Index of content:
Volume 43, Issue 7, July 2016
Within the next five years, adaptive hypofractionation will become the most common form of radiotherapy43(2016); http://dx.doi.org/10.1118/1.4951735View Description Hide Description
- TASK GROUP REPORT
The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management43(2016); http://dx.doi.org/10.1118/1.4947547View Description Hide Description
The increasing complexity of modern radiation therapy planning and delivery challenges traditional prescriptive quality management (QM) methods, such as many of those included in guidelines published by organizations such as the AAPM, ASTRO, ACR, ESTRO, and IAEA. These prescriptive guidelines have traditionally focused on monitoring all aspects of the functional performance of radiotherapy (RT) equipment by comparing parameters against tolerances set at strict but achievable values. Many errors that occur in radiation oncology are not due to failures in devices and software; rather they are failures in workflow and process. A systematic understanding of the likelihood and clinical impact of possible failures throughout a course of radiotherapy is needed to direct limit QM resources efficiently to produce maximum safety and quality of patient care. Task Group 100 of the AAPM has taken a broad view of these issues and has developed a framework for designing QM activities, based on estimates of the probability of identified failures and their clinical outcome through the RT planning and delivery process. The Task Group has chosen a specific radiotherapy process required for “intensity modulated radiation therapy (IMRT)” as a case study. The goal of this work is to apply modern risk-based analysis techniques to this complex RT process in order to demonstrate to the RT community that such techniques may help identify more effective and efficient ways to enhance the safety and quality of our treatment processes. The task group generated by consensus an example quality management program strategy for the IMRT process performed at the institution of one of the authors. This report describes the methodology and nomenclature developed, presents the process maps, FMEAs, fault trees, and QM programs developed, and makes suggestions on how this information could be used in the clinic. The development and implementation of risk-assessment techniques will make radiation therapy safer and more efficient.
- THERAPEUTIC INTERVENTIONS
- Research Articles
43(2016); http://dx.doi.org/10.1118/1.4952729View Description Hide DescriptionPurpose:
Delivery errors during radiotherapy may lead to medical harm and reduced life expectancy for patients. Such serious incidents can be avoided by performing dose verification online, i.e., while the patient is being irradiated, creating the possibility of halting the linac in case of a large overdosage or underdosage. The offline EPID-based 3D in vivo dosimetry system clinically employed at our institute is in principle suited for online treatment verification, provided the system is able to complete 3D dose reconstruction and verification within 420 ms, the present acquisition time of a single EPID frame. It is the aim of this study to show that our EPID-based dosimetry system can be made fast enough to achieve online 3D in vivo dose verification.Methods:
The current dose verification system was sped up in two ways. First, a new software package was developed to perform all computations that are not dependent on portal image acquisition separately, thus removing the need for doing these calculations in real time. Second, the 3D dose reconstruction algorithm was sped up via a new, multithreaded implementation. Dose verification was implemented by comparing planned with reconstructed 3D dose distributions delivered to two regions in a patient: the target volume and the nontarget volume receiving at least 10 cGy. In both volumes, the mean dose is compared, while in the nontarget volume, the near-maximum dose (D2) is compared as well. The real-time dosimetry system was tested by irradiating an anthropomorphic phantom with three VMAT plans: a 6 MV head-and-neck treatment plan, a 10 MV rectum treatment plan, and a 10 MV prostate treatment plan. In all plans, two types of serious delivery errors were introduced. The functionality of automatically halting the linac was also implemented and tested.Results:
The precomputation time per treatment was ∼180 s/treatment arc, depending on gantry angle resolution. The complete processing of a single portal frame, including dose verification, took 266 ± 11 ms on a dual octocore Intel Xeon E5-2630 CPU running at 2.40 GHz. The introduced delivery errors were detected after 5–10 s irradiation time.Conclusions:
A prototype online 3D dose verification tool using portal imaging has been developed and successfully tested for two different kinds of gross delivery errors. Thus, online 3D dose verification has been technologically achieved.
Quantitative analysis of treatment process time and throughput capacity for spot scanning proton therapy43(2016); http://dx.doi.org/10.1118/1.4952731View Description Hide DescriptionPurpose:
To determine the patient throughput and the overall efficiency of the spot scanning system by analyzing treatment time, equipment availability, and maximum daily capacity for the current spot scanning port at Proton Therapy Center Houston and to assess the daily throughput capacity for a hypothetical spot scanning proton therapy center.Methods:
At their proton therapy center, the authors have been recording in an electronic medical record system all treatment data, including disease site, number of fields, number of fractions, delivered dose, energy, range, number of spots, and number of layers for every treatment field. The authors analyzed delivery system downtimes that had been recorded for every equipment failure and associated incidents. These data were used to evaluate the patient census, patient distribution as a function of the number of fields and total target volume, and equipment clinical availability. The duration of each treatment session from patient walk-in to patient walk-out of the spot scanning treatment room was measured for 64 patients with head and neck, central nervous system, thoracic, and genitourinary cancers. The authors retrieved data for total target volume and the numbers of layers and spots for all fields from treatment plans for a total of 271 patients (including the above 64 patients). A sensitivity analysis of daily throughput capacity was performed by varying seven parameters in a throughput capacity model.Results:
The mean monthly equipment clinical availability for the spot scanning port in April 2012–March 2015 was 98.5%. Approximately 1500 patients had received spot scanning proton therapy as of March 2015. The major disease sites treated in September 2012–August 2014 were the genitourinary system (34%), head and neck (30%), central nervous system (21%), and thorax (14%), with other sites accounting for the remaining 1%. Spot scanning beam delivery time increased with total target volume and accounted for approximately 30%–40% of total treatment time for the total target volumes exceeding 200 cm3, which was the case for more than 80% of the patients in this study. When total treatment time was modeled as a function of the number of fields and total target volume, the model overestimated total treatment time by 12% on average, with a standard deviation of 32%. A sensitivity analysis of throughput capacity for a hypothetical four-room spot scanning proton therapy center identified several priority items for improvements in throughput capacity, including operation time, beam delivery time, and patient immobilization and setup time.Conclusions:
The spot scanning port at our proton therapy center has operated at a high performance level and has been used to treat a large number of complex cases. Further improvements in efficiency may be feasible in the areas of facility operation, beam delivery, patient immobilization and setup, and optimization of treatment scheduling.
43(2016); http://dx.doi.org/10.1118/1.4953205View Description Hide DescriptionPurpose:
Accurate and efficient guidance of medical devices to procedural targets lies at the heart of interventional procedures. Ultrasound imaging is commonly used for device guidance, but determining the location of the device tip can be challenging. Various methods have been proposed to track medical devices during ultrasound-guided procedures, but widespread clinical adoption has remained elusive. With ultrasonic tracking, the location of a medical device is determined by ultrasonic communication between the ultrasound imaging probe and a transducer integrated into the medical device. The signal-to-noise ratio (SNR) of the transducer data is an important determinant of the depth in tissue at which tracking can be performed. In this paper, the authors present a new generation of ultrasonic tracking in which coded excitation is used to improve the SNR without spatial averaging.Methods:
A fiber optic hydrophone was integrated into the cannula of a 20 gauge insertion needle. This transducer received transmissions from the ultrasound imaging probe, and the data were processed to obtain a tracking image of the needle tip. Excitation using Barker or Golay codes was performed to improve the SNR, and conventional bipolar excitation was performed for comparison. The performance of the coded excitation ultrasonic tracking system was evaluated in an in vivo ovine model with insertions to the brachial plexus and the uterine cavity.Results:
Coded excitation significantly increased the SNRs of the tracking images, as compared with bipolar excitation. During an insertion to the brachial plexus, the SNR was increased by factors of 3.5 for Barker coding and 7.1 for Golay coding. During insertions into the uterine cavity, these factors ranged from 2.9 to 4.2 for Barker coding and 5.4 to 8.5 for Golay coding. The maximum SNR was 670, which was obtained with Golay coding during needle withdrawal from the brachial plexus. Range sidelobe artifacts were observed in tracking images obtained with Barker coded excitation, and they were visually absent with Golay coded excitation. The spatial tracking accuracy was unaffected by coded excitation.Conclusions:
Coded excitation is a viable method for improving the SNR in ultrasonic tracking without compromising spatial accuracy. This method provided SNR increases that are consistent with theoretical expectations, even in the presence of physiological motion. With the ultrasonic tracking system in this study, the SNR increases will have direct clinical implications in a broad range of interventional procedures by improving visibility of medical devices at large depths.
Endoluminal ultrasound applicators for MR-guided thermal ablation of pancreatic tumors: Preliminary design and evaluation in a porcine pancreas model43(2016); http://dx.doi.org/10.1118/1.4953632View Description Hide DescriptionPurpose:
Endoluminal ultrasound may serve as a minimally invasive option for delivering thermal ablation to pancreatic tumors adjacent to the stomach or duodenum. The objective of this study was to explore the basic feasibility of this treatment strategy through the design, characterization, and evaluation of proof-of-concept endoluminal ultrasound applicators capable of placement in the gastrointestinal (GI) lumen for volumetric pancreas ablation under MR guidance.Methods:
Two variants of the endoluminal applicator, each containing a distinct array of two independently powered transducers (10 × 10 mm 3.2 MHz planar; or 8 × 10 × 20 mm radius of curvature 3.3 MHz curvilinear geometries) at the distal end of a meter long flexible catheter assembly, were designed and fabricated. Transducers and circulatory water flow for acoustic coupling and luminal cooling were contained by a low-profile polyester balloon covering the transducer assembly fixture. Each applicator incorporated miniature spiral MR coils and mechanical features (guiding tips and hinges) to facilitate tracking and insertion through the GI tract under MRI guidance. Acoustic characterization of each device was performed using radiation force balance and hydrophone measurements. Device delivery into the upper GI tract, adjacent to the pancreas, and heating characteristics for treatment of pancreatic tissue were evaluated in MR-guided ex vivo and in vivo porcine experiments. MR guidance was utilized for anatomical target identification, tracking/positioning of the applicator, and MR temperature imaging (MRTI) for PRF-based multislice thermometry, implemented in the real-time RTHawk software environment.Results:
Force balance and hydrophone measurements indicated efficiencies of 48.8% and 47.8% and −3 dB intensity beam-widths of 3.2 and 1.2 mm for the planar and curvilinear transducers, respectively. Ex vivo studies on whole-porcine carcasses revealed capabilities of producing ablative temperature rise (ΔT > 15 °C) contours in pancreatic tissue 4–40 mm long and 4–28 mm wide for the planar transducer applicator (1–13 min sonication duration, ∼4 W/cm2 applied acoustic intensity). Curvilinear transducers produced more selective heating, with a narrower ΔT > 15 °C contour length and width of up to 1–24 mm and 2–7 mm, respectively (1–7 min sonication duration, ∼4 W/cm2 applied acoustic intensity). Active tracking of the miniature spiral coils was achieved using a Hadamard encoding tracking sequence, enabling real-time determination of each coil’s coordinates and automated prescription of imaging planes for thermometry. In vivo MRTI-guided heating trials in three pigs demonstrated capability of ∼20 °C temperature elevation in pancreatic tissue at 2 cm depths from the applicator, with 5–7 W/cm2 applied intensity and 6–16 min sonication duration. Dimensions of thermal lesions in the pancreas ranged from 12 to 28 mm, 3 to 10 mm, and 5 to 10 mm in length, width, and depth, respectively, as verified through histological analysis of tissue sections. Multiple-baseline reconstruction and respiratory-gated acquisition were demonstrated to be effective strategies in suppressing motion artifacts for clear evolution of temperature profiles during MRTI in the in vivo studies.Conclusions:
This study demonstrates the technical feasibility of generating volumetric ablation in pancreatic tissue using endoluminal ultrasound applicators positioned in the stomach lumen. MR guidance facilitates target identification, device tracking/positioning, and treatment monitoring through real-time multislice PRF-based thermometry.
43(2016); http://dx.doi.org/10.1118/1.4953832View Description Hide DescriptionPurpose:
Volumetric modulated arc therapy (VMAT) is a widely employed radiation therapy technique, showing comparable dosimetry to static beam intensity modulated radiation therapy (IMRT) with reduced monitor units and treatment time. However, the current VMAT optimization has various greedy heuristics employed for an empirical solution, which jeopardizes plan consistency and quality. The authors introduce a novel direct aperture optimization method for VMAT to overcome these limitations.Methods:
The comprehensive VMAT (comVMAT) planning was formulated as an optimization problem with an L2-norm fidelity term to penalize the difference between the optimized dose and the prescribed dose, as well as an anisotropic total variation term to promote piecewise continuity in the fluence maps, preparing it for direct aperture optimization. A level set function was used to describe the aperture shapes and the difference between aperture shapes at adjacent angles was penalized to control MLC motion range. A proximal-class optimization solver was adopted to solve the large scale optimization problem, and an alternating optimization strategy was implemented to solve the fluence intensity and aperture shapes simultaneously. Single arc comVMAT plans, utilizing 180 beams with 2° angular resolution, were generated for a glioblastoma multiforme case, a lung (LNG) case, and two head and neck cases—one with three PTVs (H&N3PTV) and one with foue PTVs (H&N4PTV)—to test the efficacy. The plans were optimized using an alternating optimization strategy. The plans were compared against the clinical VMAT (clnVMAT) plans utilizing two overlapping coplanar arcs for treatment.Results:
The optimization of the comVMAT plans had converged within 600 iterations of the block minimization algorithm. comVMAT plans were able to consistently reduce the dose to all organs-at-risk (OARs) as compared to the clnVMAT plans. On average, comVMAT plans reduced the max and mean OAR dose by 6.59% and 7.45%, respectively, of the prescription dose. Reductions in max dose and mean dose were as high as 14.5 Gy in the LNG case and 15.3 Gy in the H&N3PTV case. PTV coverages measured by D95, D98, and D99 were within 0.25% of the prescription dose. By comprehensively optimizing all beams, the comVMAT optimizer gained the freedom to allow some selected beams to deliver higher intensities, yielding a dose distribution that resembles a static beam IMRT plan with beam orientation optimization.Conclusions:
The novel nongreedy VMAT approach simultaneously optimizes all beams in an arc and then directly generates deliverable apertures. The single arc VMAT approach thus fully utilizes the digital Linac’s capability in dose rate and gantry rotation speed modulation. In practice, the new single VMAT algorithm generates plans superior to existing VMAT algorithms utilizing two arcs.
43(2016); http://dx.doi.org/10.1118/1.4953394View Description Hide DescriptionPurpose:
This work describes the characterization and evaluation of a tissue-mimicking thermochromic phantom (TMTCP) for direct visualization and quantitative determination of temperatures during radiofrequency ablation (RFA).Methods:
TMTCP material was prepared using polyacrylamide gel and thermochromic ink that permanently changes color from white to magenta when heated. Color vs temperature calibration was generated in matlab by extracting RGB color values from digital photographs of phantom standards heated in a water bath at 25–75 °C. RGB and temperature values were plotted prior to curve fitting in mathematica using logistic functions of form f(t) = a + b/(1 + e (c(t−d))), where a, b, c, and d are coefficients and t denotes temperature. To quantify temperatures based on TMTCP color, phantom samples were heated to temperatures blinded to the investigators, and two methods were evaluated: (1) visual comparison of sample color to the calibration series and (2) in silico analysis using the inverse of the logistic functions to convert sample photograph RGB values to absolute temperatures. For evaluation of TMTCP performance with RFA, temperatures in phantom samples and in a bovine liver were measured radially from an RF electrode during heating using fiber-optic temperature probes. Heating and cooling rates as well as the area under the temperature vs time curves were compared. Finally, temperature isotherms were generated computationally based on color change in bisected phantoms following RFA and compared to temperature probe measurements.Results:
TMTCP heating resulted in incremental, permanent color changes between 40 and 64 °C. Visual and computational temperature estimation methods were accurate to within 1.4 and 1.9 °C between 48 and 67 °C, respectively. Temperature estimates were most accurate between 52 and 62 °C, resulting in differences from actual temperatures of 0.6 and 1.6 °C for visual and computational methods, respectively. Temperature measurements during RFA using fiber-optic probes matched closely with maximum temperatures predicted by color changes in the TMTCP. Heating rate and cooling rate, as well as the area under the temperature vs time curve were similar for TMTCP and ex vivo liver.Conclusions:
The TMTCP formulated for use with RFA can be used to provide quantitative temperature information in mild hyperthermic (40–45 °C), subablative (45–50 °C), and ablative (>50 °C) temperature ranges. Accurate visual or computational estimates of absolute temperatures and ablation zone geometry can be made with high spatial resolution based on TMTCP color. As such, the TMTCP can be used to assess RFA heating characteristics in a controlled, predictable environment.
4D-CT scans reveal reduced magnitude of respiratory liver motion achieved by different abdominal compression plate positions in patients with intrahepatic tumors undergoing helical tomotherapy43(2016); http://dx.doi.org/10.1118/1.4953190View Description Hide DescriptionPurpose:
While abdominal compression (AC) can be used to reduce respiratory liver motion in patients receiving helical tomotherapy for hepatocellular carcinoma, the nature and extent of this effect is not well described. The purpose of this study was to evaluate the changes in magnitude of three-dimensional liver motion with abdominal compression using four-dimensional (4D) computed tomography (CT) images of several plate positions.Methods:
From January 2012 to October 2015, 72 patients with intrahepatic carcinoma and divided into four groups underwent 4D-CT scans to assess respiratory liver motion. Of the 72 patients, 19 underwent abdominal compression of the cephalic area between the subxiphoid and umbilicus (group A), 16 underwent abdominal compression of the caudal region between the subxiphoid area and the umbilicus (group B), 11 patients underwent abdominal compression of the caudal umbilicus (group C), and 26 patients remained free breathing (group D). 4D-CT images were sorted into ten-image series, according to the respiratory phase from the end inspiration to the end expiration, and then transferred to treatment planning software. All liver contours were drawn by a single physician and confirmed by a second physician. Liver relative coordinates were automatically generated to calculate the liver respiratory motion in different axial directions to compile the 10 ten contours into a single composite image. Differences in respiratory liver motion were assessed with a one-way analysis of variance test of significance.Results:
The average respiratory liver motion in the Y axial direction was 4.53 ± 1.16, 7.56 ± 1.30, 9.95 ± 2.32, and 9.53 ± 2.62 mm in groups A, B, C, and D, respectively, with a significant change among the four groups (p < 0.001). Abdominal compression was most effective in group A (compression plate on the subxiphoid area), with liver displacement being 2.53 ± 0.93, 4.53 ± 1.16, and 2.14 ± 0.92 mm on the X-, Y-, and Z-axes, respectively. There was no significant difference in respiratory liver motion between group C (displacement: 3.23 ± 1.47, 9.95 ± 2.32, and 2.92 ± 1.10 mm on the X-, Y-, and Z-axes, respectively) and group D (displacement: 3.35 ± 1.55, 9.53 ± 2.62, and 3.35 ± 1.73 mm on the X-, Y-, and Z-axes, respectively). Abdominal compression was least effective in group C (compression on caudal umbilicus), with liver motion in this group similar to that of free-breathing patients (group D).Conclusions:
4D-CT scans revealed significant liver motion control via abdominal compression of the subxiphoid area; however, this control of liver motion was not observed with compression of the caudal umbilicus. The authors, therefore, recommend compression of the subxiphoid area in patients undergoing external radiotherapy for intrahepatic carcinoma.
Prospective treatment plan-specific action limits for real-time intrafractional monitoring in surface image guided radiosurgery43(2016); http://dx.doi.org/10.1118/1.4953192View Description Hide DescriptionPurpose:
In surface image guided radiosurgery, action limits are created to determine at what point intrafractional motion exhibited by the patient is large enough to warrant intervention. Action limit values remain constant across patients despite the fact that patient motion affects the target coverage of brain metastases differently depending on the planning technique and other treatment plan-specific factors. The purpose of this work was twofold. The first purpose was to characterize the sensitivity of single-met per iso and multimet per iso treatment plans to uncorrected patient motion. The second purpose was to describe a method to prospectively determine treatment plan-specific action limits considering this sensitivity.Methods:
In their surface image guided radiosurgery technique, patient positioning is achieved with a thermoplastic mask that does not cover the patient’s face. The patient’s exposed face is imaged by a stereoscopic photogrammetry system. It is then compared to a reference surface and monitored throughout treatment. Seventy-two brain metastases (representing 29 patients) were used for this study. Twenty-five mets were treated individually (“single-met per iso plans”), and 47 were treated in a plan simultaneously with at least one other met (“multimet per iso plans”). For each met, the proportion of the gross tumor volume that remained within the 100% prescription isodose line was estimated under the influence of combinations of translations and rotations (0.0–3.0 mm and 0.0°–3.0°, respectively). The target volume and the prescription dose–volume were considered concentric spheres that each encompassed a volume determined from the treatment plan. Plan-specific contour plots and DVHs were created to illustrate the sensitivity of a specific lesion to uncorrected patient motion.Results:
Both single-met per iso and multimet per iso plans exhibited compromised target coverage under translations and rotations, though multimet per iso plans were considerably more sensitive to these transformations (2.3% and 39.8%, respectively). Plan-specific contour plots and DVHs were used to illustrate how size, distance from isocenter, and planning technique affect a particular met’s sensitivity to motion.Conclusions:
Stereotactic radiosurgery treatment plans that treat multiple brain metastases using a common isocenter are particularly susceptible to compromised target coverage as a result of uncorrected patient motion. The use of such a planning technique along with other treatment plan-specific factors should influence patient motion management. A graphical representation of the effect of translations and rotations on any particular plan can be generated to inform clinicians of the appropriate action limit when monitoring intrafractional motion.
Interfractional variation in bladder volume and its impact on cervical cancer radiotherapy: Clinical significance of portable bladder scanner43(2016); http://dx.doi.org/10.1118/1.4954206View Description Hide DescriptionPurpose:
A constant bladder volume (BV) is essential to direct the radiotherapy (RT) of pelvic tumors with precision. The purpose of this study was to investigate changes in BV and their impact on cervical cancer RT and to assess the clinical significance of a portable bladder scanner (BS) in achieving a constant BV.Methods:
A standard bladder phantom (133 ml) and measurements of actual urine volume were both used as benchmarks to evaluate the accuracy of the BS. Comparisons of BS with computed tomography (CT), cone-beam CT (CBCT), and an ultrasound diagnostic device (iU22) were made. Twenty-two consecutive patients with cervical cancer treated with external beam radical RT were divided into an experimental group (13 patients) and a control group (9 patients). In the experimental group, the BV was measured multiple times by BS pre-RT until it was consistent with that found by planning CT. Then a CBCT was performed. The BV was measured again immediately post-RT, after which the patient’s urine was collected and recorded. In the control group, CBCT only was performed pre-RT. Interfractional changes in BV and their impact on cervical cancer RT were investigated in both groups. The time of bladder filling was also recorded and analyzed.Results:
In measuring the volume of the standard bladder phantom, the BS deviated by 1.4% in accuracy. The difference between the measurements of the BS and the iU22 had no statistical significance (linear correlation coefficient 0.96, P < 0.05). The BV measured by the BS was strongly correlated with the actual urine volume (R = 0.95, P < 0.05), planning CT (R = 0.95, P < 0.05), or CBCT (R = 0.91, P < 0.05). Compared with the BV at the time of CT, its value changed by −36.1% [1 SD (standard deviation) 42.3%; range, −79.1%–29.4%] in the control group, and 5.2% (1 SD 21.5%; range, −13.3%–22.1%) in the experimental group during treatment. The change in BV affected the target position in the superior–inferior (SI) direction but had little or no effect in the anterior–posterior and right–left directions. Based on the collected data, the target displacement in the SI direction was reduced from 2.0 to 0.4 mm, while the CTV-to-PTV (CTV: clinical target volume; PTV: planning target volume) margin in the SI direction was reduced from 11.1 to 6.4 mm. The BV increased by 3.7 ± 1.0 ml/min (range, 1.7–4.7 ml/min), which depended on the amount of water ingested by the patient (R = 0.96, P < 0.05). No correlation was found between the rate of urinary inflow and the patient’s body mass. The authors were able to reduce the workload of measuring by using individual patient information including the patient’s age, the water-drinking amount, time at which water-drinking began, and patient’s diet.Conclusions:
Changes in the BV have an influence on the RT of cervical cancer. A consistent and reproducible BV is acquired by using a portable BS, whereby the target displacement and CTV-to-PTV margin can be both reduced in the SI direction.
Four-dimensional dose reconstruction through in vivo phase matching of cine images of electronic portal imaging device43(2016); http://dx.doi.org/10.1118/1.4954317View Description Hide DescriptionPurpose:
A method is proposed to reconstruct a four-dimensional (4D) dose distribution using phase matching of measured cine images to precalculated images of electronic portal imaging device (EPID).Methods:
(1) A phantom, designed to simulate a tumor in lung (a polystyrene block with a 3 cm diameter embedded in cork), was placed on a sinusoidally moving platform with an amplitude of 1 cm and a period of 4 s. Ten-phase 4D computed tomography (CT) images of the phantom were acquired. A planning target volume (PTV) was created by adding a margin of 1 cm around the internal target volume of the tumor. (2) Three beams were designed, which included a static beam, a theoretical dynamic beam, and a planning-optimized dynamic beam (PODB). While the theoretical beam was made by manually programming a simplistic sliding leaf motion, the planning-optimized beam was obtained from treatment planning. From the three beams, three-dimensional (3D) doses on the phantom were calculated; 4D dose was calculated by means of the ten phase images (integrated over phases afterward); serving as “reference” images, phase-specific EPID dose images under the lung phantom were also calculated for each of the ten phases. (3) Cine EPID images were acquired while the beams were irradiated to the moving phantom. (4) Each cine image was phase-matched to a phase-specific CT image at which common irradiation occurred by intercomparing the cine image with the reference images. (5) Each cine image was used to reconstruct dose in the phase-matched CT image, and the reconstructed doses were summed over all phases. (6) The summation was compared with forwardly calculated 4D and 3D dose distributions. Accounting for realistic situations, intratreatment breathing irregularity was simulated by assuming an amplitude of 0.5 cm for the phantom during a portion of breathing trace in which the phase matching could not be performed. Intertreatment breathing irregularity between the time of treatment and the time of planning CT was considered by utilizing the same reduced amplitude when the phantom was irradiated. To examine the phase matching in a humanoid environment, the matching was also performed in a digital phantom (4D XCAT phantom).Results:
For the static, the theoretical, and the planning-optimized dynamic beams, the 4D reconstructed doses showed agreement with the forwardly calculated 4D doses within the gamma pass rates of 92.7%, 100%, and 98.1%, respectively, at the isocenter plane given by 3%/3 mm criteria. Excellent agreement in dose volume histogram of PTV and lung-PTV was also found between the two 4D doses, while substantial differences were found between the 3D and the 4D doses. The significant breathing irregularities modeled in this study were found not to be noticeably affecting the reconstructed dose. The phase matching was performed equally well in a digital phantom.Conclusions:
The method of retrospective phase determination of a moving object under irradiation provided successful 4D dose reconstruction. This method will provide accurate quality assurance and facilitate adaptive therapy when distinguishable objects such as well-defined tumors, diaphragm, and organs with markers (pancreas and liver) are covered by treatment beam apertures.
- Technical Notes
43(2016); http://dx.doi.org/10.1118/1.4953193View Description Hide DescriptionPurpose:
The authors revisit the VMERGE treatment planning algorithm by Craft et al. [“Multicriteria VMAT optimization,” Med. Phys. 39, 686–696 (2012)] for arc therapy planning and propose two changes to the method that are aimed at improving the achieved trade-off between treatment time and plan quality at little additional planning time cost, while retaining other desirable properties of the original algorithm.Methods:
The original VMERGE algorithm first computes an “ideal,” high quality but also highly time consuming treatment plan that irradiates the patient from all possible angles in a fine angular grid with a highly modulated beam and then makes this plan deliverable within practical treatment time by an iterative fluence map merging and sequencing algorithm. We propose two changes to this method. First, we regularize the ideal plan obtained in the first step by adding an explicit constraint on treatment time. Second, we propose a different merging criterion that comprises of identifying and merging adjacent maps whose merging results in the least degradation of radiation dose.Results:
The effect of both suggested modifications is evaluated individually and jointly on clinical prostate and paraspinal cases. Details of the two cases are reported.Conclusions:
In the authors’ computational study they found that both proposed modifications, especially the regularization, yield noticeably improved treatment plans for the same treatment times than what can be obtained using the original VMERGE method. The resulting plans match the quality of 20-beam step-and-shoot IMRT plans with a delivery time of approximately 2 min.
- DIAGNOSTIC IMAGING (IONIZING AND NON-IONIZING)
- Research Articles
43(2016); http://dx.doi.org/10.1118/1.4953187View Description Hide DescriptionPurpose:
Recent new medical displays do have higher contrast and higher luminance but do not have a High Dynamic Range (HDR). HDR implies a minimum luminance value close to zero. A medical HDR display prototype based on two Liquid Crystal layers has been developed. The goal of this study is to evaluate the potential clinical benefit of such display in comparison with a low dynamic range (LDR) display.Methods:
The study evaluated the clinical performance of the displays in a search and detection task. Eight radiologists read chest x-ray images some of which contained simulated lung nodules. The study used a JAFROC (Jacknife Free Receiver Operating Characteristic) approach for analyzing FROC data. The calculated figure of merit (FoM) is the probability that a lesion is rated higher than all rated nonlesions on all images. Time per case and accuracy for locating the center of the nodules were also compared. The nodules were simulated using Samei’s model. 214 CR and DR images [half were “healthy images” (chest nodule-free) and half “diseased images”] were used resulting in a total number of nodules equal to 199 with 25 images with 1 nodule, 51 images with 2 nodules, and 24 images with 3 nodules. A dedicated software interface was designed for visualizing the images for each session. For the JAFROC1 statistical analysis, the study is done per nodule category: all nodules, difficult nodules, and very difficult nodules.Results:
For all nodules, the averaged FoMHDR is slightly higher than FoMLDR with 0.09% of difference. For the difficult nodules, the averaged FoMHDR is slightly higher than FoMLDR with 1.38% of difference. The averaged FoMHDR is slightly higher than FoMLDR with 0.71% of difference. For the true positive fraction (TPF), both displays (the HDR and the LDR ones) have similar TPF for all nodules, but looking at difficult and very difficult nodules, there are more TP for the HDR display. The true positive fraction has been also computed in function of the local average luminance around the nodules. For the lowest luminance range, there is more than 30% in favor of the HDR display. For the highest luminance range, there is less than 6% in favor of the LDR display.Conclusions:
This study shows the potential benefit of using a HDR display in radiology.
Effect of pulse sequence parameter selection on signal strength in positive-contrast MRI markers for MRI-based prostate postimplant assessment43(2016); http://dx.doi.org/10.1118/1.4953635View Description Hide DescriptionPurpose:
For postimplant dosimetric assessment, computed tomography (CT) is commonly used to identify prostate brachytherapy seeds, at the expense of accurate anatomical contouring. Magnetic resonance imaging (MRI) is superior to CT for anatomical delineation, but identification of the negative-contrast seeds is challenging. Positive-contrast MRI markers were proposed to replace spacers to assist seed localization on MRI images. Visualization of these markers under varying scan parameters was investigated.Methods:
To simulate a clinical scenario, a prostate phantom was implanted with 66 markers and 86 seeds, and imaged on a 3.0T MRI scanner using a 3D fast radiofrequency-spoiled gradient recalled echo acquisition with various combinations of scan parameters. Scan parameters, including flip angle, number of excitations, bandwidth, field-of-view, slice thickness, and encoding steps were systematically varied to study their effects on signal, noise, scan time, image resolution, and artifacts.Results:
The effects of pulse sequence parameter selection on the marker signal strength and image noise were characterized. The authors also examined the tradeoff between signal-to-noise ratio, scan time, and image artifacts, such as the wraparound artifact, susceptibility artifact, chemical shift artifact, and partial volume averaging artifact. Given reasonable scan time and managable artifacts, the authors recommended scan parameter combinations that can provide robust visualization of the MRI markers.Conclusions:
The recommended MRI pulse sequence protocol allows for consistent visualization of the markers to assist seed localization, potentially enabling MRI-only prostate postimplant dosimetry.
2D radially compensating excitation pulse in combination with an internal transceiver antenna for 3D MRI of the rectum at 7 T43(2016); http://dx.doi.org/10.1118/1.4954204View Description Hide DescriptionPurpose:
The high precession frequency in ultrahigh field MRI coincides with reduced RF penetration, increased RF power deposition and consequently can lead to reduced scan efficiency. However, the shorter wavelength enables the use of efficient antennas rather than loop coils. In fact, ultrathin monopole antennas have been demonstrated at 7 T, which fit in natural cavities like the rectum in the human body. As the RF field generated by the antenna provides an extremely nonuniform B 1 field, the use of conventional RF pulses will lead to severe image distortions and highly nonuniform contrast. However, using the two predominant dimensions (orthogonal to the antenna), 2D RF pulses can be designed that counteract the nonuniform B 1 into uniform flip angles. In this study the authors investigate the use of an ultrathin antenna not only for reception, but also for transmission in 7 T MRI of the rectum.Methods:
The 2D radially compensating excitation (2D RACE) pulse was designed in matlab. SAR calculations between the 2D RACE pulse and an adiabatic RF pulse (BIR-4) have been obtained, to visualize the gain in decreasing the SAR when using the 2D RACE pulse instead of an adiabatic RF pulse. The authors used the 7 T whole body MR system in combination with an internally placed monopole antenna used for transceiving and obtained 3D gradient echo images with a conventional sinc pulse and with the 2D RACE pulse. For extra clarity, they also reconstructed an image where the receive field of the antenna was removed.Results:
Comparing the results of the SAR simulations of the 2D RACE pulse with a BIR-4 pulse shows that for low flip angles (θ < 41°) the SAR can be decreased with a factor of 4.8 or even more, when using the 2D RACE pulse. Relative to a conventional sinc excitation, the 2D RACE pulse achieves more uniform flip angle distributions than a BIR-4 pulse with a smaller SAR increase (16 × versus 64 ×).Conclusions:
The authors have shown that the 2D RACE pulse provides more homogeneous flip angles for gradient echo sequences when compared to a conventional sinc pulse albeit at increased SAR. However, when compared to adiabatic RF pulses, as shown by simulations, the SAR of the 2D RACE pulse can be an order of magnitude less. Phantom and in vivo human rectum images are obtained to demonstrate that the 2D RACE pulse can provide a uniform excitation while transmitting with a single ultrathin endorectal antenna at 7 T. The combination of thin rectal antennas with efficient uniform transmit can open up new possibilities in high resolution imaging of rectal cancer.
43(2016); http://dx.doi.org/10.1118/1.4954008View Description Hide DescriptionPurpose:
The highest photon fluence rate that a computed tomography (CT) detector must be able to measure is an important parameter. The authors calculate the maximum transmitted fluence rate in a commercial CT scanner as a function of patient size for standard head, chest, and abdomen protocols.Methods:
The authors scanned an anthropomorphic phantom (Kyoto Kagaku PBU-60) with the reference CT protocols provided by AAPM on a GE LightSpeed VCT scanner and noted the tube current applied with the tube current modulation (TCM) system. By rescaling this tube current using published measurements on the tube current modulation of a GE scanner [N. Keat, “CT scanner automatic exposure control systems,” MHRA Evaluation Report 05016, ImPACT, London, UK, 2005], the authors could estimate the tube current that these protocols would have resulted in for other patient sizes. An ECG gated chest protocol was also simulated. Using measured dose rate profiles along the bowtie filters, the authors simulated imaging of anonymized patient images with a range of sizes on a GE VCT scanner and calculated the maximum transmitted fluence rate. In addition, the 99th and the 95th percentiles of the transmitted fluence rate distribution behind the patient are calculated and the effect of omitting projection lines passing just below the skin line is investigated.Results:
The highest transmitted fluence rates on the detector for the AAPM reference protocols with centered patients are found for head images and for intermediate-sized chest images, both with a maximum of 3.4 ⋅ 108 mm−2 s−1, at 949 mm distance from the source. Miscentering the head by 50 mm downward increases the maximum transmitted fluence rate to 5.7 ⋅ 108 mm−2 s−1. The ECG gated chest protocol gives fluence rates up to 2.3 ⋅ 108 − 3.6 ⋅ 108 mm−2 s−1 depending on miscentering.Conclusions:
The fluence rate on a CT detector reaches 3 ⋅ 108 − 6 ⋅ 108 mm−2 s−1 in standard imaging protocols, with the highest rates occurring for ECG gated chest and miscentered head scans. These results will be useful to developers of CT detectors, in particular photon counting detectors.
- Technical Notes
43(2016); http://dx.doi.org/10.1118/1.4953186View Description Hide DescriptionPurpose:
The authors discuss measurement methods and instrumentation useful for the characterization of the gray tracking performance of medical color monitors for diagnostic applications. The authors define gray tracking as the variability in the chromaticity of the gray levels in a color monitor.Methods:
The authors present data regarding the capability of color measurement instruments with respect to their abilities to measure a target white point corresponding to the CIE Standard Illuminant D65 at different luminance values within the grayscale palette of a medical display. The authors then discuss evidence of significant differences in performance among color measurement instruments currently available for medical physicists to perform calibrations and image quality checks for the consistent representation of color in medical displays. In addition, the authors introduce two metrics for quantifying grayscale chromaticity consistency of gray tracking.Results:
The authors’ findings show that there is an order of magnitude difference in the accuracy of field and reference instruments. The gray tracking metrics quantify how close the grayscale chromaticity is to the chromaticity of the full white point (equal amounts of red, green, and blue at maximum level) or to consecutive levels (equal values for red, green, and blue), with a lower value representing an improved grayscale tracking performance. An illustrative example of how to calculate and report the gray tracking performance according to the Task Group definitions is provided.Conclusions:
The authors’ proposed methodology for characterizing the grayscale degradation in chromaticity for color monitors that can be used to establish standards and procedures aiding in the quality control testing of color displays and color measurement instrumentation.
43(2016); http://dx.doi.org/10.1118/1.4954205View Description Hide DescriptionPurpose:
The objective of this project is to demonstrate the principle and operation for a simple, inexpensive, and highly portable Doppler ultrasound quality assurance (QA) phantom intended for routine QA testing. A prototype phantom has been designed, fabricated, and evaluated. The phantom described here is powered by gravity alone, requires no external equipment for operation, and produces a stable fluid velocity useful for quality assurance. Many commercially available Doppler ultrasound testing systems can suffer from issues such as a lengthy setup, prohibitive cost, nonportable size, or difficulty in use. This new phantom design aims to address some of these problems and create a phantom appropriate for assessing Doppler ultrasound stability.Methods:
The phantom was fabricated using a 3D printer. The basic design of the phantom is to provide gravity-powered flow of a Doppler fluid between two reservoirs. The printed components were connected with latex tubing and then seated in a tissue mimicking gel. Spectral Doppler waveforms were sampled to evaluate variations in the data, and the phantom was evaluated using high frame rate video to find an alternate measure of mean fluid velocity flowing in the phantom.Results:
The current system design maintains stable flow from one reservoir to the other for approximately 7 s. Color Doppler imaging of the phantom was found to be qualitatively consistent with laminar flow. Using pulsed spectral Doppler, the average fluid velocity from a sample volume approximately centered in the synthetic vessel was measured to be 56 cm/s with a standard deviation of 3.2 cm/s across 118 measurements. An independent measure of the average fluid velocity was measured to be 51.9 cm/s with a standard deviation of 0.7 cm/s over 4 measurements.Conclusions:
The developed phantom provides stable fluid flow useful for frequent clinical Doppler ultrasound testing and attempts to address several obstacles facing Doppler phantom testing. Such an ultrasound phantom can make routine testing more approachable for institutions that wish to initiate a Doppler QA program or complement a previously existing QA program.