Quality assurance for nonradiographic radiotherapy localization and positioning systems: report of Task Group 147

The first prospective implementation of markerless lung target tracking in an experimental quality assurance procedure on a standard linear accelerator

The ability to track tumour motion without implanted markers on a standard linear accelerator (linac) could enable wide access to real-time adaptive radiotherapy for cancer patients. We previously have retrospectively validated a method for 3D markerless target tracking using intra-fractional kilovoltage (kV) projections acquired on a standard linac. This paper presents the first prospective implementation of markerless lung target tracking on a standard linac and its quality assurance (QA) procedure. The workflow and the algorithm developed to track the 3D target position during volumetric modulated arc therapy treatment delivery were optimised. The linac was operated in clinical QA mode, while kV projections were streamed to a dedicated computer using a frame-grabber software. The markerless target tracking accuracy and precision were measured in a lung phantom experiment under the following conditions: static localisation of seven distinct positions, dynamic localisation of five patient-measured motion traces, and dynamic localisation with treatment interruption. The QA guidelines were developed following the AAPM Task Group 147 report with the requirement that the tracking margin components, the margins required to account for tracking errors, did not exceed 5 mm in any direction. The mean tracking error ranged from 0.0 to 0.9 mm (left-right), -0.6 to  -0.1 mm (superior-inferior) and  -0.7 to 0.1 mm (anterior-posterior) over the three tests. Larger errors were found in cases with large left-right or anterior-posterior and small superior-inferior motion. The tracking margin components did not exceed 5 mm in any direction and ranged from 0.4 to 3.2 mm (left-right), 0.7 to 1.6 mm (superior-inferior) and 0.8 to 1.5 mm (anterior-posterior). This study presents the first prospective implementation of markerless lung target tracking on a standard linac and provides a QA procedure for its safe clinical implementation, potentially enabling real-time adaptive radiotherapy for a large population of lung cancer patients.

Characterizing a deformable registration algorithm for surface-guided breast radiotherapy

PURPOSE

Surface-guided radiation therapy (SGRT) is a nonionizing imaging approach for patient setup guidance, intra-fraction monitoring, and automated breath-hold gating of radiation treatments. SGRT employs the premise that the external patient surface correlates to the internal anatomy, to infer the treatment isocenter position at time of treatment delivery. Deformations and posture variations are known to impact the correlation between external and internal anatomy. However, the degree, magnitude, and algorithm dependence of this impact are not intuitive and currently no methods exist to assess this relationship. The primary aim of this work was to develop a framework to investigate and understand how a commercial optical surface imaging system (C-RAD, Uppsala, Sweden), which uses a nonrigid registration algorithm, handles rotations and surface deformations.

METHODS

A workflow consisting of a female torso phantom and software-introduced transformations to the corresponding digital reference surface was developed. To benchmark and validate the approach, known rigid translations and rotations were first applied. Relevant breast radiotherapy deformations related to breast size, hunching/arching back, distended/deflated abdomen, and an irregular surface to mimic a cover sheet over the lower part of the torso were investigated. The difference between rigid and deformed surfaces was evaluated as a function of isocenter location.

RESULTS

For all introduced rigid body transformations, C-RAD computed isocenter shifts were determined within 1 mm and 1˚. Additional translational shifts to correct for rotations as a function of isocenter location were determined with the same accuracy. For yaw setup errors, the difference in shift corrections between a plan with an isocenter placed in the center of the breast (BrstIso) and one located 12 cm superiorly (SCFIso) was 2.3 mm/1˚ in lateral direction. Pitch setup errors resulted in a difference of 2.1 mm/1˚ in vertical direction. For some of the deformation scenarios, much larger differences up to 16 mm and 7˚ in the calculated shifts between BrstIso and SCFIso were observed that could lead to large unintended gaps or overlap between adjacent matched fields if uncorrected.

CONCLUSIONS

The methodology developed lends itself well for quality assurance (QA) of SGRT systems. The deformable C-RAD algorithm determined accurate shifts for rigid transformations, and this was independent of isocenter location. For surface deformations, the position of the isocenter had considerable impact on the registration result. It is recommended to avoid off-axis isocenters during treatment planning to optimally utilize the capabilities of the deformable image registration algorithm, especially when multiple isocenters are used with fields that share a field edge.

Modern Radiation Therapy Planning and Delivery

Modern radiation therapy treatment planning and delivery is a complex process that relies on advanced imaging and computing technology as well as expertise from the medical team. The process begins with simulation imaging, in which three-dimensional computed tomography images (or magnetic resonance images in some cases) are used to characterize the patient anatomy. From there, the radiation oncologist delineates the relevant target/tumor volumes and normal tissue and communicates the goals for treatment planning. The planning process attempts to generate a radiation therapy treatment plan that will deliver a therapeutic dose of radiation to the tumor while sparing nearby normal tissue.

Real-time intrafraction motion monitoring in external beam radiotherapy

Radiotherapy (RT) aims to deliver a spatially conformal dose of radiation to tumours while maximizing the dose sparing to healthy tissues. However, the internal patient anatomy is constantly moving due to respiratory, cardiac, gastrointestinal and urinary activity. The long term goal of the RT community to 'see what we treat, as we treat' and to act on this information instantaneously has resulted in rapid technological innovation. Specialized treatment machines, such as robotic or gimbal-steered linear accelerators (linac) with in-room imaging suites, have been developed specifically for real-time treatment adaptation. Additional equipment, such as stereoscopic kilovoltage (kV) imaging, ultrasound transducers and electromagnetic transponders, has been developed for intrafraction motion monitoring on conventional linacs. Magnetic resonance imaging (MRI) has been integrated with cobalt treatment units and more recently with linacs. In addition to hardware innovation, software development has played a substantial role in the development of motion monitoring methods based on respiratory motion surrogates and planar kV or Megavoltage (MV) imaging that is available on standard equipped linacs. In this paper, we review and compare the different intrafraction motion monitoring methods proposed in the literature and demonstrated in real-time on clinical data as well as their possible future developments. We then discuss general considerations on validation and quality assurance for clinical implementation. Besides photon RT, particle therapy is increasingly used to treat moving targets. However, transferring motion monitoring technologies from linacs to particle beam lines presents substantial challenges. Lessons learned from the implementation of real-time intrafraction monitoring for photon RT will be used as a basis to discuss the implementation of these methods for particle RT.

Development and accuracy evaluation of a single-camera intra-bore surface scanning system for radiotherapy in an O-ring linac

Background and purpose

Current commercial surface scanning systems are not able to monitor patients during radiotherapy fractions in closed-bore linacs during adaptive workflows. In this work a surface scanning system for monitoring in an O-ring linac is proposed.

Methods and materials

A depth camera was mounted at the backend of the bore. The acquired surface point cloud was transformed to the linac coordinate system after a cube detection calibration step. The real-time surface was registered using an Iterative Closest Point algorithm to a reference region-of-interest of the body contour from the planning CT and of a depth camera surface acquisition from the first fraction. The positioning accuracy was investigated using anthropomorphic 3D-printed phantoms with embedded markers: a head, hand and breast. To simulate clinically observed positioning errors, each phantom was placed 24 times with 0-10 mm and 0-8° offsets from the planned position. At every position a cone-beam CT (CBCT) was acquired and a surface registration performed. The surface registration error was determined as the difference between the surface registration and the CBCT-to-CT fiducial marker registration.

Results

The registration errors were (mean ± SD): lat: 0.4 ± 0.8 mm, vert: -0.2 ± 0.2 mm, long: 0.3 ± 0.5 mm and Yaw: -0.2 ± 0.6°, Pitch: 0.4 ± 0.2°, Roll: 0.5 ± 0.8° for the body contour reference, and lat: -0.7 ± 0.7 mm, vert: 0.3 ± 0.2 mm, long: 0.2 ± 0.5 mm and Yaw: -0.5 ± 0.5°, Pitch: 0.1 ± 0.3°, Roll: -0.7 ± 0.7° for the captured surface reference.

Conclusion

The proposed single camera intra-bore surface system was capable of accurately detecting phantom displacements and allows intrafraction motion monitoring for surface guided radiotherapy inside the bore of O-ring gantries.

A novel deformable lung phantom with programably variable external and internal correlation

PURPOSE

Lung motion phantoms used to validate radiotherapy motion management strategies have fairly simplistic designs that do not adequately capture complex phenomena observed in human respiration such as external and internal deformation, variable hysteresis and variable correlation between different parts of the thoracic anatomy. These limitations make reliable evaluation of sophisticated motion management techniques quite challenging. In this work, we present the design and implementation of a programmable, externally and internally deformable lung motion phantom that allows for a reproducible change in external-internal and internal-internal correlation of embedded markers.

METHODS

An in-house-designed lung module, made from natural latex foam was inserted inside the outer shell of a commercially available lung phantom (RSD, Long Beach, CA, USA). Radiopaque markers were placed on the external surface and embedded into the lung module. Two independently programmable high-precision linear motion actuators were used to generate primarily anterior-posterior (AP) and primarily superior-inferior (SI) motion in a reproducible fashion in order to enable (a) variable correlation between the displacement of interior volume and the exterior surface, (b) independent changes in the amplitude of the AP and SI motions, and (c) variable hysteresis. The ability of the phantom to produce complex and variable motion accurately and reproducibly was evaluated by programming the two actuators with mathematical and patient-recorded lung tumor motion traces, and recording the trajectories of various markers using kV fluoroscopy. As an example application, the phantom was used to evaluate the performance of lung motion models constructed from kV fluoroscopy and 4DCT images.

RESULTS

The phantom exhibited a high degree of reproducibility and marker motion ranges were reproducible to within 0.5 mm. Variable correlation was observed between the displacements of internal-internal and internal-external markers. The SI and AP components of motion of a specific marker had a correlation parameter that varied from -11 to 17. Monitoring a region of interest on the phantom's surface to estimate internal marker motion led to considerably lower uncertainties than when a single point was monitored.

CONCLUSIONS

We successfully designed and implemented a programmable, externally and internally deformable lung motion phantom that allows for a reproducible change in external-internal and internal-internal correlation of embedded markers.

Optical Surface Scanning for Patient Positioning in Radiation Therapy: A Prospective Analysis of 1902 Fractions

Purpose/Objective:

Reproducible patient positioning remains one of the major challenges in modern radiation therapy. Recently, optical surface scanners have been introduced into clinical practice in addition to well-established positioning systems, such as room laser and skin marks. The aim of this prospective study was to evaluate setup errors of the optical surface scanner Catalyst HD (C-RAD AB) in different anatomic regions.

Material/Methods:

Between October 2016 and June 2017 a total of 1902 treatment sessions in 110 patients were evaluated. The workflow of this study included conventional setup procedures using laser-based positioning with skin marks and an additional registration of the 3-dimensional (3D) deviations detected by the Catalyst system. The deviations of the surface-based method were then compared to the corrections of cone beam computed tomography alignment which was considered as gold standard. A practical Catalyst setup error was calculated between the translational deviations of the surface scanner and the laser positioning. Two one-sided t tests for equivalence were used for statistical analysis.

Results:

Data analysis revealed total deviations of 0.09 mm ± 2.03 mm for the lateral axis, 0.07 mm ± 3.21 mm for the longitudinal axis, and 0.44 mm ± 3.08 mm vertical axis for the Catalyst system, compared to −0.06 ± 3.54 mm lateral, 0.53 ± 3.47 mm longitudinal, and 0.19 ± 3.49 mm vertical for the laser positioning compared to cone beam computed tomography. The lowest positional deviations were found in the cranial region, and larger deviations occurred in the thoracic and abdominal sites. A statistical comparison using 2 one-sided t tests showed a general concordance of the 2 methods (P ≤ 0.036), excluding the vertical direction of the abdominal region (P = 0.198).

Conclusion:

The optical surface scanner Catalyst HD is a reliable and feasible patient positioning system without any additional radiation exposure. From the head to the thoracic and abdominal region, a decrease in accuracy was observed within a comparable range for Catalyst and laser-assisted positioning.

First clinical implementation of real-time, real anatomy tracking and radiation beam control

PURPOSE

We describe the acceptance testing, commissioning, periodic quality assurance, and workflow procedures developed for the first clinically implemented magnetic resonance imaging-guided radiation therapy (MR-IGRT) system for real-time tracking and beam control.

METHODS

The system utilizes real-time cine imaging capabilities at 4 frames per second for real-time tracking and beam control. Testing of the system was performed using an in-house developed motion platform and a commercially available motion phantom. Anatomical tracking is performed by first identifying a target (a region of interest that is either tissue to be treated or a critical structure) and generating a contour around it. A boundary contour is also created to identify tracking margins. The tracking algorithm deforms the anatomical contour (target or a normal organ) on every subsequent cine frame and compares it to the static boundary contour. If the anatomy of interest moves outside the boundary, the radiation delivery is halted until the tracked anatomy returns to treatment portal. The following were performed to validate and clinically implement the system: (a) spatial integrity evaluation; (b) tracking accuracy; (c) latency; (d) relative point dose and spatial dosimetry; (e) development of clinical workflow for gating; and (f) independent verification by an outside credentialing service.

RESULTS

The spatial integrity of the MR system was found to be within 2 mm over a 45-cm diameter field-of-view. The tracking accuracy for geometric targets was within 1.2 mm. The average system latency was measured to be within 394 ms. The dosimetric accuracy using ionization chambers was within 1.3% ± 1.7%, and the dosimetric spatial accuracy was within 2 mm. The phantom irradiation for the outside credentialing service had satisfactory results, as well.

CONCLUSIONS

The first clinical MR-IGRT system was validated for real-time tracking and gating capabilities and shown to be reliable and accurate. Patient workflow methods were developed for efficient treatment. Periodic quality assurance tests can be efficiently performed with commercially available equipment to ensure accurate system performance.

A novel-integrated quality assurance phantom for radiographic and nonradiographic radiotherapy localization and positioning systems

PURPOSE

Various localization and positioning systems utilizing radiographic or nonradiographic methods have been developed to improve the accuracy of radiation treatment. Each quality assurance (QA) procedure requires its own phantom and is independent from each other, so the deviation between each system is unavailable. The purpose of this work is to develop and evaluate a single-integrated QA phantom for different localization and positioning systems.

METHODS

The integrated phantom was designed in three-dimensional (3D) CAD software and 3D printed. The phantom was designed with laser alignment marks, a raised letter "S" on the anterior surface for optical surface monitoring system registration, a core for radiofrequency (RF) tracking system alignment, eight internal fiducials for image alignment, and an isocentric bearing for Winston-Lutz test. Tilt legs and rotational stage were designed for rotational verification of optical surface mapping system and RF tracking system, respectively. The phantom was scanned using a CT scanner and a QA plan was created. This prototype phantom was evaluated against established QA techniques.

RESULTS

The QA result between the proposed procedure and established QA technique are 1.12 ± 0.31 and 1.14 ± 0.31 mm, respectively, for RF tracking system and 0.18 ± 0.06 and 0.18 ± 0.05 mm for Winston-Lutz test. There is no significant difference for the QA results between the established QA and proposed procedure (P > 0.05, t test). The accuracy of rotational verification for surface mapping system and RF tracking system are less than 0.5 and 1° compared the predefined value. The isocenter deviation of each location system is around l mm.

CONCLUSION

We have designed and evaluated a novel-integrated phantom for radiographic and nonradiographic localization and positioning systems for radiotherapy. With this phantom, we will reduce the variation in measurements and simplify the QA procedures.

Evaluation of the new respiratory gating system

Objective

The newly released Respiratory Gating for Scanners (RGSC; Varian Medical Systems, Palo Alto, CA, USA) system has limited existing quality assurance (QA) protocols and pertinent publications. Herein, we report our experiences of the RGSC system acceptance and QA.

Methods

The RGSC system integration was tested with peripheral equipment, spatial reproducibility, and dynamic localization accuracy for regular and irregular breathing patterns, respectively. A QUASAR Respiratory Motion Phantom and a mathematical fitting method were used for data acquisition and analysis.

Results

The results showed that the RGSC system could accurately measure regular motion periods of 3–10 s. For irregular breathing patterns, differences from the existing Real-time Position Management (RPM; Varian Medical Systems, Palo Alto, CA) system were observed. For dynamic localization measurements, the RGSC system showed 76% agreement with the programmed test data within ±5% tolerance in terms of fitting period. As s comparison, the RPM system showed 66% agreement within ±5% tolerance, and 65% for the RGSC versus RPM measurements.

Conclusions

New functions and positioning accuracy improve the RGSC system’s ability to achieve higher dynamic treatment precision. A 4D phantom is helpful for the QA tests. Further investigation is required for the whole RGSC system performance QA.

Recent advances in radiation oncology

Radiotherapy (RT) is very much a technology-driven treatment modality in the management of cancer. RT techniques have changed significantly over the past few decades, thanks to improvements in engineering and computing. We aim to highlight the recent developments in radiation oncology, focusing on the technological and biological advances. We will present state-of-the-art treatment techniques, employing photon beams, such as intensity-modulated RT, volumetric-modulated arc therapy, stereotactic body RT and adaptive RT, which make possible a highly tailored dose distribution with maximum normal tissue sparing. We will analyse all the steps involved in the treatment: imaging, delineation of the tumour and organs at risk, treatment planning and finally image-guidance for accurate tumour localisation before and during treatment delivery. Particular attention will be given to the crucial role that imaging plays throughout the entire process. In the case of adaptive RT, the precise identification of target volumes as well as the monitoring of tumour response/modification during the course of treatment is mainly based on multimodality imaging that integrates morphological, functional and metabolic information. Moreover, real-time imaging of the tumour is essential in breathing adaptive techniques to compensate for tumour motion due to respiration. Brief reference will be made to the recent spread of particle beam therapy, in particular to the use of protons, but also to the yet limited experience of using heavy particles such as carbon ions. Finally, we will analyse the latest biological advances in tumour targeting. Indeed, the effectiveness of RT has been improved not only by technological developments but also through the integration of radiobiological knowledge to produce more efficient and personalised treatment strategies.

Development of a room laser based real-time alignment monitoring system using an array of photodiodes

PURPOSE

To develop a real-time alignment monitoring system (RAMS) to compensate for the limitations of the conventional room-laser-based alignment system. To verify the feasibility of the RAMS, reproducibility and accuracy tests were conducted.

METHODS

RAMS was composed of a room laser sensing array (RLSA), an electric circuit, an analog-to-digital converter (ADC), and a control PC. The RLSA was designed to arrange photodiodes in a pattern that results in the RAMS having a resolution of 1mm. The photodiodes were used for quantitative assessment of the alignment condition. To verify the usability of the developed system, we conducted tests of temporal reproducibility, repeatability, and accuracy.

RESULTS

The results of the temporal reproducibility test suggested that the signal of the RAMS was stable with respect to time. Further, the repeatability test resulted in a maximum coefficient of variance of 1.14%, suggesting that the signal of the RAMS was stable over repeated set-ups. The accuracy test confirmed that the "on" and "off" signals could be distinguished by signal intensity, considering that the "off" signal was below 75% of the "on" signal in every case. In addition, we confirmed that the system can detect 1mm of movement by monitoring the pattern of the "on" and "off" signals.

CONCLUSION

We developed a room laser based alignment monitoring system. The feasibility test verified that the system is capable of quantitative alignment monitoring in real time. We expect that the RAMS can propose the potential of the room laser based alignment monitoring method.

Utilization of optical tracking to assess efficacy of intracranial immobilization techniques in proton therapy

We present a quantitative methodology to measure head interfraction movements within intracranial masks of commercial immobilization devices used for proton radiotherapy. A three‐points tracking (3PtTrack) method was developed to measure the mask location for each treatment field over an average of 10 fractions for seven patients. Five patients were treated in supine with the Qfix Base‐of‐Skull (BoS) headframe, and two patients were treated in prone with the CIVCO Uni‐frame baseplate. Patients were first localized by an in‐room, image‐guidance (IG) system, and then the mask location was measured using the 3PtTrack method. Measured mask displacements from initial location at the first fraction are considered equivalent to the head interfraction movement within the mask. The trends of head movements and couch displacements and rotation were analyzed in three major directions. The accuracy of 3PtTrack method was shown to be within 1.0 mm based on daily measurements of a QA device after localization by the IG system for a period of three months. For seven patients, mean values of standard deviation (SD) in anterior–posterior, lateral, and superior–inferior directions were 1.1 mm, 1.4 mm, and 1.6 mm for head movements, and were 1.4 mm, 1.8 mm, and 3.4 mm for couch displacements. The mean SD values of couch rotations were 1.1°, 0.9°, and 1.1° for yaw, pitch, and roll, respectively. The overall patterns of head movements and couch displacements were similar for patients treated in either supine or prone, with larger deviations in the superior–inferior (SI) direction. A suboptimal mask fixation to the frame of the mask to the H&N frame is likely the cause for the observed larger head movements and couch displacements in the SI direction compared to other directions. The optical‐tracking methodology provided a quantitative assessment of the magnitude of head motion.

PACS number: 87.55.km

Quality assurance for the clinical implementation of kilovoltage intrafraction monitoring for prostate cancer VMAT

PURPOSE

Kilovoltage intrafraction monitoring (KIM) is a real-time 3D tumor monitoring system for cancer radiotherapy. KIM uses the commonly available gantry-mounted x-ray imager as input, making this method potentially more widely available than dedicated real-time 3D tumor monitoring systems. KIM is being piloted in a clinical trial for prostate cancer patients treated with VMAT (NCT01742403). The purpose of this work was to develop clinical process and quality assurance (QA) practices for the clinical implementation of KIM.

METHODS

Informed by and adapting existing guideline documents from other real-time monitoring systems, KIM-specific QA practices were developed. The following five KIM-specific QA tests were included: (1) static localization accuracy, (2) dynamic localization accuracy, (3) treatment interruption accuracy, (4) latency measurement, and (5) clinical conditions accuracy. Tests (1)-(4) were performed using KIM to measure static and representative patient-derived prostate motion trajectories using a 3D programmable motion stage supporting an anthropomorphic phantom with implanted gold markers to represent the clinical treatment scenario. The threshold for system tolerable latency is <1 s. The tolerances for all other tests are that both the mean and standard deviation of the difference between the programmed trajectory and the measured data are <1 mm. The (5) clinical conditions accuracy test compared the KIM measured positions with those measured by kV/megavoltage (MV) triangulation from five treatment fractions acquired in a previous pilot study.

RESULTS

For the (1) static localization, (2) dynamic localization, and (3) treatment interruption accuracy tests, the mean and standard deviation of the difference are <1.0 mm. (4) The measured latency is 350 ms. (5) For the tests with previously acquired patient data, the mean and standard deviation of the difference between KIM and kV/MV triangulation are <1.0 mm.

CONCLUSIONS

Clinical process and QA practices for the safe clinical implementation of KIM, a novel real-time monitoring system using commonly available equipment, have been developed and implemented for prostate cancer VMAT.

AAPM and GEC-ESTRO guidelines for image-guided robotic brachytherapy: report of Task Group 192

In the last decade, there have been significant developments into integration of robots and automation tools with brachytherapy delivery systems. These systems aim to improve the current paradigm by executing higher precision and accuracy in seed placement, improving calculation of optimal seed locations, minimizing surgical trauma, and reducing radiation exposure to medical staff. Most of the applications of this technology have been in the implantation of seeds in patients with early-stage prostate cancer. Nevertheless, the techniques apply to any clinical site where interstitial brachytherapy is appropriate. In consideration of the rapid developments in this area, the American Association of Physicists in Medicine (AAPM) commissioned Task Group 192 to review the state-of-the-art in the field of robotic interstitial brachytherapy. This is a joint Task Group with the Groupe Européen de Curiethérapie-European Society for Radiotherapy & Oncology (GEC-ESTRO). All developed and reported robotic brachytherapy systems were reviewed. Commissioning and quality assurance procedures for the safe and consistent use of these systems are also provided. Manual seed placement techniques with a rigid template have an estimated in vivo accuracy of 3-6 mm. In addition to the placement accuracy, factors such as tissue deformation, needle deviation, and edema may result in a delivered dose distribution that differs from the preimplant or intraoperative plan. However, real-time needle tracking and seed identification for dynamic updating of dosimetry may improve the quality of seed implantation. The AAPM and GEC-ESTRO recommend that robotic systems should demonstrate a spatial accuracy of seed placement ≤1.0 mm in a phantom. This recommendation is based on the current performance of existing robotic brachytherapy systems and propagation of uncertainties. During clinical commissioning, tests should be conducted to ensure that this level of accuracy is achieved. These tests should mimic the real operating procedure as closely as possible. Additional recommendations on robotic brachytherapy systems include display of the operational state; capability of manual override; documented policies for independent check and data verification; intuitive interface displaying the implantation plan and visualization of needle positions and seed locations relative to the target anatomy; needle insertion in a sequential order; robot-clinician and robot-patient interactions robustness, reliability, and safety while delivering the correct dose at the correct site for the correct patient; avoidance of excessive force on radioactive sources; delivery confirmation of the required number or position of seeds; incorporation of a collision avoidance system; system cleaning, decontamination, and sterilization procedures. These recommendations are applicable to end users and manufacturers of robotic brachytherapy systems.

Utilization of optical tracking to validate a software-driven isocentric approach to robotic couch movements for proton radiotherapy

PURPOSE

An optical tracking and positioning system (OTPS) was developed to validate the software-driven isocentric (SDI) approach to control the six-degrees-of-freedom movement of a robotic couch.

METHODS

The SDI approach to movements rotating around a predefined isocenter, referred to as a GeoIso, instead of a mechanical pivot point was developed by the robot automation industry. With robotic couch-sag corrections for weight load in a traditional SDI approach, movements could be accurately executed for a GeoIso located within a 500 mm cubic volume on the couch for treatments. The accuracy of SDI movement was investigated using the OTPS. The GeoIso was assumed to align with the proton beam isocenter (RadIso) for gantry at the reference angle. However, the misalignment between GeoIso and RadIso was quantitatively investigated by measuring the displacements at various couch angles for a target placed at the RadIso at an initial couch angle. When circular target displacements occur on a plane, a relative isocenter shift (RIS) correction could be applied in the SDI movement to minimize target displacements. Target displacements at a fixed gantry angle without and with RIS correction were measured for 12 robotic couches. Target displacements for various gantry angles were performed on three couches in gantry rooms to study the gantry-induced RadIso shift. The RIS correction can also be applied for the RadIso shift. A new SDI approach incorporating the RIS correction with the couch sag is described in this study. In parallel, the accuracy of SDI translation movements for various weight loads of patients on the couch was investigated during positioning of patients for proton prostate treatments.

RESULTS

For a fixed gantry angle, measured target displacements without RIS correction for couch rotations in the horizontal plane varied from 4 to 20 mm. However, measured displacements perpendicular to couch rotation plane were about 2 mm for all couches. Extracted misalignments of GeoIso and RadIso in the horizontal plane were about 10 mm for one couch and within 3 mm for the rest of couches. After applying the RIS correction, the residual target displacements for couch rotations were within 0.5 mm to RadIso for all couches. For various gantry angles, measured target location for each angle was within 0.5 mm to its excepted location by the preset RadIso shift. Measured target displacements for ± 30° of couch rotations were within 0.5 mm for gantry angles at 0° and 180°. Overall, nearly 85% of couch movements were within 0.5 mm in the horizontal plane and 0.7 mm vector distance from required displacements.

CONCLUSIONS

The authors present an optical tracking methodology to quantify for software-driven isocentric movements of robotic couches. By applying proper RIS correction for misaligned GeoIso and RadIso for each couch, and the RadIso shifts for a moving gantry, residual target displacements for isocentric couch movements around the actual RadIso can be reduced to submillimeter tolerance.

Image-guided intraoperative radiation therapy: current developments and future perspectives

Intraoperative electron beam radiation therapy (IOERT) procedures involve the delivery of radiation to a target area during surgery by means of a specific applicator. This treatment is currently planned by means of specific systems that incorporate tools for both surgical simulation and radiation dose distribution estimation. Although the planning step improves treatment quality and facilitates follow-up, the actual position of the patient, the applicator and other tools during the surgical procedure is unknown. Image-guided navigation technologies could be introduced in IOERT treatments, but an innovative solution that overcomes the limitations of these systems in complex surgical scenarios is needed. A recent publication describes a multi-camera optical tracking system integrated in IOERT workflow. This technology has shown appropriate accuracy in phantom experiments, and could also be of interest in other surgical interventions, where the restrictions solved by this system are also present.

Improving radiotherapy planning, delivery accuracy, and normal tissue sparing using cutting edge technologies

In the United States, more than half of all new invasive cancers diagnosed are non-small cell lung cancer, with a significant number of these cases presenting at locally advanced stages, resulting in about one-third of all cancer deaths. While the advent of stereotactic ablative radiation therapy (SABR, also known as stereotactic body radiotherapy, or SBRT) for early-staged patients has improved local tumor control to >90%, survival results for locally advanced stage lung cancer remain grim. Significant challenges exist in lung cancer radiation therapy including tumor motion, accurate dose calculation in low density media, limiting dose to nearby organs at risk, and changing anatomy over the treatment course. However, many recent technological advancements have been introduced that can meet these challenges, including four-dimensional computed tomography (4DCT) and volumetric cone-beam computed tomography (CBCT) to enable more accurate target definition and precise tumor localization during radiation, respectively. In addition, advances in dose calculation algorithms have allowed for more accurate dosimetry in heterogeneous media, and intensity modulated and arc delivery techniques can help spare organs at risk. New delivery approaches, such as tumor tracking and gating, offer additional potential for further reducing target margins. Image-guided adaptive radiation therapy (IGART) introduces the potential for individualized plan adaptation based on imaging feedback, including bulky residual disease, tumor progression, and physiological changes that occur during the treatment course. This review provides an overview of the current state of the art technology for lung cancer volume definition, treatment planning, localization, and treatment plan adaptation.

Joint surface reconstruction and 4D deformation estimation from sparse data and prior knowledge for marker-less Respiratory motion tracking

PURPOSE

The intraprocedural tracking of respiratory motion has the potential to substantially improve image-guided diagnosis and interventions. The authors have developed a sparse-to-dense registration approach that is capable of recovering the patient's external 3D body surface and estimating a 4D (3D + time) surface motion field from sparse sampling data and patient-specific prior shape knowledge.

METHODS

The system utilizes an emerging marker-less and laser-based active triangulation (AT) sensor that delivers sparse but highly accurate 3D measurements in real-time. These sparse position measurements are registered with a dense reference surface extracted from planning data. Thereby a dense displacement field is recovered, which describes the spatio-temporal 4D deformation of the complete patient body surface, depending on the type and state of respiration. It yields both a reconstruction of the instantaneous patient shape and a high-dimensional respiratory surrogate for respiratory motion tracking. The method is validated on a 4D CT respiration phantom and evaluated on both real data from an AT prototype and synthetic data sampled from dense surface scans acquired with a structured-light scanner.

RESULTS

In the experiments, the authors estimated surface motion fields with the proposed algorithm on 256 datasets from 16 subjects and in different respiration states, achieving a mean surface reconstruction accuracy of ± 0.23 mm with respect to ground truth data-down from a mean initial surface mismatch of 5.66 mm. The 95th percentile of the local residual mesh-to-mesh distance after registration did not exceed 1.17 mm for any subject. On average, the total runtime of our proof of concept CPU implementation is 2.3 s per frame, outperforming related work substantially.

CONCLUSIONS

In external beam radiation therapy, the approach holds potential for patient monitoring during treatment using the reconstructed surface, and for motion-compensated dose delivery using the estimated 4D surface motion field in combination with external-internal correlation models.

Evaluation of imaging performance of megavoltage cone-beam CT over an extended period

A linear accelerator vendor and the AAPM TG-142 report propose that quality assurance testing for image-guided devices such megavoltage cone-beam CT (MV-CBCT) be conducted on a monthly basis. In clinical settings, however, unpredictable errors such as image artifacts can occur even when quality assurance results performed at this frequency are within tolerance limits. Here, we evaluated the imaging performance of MV-CBCT on a weekly basis for ∼ 1 year using a Siemens ONCOR machine with a 6-MV X-ray and an image-quality phantom. Image acquisition was undertaken using 15 monitor units. Geometric distortion was evaluated with beads evenly distributed in the phantom, and the results were compared with the expected position in three dimensions. Image-quality characteristics of the system were measured and assessed qualitatively and quantitatively, including image noise and uniformity, low-contrast resolution, high-contrast resolution and spatial resolution. All evaluations were performed 100 times each. For geometric distortion, deviation between the measured and expected values was within the tolerance limit of 2 mm. However, a subtle systematic error was found which meant that the phantom was rotated slightly in a clockwise manner, possibly due to geometry calibration of the MV-CBCT system. Regarding image noise and uniformity, two incidents over tolerance occurred in 100 measurements. This phenomenon disappeared after dose calibration of beam output for MV-CBCT. In contrast, all results for low-contrast resolution, high-contrast resolution and spatial resolution were within their respective tolerances.

Feasibility of integrating a multi-camera optical tracking system in intra-operative electron radiation therapy scenarios

Intra-operative electron radiation therapy (IOERT) combines surgery and ionizing radiation applied directly to an exposed unresected tumour mass or to a post-resection tumour bed. The radiation is collimated and conducted by a specific applicator docked to the linear accelerator. The dose distribution in tissues to be irradiated and in organs at risk can be planned through a pre-operative computed tomography (CT) study. However, surgical retraction of structures and resection of a tumour affecting normal tissues significantly modify the patient's geometry. Therefore, the treatment parameters (applicator dimension, pose (position and orientation), bevel angle, and beam energy) may require the original IOERT treatment plan to be modified depending on the actual surgical scenario. We propose the use of a multi-camera optical tracking system to reliably record the actual pose of the IOERT applicator in relation to the patient's anatomy in an environment prone to occlusion problems. This information can be integrated in the radio-surgical treatment planning system in order to generate a real-time accurate description of the IOERT scenario. We assessed the accuracy of the applicator pose by performing a phantom-based study that resembled three real clinical IOERT scenarios. The error obtained (2 mm) was below the acceptance threshold for external radiotherapy practice, thus encouraging future implementation of this approach in real clinical IOERT scenarios.

Prevention of gross setup errors in radiotherapy with an efficient automatic patient safety system

Treatment of the wrong body part due to incorrect setup is among the leading types of errors in radiotherapy. The purpose of this paper is to report an efficient automatic patient safety system (PSS) to prevent gross setup errors. The system consists of a pair of charge‐coupled device (CCD) cameras mounted in treatment room, a single infrared reflective marker (IRRM) affixed on patient or immobilization device, and a set of in‐house developed software. Patients are CT scanned with a CT BB placed over their surface close to intended treatment site. Coordinates of the CT BB relative to treatment isocenter are used as reference for tracking. The CT BB is replaced with an IRRM before treatment starts. PSS evaluates setup accuracy by comparing real‐time IRRM position with reference position. To automate system workflow, PSS synchronizes with the record‐and‐verify (R&V) system in real time and automatically loads in reference data for patient under treatment. Special IRRMs, which can permanently stick to patient face mask or body mold throughout the course of treatment, were designed to minimize therapist's workload. Accuracy of the system was examined on an anthropomorphic phantom with a designed end‐to‐end test. Its performance was also evaluated on head and neck as well as abdominalpelvic patients using cone‐beam CT (CBCT) as standard. The PSS system achieved a seamless clinic workflow by synchronizing with the R&V system. By permanently mounting specially designed IRRMs on patient immobilization devices, therapist intervention is eliminated or minimized. Overall results showed that the PSS system has sufficient accuracy to catch gross setup errors greater than 1 cm in real time. An efficient automatic PSS with sufficient accuracy has been developed to prevent gross setup errors in radiotherapy. The system can be applied to all treatment sites for independent positioning verification. It can be an ideal complement to complex image‐guidance systems due to its advantages of continuous tracking ability, no radiation dose, and fully automated clinic workflow.

PACS number: 87.55.Qr

A measurement technique to determine the calibration accuracy of an electromagnetic tracking system to radiation isocenter

PURPOSE

To present and characterize a measurement technique to quantify the calibration accuracy of an electromagnetic tracking system to radiation isocenter.

METHODS

This technique was developed as a quality assurance method for electromagnetic tracking systems used in a multi-institutional clinical hypofractionated prostate study. In this technique, the electromagnetic tracking system is calibrated to isocenter with the manufacturers recommended technique, using laser-based alignment. A test patient is created with a transponder at isocenter whose position is measured electromagnetically. Four portal images of the transponder are taken with collimator rotations of 45° 135°, 225°, and 315°, at each of four gantry angles (0°, 90°, 180°, 270°) using a 3×6 cm2 radiation field. In each image, the center of the copper-wrapped iron core of the transponder is determined. All measurements are made relative to this transponder position to remove gantry and imager sag effects. For each of the 16 images, the 50% collimation edges are identified and used to find a ray representing the rotational axis of each collimation edge. The 16 collimator rotation rays from four gantry angles pass through and bound the radiation isocenter volume. The center of the bounded region, relative to the transponder, is calculated and then transformed to tracking system coordinates using the transponder position, allowing the tracking system's calibration offset from radiation isocenter to be found. All image analysis and calculations are automated with inhouse software for user-independent accuracy. Three different tracking systems at two different sites were evaluated for this study.

RESULTS

The magnitude of the calibration offset was always less than the manufacturer's stated accuracy of 0.2 cm using their standard clinical calibration procedure, and ranged from 0.014 to 0.175 cm. On three systems in clinical use, the magnitude of the offset was found to be 0.053±0.036, 0.121±0.023, and 0.093±0.013 cm.

CONCLUSIONS

The method presented here provides an independent technique to verify the calibration of an electromagnetic tracking system to radiation isocenter. The calibration accuracy of the system was better than the 0.2 cm accuracy stated by the manufacturer. However, it should not be assumed to be zero, especially for stereotactic radiation therapy treatments where planning target volume margins are very small.