Evaluation of 4D CT acquisition methods designed to reduce artifacts

Four-dimensional computed tomography (4D CT) is used to account for respiratory motion in radiation treatment planning, but artifacts resulting from the acquisition and postprocessing limit its accuracy. We investigated the efficacy of three experimental 4D CT acquisition methods to reduce artifacts in a prospective institutional review board approved study. Eighteen thoracic patients scheduled to undergo radiation therapy received standard clinical 4D CT scans followed by each of the alternative 4D CT acquisitions: 1) data oversampling, 2) beam gating with breathing irregularities, and 3) rescanning the clinical acquisition acquired during irregular breathing. Relative values of a validated correlation-based artifact metric (CM) determined the best acquisition method per patient. Each 4D CT was processed by an extended phase sorting approach that optimizes the quantitative artifact metric (CM sorting). The clinical acquisitions were also postprocessed by phase sorting for artifact comparison of our current clinical implementation with the experimental methods. The oversampling acquisition achieved the lowest artifact presence among all acquisitions, achieving a 27% reduction from the current clinical 4D CT implementation (95% confidence interval = 34-20). The rescan method presented a significantly higher artifact presence from the clinical acquisition (37%; p < 0.002), the gating acquisition (26%; p < 0.005), and the oversampling acquisition (31%; p < 0.001), while the data lacked evidence of a significant difference between the clinical, gating, and oversampling methods. The oversampling acquisition reduced artifact presence from the current clinical 4D CT implementation to the largest degree and provided the simplest and most reproducible implementation. The rescan acquisition increased artifact presence significantly, compared to all acquisitions, and suffered from combination of data from independent scans over which large internal anatomic shifts occurred.

On the feasibility of comprehensive high-resolution 3D remote dosimetry

PURPOSE

This study investigates the feasibility of remote high-resolution 3D dosimetry with the PRESAGE®/Optical-CT system. In remote dosimetry, dosimeters are shipped out from a central base institution to a remote institution for irradiation, then shipped back to the base institution for subsequent readout and analysis.

METHODS

Two nominally identical optical-CT scanners for 3D dosimetry were constructed and placed at the base (Duke University) and remote (Radiological Physics Center) institutions. Two formulations of PRESAGE® (SS1, SS2) radiochromic dosimeters were investigated. Higher sensitivity was expected in SS1, which had higher initiator content (0.25% bromotrichloromethane), while greater temporal stability was expected in SS2. Four unirradiated PRESAGE® dosimeters (two per formulation, cylindrical dimensions 11 cm diameter, 8.5-9.5 cm length) were imaged at the base institution, then shipped to the remote institution for planning and irradiation. Each dosimeter was irradiated with the same simple treatment plan: an isocentric 3-field "cross" arrangement of 4 × 4 cm open 6 MV beams configured as parallel opposed laterals with an anterior beam. This simple plan was amenable to accurate and repeatable setup, as well as accurate dose modeling by a commissioned treatment planning system (Pinnacle). After irradiation and subsequent (within 1 h) optical-CT readout at the remote institution, the dosimeters were shipped back to the base institution for remote dosimetry readout 3 days postirradiation. Measured on-site and remote relative 3D dose distributions were registered to the Pinnacle dose calculation, which served as the reference distribution for 3D gamma calculations with passing criteria of 5%/2 mm, 3%/3 mm, and 3%/2 mm with a 10% dose threshold. Gamma passing rates, dose profiles, and color-maps were all used to assess and compare the performance of both PRESAGE® formulations for remote dosimetry.

RESULTS

The best agreements between the Pinnacle plan and dosimeter readout were observed in PRESAGE® formulation SS2. Under 3%/3 mm 3D gamma passing criteria, passing rates were 91.5% ± 3.6% (SS1) and 97.4% ± 2.2% (SS2) for immediate on-site dosimetry, 96.7% ± 2.4% (SS1) and 97.6% ± 0.6% (SS2) for remote dosimetry. These passing rates are well within TG119 recommendations (88%-90% passing). Under the more stringent criteria of 3%/2 mm, there is a pronounced difference [8.0 percentage points (pp)] between SS1 formulation passing rates for immediate and remote dosimetry while the SS2 formulation maintains both higher passing rates and consistency between immediate and remote results (differences ≤ 1.2 pp) at all metrics. Both PRESAGE® formulations under study maintained high linearity of dose response (R(2) > 0.996) for 1-8 Gy over 14 days with response slope consistency within 4.9% (SS1) and 6.6% (SS2), and a relative dose distribution that remained stable over time was demonstrated in the SS2 dosimeters.

CONCLUSIONS

Remote 3D dosimetry was shown to be feasible with a PRESAGE® dosimeter formulation (SS2) that exhibited relative temporal stability and high accuracy when read off-site 3 days postirradiation. Characterization of the SS2 dose response demonstrated linearity (R(2) > 0.998) over 14 days and suggests accurate readout over longer periods of time would be possible. This result provides a foundation for future investigations using remote dosimetry to study the accuracy of advanced radiation treatments. Further work is planned to characterize dosimeter reproducibility and dose response over longer periods of time.

Prognostic value and reproducibility of pretreatment CT texture features in stage III non-small cell lung cancer

PURPOSE

To determine whether pretreatment CT texture features can improve patient risk stratification beyond conventional prognostic factors (CPFs) in stage III non-small cell lung cancer (NSCLC).

METHODS AND MATERIALS

We retrospectively reviewed 91 cases with stage III NSCLC treated with definitive chemoradiation therapy. All patients underwent pretreatment diagnostic contrast enhanced computed tomography (CE-CT) followed by 4-dimensional CT (4D-CT) for treatment simulation. We used the average-CT and expiratory (T50-CT) images from the 4D-CT along with the CE-CT for texture extraction. Histogram, gradient, co-occurrence, gray tone difference, and filtration-based techniques were used for texture feature extraction. Penalized Cox regression implementing cross-validation was used for covariate selection and modeling. Models incorporating texture features from the 33 image types and CPFs were compared to those with models incorporating CPFs alone for overall survival (OS), local-regional control (LRC), and freedom from distant metastases (FFDM). Predictive Kaplan-Meier curves were generated using leave-one-out cross-validation. Patients were stratified based on whether their predicted outcome was above or below the median. Reproducibility of texture features was evaluated using test-retest scans from independent patients and quantified using concordance correlation coefficients (CCC). We compared models incorporating the reproducibility seen on test-retest scans to our original models and determined the classification reproducibility.

RESULTS

Models incorporating both texture features and CPFs demonstrated a significant improvement in risk stratification compared to models using CPFs alone for OS (P=.046), LRC (P=.01), and FFDM (P=.005). The average CCCs were 0.89, 0.91, and 0.67 for texture features extracted from the average-CT, T50-CT, and CE-CT, respectively. Incorporating reproducibility within our models yielded 80.4% (±3.7% SD), 78.3% (±4.0% SD), and 78.8% (±3.9% SD) classification reproducibility in terms of OS, LRC, and FFDM, respectively.

CONCLUSIONS

Pretreatment tumor texture may provide prognostic information beyond that obtained from CPFs. Models incorporating feature reproducibility achieved classification rates of ∼80%. External validation would be required to establish texture as a prognostic factor.

Assessment of a quantitative metric for 4D CT artifact evaluation by observer consensus

The benefits of four-dimensional computed tomography (4D CT) are limited by the presence of artifacts that remain difficult to quantify. A correlation-based metric previously proposed for ciné 4D CT artifact identification was further validated as an independent artifact evaluator by using a novel qualitative assessment featuring a group of observers reaching a consensus decision on artifact location and magnitude. The consensus group evaluated ten ciné 4D CT scans for artifacts over each breathing phase of coronal lung views assuming one artifact per couch location. Each artifact was assigned a magnitude score of 1-5, 1 indicating lowest severity and 5 indicating highest severity. Consensus group results served as the ground truth for assessment of the correlation metric. The ten patients were split into two cohorts; cohort 1 generated an artifact identification threshold derived from receiver operating characteristic analysis using the Youden Index, while cohort 2 generated sensitivity and specificity values from application of the artifact threshold. The Pearson correlation coefficient was calculated between the correlation metric values and the consensus group scores for both cohorts. The average sensitivity and specificity values found with application of the artifact threshold were 0.703 and 0.476, respectively. The correlation coefficients of artifact magnitudes for cohort 1 and 2 were 0.80 and 0.61, respectively, (p < 0.001 for both); these correlation coefficients included a few scans with only two of the five possible magnitude scores. Artifact incidence was associated with breathing phase (p < 0.002), with presentation less likely near maximum exhale. Overall, the correlation metric allowed accurate and automated artifact identification. The consensus group evaluation resulted in efficient qualitative scoring, reduced interobserver variation, and provided consistent identification of artifact location and magnitudes.

MRI characterization of cobalt dichloride-N-acetyl cysteine (C4) contrast agent marker for prostate brachytherapy

Brachytherapy, a radiotherapy technique for treating prostate cancer, involves the implantation of numerous radioactive seeds into the prostate. While the implanted seeds can be easily identified on a computed tomography image, distinguishing the prostate and surrounding soft tissues is not as straightforward. Magnetic resonance imaging (MRI) offers superior anatomical delineation, but the seeds appear as dark voids and are difficult to identify, thus creating a conundrum. Cobalt dichloride-N-acetyl-cysteine (C4) has previously been shown to be promising as an encapsulated contrast agent marker. We performed spin-lattice relaxation time (T1) and spin-spin relaxation time (T2) measurements of C4 solutions with varying cobalt dichloride concentrations to determine the corresponding relaxivities, r1 and r2. These relaxation parameters were investigated at different field strengths, temperatures and orientations. T1 measurements obtained at 1.5 and 3.0 T, as well as at room and body temperature, showed that r1 is field-independent and temperature-independent. Conversely, the T2 values at 3.0 T were shorter than at 1.5 T, while the T2 values at body temperature were slightly higher than at room temperature. By examining the relaxivities with the C4 vials aligned in three different planes, we found no orientation-dependence. With these relaxation characteristics, we aim to develop pulse sequences that will enhance the C4 signal against prostatic stroma. Ultimately, the use of C4 as a positive contrast agent marker will encourage the use of MRI to obtain an accurate representation of the radiation dose delivered to the prostate and surrounding normal anatomical structures.

Addendum to the AAPM's TG-51 protocol for clinical reference dosimetry of high-energy photon beams

An addendum to the AAPM's TG-51 protocol for the determination of absorbed dose to water in megavoltage photon beams is presented. This addendum continues the procedure laid out in TG-51 but new kQ data for photon beams, based on Monte Carlo simulations, are presented and recommendations are given to improve the accuracy and consistency of the protocol's implementation. The components of the uncertainty budget in determining absorbed dose to water at the reference point are introduced and the magnitude of each component discussed. Finally, the consistency of experimental determination of ND,w coefficients is discussed. It is expected that the implementation of this addendum will be straightforward, assuming that the user is already familiar with TG-51. The changes introduced by this report are generally minor, although new recommendations could result in procedural changes for individual users. It is expected that the effort on the medical physicist's part to implement this addendum will not be significant and could be done as part of the annual linac calibration.