Index of content:
Volume 41, Issue 3, March 2014
Various types of cancers including prostate cancer are known to be associated with biological changes that lead to tissue stiffening. Digital rectal examination is based on manually palpating the prostate tissue via the rectum. This test lacks sufficient accuracy required for early diagnosis which is necessary for effective management of prostate cancer. To develop an effective prostate cancer diagnostic technique, the authors propose an imaging technique that maps the distribution of the relative prostate tissue's elasticity modulus. Unlike digital rectal examination, this technique is quantitative, capable of accurately detecting small prostate lesions that cannot be sensed by manual palpation, and its accuracy is independent of the physician's experience.Methods:
The proposed technique is a quasistatic elastography technique which uses ultrasound imaging to acquire tissue displacements resulting from transrectal ultrasound mechanical stimulation. The system involves a standard ultrasound imaging unit with accessibility to its radiofrequency data. The displacements are used as data for the tissue elasticity reconstruction. This reconstruction does not require tissue segmentation and is based on physics governing tissue mechanics. It is formulated using an inverse problem framework where elastic tissue deformation equations are fully inverted using an iterative scheme where each iteration involves stress calculation followed by elastic modulus updating until convergence is achieved.In silico and tissue mimicking phantom studies were conducted to validate the proposed technique, followed by a clinical pilot study involving two prostate cancer patients with whole-mount histopathology analysis on prostatectomy specimens to confirm a cancer location.Results:
The phantom studies demonstrated robustness and reasonably high accuracy of the proposed method. Obtained Young's modulus ratios indicated reconstruction errors of less than 12%. Reconstructed elastic modulus images of the two clinical cases were compared to whole-mount histopathology slides where cancerous areas were identified. This comparison indicated marked tissue stiffening in the cancer area with reasonably accurate consistency observed between cancerous lesions identified by histopathology and high stiffness areas of the elastography images.Conclusions:
Results obtained from the phantom and patient studies indicate that the proposed method is reasonably accurate for detecting cancerous lesions. The proposed system does not require any additional hardware attachment for mechanical stimulation or data acquisition while the elasticity reconstruction algorithm can be easily implemented, leading to a low cost system that can be potentially utilized as an effective clinical tool for prostate cancer diagnosis.
- TASK GROUP REPORT (Online only)
Monitor unit calculations for external photon and electron beams: Report of the AAPM Therapy Physics Committee Task Group No. 7141(2014); http://dx.doi.org/10.1118/1.4864244View Description Hide Description
A protocol is presented for the calculation of monitor units (MU) for photon and electron beams, delivered with and without beam modifiers, for constant source-surface distance (SSD) and source-axis distance (SAD) setups. This protocol was written by Task Group 71 of the Therapy Physics Committee of the American Association of Physicists in Medicine (AAPM) and has been formally approved by the AAPM for clinical use. The protocol defines the nomenclature for the dosimetric quantities used in these calculations, along with instructions for their determination and measurement. Calculations are made using the dose per MU under normalization conditions, , that is determined for each user's photon and electron beams. For electron beams, the depth of normalization is taken to be the depth of maximum dose along the central axis for the same field incident on a water phantom at the same SSD, where = 1 cGy/MU. For photon beams, this task group recommends that a normalization depth of 10 cm be selected, where an energy-dependent ≤ 1 cGy/MU is required. This recommendation differs from the more common approach of a normalization depth of d m , with = 1 cGy/MU, although both systems are acceptable within the current protocol. For photon beams, the formalism includes the use of blocked fields, physical or dynamic wedges, and (static) multileaf collimation. No formalism is provided for intensity modulated radiation therapy calculations, although some general considerations and a review of current calculation techniques are included. For electron beams, the formalism provides for calculations at the standard and extended SSDs using either an effective SSD or an air-gap correction factor. Example tables and problems are included to illustrate the basic concepts within the presented formalism.
- RADIATION THERAPY PHYSICS
Dose impact in radiographic lung injury following lung SBRT: Statistical analysis and geometric interpretation41(2014); http://dx.doi.org/10.1118/1.4863483View Description Hide DescriptionPurpose:
To demonstrate a new method of evaluating dose response of treatment-induced lung radiographic injury post-SBRT (stereotactic body radiotherapy) treatment and the discovery of bimodal dose behavior within clinically identified injury volumes.Methods:
Follow-up CT scans at 3, 6, and 12 months were acquired from 24 patients treated with SBRT for stage-1 primary lung cancers or oligometastic lesions. Injury regions in these scans were propagated to the planning CT coordinates by performing deformable registration of the follow-ups to the planning CTs. A bimodal behavior was repeatedly observed from the probability distribution for dose values within the deformed injury regions. Based on a mixture-Gaussian assumption, an Expectation-Maximization (EM) algorithm was used to obtain characteristic parameters for such distribution. Geometric analysis was performed to interpret such parameters and infer the critical dose level that is potentially inductive of post-SBRT lung injury.Results:
The Gaussian mixture obtained from the EM algorithm closely approximates the empirical dose histogram within the injury volume with good consistency. The average Kullback-Leibler divergence values between the empirical differential dose volume histogram and the EM-obtained Gaussian mixture distribution were calculated to be 0.069, 0.063, and 0.092 for the 3, 6, and 12 month follow-up groups, respectively. The lower Gaussian component was located at approximately 70% prescription dose (35 Gy) for all three follow-up time points. The higher Gaussian component, contributed by the dose received by planning target volume, was located at around 107% of the prescription dose. Geometrical analysis suggests the mean of the lower Gaussian component, located at 35 Gy, as a possible indicator for a critical dose that induces lung injury after SBRT.Conclusions:
An innovative and improved method for analyzing the correspondence between lung radiographic injury and SBRT treatment dose has been demonstrated. Bimodal behavior was observed in the dose distribution of lung injury after SBRT. Novel statistical and geometrical analysis has shown that the systematically quantified low-dose peak at approximately 35 Gy, or 70% prescription dose, is a good indication of a critical dose for injury. The determined critical dose of 35 Gy resembles the critical dose volume limit of 30 Gy for ipsilateral bronchus in RTOG 0618 and results from previous studies. The authors seek to further extend this improved analysis method to a larger cohort to better understand the interpatient variation in radiographic lung injury dose response post-SBRT.
41(2014); http://dx.doi.org/10.1118/1.4863597View Description Hide DescriptionPurpose:
To maximize the benefits of respiratory gated radiotherapy (RGRT) of lung tumors real-time verification of the tumor position is required. This work investigates the feasibility of markerless tracking of lung tumors during beam-on time in electronic portal imaging device (EPID) images of the MV therapeutic beam.Methods:
EPID movies were acquired at ∼2 fps for seven lung cancer patients with tumor peak-to-peak motion ranges between 7.8 and 17.9 mm (mean: 13.7 mm) undergoing stereotactic body radiotherapy. The external breathing motion of the abdomen was synchronously measured. Both datasets were retrospectively analyzed inPortalTrack, an in-house developed tracking software. The authors define a three-step procedure to run the simulations: (1) gating window definition, (2) gated-beam delivery simulation, and (3) tumor tracking. First, an amplitude threshold level was set on the external signal, defining the onset of beam-on/-off signals. This information was then mapped onto a sequence of EPID images to generate stamps of beam-on/-hold periods throughout the EPID movies in PortalTrack, by obscuring the frames corresponding to beam-off times. Last, tumor motion in the superior-inferior direction was determined on portal images by the tracking algorithm during beam-on time. The residual motion inside the gating window as well as target coverage (TC) and the marginal target displacement (MTD) were used as measures to quantify tumor position variability.Results:
Tumor position monitoring and estimation from beam's-eye-view images during RGRT was possible in 67% of the analyzed beams. For a reference gating window of 5 mm, deviations ranging from 2% to 86% (35% on average) were recorded between the reference and measured residual motion. TC (range: 62%–93%; mean: 77%) losses were correlated with false positives incidence rates resulting mostly from intra-/inter-beam baseline drifts, as well as sudden cycle-to-cycle fluctuations in exhale positions. Both phenomena can lead to considerable deviations (with MTD values up to a maximum of 7.8 mm) from the intended tumor position, and in turn may result in a marginal miss. The difference between tumor traces determined within the gating window against ground truth trajectory maps was 1.1 ± 0.7 mm on average (range: 0.4–2.3 mm).Conclusions:
In this retrospective analysis of motion data, it is demonstrated that the system is capable of determining tumor positions in the plane perpendicular to the beam direction without the aid of fiducial markers, and may hence be suitable as an online verification tool in RGRT. It may be possible to use the tracking information to enable on-the-fly corrections to intra-/inter-beam variations by adapting the gating window by means of a robotic couch.
Toward adaptive radiotherapy for head and neck patients: Feasibility study on using CT-to-CBCT deformable registration for “dose of the day” calculations41(2014); http://dx.doi.org/10.1118/1.4864240View Description Hide DescriptionPurpose:
The aim of this study was to evaluate the appropriateness of using computed tomography (CT) to cone-beam CT (CBCT) deformable image registration (DIR) for the application of calculating the “dose of the day” received by a head and neck patient.Methods:
NiftyReg is an open-source registration package implemented in our institution. The affine registration uses a Block Matching-based approach, while the deformable registration is a GPU implementation of the popular B-spline Free Form Deformation algorithm. Two independent tests were performed to assess the suitability of our registrations methodology for “dose of the day” calculations in a deformed CT. A geometric evaluation was performed to assess the ability of the DIR method to map identical structures between the CT and CBCT datasets. Features delineated in the planning CT were warped and compared with features manually drawn on the CBCT. The authors computed the dice similarity coefficient (DSC), distance transformation, and centre of mass distance between features. A dosimetric evaluation was performed to evaluate the clinical significance of the registrations errors in the application proposed and to identify the limitations of the approximations used. Dose calculations for the same intensity-modulated radiation therapy plan on the deformed CT and replan CT were compared. Dose distributions were compared in terms of dose differences (DD), gamma analysis, target coverage, and dose volume histograms (DVHs). Doses calculated in a rigidly aligned CT and directly in an extended CBCT were also evaluated.Results:
A mean value of 0.850 in DSC was achieved in overlap between manually delineated and warped features, with the distance between surfaces being less than 2 mm on over 90% of the pixels. Deformable registration was clearly superior to rigid registration in mapping identical structures between the two datasets. The dose recalculated in the deformed CT is a good match to the dose calculated on a replan CT. The DD is smaller than 2% of the prescribed dose on 90% of the body's voxels and it passes a 2% and 2 mm gamma-test on over 95% of the voxels. Target coverage similarity was assessed in terms of the 95%-isodose volumes. A mean value of 0.962 was obtained for the DSC, while the distance between surfaces is less than 2 mm in 95.4% of the pixels. The method proposed provided adequate dose estimation, closer to the gold standard than the other two approaches. Differences in DVH curves were mainly due to differences in the OARs definition (manual vs warped) and not due to differences in dose estimation (dose calculated in replan CT vs dose calculated in deformed CT).Conclusions:
Deforming a planning CT to match a daily CBCT provides the tools needed for the calculation of the “dose of the day” without the need to acquire a new CT. The initial clinical application of our method will be weekly offline calculations of the “dose of the day,” and use this information to inform adaptive radiotherapy (ART). The work here presented is a first step into a full implementation of a “dose-driven” online ART.
Three-dimensional analysis of the respiratory interplay effect in helical tomotherapy: Baseline variations cause the greater part of dose inhomogeneities seen41(2014); http://dx.doi.org/10.1118/1.4864241View Description Hide DescriptionPurpose:
Dose differences from those planned can occur due to the respiratory interplay effect on helical tomotherapy. The authors present a technique to calculate single-fraction doses in three-dimensions resulting from craniocaudal motion applied to a patient CT set. The technique is applied to phantom and patient plans using patient respiratory traces. An additional purpose of the work is to determine the contribution toward the interplay effect of different components of the respiratory trace.Methods:
MATLAB code used to calculate doses to a CT dataset from a helical tomotherapy plan has been modified to permit craniocaudal motion and improved temporal resolution. Real patient traces from seven patients were applied to ten phantom plans of differing field width, modulation factor, pitch and fraction dose, and simulations made with peak-to-peak amplitudes ranging from 0 to 2.5 cm. PTV voxels near the superior or inferior limits of the PTV are excluded from the analysis. The maximum dose discrepancy compared with the static case recorded along with the proportion of voxels receiving more than 10% and 20% different from prescription dose. The analysis was repeated with the baseline variation of the respiratory trace removed, leaving the cyclic component of motion only. Radiochromic film was used on one plan-trace combination and compared with the software simulation. For one case, filtered traces were generated and used in simulations which consisted only of frequencies near to particular characteristic frequencies of the treatment delivery. Intraslice standard deviation of dose differences was used to identify potential MLC interplay, which was confirmed using nonmodulated simulations. Software calculations were also conducted for four realistic patient plans and modeling movement of a patient CT set with amplitudes informed by the observed motion of the GTV on 4DCT.Results:
The maximum magnitude of dose difference to a PTV voxel due to the interplay effect within a particular plan-trace combination for peak-to-peak amplitudes of up to 2.5 cm ranged from 4.5% to 51.6% (mean: 23.8%) of the dose delivered in the absence of respiratory motion. For cyclic motion only, the maximum dose differences in each combination ranged from 2.1% to 26.2% (mean: 9.2%). There is reasonable correspondence between an example of the phantom plan simulations and radiochromic film measurement. The filtered trace simulations revealed that frequencies close to the characteristic frequency of the jaw motion across the target were found to generate greater interplay effect than frequencies close to the gantry frequency or MLC motion. There was evidence of interplay between respiratory motion and MLC modulation, but this is small compared with the interplay between respiratory motion and jaw motion. For patient-plan simulations, dose discrepancies are seen of up to 9.0% for a patient with 0.3 cm peak-to-peak respiratory amplitude and up to 17.7% for a patient with 0.9 cm peak-to-peak amplitude. These values reduced to 1.3% and 6.5%, respectively, when only cyclic motion was considered.Conclusions:
Software has been developed to simulate craniocaudal respiratory motion in phantom and patient plans using real patient respiratory traces. Decomposition of the traces into baseline andcyclic components reveals that the large majority of the interplay effect seen with the full trace is due to baseline variation during treatment.
Geometric and dosimetric accuracy of dynamic tumor-tracking conformal arc irradiation with a gimbaled x-ray heada)41(2014); http://dx.doi.org/10.1118/1.4864242View Description Hide DescriptionPurpose:
The Vero4DRT system has the capability for dynamic tumor-tracking (DTT) stereotactic irradiation using a unique gimbaled x-ray head. The purposes of this study were to develop DTT conformal arc irradiation and to estimate its geometric and dosimetric accuracy.Methods:
The gimbaled x-ray head, supported on an O-ring gantry, was moved in the pan and tilt directions during O-ring gantry rotation. To evaluate the mechanical accuracy, the gimbaled x-ray head was moved during the gantry rotating according to input command signals without a target tracking, and a machine log analysis was performed. The difference between a command and a measured position was calculated as mechanical error. To evaluate beam-positioning accuracy, a moving phantom, which had a steel ball fixed at the center, was driven based on a sinusoidal wave (amplitude [A]: 20 mm, time period [T]: 4 s), a patient breathing motion with a regular pattern (A: 16 mm, average T: 4.5 s), and an irregular pattern (A: 7.2–23.0 mm, T: 2.3–10.0 s), and irradiated with DTT during gantry rotation. The beam-positioning error was evaluated as the difference between the centroid position of the irradiated field and the steel ball on images from an electronic portal imaging device. For dosimetric accuracy, dose distributions in static and moving targets were evaluated with DTT conformal arc irradiation.Results:
The root mean squares (RMSs) of the mechanical error were up to 0.11 mm for pan motion and up to 0.14 mm for tilt motion. The RMSs of the beam-positioning error were within 0.23 mm for each pattern. The dose distribution in a moving phantom with tracking arc irradiation was in good agreement with that in static conditions.Conclusions:
The gimbal positional accuracy was not degraded by gantry motion. As in the case of a fixed port, the Vero4DRT system showed adequate accuracy of DTT conformal arc irradiation.
Monte Carlo dosimetry for 103Pd, 125I, and 131Cs ocular brachytherapy with various plaque models using an eye phantom41(2014); http://dx.doi.org/10.1118/1.4864474View Description Hide DescriptionPurpose:
To investigate dosimetry for ocular brachytherapy for a range of eye plaque models containing103Pd, 125I, or 131Cs seeds with model-based dose calculations.Methods:
Five representative plaque models are developed based on a literature review and are compared to the standardized COMS plaque, including plaques consisting of a stainless steel backing and acrylic insert, and gold alloy backings with: short collimating lips and acrylic insert, no lips and silicone polymer insert, no lips and a thin acrylic layer, and individual collimating slots for each seed within the backing and no insert. Monte Carlo simulations are performed using the EGSnrc user-code BrachyDose for single and multiple seed configurations for the plaques in water and within an eye model (including nonwater media). Simulations under TG-43 assumptions are also performed, i.e., with the same seed configurations in water, neglecting interseed and plaque effects. Maximum and average doses to ocular structures as well as isodose contours are compared for simulations of each radionuclide within the plaque models.Results:
The presence of the plaque affects the dose distribution substantially along the plaque axis for both single seed and multiseed simulations of each plaque design in water. Of all the plaque models, the COMS plaque generally has the largest effect on the dose distribution in water along the plaque axis. Differences between doses for single and multiple seed configurations vary between plaque models and radionuclides. Collimation is most substantial for the plaque with individual collimating slots. For plaques in the full eye model, average dose in the tumor region differs from those for the TG-43 simulations by up to 10% for125I and 131Cs, and up to 17% for 103Pd, and in the lens region by up to 29% for 125I, 34% for 103Pd, and 28% for 131Cs. For the same prescription dose to the tumor apex, the lowest doses to critical ocular structures are generally delivered with plaques containing 103Pd seeds.Conclusions:
The combined effects of ocular and plaque media on dose are significant and vary with plaque model and radionuclide, suggesting the importance of model-based dose calculations employing accurate ocular and plaque media and geometries for eye plaque brachytherapy.
Generic method for automatic bladder segmentation on cone beam CT using a patient-specific bladder shape model41(2014); http://dx.doi.org/10.1118/1.4865762View Description Hide DescriptionPurpose:
The aim of this study is to develop and validate a generic method for automatic bladder segmentation on cone beam computed tomography (CBCT), independent of gender and treatment position (prone or supine), using only pretreatment imaging data.Methods:
Data of 20 patients, treated for tumors in the pelvic region with the entire bladder visible on CT and CBCT, were divided into four equally sized groups based on gender and treatment position. The full and empty bladder contour, that can be acquired with pretreatment CT imaging, were used to generate a patient-specific bladder shape model. This model was used to guide the segmentation process on CBCT. To obtain the bladder segmentation, the reference bladder contour was deformed iteratively by maximizing the cross-correlation between directional grey value gradients over the reference and CBCT bladder edge. To overcome incorrect segmentations caused by CBCT image artifacts, automatic adaptations were implemented. Moreover, locally incorrect segmentations could be adapted manually. After each adapted segmentation, the bladder shape model was expanded and new shape patterns were calculated for following segmentations. All available CBCTs were used to validate the segmentation algorithm. The bladder segmentations were validated by comparison with the manual delineations and the segmentation performance was quantified using the Dice similarity coefficient (DSC), surface distance error (SDE) and SD of contour-to-contour distances. Also, bladder volumes obtained by manual delineations and segmentations were compared using a Bland-Altman error analysis.Results:
The mean DSC, mean SDE, and mean SD of contour-to-contour distances between segmentations and manual delineations were 0.87, 0.27 cm and 0.22 cm (female, prone), 0.85, 0.28 cm and 0.22 cm (female, supine), 0.89, 0.21 cm and 0.17 cm (male, supine) and 0.88, 0.23 cm and 0.17 cm (male, prone), respectively. Manual local adaptations improved the segmentation results significantly (p < 0.01) based on DSC (6.72%) and SD of contour-to-contour distances (0.08 cm) and decreased the 95% confidence intervals of the bladder volume differences. Moreover, expanding the shape model improved the segmentation results significantly (p < 0.01) based on DSC and SD of contour-to-contour distances.Conclusions:
This patient-specific shape model based automatic bladder segmentation method on CBCT is accurate and generic. Our segmentation method only needs two pretreatment imaging data sets as prior knowledge, is independent of patient gender and patient treatment position and has the possibility to manually adapt the segmentation locally.
41(2014); http://dx.doi.org/10.1118/1.4865766View Description Hide DescriptionPurpose:
To investigate the impact of exclusively using intravenous (IV) contrast x-ray computed tomography (CT) scans on lung cancer intensity-modulated radiation therapy (IMRT) treatment planning.Methods:
Eight patients with lung cancer (one small cell, seven nonsmall cell) scheduled to receive IMRT consented to acquisition of simulation CT scans with and without IV contrast. Clinical treatment plans optimized on the noncontrast scans were recomputed on contrast scans and dose coverage was compared, along with the γ passing rates.Results:
IV contrast enhanced scans provided better target and critical structure conspicuity than the noncontrast scans. Using noncontrast scan as a reference, the median absolute/relative differences in mean, maximum, and minimum doses to the planning target volume (PTV) were −4.5 cGy/−0.09%, 41.1 cGy/0.62%, and −19.7 cGy/−0.50%, respectively. Regarding organs-at-risk (OARs), the median absolute/relative differences of maximum dose to heart was −13.3 cGy/−0.32%, to esophagus was −63.4 cGy/−0.89%, and to spinal cord was −16.3 cGy/−0.46%. The median heart region of interest CT Hounsfield Unit (HU) number difference between noncontrast and contrast scans was 136.4 HU (range, 94.2–161.8 HU). Subjectively, the regions with absolute dose differences greater than 3% of the prescription dose were small and typically located at the patient periphery and/or at the beam edges. The median γ passing rate was 0.9981 (range, 0.9654–0.9999) using 3% absolute dose difference/3 mm distance-to-agreement criteria. Overall, all evaluated cases were found to be clinically equivalent.Conclusions:
PTV and OARs dose differences between noncontrast and contrast scans appear to be minimal for lung cancer patients undergoing IMRT. Using IV contrast scans as the primary simulation dataset could increase treatment planning efficiency and accuracy by avoiding unnecessary scans, manually region overriding, and planning errors caused by nonperfect image registrations.
Dosimetric comparison of flattened and unflattened beams for stereotactic ablative radiotherapy of stage I non-small cell lung cancer41(2014); http://dx.doi.org/10.1118/1.4866231View Description Hide DescriptionPurpose:
To compare contribution and accuracy of delivery for two flattening filter free (FFF) beams of the nominal energy 6 and 10 MV and a 6 MV flattened beam for early stage lung cancer.Methods:
For each of 11 patients with stage I nonsmall cell lung cancer three volumetric modulated arc therapy plans were prepared utilizing a 6 MV flattened photon beam (X6FF) and two nonflattened beams of nominal energy 6 and 10 MV (X6FFF, X10FFF). Optimization constraints were set to produce dose distributions that meet the criteria of the RTOG-0915 protocol. The radiation schedule used for plan comparison in all patients was 50 Gy in five fractions. Dosimetric parameters of planning target volume (PTV) and organs-at-risk and delivery times were assessed and compared. All plans were subject to verification using Delta4 unit (Scandidos, Sweden) and absolutely calibrated gafchromic films in a thorax phantom.Results:
All plans had a qualitatively comparable outcome. Obtained dose distributions were conformal (CI < 1.17) and exhibited a steep dose fall-off outside the PTV. The ratio of monitor units for FFF versus FF plans in the authors' study ranged from 0.95 to 1.21 and from 0.93 to 1.25 for X6FFF/X6FF and X10FFF/X6FF comparisons, respectively. The ratio systematically increased with increasing size of the PTV (up to +25% for 150 cm3 PTV). Yet the integral dose to healthy tissue did not follow this trend. Comparison of cumulative dose volume histograms for a patient's body showed that X6FFF plans exhibit improved conformity and reduced the volume of tissue that received more than 50% of the prescription dose. Parameters related to dose gradient showed statistically significant improvement. CI50%, CI60%, CI80%, and CI100% were on average reduced by 4.6% (p < 0.001), 4.6% (p = 0.002), 3.1% (p = 0.002), and 1.2% (p = 0.039), respectively. Gradient measure was on average reduced by 4.2% (p < 0.001). Due to dose reduction in the surrounding lung tissue, the V 20 Gy and V 12.5 Gy were reduced by 5.5% (p = 0.002) and 4.5% (p < 0.001). These dosimetric improvements in the fall-off were not observed for the X10FFF plans. Differences in sparing of normal tissues were not found to be statistically significant for either of the two FFF beams. Mean beam-on times were 111 s (2SD = 11 s) for X10FFF, 128 s (2SD = 19 s) for X6FFF, and X6FF plans required on average 269 s (2SD = 71 s). While the mean dose rate was 1555 ± 264 and 1368 ± 63 MU/min, for X10FFF and X6FFF, plans using the conventional X6FF were delivered with the constant maximum dose rate of 600 MU/min. Verification of all plans showed acceptable and comparable results for all plans in homogeneous as well as heterogeneous phantoms. Mean GS (3%, 2 mm) using the Delta4 phantom were 98.9% (2SD = 3.2%), 99.2% (2SD = 2.3%), and 99.2% (2SD = 2.3%) for X6FFF, X6FF, and X10FFF modalities. Verification using a thorax phantom showed GS > 98% in all cases.Conclusions:
The use of FFF beams for stereotactic radiation therapy of nonsmall cell lung cancer patients yielded dose distributions qualitatively comparable to flattened beams and significantly reduced treatment delivery time. Utilizing the X6FFF beam improved conformity of dose distribution. On the other hand, X10FFF beam offered a slight improvement in treatment efficiency, and lower skin and peripheral dose. All effects were relatively small.
Assessment and management of interfractional variations in daily diagnostic-quality-CT guided prostate-bed irradiation after prostatectomy41(2014); http://dx.doi.org/10.1118/1.4866222View Description Hide DescriptionPurpose:
To quantify interfractional anatomic variations and limitations of the current practice of image-guided radiation therapy (IGRT) for prostate-bed patients and to study dosimetric benefits of an online adaptive replanning scheme that addresses the interfractional variations.Methods:
Contours for the targets and organs at risk (OARs) from daily diagnostic-quality CTs acquired with in-room CT (CTVision, Siemens) were generated by populating the planning contours using an autosegmentation tool based on deformable registration (ABAS, Elekta) with manual editing for ten prostate-bed patients treated with postoperative daily CT-guided IMRT. Dice similarity coefficient (DSC) obtained by maximizing the overlap of contours for a structure between the daily and plan contours was used to quantify the organ deformation between the plan and daily CTs. Three interfractional-variation-correction schemes, the current standard practice of IGRT repositioning, a previously developed online adaptive RT (ART), and the full reoptimization, were applied to these daily CTs and a number of dose-volume quantities for the targets and organs at risk were compared for their effectiveness to account for the interfractional variations.Results:
Large interfractional organ deformations in prostate-bed irradiation were seen. The mean DSCs for CTV, rectum, and bladder were 86.6 ± 5.1% (range from 61% to 97%), 77.3% ± 7.4% (range from 55% to 90%), and 75.4% ± 11.2% (range from 46% to 96%), respectively. The fractional and cumulative dose-volume quantities for CTV and PTV: V100 (volume received at least 100% prescription dose), and rectum and bladder: V45Gy and V60Gy (volume received at least 45 or 60 Gy), were compared for the repositioning, adaptive, reoptimization, and original plans. The fractional and cumulative dosimetric results were nearly the same. The average cumulative CTV V100 were 88.0%, 98.4%, 99.2%, and 99.3% for the IGRT, ART, reoptimization, and original plans, respectively. The corresponding rectal V45Gy (V60Gy) were 58.7% (27.3%), 48.1% (20.7%), 43.8% (16.1%), and 44.9% (16.8%). The results for bladder were comparable among three schemes. Paired two-tailed Wilcoxon signed-rank tests were performed and it was found that ART and reoptimization provide better target coverage and better OAR sparing, especially rectum sparing.Conclusions:
The interfractional organ motions and deformations during prostate-bed irradiation are significant. The online adaptive replanning scheme is capable of effectively addressing the large organ deformation, resulting in cumulative doses equivalent to those originally planned.
41(2014); http://dx.doi.org/10.1118/1.4866225View Description Hide DescriptionPurpose:
To assess the long-term mechanical stability and accuracy of the patient positioning system (PPS) of the Leksell Gamma Knife® Perfexion™ (LGK PFX).Methods:
The mechanical stability of the PPS of the LGK PFX was evaluated using measurements obtained between September 2007 and June 2011. Three methods were employed to measure the deviation of the coincidence of the radiological focus point (RFP) and the PPS calibration center point (CCP). In the first method, the onsite diode test tool with single diode detector was used together with the 4 mm collimator on a daily basis. In the second method, a service diode test tool with three diode detectors was used biannually at the time of the routine preventive maintenance. The test performed with the service diode test tool measured the deviations for all three collimators 4, 8, and 16 mm and also for three different positions of the PPS. The third method employed the conventional film pin-prick method. This test was performed annually for the 4 mm collimator at the time of the routine annual QA. To estimate the effect of the patient weight on the performance of the PPS, the focus precision tests were also conducted with varying weights on the PPS using a set of lead bricks.Results:
The average deviations measured from the 641 daily focus precision tests were 0.1 ± 0.1, 0.0 ± 0.0, and 0.0 ± 0.0 mm, respectively, for the 4 mm collimator in the X (left/right of the patient), Y (anterior/posterior of the patient), and Z (superior/inferior of the patient) directions. The average of the total radial deviations as measured during ten semiannual measurements with the service diode test tool were 0.070 ± 0.029, 0.060 ± 0.022, and 0.103 ± 0.028 mm, respectively for the central, long, and short diodes for the 4 mm collimator. Similarly, the average total radial deviations measured during the semiannual measurements for the 4, 8, and 16 mm collimators and using the central diode were 0.070 ± 0.029, 0.097 ± 0.025, 0.159 ± 0.028 mm, respectively. The average values of the deviations as obtained from the five annual film pin-prick tests for the 4 mm collimator were 0.10 ± 0.06, 0.06 ± 0.09, and 0.03 ± 0.03 mm for the X, Y, Z stereotactic directions, respectively. Only a minor change was observed in the total radial deviations of the PPS as a function of the simulated patient weight up to 202 kg on the PPS.Conclusions:
Excellent long-term mechanical stability and high accuracy was observed for the PPS of the LGK PFX. No PPS recalibration or any adjustment in the PPS was needed during the monitored period of time. Similarly, the weight on the PPS did not cause any significant disturbance in the performance of the PPS for up to 202 kg simulated patient weight.
41(2014); http://dx.doi.org/10.1118/1.4866227View Description Hide DescriptionPurpose:
This paper describes the development of a forward planning process for modulated electron radiotherapy (MERT). The approach is based on a previously developed electron beam model used to calculate dose distributions of electron beams shaped by a photon multi leaf collimator (pMLC).Methods:
As the electron beam model has already been implemented into the Swiss Monte Carlo Plan environment, the Eclipse treatment planning system (Varian Medical Systems, Palo Alto, CA) can be included in the planning process for MERT. In a first step, CT data are imported into Eclipse and a pMLC shaped electron beam is set up. This initial electron beam is then divided into segments, with the electron energy in each segment chosen according to the distal depth of the planning target volume (PTV) in beam direction. In order to improve the homogeneity of the dose distribution in the PTV, a feathering process (Gaussian edge feathering) is launched, which results in a number of feathered segments. For each of these segments a dose calculation is performed employing the in-house developed electron beam model along with the macro Monte Carlo dose calculation algorithm. Finally, an automated weight optimization of all segments is carried out and the total dose distribution is read back into Eclipse for display and evaluation. One academic and two clinical situations are investigated for possible benefits of MERT treatment compared to standard treatments performed in our clinics and treatment with a bolus electron conformal (BolusECT) method.Results:
The MERT treatment plan of the academic case was superior to the standard single segment electron treatment plan in terms of organs at risk (OAR) sparing. Further, a comparison between an unfeathered and a feathered MERT plan showed better PTV coverage and homogeneity for the feathered plan, with V95% increased from 90% to 96% and V107% decreased from 8% to nearly 0%. For a clinical breast boost irradiation, the MERT plan led to a similar homogeneity in the PTV compared to the standard treatment plan while the mean body dose was lower for the MERT plan. Regarding the second clinical case, a whole breast treatment, MERT resulted in a reduction of the lung volume receiving more than 45% of the prescribed dose when compared to the standard plan. On the other hand, the MERT plan leads to a larger low-dose lung volume and a degraded dose homogeneity in the PTV. For the clinical cases evaluated in this work, treatment plans using the BolusECT technique resulted in a more homogenous PTV and CTV coverage but higher doses to the OARs than the MERT plans.Conclusions:
MERT treatments were successfully planned for phantom and clinical cases, applying a newly developed intuitive and efficient forward planning strategy that employs a MC based electron beam model for pMLC shaped electron beams. It is shown that MERT can lead to a dose reduction in OARs compared to other methods. The process of feathering MERT segments results in an improvement of the dose homogeneity in the PTV.
41(2014); http://dx.doi.org/10.1118/1.4866228View Description Hide DescriptionPurpose:
The aim of this work is to characterize a new linear accelerator collimator which contains a single pair of sculpted diaphragms mounted orthogonally to a 160 leaf multileaf collimator (MLC). The diaphragms have “thick” regions providing full attenuation and “thin” regions where attenuation is provided by both the leaves and the diaphragm. The leaves are mounted on a dynamic leaf guide allowing rapid leaf motion and leaf travel over 350 mm.Methods:
Dosimetric characterization, including assessment of leaf transmission, leaf tip transmission, penumbral width, was performed in a plotting tank. Head scatter factor was measured using a mini-phantom and the effect of leaf guide position on output was assessed using a water phantom. The tongue and groove effect was assessed using multiple exposures on radiochromic film. Leaf reproducibility was assessed from portal images of multiple abutting fields.Results:
The maximum transmission through the multileaf collimator is 0.44% at 6 MV and 0.52% at 10 MV. This reduced to 0.22% and 0.27%, respectively, when the beam passes through the dynamic leaf guide in addition to the MLC. The maximum transmission through the thick part of the diaphragm is 0.32% and 0.36% at 6 and 10 MV. The combination of leaf and diaphragm transmission ranges from 0.08% to 0.010% at 6 MV and 0.10% to 0.14% depending on whether the shielding is through the thick or thin part of the diaphragm. The off-axis intertip transmission for a zero leaf gap is 2.2% at 6 and 10 MV. The leaf tip penumbra for a 100 × 100 mm field ranges from 5.4 to 4.3 mm at 6 and 10 MV across the full range of leaf motion when measured in the AB direction, which reduces to 4.0–3.4 mm at 6 MV and 4.5–3.8 mm at 10 MV when measured in the GT direction. For a 50 × 50 mm field, the diaphragm penumbra ranges from 4.3 to 3.7 mm at 6 MV and 4.5 to 4.1 mm at 10 MV in the AB direction and 3.7 to 3.2 mm at 6 MV and 4.2 to 3.7 mm when measured in the GT direction. The tongue and groove effect observed from exposure of a radiochromic film to two abutting fields is an underdose of 25%. The head scatter factor at both 6 and 10 MV is similar to that from the MLCi2 collimator to within 0.8%. The uncertainty in the leaf position reproducibility is 0.05 mm (2σ).Conclusions:
The Agility collimator is a low leakage, high definition collimator where both the MLC and the sculpted diaphragm have been optimized for dynamic treatments.
41(2014); http://dx.doi.org/10.1118/1.4866215View Description Hide DescriptionPurpose:
To compare the dosimetric and geometric properties of a commercial x-ray based image-guided small animal irradiation system, installed at three institutions and to establish a complete and broadly accessible commissioning procedure.Methods:
The system consists of a 225 kVp x-ray tube with fixed field size collimators ranging from 1 to 44 mm equivalent diameter. The x-ray tube is mounted opposite a flat-panel imaging detector, on a C-arm gantry with 360° coplanar rotation. Each institution performed a full commissioning of their system, including half-value layer, absolute dosimetry, relative dosimetry (profiles, percent depth dose, and relative output factors), and characterization of the system geometry and mechanical flex of the x-ray tube and detector. Dosimetric measurements were made using Farmer-type ionization chambers, small volume air and liquid ionization chambers, and radiochromic film. The results between the three institutions were compared.Results:
At 225 kVp, with 0.3 mm Cu added filtration, the first half value layer ranged from 0.9 to 1.0 mm Cu. The dose-rate in-air for a 40 × 40 mm2 field size, at a source-to-axis distance of 30 cm, ranged from 3.5 to 3.9 Gy/min between the three institutions. For field sizes between 2.5 mm diameter and 40 × 40 mm2, the differences between percent depth dose curves up to depths of 3.5 cm were between 1% and 4% on average, with the maximum difference being 7%. The profiles agreed very well for fields >5 mm diameter. The relative output factors differed by up to 6% for fields larger than 10 mm diameter, but differed by up to 49% for fields ≤5 mm diameter. The mechanical characteristics of the system (source-to-axis and source-to-detector distances) were consistent between all three institutions. There were substantial differences in the flex of each system.Conclusions:
With the exception of the half-value layer, and mechanical properties, there were significant differences between the dosimetric and geometric properties of the three systems. This underscores the need for careful commissioning of each individual system for use in radiobiological experiments.
- RADIATION IMAGING PHYSICS
A quality assurance framework for the fully automated and objective evaluation of image quality in cone-beam computed tomography41(2014); http://dx.doi.org/10.1118/1.4863507View Description Hide DescriptionPurpose:
Thousands of cone-beam computed tomography (CBCT) scanners for vascular, maxillofacial, neurological, and body imaging are in clinical use today, but there is no consensus on uniform acceptance and constancy testing for image quality (IQ) and dose yet. The authors developed a quality assurance (QA) framework for fully automated and time-efficient performance evaluation of these systems. In addition, the dependence of objective Fourier-based IQ metrics on direction and position in 3D volumes was investigated for CBCT.Methods:
The authors designed a dedicated QA phantom 10 cm in length consisting of five compartments, each with a diameter of 10 cm, and an optional extension ring 16 cm in diameter. A homogeneous section of water-equivalent material allows measuring CT value accuracy, image noise and uniformity, and multidimensional global and local noise power spectra (NPS). For the quantitative determination of 3D high-contrast spatial resolution, the modulation transfer function (MTF) of centrally and peripherally positioned aluminum spheres was computed from edge profiles. Additional in-plane and axial resolution patterns were used to assess resolution qualitatively. The characterization of low-contrast detectability as well as CT value linearity and artifact behavior was tested by utilizing sections with soft-tissue-equivalent and metallic inserts. For an automated QA procedure, a phantom detection algorithm was implemented. All tests used in the dedicated QA program were initially verified in simulation studies and experimentally confirmed on a clinical dental CBCT system.Results:
The automated IQ evaluation of volume data sets of the dental CBCT system was achieved with the proposed phantom requiring only one scan for the determination of all desired parameters. Typically, less than 5 min were needed for phantom set-up, scanning, and data analysis. Quantitative evaluation of system performance over time by comparison to previous examinations was also verified. The maximum percentage interscan variation of repeated measurements was less than 4% and 1.7% on average for all investigated quality criteria. The NPS-based image noise differed by less than 5% from the conventional standard deviation approach and spatially selective 10% MTF values were well comparable to subjective results obtained with 3D resolution pattern. Determining only transverse spatial resolution and global noise behavior in the central field of measurement turned out to be insufficient.Conclusions:
The proposed framework transfers QA routines employed in conventional CT in an advanced version to CBCT for fully automated and time-efficient evaluation of technical equipment. With the modular phantom design, a routine as well as an expert version for assessing IQ is provided. The QA program can be used for arbitrary CT units to evaluate 3D imaging characteristics automatically.
41(2014); http://dx.doi.org/10.1118/1.4863510View Description Hide DescriptionPurpose
: X-ray fluorescence (XRF) is a promising technique with sufficient specificity and sensitivity for identifying and quantifying features in small samples containing high atomic number (Z) materials such as iodine, gadolinium, and gold. In this study, the feasibility of applying XRF to early breast cancer diagnosis and treatment is studied using a novel approach for three-dimensional (3D) x-ray fluorescence mapping (XFM) of gold nanoparticle (GNP)-loaded objects in a physical phantom at the technical level.Methods
: All the theoretical analysis and experiments are conducted under the condition of using x-ray pencil beam and a compactly integrated x-ray spectrometer. The penetrability of the fluorescence x-rays from GNPs is first investigated by adopting a combination of BR12 with 70 mm/50 mm in thickness on the excitation/emission path to mimic the possible position of tumor gold in vivo. Then, a physical phantom made of BR12 is designed to translate in 3D space with three precise linear stages and subsequently the step by step XFM scanning is performed. The experimental technique named as background subtraction is applied to isolate the gold fluorescence from each spectrum obtained by the spectrometer. Afterwards, the attenuations of both the incident primary x-ray beam with energies beyond the gold K-edge energy (80.725 keV) and the isolated gold K α fluorescence x-rays (65.99 –69.80 keV) acquired after background subtraction are well calibrated, and finally the unattenuated K α fluorescence counts are used to realize mapping reconstruction and to describe the linear relationship between gold fluorescence counts and corresponding concentration of gold solutions.Results
: The penetration results show that the gold K α fluorescence x-rays have sufficient penetrability for this phantom study, and the reconstructed mapping results indicate that both the spatial distribution and relative concentration of GNPs within the designed BR12 phantom can be well identified and quantified.Conclusions
: Although the XFM method in this investigation is still studied at the technical level and is not yet practical for routinein vivo mapping tasks with GNPs, the current penetrability measurements and phantom study strongly suggest the feasibility to establish and develop a 3D XFM system.
41(2014); http://dx.doi.org/10.1118/1.4864236View Description Hide DescriptionPurpose:
Expert manual labeling is the gold standard for image segmentation, but this process is difficult, time-consuming, and prone to inter-individual differences. While fully automated methods have successfully targeted many anatomies, automated methods have not yet been developed for numerous essential structures (e.g., the internal structure of the spinal cord as seen on magnetic resonance imaging). Collaborative labeling is a new paradigm that offers a robust alternative that may realize both the throughput of automation and the guidance of experts. Yet, distributing manual labeling expertise across individuals and sites introduces potential human factors concerns (e.g., training, software usability) and statistical considerations (e.g., fusion of information, assessment of confidence, bias) that must be further explored. During the labeling process, it is simple to ask raters to self-assess the confidence of their labels, but this is rarely done and has not been previously quantitatively studied. Herein, the authors explore the utility of self-assessment in relation to automated assessment of rater performance in the context of statistical fusion.Methods:
The authors conducted a study of 66 volumes manually labeled by 75 minimally trained human raters recruited from the university undergraduate population. Raters were given 15 min of training during which they were shown examples of correct segmentation, and the online segmentation tool was demonstrated. The volumes were labeled 2D slice-wise, and the slices were unordered. A self-assessed quality metric was produced by raters for each slice by marking a confidence bar superimposed on the slice. Volumes produced by both voting and statistical fusion algorithms were compared against a set of expert segmentations of the same volumes.Results:
Labels for 8825 distinct slices were obtained. Simple majority voting resulted in statistically poorer performance than voting weighted by self-assessed performance. Statistical fusion resulted in statistically indistinguishable performance from self-assessed weighted voting. The authors developed a new theoretical basis for using self-assessed performance in the framework of statistical fusion and demonstrated that the combined sources of information (both statistical assessment and self-assessment) yielded statistically significant improvement over the methods considered separately.Conclusions:
The authors present the first systematic characterization of self-assessed performance in manual labeling. The authors demonstrate that self-assessment and statistical fusion yield similar, but complementary, benefits for label fusion. Finally, the authors present a new theoretical basis for combining self-assessments with statistical label fusion.
41(2014); http://dx.doi.org/10.1118/1.4864239View Description Hide DescriptionPurpose:
Proton computed tomography (CT) is a promising image modality for improving the stopping power estimates and dose calculations for particle therapy. However, the finite range of about 33 cm of water of most commercial proton therapy systems limits the sites that can be scanned from a full 360° rotation. In this paper the authors propose a method to overcome the problem using a dual modality reconstruction (DMR) combining the proton data with a cone-beam x-ray prior.Methods:
A Catphan 600 phantom was scanned using a cone beam x-ray CT scanner. A digital replica of the phantom was created in the Monte Carlo code Geant4 and a 360° proton CT scan was simulated, storing the entrance and exit position and momentum vector of every proton. Proton CT images were reconstructed using a varying number of angles from the scan. The proton CT images were reconstructed using a constrained nonlinear conjugate gradient algorithm, minimizing total variation and the x-ray CT prior while remaining consistent with the proton projection data. The proton histories were reconstructed along curved cubic-spline paths.Results:
The spatial resolution of the cone beam CT prior was retained for the fully sampled case and the 90° interval case, with the MTF = 0.5 (modulation transfer function) ranging from 5.22 to 5.65 linepairs/cm. In the 45° interval case, the MTF = 0.5 dropped to 3.91 linepairs/cm For the fully sampled DMR, the maximal root mean square (RMS) error was 0.006 in units of relative stopping power. For the limited angle cases the maximal RMS error was 0.18, an almost five-fold improvement over the cone beam CT estimate.Conclusions:
Dual modality reconstruction yields the high spatial resolution of cone beam x-ray CT while maintaining the improved stopping power estimation of proton CT. In the case of limited angles, the use of prior image proton CT greatly improves the resolution and stopping power estimate, but does not fully achieve the quality of a 360° proton CT scan.