, the comparison between the results of TPS with that of measurements indicates a good agreement for lateral penumbra, with TPS predicting higher values compared to measurements.Conclusions
: Lateral penumbra of uniform scanning proton beams depends on air gap, proton range, compensator thickness, and depth, whereas lateral penumbra is not dependent on modulation. The XiO TPS typically overpredicted lateral penumbra compared to measurements, within 1 mm for most cases, but the difference could be up to 2.5 mm at a deep depth and large air gap.
Application of activity pencil beam algorithm using measured distribution data of positron emitter nuclei for therapeutic SOBP proton beam40(2013); http://dx.doi.org/10.1118/1.4818057View Description Hide DescriptionPurpose:
Recently, much research on imaging the clinical proton-irradiated volume using positron emitter nuclei based on target nuclear fragment reaction has been carried out. The purpose of this study is to develop an activity pencil beam (APB) algorithm for a simulation system for proton-activated positron-emitting imaging in clinical proton therapy using spread-out Bragg peak (SOBP) beams.Methods:
The target nuclei of activity distribution calculations are12C nuclei, 16O nuclei, and 40Ca nuclei, which are the main elements in a human body. Depth activity distributions with SOBP beam irradiations were obtained from the material information of ridge filter (RF) and depth activity distributions of compounds of the three target nuclei measured by BOLPs-RGp (beam ON-LINE PET system mounted on a rotating gantry port) with mono-energetic Bragg peak (MONO) beam irradiations. The calculated data of depth activity distributions with SOBP beam irradiations were sorted in terms of kind of nucleus, energy of proton beam, SOBP width, and thickness of fine degrader (FD), which were verified. The calculated depth activity distributions with SOBP beam irradiations were compared with the measured ones. APB kernels were made from the calculated depth activity distributions with SOBP beam irradiations to construct a simulation system using the APB algorithm for SOBP beams.Results:
The depth activity distributions were prepared using the material information of RF and the measured depth activity distributions with MONO beam irradiations for clinical therapy using SOBP beams. With the SOBP width widening, the distal fall-offs of depth activity distributions and the difference from the depth dose distributions were large. The shapes of the calculated depth activity distributions nearly agreed with those of the measured ones upon comparison between the two. The APB kernels of SOBP beams were prepared by making use of the data on depth activity distributions with SOBP beam irradiations that were made from the depth activity distributions with MONO beam irradiations and sorted in terms of energy, SOBP width, and thickness of FD. The data on APB kernels of SOBP beams were determined as installment data for the simulation system using the APB algorithm for SOBP beam irradiations.Conclusions:
A method of obtaining the depth activity distributions and the APB algorithm for clinical use of SOBP beams have been developed. It is suggested that the simulation system for imaging the clinical irradiated volume with the APB algorithm can be used in clinical proton therapy using SOBP beams by preparing and investigating the data on APB kernels of SOBP beams.
Experimentally studied dynamic dose interplay does not meaningfully affect target dose in VMAT SBRT lung treatments40(2013); http://dx.doi.org/10.1118/1.4818255View Description Hide DescriptionPurpose:
The effects of respiratory motion on the tumor dose can be divided into the gradient and interplay effects. While the interplay effect is likely to average out over a large number of fractions, it may play a role in hypofractionated [stereotactic body radiation therapy (SBRT)] treatments. This subject has been extensively studied for intensity modulated radiation therapy but less so for volumetric modulated arc therapy (VMAT), particularly in application to hypofractionated regimens. Also, no experimental study has provided full four-dimensional (4D) dose reconstruction in this scenario. The authors demonstrate how a recently described motion perturbation method, with full 4D dose reconstruction, is applied to describe the gradient and interplay effects during VMAT lung SBRT treatments.Methods:
VMAT dose delivered to a moving target in a patient can be reconstructed by applying perturbations to the treatment planning system-calculated static 3D dose. Ten SBRT patients treated with 6 MV VMAT beams in five fractions were selected. The target motion (motion kernel) was approximated by 3D rigid body translation, with the tumor centroids defined on the ten phases of the 4DCT. The motion was assumed to be periodic, with the period T being an average from the empirical 4DCT respiratory trace. The real observed tumor motion (total displacement ≤8 mm) was evaluated first. Then, the motion range was artificially increased to 2 or 3 cm. Finally, T was increased to 60 s. While not realistic, making T comparable to the delivery time elucidates if the interplay effect can be observed. For a single fraction, the authors quantified the interplay effect as the maximum difference in the target dosimetric indices, most importantly the near-minimum dose (D99%), between all possible starting phases. For the three- and five-fractions, statistical simulations were performed when substantial interplay was found.Results:
For the motion amplitudes and periods obtained from the 4DCT, the interplay effect is negligible (<0.2%). It is also small (0.9% average, 2.2% maximum) when the target excursion increased to 2–3 cm. Only with large motion and increased period (60 s) was a significant interplay effect observed, with D99% ranging from 16% low to 17% high. The interplay effect was statistically significantly lower for the three- and five-fraction statistical simulations. Overall, the gradient effect dominates the clinical situation.Conclusions:
A novel method was used to reconstruct the volumetric dose to a moving tumor during lung SBRT VMAT deliveries. With the studied planning and treatment technique for realistic motion periods, regardless of the amplitude, the interplay has nearly no impact on the near-minimum dose. The interplay effect was observed, for study purposes only, with the period comparable to the VMAT delivery time.
Feasibility of kilovoltage x-ray energy modulation by gaseous media and its application in contrast-enhanced radiotherapy40(2013); http://dx.doi.org/10.1118/1.4818422View Description Hide DescriptionPurpose:
To present a method to modulate the energy contents of a kilovoltage x-ray beam that makes use of a gas as the modulating medium. The method is capable of producing arbitrary x-ray spectra by varying the pressure of the modulating gas and the peak kilovoltage (kVp) of the x-ray beams whose energy is being modulated.Methods:
An aluminum chamber was machined with a 0.5 cm wall thickness, designed to withstand pressures of more than 80 atm. A pressure sensor and electrovalves were used to monitor and regulate the gas pressure. Argon was used as the modulating gas. A CdTe spectrometer was used to measure x-ray spectra for different combinations of kVp and gas pressure, thus obtaining a set of basis x-ray functions. An arbitrary x-ray spectrum can then be formed by the linear combination of such basis functions. In order to show one possible application of the modulation method, a contrast-enhanced radiotherapy prostate treatment was optimized with respect to the x-ray beam energy, without restrictions on the possible shape of the resultant x-ray spectra.Results:
The x-ray spectra basis functions obtained display a smooth and gradual variation of their average energy as a function of the gas pressure for a given kVp, sometimes in the order of 1 or 2 keV. This gradual variation would be difficult to obtain with a conventional aluminum or copper filters, as the change in thickness necessary to reproduce the data presented would be in the order of micrometers, making necessary the use of a large number of such filters. Using the modulation method presented here, the authors were able to reconstruct the optimized x-ray spectra from the measured basis functions, for different optimization objectives.Conclusions:
A method has been developed that allows for the controlled modulation of the energy contents of kilovoltage x-ray spectra. The method has been shown to be able to reproduce spectra of arbitrary shape, such as those obtained from the optimization of contrast-enhanced radiotherapy. The method may have other applications as well, such as in the precise matching of diagnostic x-ray catalog spectra.
40(2013); http://dx.doi.org/10.1118/1.4818656View Description Hide DescriptionPurpose:
Current pretreatment, 4D imaging techniques are suboptimal in that they sample breathing motion over a very limited “snapshot” in time. Heretofore, long-duration, 4D motion characterization for radiotherapy planning, margin optimization, and validation have been impractical for safety reasons, requiring invasive markers imaged under x-ray fluoroscopy. To characterize 3D tumor motion and associated variability over durations more consistent with treatments, the authors have developed a practical dynamic MRI (dMRI) technique employing two orthogonal planes acquired in a continuous, interleaved fashion.Methods:
2D balanced steady-state free precession MRI was acquired continuously over 9–14 min at approximately 4 Hz in three healthy volunteers using a commercial 1.5 T system; alternating orthogonal imaging planes (sagittal, coronal, sagittal, etc.) were employed. The 2D in-plane pixel resolution was 2 × 2 mm2 with a 5 mm slice profile. Simultaneous with image acquisition, the authors monitored a 1D surrogate respiratory signal using a device available with the MRI system. 2D template matching-based anatomic feature registration, or tracking, was performed independently in each orientation. 4D feature tracking at the raw frame rate was derived using spline interpolation.Results:
Tracking vascular features in the lung for two volunteers and pancreatic features in one volunteer, the authors have successfully demonstrated this method. Registration error, defined here as the difference between the sagittal and coronal tracking result in the SI direction, ranged from 0.7 to 1.6 mm (1σ) which was less than the acquired image resolution. Although the healthy volunteers were instructed to relax and breathe normally, significantly variable respiration was observed. To demonstrate potential applications of this technique, the authors subsequently explored the intrafraction stability of hypothetical tumoral internal target volumes and 3D spatial probability distribution functions. The surrogate respiratory information allowed the authors to show how this technique can be used to study correlations between internal and external (surrogate) information over these prolonged durations. However, compared against the gold standard of the time stamps in the dMRI frames, the temporal synchronization of the surrogate 1D respiratory information was shown to be likely unreliable.Conclusions:
The authors have established viability of a novel and practical pretreatment, 4D tumor centroid tracking method employing a commercially available dynamic MRI sequence. Further developments from the vendor are likely needed to provide a reliably synchronized surrogate 1D respiratory signal, which will likely broaden the utility of this method in the pretreatment radiotherapy planning context.
40(2013); http://dx.doi.org/10.1118/1.4818655View Description Hide DescriptionPurpose:
To provide real-time lung tumor motion estimation during radiotherapy treatment delivery without the need for implanted fiducial markers or additional imaging dose to the patient.Methods:
2D radiographs from the therapy beam's-eye-view (BEV) perspective are captured at a frame rate of 12.8 Hz with a frame grabber allowing direct RAM access to the image buffer. An in-house developed real-time soft tissue localization algorithm is utilized to calculate soft tissue displacement from these images in real-time. The system is tested with a Varian TX linear accelerator and an AS-1000 amorphous silicon electronic portal imaging device operating at a resolution of 512 × 384 pixels. The accuracy of the motion estimation is verified with a dynamic motion phantom. Clinical accuracy was tested on lung SBRT images acquired at 2 fps.Results:
Real-time lung tumor motion estimation from BEV images without fiducial markers is successfully demonstrated. For the phantom study, a mean tracking error <1.0 mm [root mean square (rms) error of 0.3 mm] was observed. The tracking rms accuracy on BEV images from a lung SBRT patient (≈20 mm tumor motion range) is 1.0 mm.Conclusions:
The authors demonstrate for the first time real-time markerless lung tumor motion estimation from BEV images alone. The described system can operate at a frame rate of 12.8 Hz and does not require prior knowledge to establish traceable landmarks for tracking on the fly. The authors show that the geometric accuracy is similar to (or better than) previously published markerless algorithms not operating in real-time.
Total target volume is a better predictor of whole brain dose from gamma stereotactic radiosurgery than the number, shape, or location of the lesions40(2013); http://dx.doi.org/10.1118/1.4818825View Description Hide DescriptionPurpose:
To assess the hypothesis that the volume of whole brain that receives a certain dose level is primarily dependent on the treated volume rather than on the number, shape, or location of the lesions. This would help a physician validate the suitability of GammaKnife® based stereotactic radiosurgery (GKSR) prior to treatment.Methods:
Simulation studies were performed to establish the hypothesis for both oblong and spherical shaped lesions of various numbers and sizes. Forty patients who underwent GKSR [mean age of 54 years (range 7–80), mean number of lesions of 2.5 (range 1–6), and mean lesion volume of 4.4 cm3 (range 0.02–22.2 cm3)] were also studied retrospectively. Following recommendations of QUANTEC, the volume of brain irradiated by the 12 Gy (VB12) isodose line was measured and a power-law based relation is proposed here for estimating VB12 from the known tumor volume and the prescription dose.Results:
In the simulation study on oblong, spherical, and multiple lesions, the volume of brain irradiated by 50%, 10%, and 1% of maximum dose was found to have linear, linear, and exponentially increasing dependence on the volume of the treated region, respectively. In the retrospective study on 40 GKSR patients, a similar relationship was found to predict the brain dose with a Spearman correlation coefficient >0.9. In both the studies, the volume of brain irradiated by a certain dose level does not have a statistically significant relationship (p ≥ 0.05) with the number, shape, or position of the lesions. The measured VB12 agrees with calculation to within 1.7%.Conclusions:
The results from the simulation and the retrospective clinical studies indicate that the volume of whole brain that receives a certain percentage of the maximum dose is primarily dependent on the treated volume and less on the number, shape, and location of the lesions.
Automated treatment planning for a dedicated multi-source intra-cranial radiosurgery treatment unit accounting for overlapping structures and dose homogeneity40(2013); http://dx.doi.org/10.1118/1.4817555View Description Hide DescriptionPurpose:
The purpose of this work is to advance the two-step approach for Gamma Knife® Perfexion™ (PFX) optimization to account for dose homogeneity and overlap between the planning target volume (PTV) and organs-at-risk (OARs).Methods:
In the first step, a geometry-based algorithm is used to quickly select isocentre locations while explicitly accounting for PTV-OARs overlaps. In this approach, the PTV is divided into subvolumes based on the PTV-OARs overlaps and the distance of voxels to the overlaps. Only a few isocentres are selected in the overlap volume, and a higher number of isocentres are carefully selected among voxels that are immediately close to the overlap volume. In the second step, a convex optimization is solved to find the optimal combination of collimator sizes and their radiation duration for each isocentre location.Results:
This two-step approach is tested on seven clinical cases (comprising 11 targets) for which the authors assess coverage, OARs dose, and homogeneity index and relate these parameters to the overlap fraction for each case. In terms of coverage, the meanV 99 for the gross target volume (GTV) was 99.8% while the V 95 for the PTV averaged at 94.6%, thus satisfying the clinical objectives of 99% for GTV and 95% for PTV, respectively. The mean relative dose to the brainstem was 87.7% of the prescription dose (with maximum 108%), while on average, 11.3% of the PTV overlapped with the brainstem. The mean beam-on time per fraction per dose was 8.6 min with calibration dose rate of 3.5 Gy/min, and the computational time averaged at 205 min. Compared with previous work involving single-fraction radiosurgery, the resulting plans were more homogeneous with average homogeneity index of 1.18 compared to 1.47.Conclusions:
PFX treatment plans with homogeneous dose distribution can be achieved by inverse planning using geometric isocentre selection and mathematical modeling and optimization techniques. The quality of the obtained treatment plans are clinically satisfactory while the homogeneity index is improved compared to conventional PFX plans.
In vivo dosimetry with optically stimulated dosimeters and RTQA2 radiochromic film for intraoperative radiotherapy of the breast40(2013); http://dx.doi.org/10.1118/1.4819825View Description Hide DescriptionPurpose:
Measurements were taken with optically stimulated luminescence dosimeters (OSLDs) and with RTQA2 radiochromic film to evaluate the use of each forin vivo dosimetry with intraoperative radiotherapy of the breast.Methods:
Nonlinear calibration curves were established for OSLDs and RTQA2 radiochromic film using the Intrabeam 50 kVp source. Measurements were taken in a water phantom and compared to absolute dose measurements taken with an ionization chamber to investigate the characteristics of both types of dosimeters, including energy response and radiative absorption. In vivo readings were taken on the skin and in the tumor cavity using OSLDs and RTQA2 radiochromic film for 10 patients and 20 patients respectively. A prescription of 20 Gy to the surface of the applicator was used for all in vivo measurements in this study.Results:
OSLDs were found to have an approximate uncertainty of ±7% for readings near the surface of the applicator and ±17% for readings at distances typical to the skin. The radiative absorption by OSLD was negative, indicating that this type of dosimeter absorbs less radiation than water in the targeted intraoperative radiotherapy energy range. RTQA2 film exhibited no energy dependence and all film readings were within ±8% of the delivered dose. The maximum radiative absorption in film was 8.5%. Radiochromic film measurements were found to be on average 18.2 ± 3.3 Gy for the tumor cavity and 2.1 ± 0.8 Gy for positions on the skin superior and inferior to the Intrabeam applicator. Average cavity measurements taken with OSLDs were 15.9 ± 3.9 Gy and average skin doses were 1.4 ± 0.8 Gy.Conclusions:
OSLDs produce results with an uncertainty comparable to other dosimeters near the surface of the applicator but the uncertainty increases to an unacceptably high level with distance from the applicator. RTQA2 radiochromic film is shown to be accurate both at the surface of the applicator and at distances of 1–2 cm.
Characterizing the modulation transfer function (MTF) of proton/carbon radiography using Monte Carlo simulations40(2013); http://dx.doi.org/10.1118/1.4819816View Description Hide DescriptionPurpose:
To characterize the modulation transfer function (MTF) of proton/carbon radiography using Monte Carlo simulations. To assess the spatial resolution of proton/carbon radiographic imaging.Methods:
A phantom was specifically modeled with inserts composed of two materials with three different densities of bone and lung. The basic geometry of the phantom consists of cube-shaped inserts placed in water. The thickness of the water, the thickness of the cubes, the depth of the cubes in the water, and the particle beam energy have all been varied and studied. There were two phantom thicknesses considered 20 and 28 cm. This represents an average patient thickness and a thicker sized patient. Radiographs were produced for proton beams at 230 and 330 MeV and for a carbon ion beam at 400 MeV per nucleon. The contrast-to-noise ratio (CNR) was evaluated at the interface of two materials on the radiographs, i.e., lung-water and bone-water. The variation in CNR at interface between lung-water and bone-water were study, where a sigmoidal fit was performed between the lower and the higher CNR values. The full width half-maximum (FWHM) value was then obtained from the sigmoidal fit. Ultimately, spatial resolution was defined by the 10% point of the modulation-transfer-function ( ), in units of line-pairs per mm (lp/mm).Results:
For the 20 cm thick phantom, the FWHM values varied between 0.5 and 0.7 mm at the lung-water and bone-water interfaces, for the proton beam energies of 230 and 330 MeV and the 400 MeV/n carbon beam. For the 28 cm thick phantom, the FWHM values varied between 0.5 and 1.2 mm at the lung-water and bone-water interface for the same inserts and beam energies. For the 20 cm phantom the for lung-water interface is 2.3, 2.4, and 2.8 lp/mm, respectively, for 230, 330, and 400 MeV/n beams. For the same 20 cm thick phantom but for the bone-water interface the yielded 1.9, 2.3, and 2.7 lp/mm, respectively, for 230, 330, and 400 MeV/n beams. In the case of the thicker 28 cm phantom, the authors observed that at the lung-water interface the is 1.6, 1.9, and 2.6 lp/mm, respectively, for 230, 330, and 400 MeV/n beams. While for the bone-water interface the was 1.4, 1.9, and 2.9 lp/mm, respectively, for 230, 330, and 400 MeV/n beams.Conclusions:
Carbon radiography (400 MeV/n) yielded best spatial resolution, with = 2.7 and 2.8 lp/mm, respectively, at the lung-water and bone-water interfaces. The spatial resolution of the 330 MeV proton beam was better than the 230 MeV proton, because higher incident proton energy suffer smaller deflections within the patient and thus yields better proton radiographic images. The authors also observed that submillimeter resolution can be obtained with both proton and carbon beams.
Interfraction variation in lung tumor position with abdominal compression during stereotactic body radiotherapy40(2013); http://dx.doi.org/10.1118/1.4819940View Description Hide DescriptionPurpose:
To assess the effect of abdominal compression on the interfraction variation in tumor position in lung stereotactic body radiotherapy (SBRT) using cone-beam computed tomography (CBCT) in a larger series of patients with large tumor motion amplitude.Methods:
Thirty patients with lung tumor motion exceeding 8 mm who underwent SBRT were included in this study. After translational and rotational initial setup error was corrected based on bone anatomy, CBCT images were acquired for each fraction. The residual interfraction variation was defined as the difference between the centroid position of the visualized target in three dimensions derived from CBCT scans and those derived from averaged intensity projection images. The authors compared the magnitude of the interfraction variation in tumor position between patients treated with [n = 16 (76 fractions)] and without [n = 14 (76 fractions)] abdominal compression.Results:
The mean ± standard deviation (SD) of the motion amplitude in the longitudinal direction before abdominal compression was 19.9 ± 7.3 (range, 10–40) mm and was significantly (p < 0.01) reduced to 12.4 ± 5.8 (range, 5–30) mm with compression. The greatest variance of the interfraction variation with abdominal compression was observed in the longitudinal direction, with a mean ± SD of 0.79 ± 3.05 mm, compared to −0.60 ± 2.10 mm without abdominal compression. The absolute values of the 95th percentile of the interfraction variation for one side in each direction were 3.97/6.21 mm (posterior/anterior), 4.16/3.76 mm (caudal/cranial), and 2.90/2.32 mm (right/left) without abdominal compression, and 2.14/5.03 mm (posterior/anterior), 3.93/9.23 mm (caudal/cranial), and 2.37/5.45 mm (right/left) with abdominal compression. An absolute interfraction variation greater than 5 mm was observed in six (9.2%) fractions without and 13 (17.1%) fractions with abdominal compression.Conclusions:
Abdominal compression was effective for reducing the amplitude of tumor motion. However, in most of the authors’ patients, the use of abdominal compression seemed to increase the interfraction variation in tumor position, despite reducing lung tumor motion. The daily tumor position deviated more systematically from the tumor position in the planning CT scan in the lateral and longitudinal directions in patients treated with abdominal compression compared to those treated without compression. Therefore, target matching is required to correct or minimize the interfraction variation.