Assessment of residual error for online cone-beam CT-guided treatment of prostate cancer patients

Increasing the efficiency of cone-beam CT based delta-radiomics using automated contours to predict radiotherapy-related toxicities in prostate cancer

Extracting longitudinal image quantitative data, known as delta-radiomics, has the potential to capture changes in a patient's anatomy throughout the course of radiation treatment for prostate cancer. Some of the major challenges of delta-radiomics studies are contouring the structures for individual fractions and accruing patients' data in an efficient manner. The manual contouring process is often time consuming and would limit the efficiency of accruing larger sample sizes for future studies. The problem is amplified because the contours are often made by highly trained radiation oncologists with limited time to dedicate to research studies of this nature. This work compares the use of automated prostate contours generated using a deformable image-based algorithm to make predictive models of genitourinary and changes in total international prostate symptom score in comparison to manually contours for a cohort of fifty patients. Area under the curve of manual and automated models were compared using the Delong test. This study demonstrated that the delta-radiomics models were similar for both automated and manual delta-radiomics models.

Stereotactic Magnetic Resonance-Guided Adaptive and Non-Adaptive Radiotherapy on Combination MR-Linear Accelerators: Current Practice and Future Directions

Stereotactic body radiotherapy (SBRT) is an effective radiation therapy technique that has allowed for shorter treatment courses, as compared to conventionally dosed radiation therapy. As its name implies, SBRT relies on daily image guidance to ensure that each fraction targets a tumor, instead of healthy tissue. Magnetic resonance imaging (MRI) offers improved soft-tissue visualization, allowing for better tumor and normal tissue delineation. MR-guided RT (MRgRT) has traditionally been defined by the use of offline MRI to aid in defining the RT volumes during the initial planning stages in order to ensure accurate tumor targeting while sparing critical normal tissues. However, the ViewRay MRIdian and Elekta Unity have improved upon and revolutionized the MRgRT by creating a combined MRI and linear accelerator (MRL), allowing MRgRT to incorporate online MRI in RT. MRL-based MR-guided SBRT (MRgSBRT) represents a novel solution to deliver higher doses to larger volumes of gross disease, regardless of the proximity of at-risk organs due to the (1) superior soft-tissue visualization for patient positioning, (2) real-time continuous intrafraction assessment of internal structures, and (3) daily online adaptive replanning. Stereotactic MR-guided adaptive radiation therapy (SMART) has enabled the safe delivery of ablative doses to tumors adjacent to radiosensitive tissues throughout the body. Although it is still a relatively new RT technique, SMART has demonstrated significant opportunities to improve disease control and reduce toxicity. In this review, we included the current clinical applications and the active prospective trials related to SMART. We highlighted the most impactful clinical studies at various tumor sites. In addition, we explored how MRL-based multiparametric MRI could potentially synergize with SMART to significantly change the current treatment paradigm and to improve personalized cancer care.

UroLift implants as surrogate fiducial markers for cone-beam CT-based prostate image-guided radiotherapy

Introduction:

UroLift implants are a novel treatment for the obstructive lower urinary tract symptoms arising from benign prostatic hyperplasia. This case study aimed to assess their effectiveness as fiducial marker (FM) surrogates in prostate image-guided radiotherapy (IGRT).

Method:

Cone-beam CT images from a patient receiving prostate radiation therapy underwent manual alignment using UroLift implants and also prostate soft-tissue matching by five experienced therapeutic radiographers. The match values of both methods were compared using Bland–Altman analysis. All five observers were also asked to score the ease of matching using both approaches.

Results:

The 95% mean level of agreement for the UroLift matches were within a 2-mm threshold in all dimensions. Comparison of UroLift and prostate matches had 95% limit of agreement values of −0·98 to 1·78, −0·58 to 0·49 and −1·83 to 1·04 mm in the vertical, longitudinal and lateral planes, respectively. All of the UroLift matches were rated as ‘very easy’ or ‘possible with little difficulty’ by the five observers.

Conclusion:

A small difference between the CBCT UroLift and CBCT prostate match was found. It has been shown that IGRT to the prostate with the aid of the UroLift system implants and CBCT is feasible and can eliminate the need for FM implants. Wider evaluation in a large cohort is recommended.

Normal tissue risk estimation using biological knowledge-based fuzzy logic in volumetric modulated Arc therapy of prostate cancer: Rectum

Objective:

Most radiotherapy patients with prostate cancer are treated with volumetric modulated arc therapy (VMAT). Advantages of VMAT may be limited by daily treatment uncertainties such as setup errors, internal organ motion, and deformation. The position and shape of prostate target as well as normal organ, i.e., rectum volume around the target, may change during the course of treatment. The aim of the present work is to estimate rectal toxicity estimation using a novel two-level biological knowledge-based fuzzy logic method. Both prostate and rectal internal motions as well as setup uncertainties are considered without compromising target dose distribution in the present study.

Materials and Methods:

The Mamdani-type fuzzy logic framework was considered in two levels. The prostate target volume changes from minimum to maximum during the course of treatment. In the first level, the fuzzy logic was applied for determining biological acceptable target margin using tumor control probability and normal tissue complication probability (NTCP) parameters based on prostate target motion limits, and then, fuzzy margin was derived. The output margin of first-level fuzzy logic was compared to currently used margins. In second-level fuzzy, rectal volume variation with weekly analysis of cone-beam computed tomography (CBCT) was considered. The biological parameter (NTCP) was calculated corresponding to rectal subvolume variation with weekly CBCT image analysis. Using irradiated volume versus organ risk relationship from treatment planning, the overlapped risk volumes were estimated. Fuzzy rules and membership function were used based on setup errors, asymmetrical nature of organ motion, and limitations of normal tissue toxicity in Mamdani-type Fuzzy Inference System.

Results:

For total displacement, standard errors of prostate ranging from 0 to 5 mm range were considered in the present study. In the first level, fuzzy planning target volume (PTV) margin was found to be similar or up to 0.5 mm bigger than the conventional margin, but taking the modeling uncertainty into account resulted in a good match between the calculated fuzzy PTV margin and conventional margin formulations under error 0–5 mm standard deviation (SD) range. With application of fuzzy margin obtained from first-level fuzzy, overlapped rectal volumes and corresponding NTCP values were fuzzified in second-level fuzzy using rectal volume variations. The final risk factor (RF) of rectum was qualitatively assessed and found clinically acceptable for each fractional volume of irradiated to total volume and relevant NTCP values. The reason may be at 5 mm SD displacement error range, NTCP values would be within acceptable limit without compromising the tumor dose distribution though the confounding factors such as organ motion, deformation of rectum, and in-house image matching protocols exist.

Conclusion:

A new approach of two-level fuzzy logic may be suitable to estimate possible organ-at-risk (OAR) toxicity biologically without compromising tumor volume that includes both prostate target and OAR rectum deformation even at displacement standard errors of prostate ranging from 0 to 5 mm range which was considered in the present study. Using proposed simple and fast method, there is an interplay between volume-risk relationship and NTCP of OARs to judge real-time normal organ risk level or alter the treatment margins, particularly concern to individual factors such as comorbidities, genetic predisposition, and other lifestyle choices even at high displacement errors >5 mm SD range.

Assessment of daily dose accumulation for robustly optimized intensity modulated proton therapy treatment of prostate cancer

PURPOSE

To implement a daily CBCT based dose accumulation technique in order to assess ideal robust optimization (RO) parameters for IMPT treatment of prostate cancer.

METHODS

Ten prostate cancer patients previously treated with VMAT and having daily CBCT were included. First, RO-IMPT plans were created with ± 3 mm and ± 5 mm patient setup and ± 3% proton range uncertainties, respectively. Second, the planning CT (pCT) was deformably registered to the CBCT to create a synthetic CT (sCT). Both daily and weekly sampling strategies were employed to determine optimal dose accumulation frequency. Doses were recalculated on sCTs for both ± 3 mm/±3% and ± 5 mm/±3% uncertainties and were accumulated back to the pCT. Accumulated doses generated from ± 3 mm/±3% and ± 5 mm/±3% RO-IMPT plans were evaluated using the clinical dose volume constraints for CTV, bladder, and rectum.

RESULTS

Daily accumulated dose based on both ± 3mm/±3% and ±5 mm/±3% uncertainties for RO-IMPT plans resulted in satisfactory CTV coverage (RO-IMPT_3mm/3% CTV_V95 = 99.01 ± 0.87% vs. RO-IMPT_5mm/3% CTV_V95 = 99.81 ± 0.2%, P = 0.002). However, the accumulated dose based on ± 3 mm/3% RO-IMPT plans consistently provided greater OAR sparing than ±5 mm/±3% RO-IMPT plans (RO-IMPT_3mm/3% rectum_V65Gy = 2.93 ± 2.39% vs. RO-IMPT_5mm/3% rectum_V65Gy = 4.38 ± 3%, P < 0.01; RO-IMPT_3mm/3% bladder_V65Gy = 5.2 ± 7.12% vs. RO-IMPT_5mm/3% bladder_V65Gy = 7.12 ± 9.59%, P < 0.01). The gamma analysis showed high dosimetric agreement between weekly and daily accumulated dose distributions.

CONCLUSIONS

This study demonstrated that for RO-IMPT optimization, ±3mm/±3% uncertainty is sufficient to create plans that meet desired CTV coverage while achieving superior sparing to OARs when compared with ± 5 mm/±3% uncertainty. Furthermore, weekly dose accumulation can accurately estimate the overall dose delivered to prostate cancer patients.

Detectability of fiducials' positions for real-time target tracking system equipping with a standard linac for multiple fiducial markers

PURPOSE

To investigate the detectability of fiducial markers' positions for real-time target tracking system equipping with a standard linac. The hypothesis is that the detectability depends on the type of fiducial marker and the gantry angle of acquired triggered images.

METHODS

Three types of ball fiducials and four slim fiducials with lengths of 3 and 5 mm were prepared for this study. Triggered images with three similar fiducials were acquired at every 10° during the conformal arc irradiation to detect the target position. Although only one type of arrangement was prepared for the ball fiducials, a three-type arrangement was prepared for the slim fiducials, such as parallel, orthogonal, and oblique with 45° to the gantry-couch direction. To measure the detectability of the real-time target tracking system for each fiducial and arrangement, detected marker positions were compared with expected marker positions at every angle of acquired triggered images.

RESULTS

For the ball-type fiducial, the maximum difference between the detected marker positions and expected marker positions was 0.3 mm in all directions. For the slim fiducial arranged parallel and oblique with 45°, the maximum difference was 0.4 mm in all directions. When each slim fiducial was arranged orthogonal to the gantry-couch direction, the maximum difference was 1.5 mm for the length of 3 mm, and 3.2 mm for the length of 5 mm.

CONCLUSIONS

The detectability of fiducial markers' positions for the real-time target tracking system equipping with a standard linac depends on the form and insertion angles of the fiducials.

Visual enhancement of Cone-beam CT by use of CycleGAN

PURPOSE

Cone-beam computed tomography (CBCT) offers advantages over conventional fan-beam CT in that it requires a shorter time and less exposure to obtain images. However, CBCT images suffer from low soft-tissue contrast, noise, and artifacts compared to conventional fan-beam CT images. Therefore, it is essential to improve the image quality of CBCT.

METHODS

In this paper, we propose a synthetic approach to translate CBCT images with deep neural networks. Our method requires only unpaired and unaligned CBCT images and planning fan-beam CT (PlanCT) images for training. The CBCT images and PlanCT images may be obtained from other patients as long as they are acquired with the same scanner settings. Once trained, three-dimensionally reconstructed CBCT images can be directly translated into high-quality PlanCT-like images.

RESULTS

We demonstrate the effectiveness of our method with images obtained from 20 prostate patients, and provide a statistical and visual comparison. The image quality of the translated images shows substantial improvement in voxel values, spatial uniformity, and artifact suppression compared to those of the original CBCT. The anatomical structures of the original CBCT images were also well preserved in the translated images.

CONCLUSIONS

Our method produces visually PlanCT-like images from CBCT images while preserving anatomical structures.

Soft-tissue prostate intrafraction motion tracking in 3D cine-MR for MR-guided radiotherapy

To develop a method to automatically determine intrafraction motion of the prostate based on soft tissue contrast on 3D cine-magnetic resonance (MR) images with high spatial and temporal resolution. Twenty-nine patients who underwent prostate stereotactic body radiotherapy (SBRT), with four implanted cylindrical gold fiducial markers (FMs), had cine-MR imaging sessions after each of five weekly fractions. Each cine-MR session consisted of 55 sequentially obtained 3D data sets ('dynamics') and was acquired over an 11 s period, covering a total of 10 min. The prostate was delineated on the first dynamic of every dataset and this delineation was used as the starting position for the soft tissue tracking (SST). Each subsequent dynamic was rigidly aligned to the first dynamic, based on the contrast of the prostate. The obtained translation and rotation describes the intrafraction motion of the prostate. The algorithm was applied to 6270 dynamics over 114 scans of 29 patients and the results were validated by comparing to previously obtained fiducial marker tracking data of the same dataset. Our proposed tracking method was also retro-perspectively applied to cine-MR images acquired during MR-guided radiotherapy of our first prostate patient treated on the MR-Linac. The difference in the 3D translation results between the soft tissue and marker tracking was below 1 mm for 98.2% of the time. The mean translation at 10 min were X: 0.0 [Formula: see text] 0.8 mm, Y: 1.0 [Formula: see text] 1.8 mm and Z: [Formula: see text] mm. The mean rotation results at 10 min were X: [Formula: see text], Y: 0.1 [Formula: see text] 0.6° and Z: 0.0 [Formula: see text] 0.7°. A fast, robust and accurate SST algorithm was developed which obviates the need for FMs during MR-guided prostate radiotherapy. To our knowledge, this is the first data using full 3D cine-MR images for real-time soft tissue prostate tracking, which is validated against previously obtained marker tracking data.

The impact of the three degrees-of-freedom fiducial marker-based setup compared to soft tissue-based setup in hypofractionated intensity-modulated radiotherapy for prostate cancer

Purpose

We evaluated the setup accuracy of a three‐degree‐of‐freedom fiducial marker (3DOF‐FM)‐based setup compared to a soft tissue (ST)‐based setup in hypofractionated intensity‐modulated radiotherapy (IMRT) for prostate cancer.

Materials and Methods

We analyzed the setup accuracy for 17 consecutive prostate cancer patients with three implanted FMs who underwent hypofractionated IMRT. The 3DOF‐ST‐based setup using cone‐beam computed tomography (CT) was performed after a six DOF‐bony structure (BS)‐based setup using an ExacTrac x‐ray system. The 3DOF‐FM‐based matching using the ExacTrac x‐ray system was done during the BS‐ and ST‐based setups. We determined the mean absolute differences and the correlation between the FM‐ and ST‐based translational shifts relative to the BS‐based setup position. The rotational mean shifts detected by the ExacTrac x‐ray system were also evaluated.

Results

The mean differences in the anterior‐posterior (AP), superior‐inferior (SI), and left‐right (LR) dimensions were 0.69, 0.0, and 0.30 mm, respectively. The Pearson correlation coefficients for both shifts were 0.92 for AP, 0.91 for SI, and 0.68 for LR. The percentages of shift agreements within 2 mm were 85% for AP, 93% for SI, and 99% for LR. The absolute values of rotational shifts were 0.1° for AP, 0.3°, and 1.2° for LR.

Conclusions

The setup accuracy of the 3DOF‐FM‐based setup has the potential to be interchangeable with a ST‐based setup. Our data are likely to be useful in clinical practice along with the popularization of the hypofractionated IMRT in prostate cancer.

Complementary Relation Between the Improvement of Dose Delivery Technique and PTV Margin Reduction in Dose-Escalated Radiation Therapy for Prostate Cancer

PURPOSE

The purpose of this study is to demonstrate quantitatively the complementary relationship between the introduction of intensity modulated radiation therapy (IMRT) and planning target volume (PTV) margin reduction with an image guided technique in reducing the risk of rectal toxicity in dose-escalating prostate radiation therapy.

METHODS AND MATERIALS

Three-dimensional conformal radiation therapy (CRT) and IMRT plans were generated for 10 patients with prostate cancer based on 2 PTV margin protocols (10/8 mm and 6/5 mm) and 2 dose prescriptions (70 Gy and 78 Gy). The normal tissue complication probability (NTCP) for each of the 8 scenarios was calculated using the Lyman-Kutcher-Burman model to estimate the risk of rectal and bladder late toxicity. The conformity and homogeneity indices of PTVs were calculated for each plan.

RESULTS

The IMRT plans showed superiority in conformity and inferiority in homogeneity over 3-dimensional CRT plans. The rectal NTCPs were increased 3.5 to 4.1 times when the prescribed total dose was changed from 70 Gy to 78 Gy and the dose delivery and the image guided radiation therapy techniques remained unchanged. PTV margin reduction was shown to reduce the value of rectal NTCP significantly. Overall, implementing the IMRT technique alone could reduce the NTCP values only by 2.1% to 7.3% from those of 3-dimensional CRT. The introduction of both IMRT and PTV margin reduction was found to be necessary for rectal NTCP to remain <5% in the dose escalation from 70 to 78 Gy.

CONCLUSIONS

The complementary relationship between the introduction of IMRT and PTV margin reduction was proven. We found that both approaches need to be implemented to safely deliver a curative dose in dose-escalating prostate radiation therapy.

Assessing the impact of choosing different deformable registration algorithms on cone-beam CT enhancement by histogram matching

Background

The aim of this work is to assess the impact of using different deformable registration (DR) algorithms on the quality of cone-beam CT (CBCT) correction with histogram matching (HM).

Methods and materials

Data sets containing planning CT (pCT) and CBCT images for ten patients with prostate cancer were used. Each pCT image was registered to its corresponding CBCT image using one rigid registration algorithm with mutual information similarity metric (RR-MI) and three DR algorithms with normalized correlation coefficient, mutual information and normalized mutual information (DR-NCC, DR-MI and DR-NMI, respectively). Then, the HM was performed between deformed pCT and CBCT in order to correct the distribution of the Hounsfield Units (HU) in CBCT images.

Results

The visual assessment showed that the absolute difference between corrected CBCT and deformed pCT was reduced after correction with HM except for soft tissue-air and soft-tissue-bone interfaces due to the improper registration. Furthermore, volumes comparison in terms of average HU error showed that using DR-NCC algorithm with HM yielded the lowest error values of about 55.95 ± 10.43 HU compared to DR-MI and DR-NMI for which the errors were 58.60 ± 10.35 and 56.58 ± 10.51 HU, respectively. Tissue class’s comparison by the mean absolute error (MAE) plots confirmed the performance of DR-NCC algorithm to produce corrected CBCT images with lowest values of MAE even in regions where the misalignment is more pronounced. It was also found that the used method had successfully improved the spatial uniformity in the CBCT images by reducing the root mean squared difference (RMSD) between the pCT and CBCT in fat and muscle from 57 and 25 HU to 8HU, respectively.

Conclusion

The choice of an accurate DR algorithm before performing the HM leads to an accurate correction of CBCT images. The results suggest that applying DR process based on NCC similarity metric reduces significantly the uncertainties in CBCT images and generates images in good agreement with pCT.

Adaptive Radiotherapy Enabled by MRI Guidance

Adaptive radiotherapy (ART) strategies systematically monitor variations in target and neighbouring structures to inform treatment-plan modification during radiotherapy. This is necessary because a single plan designed before treatment is insufficient to capture the actual dose delivered to the target and adjacent critical structures during the course of radiotherapy. Magnetic resonance imaging (MRI) provides superior soft-tissue image contrast over current standard X-ray-based technologies without additional radiation exposure. With integrated MRI and radiotherapy platforms permitting motion monitoring during treatment delivery, it is possible that adaption can be informed by real-time anatomical imaging. This allows greater treatment accuracy in terms of dose delivered to target with smaller, individualised treatment margins. The use of functional MRI sequences would permit ART to be informed by imaging biomarkers, so allowing both personalised geometric and biological adaption. In this review, we discuss ART solutions enabled by MRI guidance and its potential gains for our patients across tumour types.

Analysis of Motion-dependent Clinical Outcome of Tumor Tracking Stereotactic Body Radiotherapy for Prostate Cancer

BACKGROUND

To analyze clinical outcome of CyberKnife (CK) tumor-tracking stereotactic body radiotherapy (SBRT) for prostate cancer (Pca) according to the magnitude of intra-fractional prostate motion.

METHODS

Medical records and daily treatment logs for 71 patients who received CK tumor-tracking SBRT were retrospectively analyzed. Statistical relationships between prostate motion and various outcome results, including local recurrence (LR), biochemical failure (BF), and treatment-related toxicity, were investigated in order to evaluate motion-dependent efficacy of tumor-tracking SBRT for Pca.

RESULTS

In a total 71 patients, 3 (4.2%) patients with LR, 12 (16.9%) patients with BF, and 22 (31%) patients with grade-II or worse toxicities to rectal or bladder (22 to rectal, 22 to bladder and 8 patients to both) were observed in a median follow-up of 47 months. Magnitudes of intra-fractional tumor motion along superior-inferior, right-left, and anterior-posterior (AP) axes were 0.15 ± 0.31, 0.12 ± 0.19, and 0.73 ± 0.32 mm, respectively. Radial magnitude was estimated to be 1.0 ± 0.35 mm. Intra-fractional movement was not significantly correlated with tumor control. However, it was significant correlated with the incidence of grade-II or worse toxicity to rectum or bladder particularly when tumor motion was in the AP axis.

CONCLUSION

Our quantitative results revealed that toxicity related to SBRT treatment was highly sensitive to intra-fractional prostate movements, although local-tumor control was not affected by such movements. Our results demonstrate that precise motion correction is essential in prostate SBRT, even if it seems to be small.

Magnetic Resonance Imaging-Guided Adaptive Radiation Therapy: A "Game Changer" for Prostate Treatment?

Radiation therapy to the prostate involves increasingly sophisticated delivery techniques and changing fractionation schedules. With a low estimated α/β ratio, a larger dose per fraction would be beneficial, with moderate fractionation schedules rapidly becoming a standard of care. The integration of a magnetic resonance imaging (MRI) scanner and linear accelerator allows for accurate soft tissue tracking with the capacity to replan for the anatomy of the day. Extreme hypofractionation schedules become a possibility using the potentially automated steps of autosegmentation, MRI-only workflow, and real-time adaptive planning. The present report reviews the steps involved in hypofractionated adaptive MRI-guided prostate radiation therapy and addresses the challenges for implementation.

Implementation and application of a Monte Carlo model for an in vivo micro computed tomography system

Micro computed tomography (µCT) scanners are used to create high-resolution images and to quantify properties of the scanned objects. While modern µCT scanners benefit from the cone beam geometry, they are compromised by scatter radiation. This work aims to develop a Monte Carlo (MC) model of a µCT scanner in order to characterize the scatter radiation in the detector plane. The EGS++ framework with the MC code EGSnrc was used to simulate the particle transport through the main components of the XtremeCT (SCANCO Medical AG, Switzerland). The developed MC model was based on specific information of the manufacturer and was validated against measurements. The primary and the scatter radiation were analyzed and by implementing a dedicated tracing method, the scatter radiation was subdivided into different scatter components. The comparisons of measured and simulated transmission values for different absorber and filter combinations result in a mean difference of 0.2% ± 1.4%, with a maximal local difference of 3.4%. The reconstructed image of the phantom based on measurements agrees well with the image reconstructed using the MC model. The local contribution of scattered radiation is up to 10% of the total radiation in the detector plane and most of the scattered particles result from interactions in the scanned object. The MC simulations show that scatter radiation contains information about the structure of the object. In conclusion, a MC model for a µCT scanner was successfully validated and applied to analyze the characteristics of the scatter radiation for a µCT scanner.

Cumulative dose of radiation therapy of hepatocellular carcinoma patients and its deterministic relation to radiation-induced liver disease

This study aimed to investigate the relationship between dose and radiation-induced liver disease (RILD) in patients with hepatocellular carcinoma (HCC) receiving 3-dimensional conformal radiotherapy (3DCRT). Twenty-three patients with HCC who received conventional fractionated 3DCRT, including 7 who were diagnosed with classic RILD, were enrolled in this retrospective investigation. Cone-beam computed tomography (CBCT) scans were acquired at the time of treatment for each patient. The beams from each patient's treatment plan were applied to each pretreatment CBCT (the modified CBCT or mCBCT) to construct the delivered dose distribution of the day considering inter-treatment anatomy changes. The daily doses were summed together with the help of deformable image registration (DIR) to obtain the adjusted cumulative dose (D_adjusted). The dose changes to the normal liver between the original planned dose (D_plan) and D_adjusted were evaluated by V20, V30, V40, and the mean dose to normal liver (MDTNL). Univariate analysis was performed to identify the significant dose changes. Among the 23 patients, the liver V20, V30, V40, and MDTNL showed significant differences between D_plan and D_adjusted, with average values of these parameters increased by 4.1%, 4.7%, 4.5%, and 3.9 Gy, respectively (p < 0.05). The adjusted liver dose in 21 patients (91%) was higher than the planned value. For patients without and with RILD,the MDTNL was increased on average by 3.5 Gy and 4.7 Gy, and normal tissue complication probability (NTCP) increased on average by 2.8% and 7.5%, respectively. Our study found that the adjusted cumulative dose based on calculations using pretreatment mCBCT differs significantly from planned dose; the use of the dosimetric results of the initial plan was found to be less predictive of RILD as compared with D_adjusted. Determination of a reconstructed D_adjusted using the mCBCT scans are more accurate in predicting RILD and has the potential to reduce the risk of RILD.

Effect of imaging frequency on PTV margins and geographical miss during image guided radiation therapy for prostate cancer

BACKGROUND

The relationship between frequency of imaging during image guided radiation therapy (IGRT) and planning target volume (PTV) margin remains unclear. This issue is of practical significance given resource and time intensive nature of IGRT. The purpose of this study was to evaluate PTV margins with predefined and commonly used less-than-daily IGRT schedules using data obtained from patients treated with daily IGRT for prostate cancer.

METHODS AND MATERIALS

Daily setup error and 3-dimensional daily alignment data for a total of 108 consecutive patients with prostate cancer treated with 2700 fractions of daily image guidance on tomotherapy were retrospectively analyzed. Five IGRT scenarios were simulated: alternate day, twice weekly, once weekly, first 3 days only, and no image guidance. The daily alignment data were modeled to simulate the 5 predefined scenarios by applying appropriate corrections to determine the PTV margin for each image guidance scenario. The data were also analyzed to predict possible geographical miss in any direction using 2 frequently used PTV margins of 7 and 5 mm for all the scenarios.

RESULTS

Decreasing the frequency of image guidance increased the mean systematic error and the standard deviation of the systematic error. With decreased image guidance frequency, an increase in PTV margins was required to achieve adequate coverage of the clinical target volume. With reduction in image guidance from 50% to 12%, a gradual increase in percentage of fractions with predicted geographical miss using an isotropic PTV margin of 7 or 5 mm was seen. With every 15% decrease in imaging, a 5% increased risk of geographical miss was estimated.

CONCLUSIONS

The use of less-than-daily IGRT requires larger PTV margins for patients treated with intensity modulated radiation therapy for prostate cancer. With every 15% reduction, a 5% increased risk of geographical miss was estimated.

The Role of External-Beam Radiation Therapy in the Treatment of Clinically Localized Prostate Cancer

Background

The treatment of clinically localized prostate cancer is controversial. Options include radical prostatectomy, external-beam radiation therapy (EBRT), brachytherapy, cryotherapy, and watchful waiting.

Methods

The author reviews EBRT as treatment for clinically localized prostate cancer, with particular emphasis on the technological advances that have allowed dose escalation and fewer therapy-related side effects.

Results

Technological advances in the last two decades have significantly improved the delivery of EBRT to the prostate. This has resulted in an overall increase in the total dose that can be safely delivered to the prostate, which has led to modest improvements in biochemical outcome. An alternative approach of combining androgen suppression therapy and EBRT has also been successful in improving clinical outcomes. However, establishing the optimal therapy for prostate cancer remains controversial.

Conclusions

Recent progress has led to improvements in clinical outcomes in patients treated with EBRT for prostate cancer. It is hoped that the next decades will bring continued advances in the development of biologicals that will further improve current clinical outcomes.

ACR Appropriateness Criteria for external beam radiation therapy treatment planning for clinically localized prostate cancer, part II of II

PURPOSE

To present the most updated American College of Radiology (ACR) Appropriateness Criteria formed by an expert panel on the appropriate delivery of external beam radiation to manage stage T1 and T2 prostate cancer (in the definitive setting and post-prostatectomy) and to provide clinical variants with expert recommendations based on accompanying Appropriateness Criteria for target volumes and treatment planning.

METHODS AND MATERIALS

The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a panel of multidisciplinary experts. The guideline development and revision process includes an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In instances in which evidence is lacking or equivocal, expert opinion may supplement available evidence to recommend imaging or treatment.

RESULTS

The panel summarizes the most recent and relevant literature on the topic, including organ motion and localization methods, image guidance, and delivery techniques (eg, 3-dimensional conformal intensity modulation). The panel presents 7 clinical variants, including (1) a standard case and cases with (2) a distended rectum, (3) a large-volume prostate, (4) bilateral hip implants, (5) inflammatory bowel disease, (6) prior prostatectomy, and (7) a pannus extending into the radiation field. Each case outlines the appropriate techniques for simulation, treatment planning, image guidance, dose, and fractionation. Numerical rating and commentary is given for each treatment approach in each variant.

CONCLUSIONS

External beam radiation is a key component of the curative management of T1 and T2 prostate cancer. By combining the most recent medical literature, these Appropriateness Criteria can aid clinicians in determining the appropriate treatment delivery and personalized approaches for individual patients.

Evaluation of Imaging Dose From Different Image Guided Systems During Head and Neck Radiotherapy: A Phantom Study

This work evaluated and compared the absorbed doses to selected organs in the head and neck region from the three image guided radiotherapy systems: cone-beam computed tomography (CBCT) and kilovoltage (kV) planar imaging using the On-board Imager® (OBI) as well as the ExacTrac® X-ray system, all available on the Varian Novalis TX linear accelerator. The head and neck region of an anthropomorphic phantom was used to simulate patients' head within the imaging field. Nanodots optically stimulated luminescent dosemeters were positioned at selected sites to measure the absorbed doses. CBCT was found to be delivering the highest dose to internal organs while OBI-2D gave the highest doses to the eye lenses. The setting of half-rotation in CBCT effectively reduces the dose to the eye lenses. Daily high-quality CBCT verification was found to increase the secondary cancer risk by 0.79%.

Variable angle stereo imaging for rapid patient position correction in an in-house real-time position monitoring system

PURPOSE

To develop and validate a variable angle stereo image based position correction methodology in an X-ray based in-house online position monitoring system.

MATERIALS AND METHODS

A stereo imaging module that enables 3D position determination and couch correction of the patient based on images acquired at any arbitrary angle and arbitrary angular separation was developed and incorporated to the in-house SeedTracker real-time position monitoring system. The accuracy of the developed system was studied by imaging an anthropomorphic phantom implanted with radiopaque markers set to known offset positions from its reference position in an Elekta linear accelerator (LA) and associated XVI imaging system. The accuracy of the system was further validated using CBCT data set from 10 prostate SBRT patients. The time gains achieved with the stereo image based position correction was compared with the manual matching of seed positions in Digitally Reconstructed Radiographs (DRRs) and kV images in the Mosaiq record and verify system.

RESULTS

Based on phantom and patient CBCT dataset study stereo imaging module implemented in the SeedTracker shown to have an accuracy of 0.1(σ=0.5)mm in detecting the 3D position offset. The time comparison study showed that stereo image based methodology implemented in SeedTracker was a minimum of 80(4)s faster than the manual method implemented in Mosaiq R&V system with a maximum time saving of 146(6)s.

CONCLUSION

The variable angle stereo image based position correction method was shown to be accurate and faster than the standard manual DRR-kV image based correction approach, leading to more efficient treatment.

Continued Benefit to Rectal Separation for Prostate Radiation Therapy: Final Results of a Phase III Trial

PURPOSE

SpaceOAR, a Food and Drug Administration-approved hydrogel intended to create a rectal-prostate space, was evaluated in a single-blind phase III trial of image guided intensity modulated radiation therapy. A total of 222 men were randomized 2:1 to the spacer or control group and received 79.2 Gy in 1.8-Gy fractions to the prostate with or without the seminal vesicles. The present study reports the final results with a median follow-up period of 3 years.

METHODS AND MATERIALS

Cumulative (Common Terminology Criteria for Adverse Events, version 4.0) toxicity was evaluated using the log-rank test. Quality of life (QOL) was examined using the Expanded Prostate Cancer Index Composite (EPIC), and the mean changes from baseline in the EPIC domains were tested using repeated measures models. The proportions of men with minimally important differences (MIDs) in each domain were tested using repeated measures logistic models with prespecified thresholds.

RESULTS

The 3-year incidence of grade ≥1 (9.2% vs 2.0%; P=.028) and grade ≥2 (5.7% vs 0%; P=.012) rectal toxicity favored the spacer arm. Grade ≥1 urinary incontinence was also lower in the spacer arm (15% vs 4%; P=.046), with no difference in grade ≥2 urinary toxicity (7% vs 7%; P=0.7). From 6 months onward, bowel QOL consistently favored the spacer group (P=.002), with the difference at 3 years (5.8 points; P<.05) meeting the threshold for a MID. The control group had a 3.9-point greater decline in urinary QOL compared with the spacer group at 3 years (P<.05), but the difference did not meet the MID threshold. At 3 years, more men in the control group than in the spacer group had experienced a MID decline in bowel QOL (41% vs 14%; P=.002) and urinary QOL (30% vs 17%; P=.04). Furthermore, the control group were also more likely to have experienced large declines (twice the MID) in bowel QOL (21% vs 5%; P=.02) and urinary QOL (23% vs 8%; P=.02).

CONCLUSIONS

The benefit of a hydrogel spacer in reducing the rectal dose, toxicity, and QOL declines after image guided intensity modulated radiation therapy for prostate cancer was maintained or increased with a longer follow-up period, providing stronger evidence for the benefit of hydrogel spacer use in prostate radiation therapy.

Comparison of prostate positioning guided by three-dimensional transperineal ultrasound and cone beam CT

OBJECTIVE

The accuracy of a transperineal three-dimensional ultrasound system (3DUS) was assessed for prostate positioning and compared to fiducial- and bone-based positioning in kV cone beam computed tomography (CBCT) during definitive radiotherapy of prostate cancer.

METHODS

Each of the 7 patients had three fiducial markers implanted into the prostate before treatment. Prostate positioning was simultaneously measured by 3DUS and CBCT before each fraction. In total, 177 pairs of 3DUS and CBCT scans were collected. Bone-match and seed-match were performed for each CBCT. Using seed-match as a reference, the accuracy of 3DUS and bone-match was evaluated. Systematic and random errors as well as optimal setup margins were calculated for 3DUS and bone-match.

RESULTS

The discrepancy between 3DUS and seed-match in CBCT (average ± standard deviation) was 0.0 ± 1.7 mm laterally, 0.2 ± 2.0 mm longitudinally, and 0.3 ± 1.7 mm vertically. Using seed-match as a reference, systematic errors for 3DUS were 1.2 mm, 1.1 mm, and 0.9 mm; and random errors were 1.4 mm, 1.8 mm, and 1.6 mm, on lateral, longitudinal, and vertical axes, respectively. By analogy, the difference of bone-match to seed-match was 0.1 ± 1.1 mm laterally, 1.3 ± 3.8 mm longitudinally, and 1.3 ± 4.5 mm vertically. Systematic errors were 0.5 mm, 2.2 mm, and 2.6 mm; and random errors were 1.0 mm, 3.1 mm, and 3.9 mm on lateral, longitudinal, and vertical axes, respectively. The accuracy of 3DUS was significantly higher than that of bone-match on longitudinal and vertical axes, but not on the lateral axis.

CONCLUSION

Image-guided radiotherapy of prostate cancer based on transperineal 3DUS was feasible, with overall small discrepancy to seed-match in CBCT in this retrospective study. Compared to bone-match, transperineal 3DUS achieved higher accuracy on longitudinal and vertical axes.

Investigation of dosimetric variations of liver radiotherapy using deformable registration of planning CT and cone-beam CT

Many patients with technically unresectable or medically inoperable hepatocellular carcinoma (HCC) had hepatic anatomy variations as a result of interfraction deformation during fractionated radiotherapy. We conducted this retrospective study to investigate interfractional normal liver dosimetric consequences via reconstructing weekly dose in HCC patients. Twenty‐three patients with HCC received conventional fractionated three‐dimensional conformal radiation therapy (3DCRT) were enrolled in this retrospective investigation. Among them, seven patients had been diagnosed of radiation‐induced liver disease (RILD) and the other 16 patients had good prognosis after treatment course. The cone‐beam CT (CBCT) scans were acquired once weekly for each patient throughout the treatment, deformable image registration (DIR) of planning CT (pCT) and CBCT was performed to acquire modified CBCT (mCBCT), and the structural contours were propagated by the DIR. The same plan was applied to mCBCT to perform dose calculation. Weekly dose distribution was displayed on the pCT dose space and compared using dose difference, target coverage, and dose volume histograms. Statistical analysis was performed to identify the significant dosimetric variations. Among the 23 patients, the three weekly normal liver D₅₀ increased by 0.2 Gy, 4.2 Gy, and 4.7 Gy, respectively, for patients with RILD, and 1.0 Gy, 2.7 Gy, and 3.1 Gy, respectively, for patients without RILD. Mean dose to the normal liver (D_mean) increased by 0.5 Gy, 2.6 Gy, and 4.0 Gy, respectively, for patients with RILD, and 0.4 Gy, 3.1 Gy, and 3.4 Gy, respectively, for patients without RILD. Regarding patients with RILD, the average values of the third weekly D₅₀ and D_mean were both over hepatic radiation tolerance, while the values of patients without RILD were below. The dosimetric consequence showed that the liver dose between patients with and without RILD were different relative to the planned dose, and the RILD patients suffered from liver dose over hepatic radiation tolerance. Evaluation of routinely acquired CBCT images during radiation therapy provides biological information on the organs at risk, and dose estimation based on mCBCT could potentially form the basis for personalized response adaptive therapy.

MRI-guided prostate adaptive radiotherapy - A systematic review

Dose escalated radiotherapy improves outcomes for men with prostate cancer. A plateau for benefit from dose escalation using EBRT may not have been reached for some patients with higher risk disease. The use of increasingly conformal techniques, such as step and shoot IMRT or more recently VMAT, has allowed treatment intensification to be achieved whilst minimising associated increases in toxicity to surrounding normal structures. To support further safe dose escalation, the uncertainties in the treatment target position will need be minimised using optimal planning and image-guided radiotherapy (IGRT). In particular the increasing usage of profoundly hypo-fractionated stereotactic therapy is predicated on the ability to confidently direct treatment precisely to the intended target for the duration of each treatment. This article reviews published studies on the influences of varies types of motion on daily prostate position and how these may be mitigated to improve IGRT in future. In particular the role that MRI has played in the generation of data is discussed and the potential role of the MR-Linac in next-generation IGRT is discussed.

Analysis of Dosimetric Impacts of Cone Beam Computed Tomography-Based Volumetric Modulated Arc Therapy Planning

OBJECTIVE

To quantify the Hounsfield unit (HU) variations between computed tomography (CT) and cone beam CT (CBCT) and study its impact on volumetric modulated arc therapy (VMAT) plans.

METHODS

HU number variations in CT and CBCT images were evaluated using the Catphan-504 phantom, and changes in seven different materials within the phantom (air, polymethylpentene, low-density polyethylene, polystyrene, acrylic, Delrin, and Teflon) were studied. The HU variations in half-fan and full-fan modes of CBCT were evaluated. The effect of variations in the shape of the body cross sections was assessed by reducing the body of the Catphan by 0.5 cm and 1.0 cm. CBCT-based VMAT plans in 27 patients (10 prostate, 10 brain, and 7 head and neck (HN)) were compared with corresponding CT-based plans. The dosimetric variations were assessed referring to different points on the dose volume histogram (D_5%, D_50%, and D_95% for PTVs and D_1%, D_max, and D_mean for organs at risk). The relative percentage of difference (ΔD (%)) between CT- and CBCT-based VMAT plans were examined on these points. To evaluate the dosimetric accuracy, dose distributions were compared using Omnipro-I'mRT software. The VMAT plans were evaluated based on 3 mm-3%, 2 mm-2%, and 1 mm-1% gamma criteria.

RESULTS

The HU difference in CT and CBCT was highest for air, Delrin, and Teflon, whereas the difference was less than 20 HU for the other materials. The dose volume histograms of both CT- and CBCT-based plans were in excellent agreement in both phantom and patients, except in HN cases where the difference was 7%. The average 3 mm-3% gamma pass points in brain, prostate, and HN patients were 97 ± 0.2%, 96 ± 0.06%, and 93.3 ± 1.1%, respectively. The gamma pass rates reduced to 88.8 ± 0.06%, 91 ± 0.04%, and 79 ± 6% in 2 mm-2%, and further declined to 76.6 ± 0.09%, 75.2 ± 0.5%, and 60 ± 6% using the stringent 1 mm-1% gamma criteria for brain, prostate, and HN cases, respectively.

CONCLUSION

Based on the results of this study, it is our belief that CBCT images can be used as a tool for evaluating the dosimetric variation in patient VMAT plans.

Impact of scanning parameters and breathing patterns on image quality and accuracy of tumor motion reconstruction in 4D CBCT: a phantom study

Four-dimensional, cone-beam CT (4D CBCT) substantially reduces respiration-induced motion blurring artifacts in three-dimension (3D) CBCT. However, the image quality of 4D CBCT is significantly degraded which may affect its accuracy in localizing a mobile tumor for high-precision, image-guided radiation therapy (IGRT). The purpose of this study was to investigate the impact of scanning parameters hereinafter collectively referred to as scanning sequence) and breathing patterns on the image quality and the accuracy of computed tumor trajectory for a commercial 4D CBCT system, in preparation for its clinical implementation. We simulated a series of periodic and aperiodic sinusoidal breathing patterns with a respiratory motion phantom. The aperiodic pattern was created by varying the period or amplitude of individual sinusoidal breathing cycles. 4D CBCT scans of the phantom were acquired with a manufacturer-supplied scanning sequence (4D-S-slow) and two in-house modified scanning sequences (4D-M-slow and 4D-M-fast). While 4D-S-slow used small field of view (FOV), partial rotation (200°), and no imaging filter, 4D-M-slow and 4D-M-fast used medium FOV, full rotation, and the F1 filter. The scanning speed was doubled in 4D-M-fast (100°/min gantry rotation). The image quality of the 4D CBCT scans was evaluated using contrast-to-noise ratio (CNR), signal-to-noise ratio (SNR), and motion blurring ratio (MBR). The trajectory of the moving target was reconstructed by registering each phase of the 4D CBCT with a reference CT. The root-mean-squared-error (RMSE) analysis was used to quantify its accuracy. Significant decrease in CNR and SNR from 3D CBCT to 4D CBCT was observed. The 4D-S-slow and 4D-M-fast scans had comparable image quality, while the 4D-M-slow scans had better performance due to doubled projections. Both CNR and SNR decreased slightly as the breathing period increased, while no dependence on the amplitude was observed. The difference of both CNR and SNR between periodic and aperiodic breathing patterns was insignificant (p > 0.48). At end-exhale phases, the motion blurring was negligible for both periodic and aperiodic breathing patterns; at mid-inhale phase, the motion blurring increased as the period, the amplitude or the amount of cycle-to-cycle variation on amplitude increased. Overall, the accuracy of localizing the moving target in 4D CBCT was within 2 mm under all studied cases. No difference in the RMSEs was noticed among the three scanning sequences. The 4D-M-fast scans, free of volume truncation artifacts, exhibited comparable image quality and accuracy in tumor motion reconstruction as the 4D-S-slow scans with reduced imaging dose (0.60 cGy vs. 0.99 cGy) due to the use of faster gantry rotation and the F1 filter, suggesting its suitability for clinical use.

Magnitude of observer error using cone beam CT for prostate interfraction motion estimation: effect of reducing scan length or increasing exposure

OBJECTIVE

Cone beam CT (CBCT) enables soft-tissue registration to planning CT for position verification in radiotherapy. The aim of this study was to determine the interobserver error (IOE) in prostate position verification using a standard CBCT protocol, and the effect of reducing CBCT scan length or increasing exposure, compared with standard imaging protocol.

METHODS

CBCT images were acquired using a novel 7 cm length image with standard exposure (1644 mAs) at Fraction 1 (7), standard 12 cm length image (1644 mAs) at Fraction 2 (12) and a 7 cm length image with higher exposure (2632 mAs) at Fraction 3 (7H) on 31 patients receiving radiotherapy for prostate cancer. Eight observers (two clinicians and six radiographers) registered the images. Guidelines and training were provided. The means of the IOEs were compared using a Kruzkal-Wallis test. Levene's test was used to test for differences in the variances of the IOEs and the independent prostate position.

RESULTS

No significant difference was found between the IOEs of each image protocol in any direction. Mean absolute IOE was the greatest in the anteroposterior direction. Standard deviation (SD) of the IOE was the least in the left-right direction for each of the three image protocols. The SD of the IOE was significantly less than the independent prostate motion in the anterior-posterior (AP) direction only (1.8 and 3.0 mm, respectively: p = 0.017). IOEs were within 1 SD of the independent prostate motion in 95%, 77% and 96% of the images in the RL, SI and AP direction.

CONCLUSION

Reducing CBCT scan length and increasing exposure did not have a significant effect on IOEs. To reduce imaging dose, a reduction in CBCT scan length could be considered without increasing the uncertainty in prostate registration. Precision of CBCT verification of prostate radiotherapy is affected by IOE and should be quantified prior to implementation.

ADVANCES IN KNOWLEDGE

This study shows the importance of quantifying the magnitude of IOEs prior to CBCT implementation.

Feasibility of MRI-based reference images for image-guided radiotherapy of the pelvis with either cone-beam computed tomography or planar localization images

PURPOSE

This study introduces methods to conduct image-guided radiotherapy (IGRT) of the pelvis with either cone-beam computed tomography (CBCT) or planar localization images by relying solely on magnetic resonance imaging (MRI)-based reference images.

MATERIAL AND METHODS

Feasibility of MRI-based reference images for IGRT was evaluated against kV CBCT (50 scans, 5 prostate cancer patients) and kV & MV planar (5 & 5 image pairs and patients) localization images by comparing the achieved patient position corrections to those obtained by standard CT-based reference images. T1/T2*-weighted in-phase MRI, Hounsfield unit conversion-based heterogeneous pseudo-CT, and bulk pseudo-CT images were applied for reference against localization CBCTs, and patient position corrections were obtained by automatic image registration. IGRT with planar localization images was performed manually by 10 observers using reference digitally reconstructed radiographs (DRRs) reconstructed from the pseudo-CTs and standard CTs. Quality of pseudo-DRRs against CT-DRRs was evaluated with image similarity metrics.

RESULTS

The SDs of differences between CBCT-to-MRI and CBCT-to-CT automatic gray-value registrations were ≤1.0 mm & ≤0.8° and ≤2.5 mm & ≤3.6° with 10 cm diameter cubic VOI and prostate-shaped VOI, respectively. The corresponding values for reference heterogeneous pseudo-CT were ≤1.0 mm & ≤0.7° and ≤2.2 mm & ≤3.3°, respectively. Heterogeneous pseudo-CT was the only type of MRI-based reference image working reliably with automatic bone registration (SDs were ≤0.9 mm & ≤0.7°). The differences include possible residual errors from planning CT to MRI registration. The image similarity metrics were significantly (p≤0.01) better in agreement between heterogeneous pseudo-DRRs and CT-DRRs than between bulk pseudo-DRRs and CT-DRRs. The SDs of differences in manual registrations (3D) with planar kV and MV localization images were ≤1.0 mm and ≤1.7 mm, respectively, between heterogeneous pseudo-DRRs and CT-DRRs, and ≤1.4 mm and ≤2.1 mm between bulk pseudo-DRRs and CT-DRRs.

CONCLUSION

This study demonstrated that it is feasible to conduct IGRT of the pelvis with MRI-based reference images.

Development of CBCT-based prostate setup correction strategies and impact of rectal distension

Background

Cone-beam computed tomography (CBCT) image-guided radiotherapy (IGRT) systems are widely used tools to verify and correct the target position before each fraction, allowing to maximize treatment accuracy and precision. In this study, we evaluate automatic three-dimensional intensity-based rigid registration (RR) methods for prostate setup correction using CBCT scans and study the impact of rectal distension on registration quality.

Methods

We retrospectively analyzed 115 CBCT scans of 10 prostate patients. CT-to-CBCT registration was performed using (a) global RR, (b) bony RR, or (c) bony RR refined by a local prostate RR using the CT clinical target volume (CTV) expanded with 1-to-20-mm varying margins. After propagation of the manual CT contours, automatic CBCT contours were generated. For evaluation, a radiation oncologist manually delineated the CTV on the CBCT scans. The propagated and manual CBCT contours were compared using the Dice similarity and a measure based on the bidirectional local distance (BLD). We also conducted a blind visual assessment of the quality of the propagated segmentations. Moreover, we automatically quantified rectal distension between the CT and CBCT scans without using the manual CBCT contours and we investigated its correlation with the registration failures. To improve the registration quality, the air in the rectum was replaced with soft tissue using a filter. The results with and without filtering were compared.

Results

The statistical analysis of the Dice coefficients and the BLD values resulted in highly significant differences (p<10⁻⁶) for the 5-mm and 8-mm local RRs vs the global, bony and 1-mm local RRs. The 8-mm local RR provided the best compromise between accuracy and robustness (Dice median of 0.814 and 97% of success with filtering the air in the rectum). We observed that all failures were due to high rectal distension. Moreover, the visual assessment confirmed the superiority of the 8-mm local RR over the bony RR.

Conclusion

The most successful CT-to-CBCT RR method proved to be the 8-mm local RR. We have shown the correlation between its registration failures and rectal distension. Furthermore, we have provided a simple (easily applicable in routine) and automatic method to quantify rectal distension and to predict registration failure using only the manual CT contours.

A comparative assessment of prostate positioning guided by three-dimensional ultrasound and cone beam CT

Background

The accuracy of the Elekta Clarity™ three-dimensional ultrasound system (3DUS) was assessed for prostate positioning and compared to seed- and bone-based positioning in kilo-voltage cone-beam computed tomography (CBCT) during a definitive radiotherapy.

Methods

The prostate positioning of 6 patients, with fiducial markers implanted into the prostate, was controlled by 3DUS and CBCT. In total, 78 ultrasound scans were performed trans-abdominally and compared to bone-matches and seed-matches in CBCT scans. Setup errors detected by the different modalities were compared. Systematic and random errors were analysed, and optimal setup margins were calculated.

Results

The discrepancy between 3DUS and seed-match in CBCT was −0.2 ± 2.7 mm laterally, −1.9 ± 2.3 mm longitudinally and 0.0 ± 3.0 mm vertically and significant only in longitudinal direction. Using seed-match as reference, systematic errors of 3DUS were 1.3 mm laterally, 0.8 mm longitudinally and 1.4 mm vertically, and random errors were 2.5 mm laterally, 2.3 mm longitudinally, and 2.7 mm vertically. No significant difference could be detected for 3DUS in comparison to bone-match in CBCT.

Conclusions

3DUS is feasible for image guidance for patients with prostate cancer and appears comparable to CBCT based image guidance in the retrospective study. While 3DUS offers some distinct advantages such as no need of invasive fiducial implantation and avoidance of extra radiation, its disadvantages include the operator dependence of the technique and dependence on sufficient bladder filling. Further study of 3DUS for image guidance in a large patient cohort is warranted.

Metal artifact correction for x-ray computed tomography using kV and selective MV imaging

PURPOSE

The overall goal of this work is to improve the computed tomography (CT) image quality for patients with metal implants or fillings by completing the missing kilovoltage (kV) projection data with selectively acquired megavoltage (MV) data that do not suffer from photon starvation. When both of these imaging systems, which are available on current radiotherapy devices, are used, metal streak artifacts are avoided, and the soft-tissue contrast is restored, even for regions in which the kV data cannot contribute any information.

METHODS

Three image-reconstruction methods, including two filtered back-projection (FBP)-based analytic methods and one iterative method, for combining kV and MV projection data from the two on-board imaging systems of a radiotherapy device are presented in this work. The analytic reconstruction methods modify the MV data based on the information in the projection or image domains and then patch the data onto the kV projections for a FBP reconstruction. In the iterative reconstruction, the authors used dual-energy (DE) penalized weighted least-squares (PWLS) methods to simultaneously combine the kV/MV data and perform the reconstruction.

RESULTS

The authors compared kV/MV reconstructions to kV-only reconstructions using a dental phantom with fillings and a hip-implant numerical phantom. Simulation results indicated that dual-energy sinogram patch FBP and the modified dual-energy PWLS method can successfully suppress metal streak artifacts and restore information lost due to photon starvation in the kV projections. The root-mean-square errors of soft-tissue patterns obtained using combined kV/MV data are 10-15 Hounsfield units smaller than those of the kV-only images, and the structural similarity index measure also indicates a 5%-10% improvement in the image quality. The added dose from the MV scan is much less than the dose from the kV scan if a high efficiency MV detector is assumed.

CONCLUSIONS

The authors have shown that it is possible to improve the image quality of kV CTs for patients with metal implants or fillings by completing the missing kV projection data with selectively acquired MV data that do not suffer from photon starvation. Numerical simulations demonstrated that dual-energy sinogram patch FBP and a modified kV/MV PWLS method can successfully suppress metal streak artifacts and restore information lost due to photon starvation in kV projections. Combined kV/MV images may permit the improved delineation of structures of interest in CT images for patients with metal implants or fillings.

Calculation of planning margins for different verification techniques in radical prostate radiotherapy

Purpose

To calculate and compare planning target volume (PTV) margins for an offline 3 mm tolerance, daily bony anatomy verification, tattoo alignment and online prostate marker matching with those currently used at our institution.

Methods

Seventy patients had offline bony anatomy megavoltage verification. 23 different patients underwent fiducial marker matching using daily online kilovoltage verification. Systematic and random errors were measured in the right–left (RL), superior–inferior (SI) and anterior–posterior (AP) directions. Geometric uncertainties from literature were used to help calculate the margins.

Results

PTV margins (mm) were 7 RL, 12 SI and AP (3 mm tolerance offline bony), 6 RL, 11 SI and AP (daily online bony), 8 RL, 12 SI and AP (tattoo alignment) and 5 RL, 8 SI and 6 AP (online daily prostate marker correction).

Conclusions

Our current margins for conformal radiotherapy patients are too small for phase 2 in the SI and AP directions. Implementing online daily bony anatomy matching would not reduce the PTV margin significantly. Online daily marker correction showed current PTV71 Gy margins as excessive by (mm) 5 RL, 2 SI and 4 anterior.

Validation of planning target volume margins by analyzing intrafractional localization errors for 14 prostate cancer patients based on three-dimensional cross-correlation between the prostate images of planning CT and intrafraction cone-beam CT during volumetric modulated arc therapy

Time-averaged intreatment prostate localization errors were calculated, for the first time, by three-dimensional prostate image cross-correlation between planning CT and intrafraction kilovoltage cone-beam CT (CBCT) during volumetric modulated arc therapy (VMAT). The intrafraction CBCT volume was reconstructed by an inhouse software after acquiring cine-mode projection images during VMAT delivery. Subsequently, the margin between a clinical target volume and a planning target volume (PTV) was obtained by applying the van Herk and variant formulas using the calculated localization errors. The resulting PTV margins were approximately 2 mm in lateral direction and 4 mm in craniocaudal and anteroposterior directions, which are consistent with the margin prescription employed in our facility.

Artifact-resistant motion estimation with a patient-specific artifact model for motion-compensated cone-beam CT

PURPOSE

In image-guided radiation therapy (IGRT) valuable information for patient positioning, dose verification, and adaptive treatment planning is provided by an additional kV imaging unit. However, due to the limited gantry rotation speed during treatment the typical acquisition time is quite long. Tomographic images of the thorax suffer from motion blurring or, if a gated 4D reconstruction is performed, from significant streak artifacts. Our purpose is to provide a method that reliably estimates respiratory motion in presence of severe artifacts. The estimated motion vector fields are then used for motion-compensated image reconstruction to provide high quality respiratory-correlated 4D volumes for on-board cone-beam CT (CBCT) scans.

METHODS

The proposed motion estimation method consists of a model that explicitly addresses image artifacts because in presence of severe artifacts state-of-the-art registration methods tend to register artifacts rather than anatomy. Our artifact model, e.g., generates streak artifacts very similar to those included in the gated 4D CBCT images, but it does not include respiratory motion. In combination with a registration strategy, the model gives an error estimate that is used to compensate the corresponding errors of the motion vector fields that are estimated from the gated 4D CBCT images. The algorithm is tested in combination with a cyclic registration approach using temporal constraints and with a standard 3D-3D registration approach. A qualitative and quantitative evaluation of the motion-compensated results was performed using simulated rawdata created on basis of clinical CT data. Further evaluation includes patient data which were scanned with an on-board CBCT system.

RESULTS

The model-based motion estimation method is nearly insensitive to image artifacts of gated 4D reconstructions as they are caused by angular undersampling. The motion is accurately estimated and our motion-compensated image reconstruction algorithm can correct for it. Motion artifacts of 3D standard reconstruction are significantly reduced, while almost no new artifacts are introduced.

CONCLUSIONS

Using the artifact model allows to accurately estimate and compensate for patient motion, even if the initial reconstructions are of very low image quality. Using our approach together with a cyclic registration algorithm yields a combination which shows almost no sensitivity to sparse-view artifacts and thus ensures both high spatial and high temporal resolution.

4D ultrasound speckle tracking of intra-fraction prostate motion: a phantom-based comparison with x-ray fiducial tracking using CyberKnife

This study investigates the use of a mechanically-swept 3D ultrasound (3D-US) probe for soft-tissue displacement monitoring during prostate irradiation, with emphasis on quantifying the accuracy relative to CyberKnife® x-ray fiducial tracking. An US phantom, implanted with x-ray fiducial markers was placed on a motion platform and translated in 3D using five real prostate motion traces acquired using the Calypso system. Motion traces were representative of all types of motion as classified by studying Calypso data for 22 patients. The phantom was imaged using a 3D swept linear-array probe (to mimic trans-perineal imaging) and, subsequently, the kV x-ray imaging system on CyberKnife. A 3D cross-correlation block-matching algorithm was used to track speckle in the ultrasound data. Fiducial and US data were each compared with known phantom displacement. Trans-perineal 3D-US imaging could track superior-inferior (SI) and anterior-posterior (AP) motion to ≤0.81 mm root-mean-square error (RMSE) at a 1.7 Hz volume rate. The maximum kV x-ray tracking RMSE was 0.74 mm, however the prostate motion was sampled at a significantly lower imaging rate (mean: 0.04 Hz). Initial elevational (right-left; RL) US displacement estimates showed reduced accuracy but could be improved (RMSE <2.0 mm) using a correlation threshold in the ultrasound tracking code to remove erroneous inter-volume displacement estimates. Mechanically-swept 3D-US can track the major components of intra-fraction prostate motion accurately but exhibits some limitations. The largest US RMSE was for elevational (RL) motion. For the AP and SI axes, accuracy was sub-millimetre. It may be feasible to track prostate motion in 2D only. 3D-US also has the potential to improve high tracking accuracy for all motion types. It would be advisable to use US in conjunction with a small (∼2.0 mm) centre-of-mass displacement threshold in which case it would be possible to take full advantage of the accuracy and high imaging rate capability.

An accuracy assessment of different rigid body image registration methods and robotic couch positional corrections using a novel phantom

PURPOSE

Image guided radiotherapy (IGRT) using cone beam computed tomography (CBCT) images greatly reduces interfractional patient positional uncertainties. An understanding of uncertainties in the IGRT process itself is essential to ensure appropriate use of this technology. The purpose of this study was to develop a phantom capable of assessing the accuracy of IGRT hardware and software including a 6 degrees of freedom patient positioning system and to investigate the accuracy of the Elekta XVI system in combination with the HexaPOD robotic treatment couch top.

METHODS

The constructed phantom enabled verification of the three automatic rigid body registrations (gray value, bone, seed) available in the Elekta XVI software and includes an adjustable mount that introduces known rotational offsets to the phantom from its reference position. Repeated positioning of the phantom was undertaken to assess phantom rotational accuracy. Using this phantom the accuracy of the XVI registration algorithms was assessed considering CBCT hardware factors and image resolution together with the residual error in the overall image guidance process when positional corrections were performed through the HexaPOD couch system.

RESULTS

The phantom positioning was found to be within 0.04 (σ = 0.12)°, 0.02 (σ = 0.13)°, and -0.03 (σ = 0.06)° in X, Y, and Z directions, respectively, enabling assessment of IGRT with a 6 degrees of freedom patient positioning system. The gray value registration algorithm showed the least error in calculated offsets with maximum mean difference of -0.2(σ = 0.4) mm in translational and -0.1(σ = 0.1)° in rotational directions for all image resolutions. Bone and seed registration were found to be sensitive to CBCT image resolution. Seed registration was found to be most sensitive demonstrating a maximum mean error of -0.3(σ = 0.9) mm and -1.4(σ = 1.7)° in translational and rotational directions over low resolution images, and this is reduced to -0.1(σ = 0.2) mm and -0.1(σ = 0.79)° using high resolution images.

CONCLUSIONS

The phantom, capable of rotating independently about three orthogonal axes was successfully used to assess the accuracy of an IGRT system considering 6 degrees of freedom. The overall residual error in the image guidance process of XVI in combination with the HexaPOD couch was demonstrated to be less than 0.3 mm and 0.3° in translational and rotational directions when using the gray value registration with high resolution CBCT images. However, the residual error, especially in rotational directions, may increase when the seed registration is used with low resolution images.

Comparison of low-dose, half-rotation, cone-beam CT with electronic portal imaging device for registration of fiducial markers during prostate radiotherapy

This study evaluated the agreement of fiducial marker localization between two modalities — an electronic portal imaging device (EPID) and cone‐beam computed tomography (CBCT) — using a low‐dose, half‐rotation scanning protocol. Twenty‐five prostate cancer patients with implanted fiducial markers were enrolled. Before each daily treatment, EPID and half‐rotation CBCT images were acquired. Translational shifts were computed for each modality and two marker‐matching algorithms, seed‐chamfer and grey‐value, were performed for each set of CBCT images. The localization offsets, and systematic and random errors from both modalities were computed. Localization performances for both modalities were compared using Bland‐Altman limits of agreement (LoA) analysis, Deming regression analysis, and Cohen's kappa inter‐rater analysis. The differences in the systematic and random errors between the modalities were within 0.2 mm in all directions. The LoA analysis revealed a 95% agreement limit of the modalities of 2 to 3.5 mm in any given translational direction. Deming regression analysis demonstrated that constant biases existed in the shifts computed by the modalities in the superior–inferior (SI) direction, but no significant proportional biases were identified in any direction. Cohen's kappa analysis showed good agreement between the modalities in prescribing translational corrections of the couch at 3 and 5 mm action levels. Images obtained from EPID and half‐rotation CBCT showed acceptable agreement for registration of fiducial markers. The seed‐chamfer algorithm for tracking of fiducial markers in CBCT datasets yielded better agreement than the grey‐value matching algorithm with EPID‐based registration.

PACS numbers: 87.55.km, 87.55.Qr

Influence of the number of elongated fiducial markers on the localization accuracy of the prostate

Implanting fiducial markers for localization purposes has become an accepted practice in radiotherapy for prostate cancer. While many correction strategies correct for translations only, advanced correction protocols also require knowledge of the rotation of the prostate. For this purpose, typically, three or more markers are implanted. Elongated fiducial markers provide more information about their orientation than traditional round or cylindrical markers. Potentially, fewer markers are required. In this study, we evaluate the effect of the number of elongated markers on the localization accuracy of the prostate. To quantify the localization error, we developed a model that estimates, at arbitrary locations in the prostate, the registration error caused by translational and rotational uncertainties of the marker registration. Every combination of one, two and three markers was analysed for a group of 24 patients. The average registration errors at the prostate surface were 0.3-0.8 mm and 0.4-1 mm for registrations on, respectively, three markers and two markers located on different sides of the prostate. Substantial registration errors (2.0-2.2 mm) occurred at the prostate surface contralateral to the markers when two markers were implanted on the same side of the prostate or only one marker was used. In conclusion, there is no benefit in using three elongated markers: two markers accurately localize the prostate if they are implanted at some distance from each other.

Evaluation of automated image registration algorithm for image-guided radiotherapy (IGRT)

The performance of an image registration (IR) software was evaluated for automatically detecting known errors simulated through the movement of ExactCouch using an onboard imager. Twenty-seven set-up errors (11 translations, 10 rotations, 6 translation and rotation) were simulated by introducing offset up to ± 15 mm in three principal axes and 0° to ± 1° in yaw. For every simulated error, orthogonal kV radiograph and cone beam CT were acquired in half-fan (CBCT_HF) and full-fan (CBCT_FF) mode. The orthogonal radiographs and CBCTs were automatically co-registered to reference digitally reconstructed radiographs (DRRs) and planning CT using 2D-2D and 3D-3D matching software based on mutual information transformation. A total of 79 image sets (ten pairs of kV X-rays and 69 session of CBCT) were analyzed to determine the (a) reproducibility of IR outcome and (b) residual error, defined as the deviation between the known and IR software detected displacement in translation and rotation. The reproducibility of automatic IR of planning CT and repeat CBCTs taken with and without kilovoltage detector and kilovoltage X-ray source arm movement was excellent with mean SD of 0.1 mm in the translation and 0.0° in rotation. The average residual errors in translation and rotation were within ± 0.5 mm and ± 0.2°, ± 0.9 mm and ± 0.3°, and ± 0.4 mm and ± 0.2° for setup simulated only in translation, rotation, and both translation and rotation. The mean (SD) 3D vector was largest when only translational error was simulated and was 1.7 (1.1) mm for 2D-2D match of reference DRR with radiograph, 1.4 (0.6) and 1.3 (0.5) mm for 3D-3D match of reference CT and CBCT with full fan and half fan, respectively. In conclusion, the image-guided radiation therapy (IGRT) system is accurate within 1.8 mm and 0.4° and reproducible under control condition. Inherent error from any IGRT process should be taken into account while setting clinical IGRT protocol.

Localization of a portion of an endorectal balloon for prostate image-guided radiation therapy using cone-beam tomosynthesis: a feasibility study

PURPOSE

To assess the feasibility of using cone-beam tomosynthesis (CBTS) to localize the air-tissue interface for the application of prostate image-guided radiation therapy using an endorectal balloon for immobilization and localization.

METHODS AND MATERIALS

A Feldkamp-David-Kress-based CBTS reconstruction was applied to selected sets of cone-beam computed tomography (CBCT) projection data to simulate volumetric imaging achievable from tomosynthesis for a limited range of scan angles. Projection data were calculated from planning CT images of 10 prostate cancer patients treated with an endorectal balloon, as were experimental CBCT projections for a pelvic phantom in two patients. More than 50 points at the air-tissue interface were objectively identified by an intensity-based interface-finding algorithm. Using three-dimensional point sets extracted from CBTS images compared with points extracted from corresponding CBCT images, the relative shift resulting from a reduced scan angle was determined. Because the CBCT and CBTS images were generated from the same projection data set, shift identified was presumed to be due to distortions introduced by the tomosynthesis technique.

RESULTS

Scans of ≥60° were shown to be able to localize an air-tissue interface near the isocenter with accuracy on the order of a millimeter. The accuracy was quantified in terms of the mean discrepancy as a function of reconstruction angle.

CONCLUSION

This work provides an understanding of the effect of scan angle used in localization of a portion of an endorectal balloon by means of CBTS. CBTS with relatively small scan angles is capable of accurately localizing an extended interface near the isocenter and may provide clinically relevant measurements to guide IGRT treatments while reducing imaging radiation to the patient.

Image quality of an investigational imaging panel for use with the imaging beam line cone-beam CT

The purpose of this study was to measure and compare the contrast-to-noise ratio (CNR) as a function of dose for the cone-beam CT (CBCT) produced by the imaging beam line (IBL) for the standard and an investigational imaging panel. Two Siemens Artiste linear accelerators were modified at our institution such that the MV-CBCT would operate under an investigational IBL. The imaging panel from one of the machines was replaced with an investigational imaging panel. After the modification, a set of CBCT for a large and small phantom consisting of eight tissue-equivalent inserts was acquired for the standard imager and for the investigational imager with and without the standard copper plate. Ten dose settings for each phantom using the IBL in combination with the standard and investigational imaging panel were acquired. The CNR for each tissue-equivalent insert was calculated. Resolution measurements in line pairs per mm (lp/mm) of the CBCT for the various imaging panel setups were made. In addition, CBCT images of two patients that were imaged with each panel configuration were displayed for a group of physicians and therapists who were asked to identify the best and worst CBCT for each patient. This was used as a qualitative judge of practical image quality. The CNR of the muscle insert for the large phantom with 1.5 cGy at isocenter was 1.3 for the standard imager, 1.5 for the investigational imager with the copper plate, and 1.9 without the plate. Under the same conditions, the CNR of the trabecular bone insert was 5.9, 7.3, and 9.7, respectively. For the small phantom with the same dose to isocenter, the CNR for muscle was 1.7, 2.1, and 3.3, respectively. For the trabecular bone, the CNR was 8.1, 9.6, and 12.1 respectively. The resolution for 1 cGy at isocenter was 0.37 lp/mm for the standard imager, 0.32 and 0.33 for the investigational imager with and without the copper plate. The qualitative test ranked the CBCT of the investigational imager without the copper plate to be the best image, and the standard imager to be the worst. The investigational imaging panel improves image quality as compared to the standard imager for IBL CBCTs. A 1 cGy IBL CBCT, no matter which imager is used, is sufficient for bony anatomy localization. The investigational imager without the copper plate was judged clinically to produce the best IBL CBCT.

Multiresolution reconstruction for cone-beam tomography from raw data projections using 3D ridgelets

This paper presents a novel method which reconstructs any desired 3D image resolution from raw cone-beam CT data. X-ray attenuation through the object is approximated using ridgelet basis functions which allow us to have multiresolution representation levels. Since the Radon data have preferential orientations by nature, a spherical wavelet transform is used to compute the ridgelet coefficients from the Radon shell data. The whole method uses the classical Grangeat's relation for computing derivatives of the Radon data which are then integrated and projected to a spherical wavelet representation and back-reconstructed using a modified version of the well known back-projection algorithm. Unlike previous reconstruction methods, this proposal uses a multiscale representation of the Radon data and therefore allows fast display of low-resolution data level.

Management of the baseline shift using a new and simple method for respiratory-gated radiation therapy: detectability and effectiveness of a flexible monitoring system

PURPOSE

In respiratory-gated radiation therapy, a baseline shift decreases the accuracy of target coverage and organs at risk (OAR) sparing. The effectiveness of audio-feedback and audio-visual feedback in correcting the baseline shift in the breathing pattern of the patient has been demonstrated previously. However, the baseline shift derived from the intrafraction motion of the patient's body cannot be corrected by these methods. In the present study, the authors designed and developed a simple and flexible system.

METHODS

The system consisted of a web camera and a computer running our in-house software. The in-house software was adapted to template matching and also to no preimage processing. The system was capable of monitoring the baseline shift in the intrafraction motion of the patient's body. Another marker box was used to monitor the baseline shift due to the flexible setups required of a marker box for gated signals. The system accuracy was evaluated by employing a respiratory motion phantom and was found to be within AAPM Task Group 142 tolerance (positional accuracy <2 mm and temporal accuracy <100 ms) for respiratory-gated radiation therapy. Additionally, the effectiveness of this flexible and independent system in gated treatment was investigated in healthy volunteers, in terms of the results from the differences in the baseline shift detectable between the marker positions, which the authors evaluated statistically.

RESULTS

The movement of the marker on the sternum [1.599 +/- 0.622 mm (1 SD)] was substantially decreased as compared with the abdomen [6.547 +/- 0.962 mm (1 SD)]. Additionally, in all of the volunteers, the baseline shifts for the sternum [-0.136 +/- 0.868 (2 SD)] were in better agreement with the nominal baseline shifts than was the case for the abdomen [-0.722 +/- 1.56 mm (2 SD)]. The baseline shifts could be accurately measured and detected using the monitoring system, which could acquire the movement of the marker on the sternum. The baseline shift-monitoring system with the displacement-based methods for highly accurate respiratory-gated treatments should be used to make most of the displacement-based gating methods.

CONCLUSIONS

The advent of intensity modulated radiation therapy and volumetric modulated radiation therapy facilitates margin reduction for the planning target volumes and the OARs, but highly accurate irradiation is needed to achieve target coverage and OAR sparing with a small margin. The baseline shifts can affect treatment not only with the respiratory gating system but also without the system. Our system can manage the baseline shift and also enables treatment irradiation to be undertaken with high accuracy.