Assessing suitability and stability of materials for a head and neck anthropomorphic multimodality (MRI/CT) phantoms for radiotherapy

Objective:This study aims to identify and evaluate suitable and stable materials for developing a head and neck anthropomorphic multimodality phantom for radiotherapy purposes. These materials must mimic human head and neck tissues in both computed tomography (CT) and magnetic resonance imaging (MRI) and maintain stable imaging properties over time and after radiation exposure, including the high levels associated with linear accelerator (linac) use.Approach:Various materials were assessed by measuring their CT numbers and T1 and T2 relaxation times. These measurements were compared to literature values to determine how closely the properties of the candidate materials resemble those of human tissues in the head and neck region. The stability of these properties was evaluated monthly over a year and after radiation exposure to doses up to 1000 Gy. Statistical analyzes were conducted to identify any significant changes over time and after radiation exposure.Main results:10% and 12.6% Polyvinyl alcohol cryogel (PVA-c) both exhibited T1 and T2 relaxation times and CT numbers within the range appropriate for brain grey matter. 14.3% PVA-c and some plastic-based materials matched the MRI properties of brain white matter, with CT numbers close to the clinical range. Additionally, some plastic-based materials showed T1 and T2 relaxation times consistent with MRI properties of fat, although their CT numbers were not suitable. Over time and after irradiation, 10% PVA-c maintained consistent properties for brain grey matter. 12.6% PVA-c's T1 relaxation time decreased beyond the range after the first month.Significance:This study identified 10% PVA-c as a substitute for brain grey matter, demonstrating stable imaging properties over a year and after radiation exposure up to 1000 Gy. However, the results highlight a need for further research to find additional materials to accurately simulate a wider range of human tissues.

End-to-end testing for stereotactic radiotherapy including the development of a Multi-Modality phantom

PURPOSE

A new insert for a commercially available end-to-end test phantom was designed and in-house manufactured by 3D printing. Subsequently, the insert was tested for different stereotactic radiation therapy workflows (SRS, SBRT, FSRT, and Multimet) also in comparison to the original insert.

MATERIAL AND METHODS

Workflows contained imaging (MR, CT), treatment planning, positioning, and irradiation. Positioning accuracy was evaluated for non-coplanar x-ray, kV- and MV-CBCT systems, as well as surface guided radiation therapy. Dosimetric accuracy of the irradiation was measured with an ionization chamber at four different linear accelerators including dynamic tumor tracking for SBRT.

RESULTS

CT parameters of the insert were within the specification. For MR images, the new insert allowed quantitative analysis of the MR distortion. Positioning accuracy of the phantom with the new insert using the imaging systems of the different linacs was < 1 mm/degree also for MV-CBCT and a non-coplanar imaging system which caused > 3 mm deviation with the original insert. Deviation of point dose values was <3% for SRS, FSRT, and SBRT for both inserts. For the Multimet plans deviations exceeded 10% because the ionization chamber was not positioned in each metastasis, but in the center of phantom and treatment plan.

CONCLUSION

The in-house manufactured insert performed well in all steps of four stereotactic treatment end-to-end tests. Advantages over the commercially available alternative were seen for quantitative analysis of deformation correction in MR images, applicability for non-coplanar x-ray imaging, and dynamic tumor tracking.

Regression fitting megavoltage depth dose curves to determine material relative electron density in radiotherapy

The relative electron density (RED) parameter is ubiquitous throughout radiotherapy for clinical dosimetry and treatment planning purposes as it provides a more accurate description of the relevant radiological properties over mass density alone. RED is in practice determined indirectly from calibrated CT Hounsfield Units (HU). While CT images provide useful 3D information, the spectral differences between CT and clinical LINAC beams may impact the validity of the CT-ED calibration, especially in the context of novel tissue-mimicking materials where deviations from biologically typical atomic number to atomic weight ratios 〈Z/A〉 occur and/or high-Z materials are present. A theoretical basis for determining material properties directly in a clinical beam spectrum via an electron-density equivalent pathlength (eEPL) method has been previously established. An experimental implementation of this approach is introduced whereby material-specific measured percentage depth dose curves (PDDs) are regressed to a PDD measured in a reference material (water), providing an inference of 〈Z/A〉, which when combined with the physical density provides a determination of RED. This method is validated over a range of tissue-mimicking materials and compared against the standard CT output, as well as compositional information obtained from the manufacturer's specifications. The measured PDD regression method shows consistent results against both manufacturer-provided and CT-derived values between 0.9 and 1.15 RED. Outside of this soft-tissue range a trend was observed whereby the 〈Z/A〉 determined becomes unrealistic indicating the method is no longer reporting RED alone and the assumptions around the eEPL model are constrained. Within the soft-tissue RED range of validity, the regression method provides a practical and robust characterisation for unknown materials in the clinical setting and may be used to improve on the CT derived RED where high Z material components are suspected.

Towards a barrier-free anthropomorphic brain phantom for quantitative magnetic resonance imaging: Design, first construction attempt, and challenges

Existing magnetic resonance imaging (MRI) reference objects, or phantoms, are typically constructed from simple liquid or gel solutions in containers with specific geometric configurations to enable multi-year stability. However, there is a need for phantoms that better mimic the human anatomy without barriers between the tissues. Barriers result in regions without MRI signal between the different tissue mimics, which is an artificial image artifact. We created an anatomically representative 3D structure of the brain that mimicked the T1 and T2 relaxation properties of white and gray matter at 3 T. While the goal was to avoid barriers between tissues, the 3D printed barrier between white and gray matter and other flaws in the construction were visible at 3 T. Stability measurements were made using a portable MRI system operating at 64 mT, and T2 relaxation time was stable from 0 to 22 weeks. The phantom T1 relaxation properties did change from 0 to 10 weeks; however, they did not substantially change between 10 weeks and 22 weeks. The anthropomorphic phantom used a dissolvable mold construction method to better mimic anatomy, which worked in small test objects. The construction process, though, had many challenges. We share this work with the hope that the community can build on our experience.

Realistic 3D printed CT imaging tumor phantoms for validation of image processing algorithms

Medical imaging phantoms are widely used for validation and verification of imaging systems and algorithms in surgical guidance and radiation oncology procedures. Especially, for the performance evaluation of new algorithms in the field of medical imaging, manufactured phantoms need to replicate specific properties of the human body, e.g., tissue morphology and radiological properties. Additive manufacturing (AM) technology provides an inexpensive opportunity for accurate anatomical replication with customization capabilities. In this study, we proposed a simple and cheap protocol using Fused Deposition Modeling (FDM) technology to manufacture realistic tumor phantoms based on the filament 3D printing technology. Tumor phantoms with both homogenous and heterogeneous radiodensity were fabricated. The radiodensity similarity between the printed tumor models and real tumor data from CT images of lung cancer patients was evaluated. Additionally, it was investigated whether a heterogeneity in the 3D printed tumor phantoms as observed in the tumor patient data had an influence on the validation of image registration algorithms. A radiodensity range between -217 to 226 HUs was achieved for 3D printed phantoms using different filament materials; this range of radiation attenuation is also observed in the human lung tumor tissue. The resulted HU range could serve as a lookup-table for researchers and phantom manufactures to create realistic CT tumor phantoms with the desired range of radiodensities. The 3D printed tumor phantoms also precisely replicated real lung tumor patient data regarding morphology and could also include life-like heterogeneity of the radiodensity inside the tumor models. An influence of the heterogeneity on accuracy and robustness of the image registration algorithms was not found.

3D printing methods for radiological anthropomorphic phantoms

Three dimensional (3D) printing technology has been widely evaluated for the fabrication of various anthropomorphic phantoms during the last couple of decades. The demand for such high quality phantoms is constantly rising and gaining an ever-increasing interest. Although, in a short time 3D printing technology provided phantoms with more realistic features when compared to the previous conventional methods, there are still several aspects to be explored. One of these aspects is the further development of the current 3D printing methods and software devoted to radiological applications. The current 3D printing software and methods usually employ 3D models, while the direct association of medical images with the 3D printing process is needed in order to provide results of higher accuracy and closer to the actual tissues' texture. Another aspect of high importance is the development of suitable printing materials. Ideally, those materials should be able to emulate the entire range of soft and bone tissues, while still matching the human's anatomy. Five types of 3D printing methods have been mainly investigated so far: (a) solidification of photo-curing materials; (b) deposition of melted plastic materials; (c) printing paper-based phantoms with radiopaque ink; (d) melting or binding plastic powder; and (e) bio-printing. From the first and second category, polymer jetting technology and fused filament fabrication (FFF), also known as fused deposition modelling (FDM), are the most promising technologies for the fulfilment of the requirements of realistic and radiologically equivalent anthropomorphic phantoms. Another interesting approach is the fabrication of radiopaque paper-based phantoms using inkjet printers. Although, this may provide phantoms of high accuracy, the utilized materials during the fabrication process are restricted to inks doped with various contrast materials. A similar condition applies to the polymer jetting technology, which despite being quite fast and very accurate, the utilized materials are restricted to those capable of polymerization. The situation is better for FFF/FDM 3D printers, since various compositions of plastic filaments with external substances can be produced conveniently. Although, the speed and accuracy of this 3D printing method are lower compared to the others, the relatively low-cost, constantly improving resolution, sufficient printing volume and plethora of materials are quite promising for the creation of human size heterogeneous phantoms and their adaptation to the treatment procedures of patients in the current health systems.

Development of an anthropomorphic multimodality pelvic phantom for quantitative evaluation of a deep-learning-based synthetic computed tomography generation technique

PURPOSE

The objective of this study was to fabricate an anthropomorphic multimodality pelvic phantom to evaluate a deep-learning-based synthetic computed tomography (CT) algorithm for magnetic resonance (MR)-only radiotherapy.

METHODS

Polyurethane-based and silicone-based materials with various silicone oil concentrations were scanned using 0.35 T MR and CT scanner to determine the tissue surrogate. Five tissue surrogates were determined by comparing the organ intensity with patient CT and MR images. Patient-specific organ modeling for three-dimensional printing was performed by manually delineating the structures of interest. The phantom was finally fabricated by casting materials for each structure. For the quantitative evaluation, the mean and standard deviations were measured within the regions of interest on the MR, simulation CT (CT_sim ), and synthetic CT (CT_syn ) images. Intensity-modulated radiation therapy plans were generated to assess the impact of different electron density assignments on plan quality using CT_sim and CT_syn . The dose calculation accuracy was investigated in terms of gamma analysis and dose-volume histogram parameters.

RESULTS

For the prostate site, the mean MR intensities for the patient and phantom were 78.1 ± 13.8 and 86.5 ± 19.3, respectively. The mean intensity of the synthetic image was 30.9 Hounsfield unit (HU), which was comparable to that of the real CT phantom image. The original and synthetic CT intensities of the fat tissue in the phantom were -105.8 ± 4.9 HU and -107.8 ± 7.8 HU, respectively. For the target volume, the difference in D_95% was 0.32 Gy using CT_syn with respect to CT_sim values. The V_65Gy values for the bladder in the plans using CT_sim and CT_syn were 0.31% and 0.15%, respectively.

CONCLUSION

This work demonstrated that the anthropomorphic phantom was physiologically and geometrically similar to the patient organs and was employed to quantitatively evaluate the deep-learning-based synthetic CT algorithm.

[Material Investigation for the Development of Non-rigid Phantoms for CT-MRI Image Registration]

PURPOSE

In radiotherapy, deformable image registration (DIR) has been frequently used in different imaging examinations in recent years. However, no phantom has been established for quality assurance for DIR. In order to develop a non-rigid phantom for accuracy control between CT and MRI images, we investigated the suitability of 3D printing materials and gel materials in this study.

METHODS

We measured CT values, T₁ values, T₂ values, and the proton densities of 31 3D printer materials-purchased from three manufacturers-and one gel material. The dice coefficient after DIR was calculated for the CT-MRI images using a prototype phantom made of a gel material compatible with CT-MRI.

RESULTS

The CT number of the 3D printing materials ranged from -6.8 to 146.4 HU. On MRI, T₁ values were not measurable in most cases, whereas T₂ values were not measurable in all cases; proton density (PD) ranged from 2.51% to 4.9%. The gel material had a CT number of 111.16 HU, T₁ value of 813.65 ms, and T₂ value of 27.19 ms. The prototype phantom was flexible, and the usefulness of DIR with CT and MRI images was demonstrated using this phantom.

CONCLUSION

The CT number and T₁ and T₂ values of the gel material are close to those of the human body and may therefore be developed as a DIR verification phantom between CT and MRI. These findings may contribute to the development of non-rigid phantoms for DIR in the future.

Commissioning measurements on an Elekta Unity MR-Linac

Magnetic resonance-guided radiotherapy technology is relatively new and commissioning publications, quality assurance (QA) protocols and commercial products are limited. This work provides guidance for implementation measurements that may be performed on the Elekta Unity MR-Linac (Elekta, Stockholm, Sweden). Adaptations of vendor supplied phantoms facilitated determination of gantry angle accuracy and linac isocentre, whereas in-house developed phantoms were used for end-to-end testing and anterior coil attenuation measurements. Third-party devices were used for measuring beam quality, reference dosimetry and during treatment plan commissioning; however, due to several challenges, variations on standard techniques were required. Gantry angle accuracy was within 0.1°, confirmed with pixel intensity profiles, and MV isocentre diameter was < 0.5 mm. Anterior coil attenuation was approximately 0.6%. Beam quality as determined by TPR_20,10 was 0.705 ± 0.001, in agreement with treatment planning system (TPS) calculations, and gamma comparison against the TPS for a 22.0 × 22.0 cm² field was above 95.0% (2.0%, 2.0 mm). Machine output was 1.000 ± 0.002 Gy per 100 MU, depth 5.0 cm. During treatment plan commissioning, sub-standard results indicated issues with machine behaviour. Once rectified, gamma comparisons were above 95.0% (2.0%, 2.0 mm). Centres which may not have access to specialized equipment can use in-house developed phantoms, or adapt those supplied by the vendor, to perform commissioning work and confirm operation of the MRL within published tolerances. The plan QA techniques used in this work can highlight issues with machine behaviour when appropriate gamma criteria are set.

3D printed patient-specific thorax phantom with realistic heterogenous bone radiopacity using filament printer technology

Current medical imaging phantoms are usually limited by simplified geometry and radiographic skeletal homogeneity, which confines their usage for image quality assessment. In order to fabricate realistic imaging phantoms, replication of the entire tissue morphology and the associated CT numbers, defined as Hounsfield Unit (HU) is required. 3D printing is a promising technology for the production of medical imaging phantoms with accurate anatomical replication. So far, the majority of the imaging phantoms using 3D printing technologies tried to mimic the average HU of soft tissue human organs. One important aspect of the anthropomorphic imaging phantoms is also the replication of realistic radiodensities for bone tissues. In this study, we used filament printing technology to develop a CT-derived 3D printed thorax phantom with realistic bone-equivalent radiodensity using only one single commercially available filament. The generated thorax phantom geometry closely resembles a patient and includes direct manufacturing of bone structures while creating life-like heterogeneity within bone tissues. A HU analysis as well as a physical dimensional comparison were performed in order to evaluate the density and geometry agreement between the proposed phantom and the corresponding CT data. With the achieved density range (-482 to 968 HU) we could successfully mimic the realistic radiodensity of the bone marrow as well as the cortical bone for the ribs, vertebral body and dorsal vertebral column in the thorax skeleton. In addition, considering the large radiodensity range achieved a full thorax imaging phantom mimicking also soft tissues can become feasible. The physical dimensional comparison using both Extrema Analysis and Collision Detection methods confirmed a mean surface overlap of 90% and a mean volumetric overlap of 84,56% between the patient and phantom model. Furthermore, the reproducibility analyses revealed a good geometry and radiodensity duplicability in 24 printed cylinder replicas. Thus, according to our results, the proposed additively manufactured anthropomorphic thorax phantom has the potential to be efficiently used for validation of imaging- and radiation-based procedures in precision medicine.

Applying MRI Intensity Normalization on Non-Bone Tissues to Facilitate Pseudo-CT Synthesis from MRI

This study aimed to facilitate pseudo-CT synthesis from MRI by normalizing MRI intensity of the same tissue type to a similar intensity level. MRI intensity normalization was conducted through dividing MRI by a shading map, which is a smoothed ratio image between MRI and a three-intensity mask. Regarding pseudo-CT synthesis from MRI, a conversion model based on a three-layer convolutional neural network was trained and validated. Before MRI intensity normalization, the mean value ± standard deviation of fat tissue in 0.35 T chest MRI was 297 ± 73 (coefficient of variation (CV) = 24.58%), which was 533 ± 91 (CV = 17.07%) in 1.5 T abdominal MRI. The corresponding results were 149 ± 32 (CV = 21.48%) and 148 ± 28 (CV = 18.92%) after intensity normalization. With regards to pseudo-CT synthesis from MRI, the differences in mean values between pseudo-CT and real CT were 3, 15, and 12 HU for soft tissue, fat, and lung/air in 0.35 T chest imaging, respectively, while the corresponding results were 3, 14, and 15 HU in 1.5 T abdominal imaging. Overall, the proposed workflow is reliable in pseudo-CT synthesis from MRI and is more practicable in clinical routine practice compared with deep learning methods, which demand a high level of resources for building a conversion model.

Development of phantom materials with independently adjustable CT- and MR-contrast at 0.35, 1.5 and 3 T

Quality assurance in magnetic resonance (MR)-guided radiotherapy lacks anthropomorphic phantoms that represent tissue-equivalent imaging contrast in both computed tomography (CT) and MR imaging. In this study, we developed phantom materials with individually adjustable CT value as well as [Formula: see text]- and [Formula: see text]-relaxation times in MR imaging at three different magnetic field strengths. Additionally, their experimental stopping power ratio (SPR) for carbon ions was compared with predictions based on single- and dual-energy CT. Ni-DTPA doped agarose gels were used for individual adjustment of [Formula: see text] and [Formula: see text] at [Formula: see text] and 3.0 T. The CT value was varied by adding potassium chloride (KCl). By multiple linear regression, equations for the determination of agarose, Ni-DTPA and KCl concentrations for given [Formula: see text] [Formula: see text] and CT values were derived and employed to produce nine specific soft tissue samples. Experimental [Formula: see text] [Formula: see text] and CT values of these soft tissue samples were compared with predictions and additionally, carbon ion SPR obtained by range measurements were compared with predictions based on single- and dual-energy CT. The measured CT value, [Formula: see text] and [Formula: see text] of the produced soft tissue samples agreed very well with predictions based on the derived equations with mean deviations of less than [Formula: see text] While single-energy CT overestimates the measured SPR of the soft tissue samples, the dual-energy CT-based predictions showed a mean SPR deviation of only [Formula: see text] To conclude, anthropomorphic phantom materials with independently adjustable CT values as well as [Formula: see text] and [Formula: see text] relaxation times at three different magnetic field strengths were developed. The derived equations describe the material specific relaxation times and the CT value in dependence on agarose, Ni-DTPA and KCl concentrations as well as the chemical composition of the materials based on given [Formula: see text] and CT value. Dual-energy CT allows accurate prediction of the carbon ion range in these materials.

A Radiopaque Nanoparticle-Based Ink Using PolyJet 3D Printing for Medical Applications

The aim of this study was to develop a 3D printable radiopaque ink and successfully print a finished artifact. Radiopaque 3D printing would be hugely beneficial to improve the visibility of medical devices and implants, as well as allowing more realistic phantoms and calibration aids to be produced. Most 3D printing technologies are polymer based. Polymers are naturally radiolucent, allowing X-rays to pass through, showing up as faint dark gray regions on X-ray detectors, as for soft tissues. During this study, a 3D printable ultraviolet (UV) curable resin containing zirconium oxide (ZrO₂) nanoparticles was developed. 5 wt.% ZrO₂ was dispersed in a base resin using a high-shear mixer. Particles remained in suspension for 6-8 h at room temperature, allowing time for 3D printing. A model of a hand including radiopaque bones and a test block demonstrating a range of internal radiopaque features were successfully 3D printed. Radiopacity was demonstrated in the 3D-printed models, and there was good dispersion of ZrO₂ within the resin matrix. The impregnated resin remained UV curable and viscosity was not compromised. In this study, 3D-printed radiopaque features demonstrated clear radiopacity under X-ray and microcomputed tomography imaging.

Dosimetric and geometric end-to-end accuracy of a magnetic resonance guided linear accelerator

The introduction of real-time imaging by magnetic resonance guided linear accelerators (MR-Linacs) enabled adaptive treatments and gating on the tumor position. Different end-to-end tests monitored the accuracy of our MR-Linac during the first year of clinical operation. We report on the stability of these tests covering a static, adaptive and gating workflow. Film measurements showed gamma passing rates of 96.4% ± 3.4% for the static tests (five measurements) and for the two adaptive tests 98.9% and 99.99%, respectively (criterion 2%/2mm). The gated point dose measurements in the breathing phantom were 2.7% lower than in the static phantom.

Combination of dual-energy computed tomography and iterative metal artefact reduction to increase general quality of imaging for radiotherapy patients with high dense materials. Phantom study

PURPOSE

To evaluate the use of pseudo-monoenergetic reconstructions (PMR) from dual-energy computed tomography, combined with the iterative metal artefact reduction (iMAR) method.

METHODS

Pseudo-monoenergetic CT images were obtained using the dual-energy mode on the Siemens Somatom Definition AS scanner. A range of PMR combinations (70-130 keV) were used with and without iMAR. A Virtual Water™ phantom was used for quantitative assessment of error in the presence of high density materials: titanium, alloys 330 and 600. The absolute values of CT number differences (AD) and normalised standard deviations (NSD) were calculated for different phantom positions. Image quality was assessed using an anthropomorphic pelvic phantom with an embedded hip prosthesis. Image quality was scored blindly by five observers.

RESULTS

AD and NSD values revealed differences in CT number errors between tested sets. AD and NSD were reduced in the vicinity of metal for images with iMAR (p < 0.001 for AD/NSD). For ROIs away from metal, with and without iMAR, 70 keV PMR and pCT AD values were lower than for the other reconstructions (p = 0.039). Similarly, iMAR NSD values measured away from metal were lower for 130 keV and 70 keV PMR (p = 0.002). Image quality scores were higher for 70 keV and 130 keV PMR with iMAR (p = 0.034).

CONCLUSION

The use of 70 keV PMR with iMAR allows for significant metal artefact reduction and low CT number errors observed in the vicinity of dense materials. It is therefore an attractive alternative to high keV imaging when imaging patients with metallic implants, especially in the context of radiotherapy planning.

Development of patient-specific 3D-printed breast phantom using silicone and peanut oils for magnetic resonance imaging

Background

Despite increasing reports of 3D printing in medical applications, the use of 3D printing in breast imaging is limited, thus, personalized 3D-printed breast model could be a novel approach to overcome current limitations in utilizing breast magnetic resonance imaging (MRI) for quantitative assessment of breast density. The aim of this study is to develop a patient-specific 3D-printed breast phantom and to identify the most appropriate materials for simulating the MR imaging characteristics of fibroglandular and adipose tissues.

Methods

A patient-specific 3D-printed breast model was generated using 3D-printing techniques for the construction of the hollow skin and fibroglandular region shells. Then, the T1 relaxation times of the five selected materials (agarose gel, silicone rubber with/without fish oil, silicone oil, and peanut oil) were measured on a 3T MRI system to determine the appropriate ones to represent the MR imaging characteristics of fibroglandular and adipose tissues. Results were then compared to the reference values of T1 relaxation times of the corresponding tissues: 1,324.42±167.63 and 449.27±26.09 ms, respectively. Finally, the materials that matched the T1 relaxation times of the respective tissues were used to fill the 3D-printed hollow breast shells.

Results

The silicone and peanut oils were found to closely resemble the T1 relaxation times and imaging characteristics of these two tissues, which are 1,515.8±105.5 and 405.4±15.1 ms, respectively. The agarose gel with different concentrations, ranging from 0.5 to 2.5 wt%, was found to have the longest T1 relaxation times.

Conclusions

A patient-specific 3D-printed breast phantom was successfully designed and constructed using silicone and peanut oils to simulate the MR imaging characteristics of fibroglandular and adipose tissues. The phantom can be used to investigate different MR breast imaging protocols for the quantitative assessment of breast density.

Development of a hybrid magnetic resonance/computed tomography-compatible phantom for magnetic resonance guided radiotherapy

The purpose of the present study was to develop a hybrid magnetic resonance/computed tomography (MR/CT)-compatible phantom and tissue-equivalent materials for each MR and CT image. Therefore, the essential requirements necessary for the development of a hybrid MR/CT-compatible phantom were determined and the development process is described. A total of 12 different tissue-equivalent materials for each MR and CT image were developed from chemical components. The uniformity of each sample was calculated. The developed phantom was designed to use 14 plugs that contained various tissue-equivalent materials. Measurement using the developed phantom was performed using a 3.0-T scanner with 32 channels and a Somatom Sensation 64. The maximum percentage difference of the signal intensity (SI) value on MR images after adding K2CO3 was 3.31%. Additionally, the uniformity of each tissue was evaluated by calculating the percent image uniformity (%PIU) of the MR image, which was 82.18 ±1.87% with 83% acceptance, and the average circular-shaped regions of interest (ROIs) on CT images for all samples were within ±5 Hounsfield units (HU). Also, dosimetric evaluation was performed. The percentage differences of each tissue-equivalent sample for average dose ranged from -0.76 to 0.21%. A hybrid MR/CT-compatible phantom for MR and CT was investigated as the first trial in this field of radiation oncology and medical physics.

A Systematic Review on 3D-Printed Imaging and Dosimetry Phantoms in Radiation Therapy

INTRODUCTION

Additive manufacturing or 3-dimensional printing has become a widespread technology with many applications in medicine. We have conducted a systematic review of its application in radiation oncology with a particular emphasis on the creation of phantoms for image quality assessment and radiation dosimetry. Traditionally used phantoms for quality assurance in radiotherapy are often constraint by simplified geometry and homogenous nature to perform imaging analysis or pretreatment dosimetric verification. Such phantoms are limited due to their ability in only representing the average human body, not only in proportion and radiation properties but also do not accommodate pathological features. These limiting factors restrict the patient-specific quality assurance process to verify image-guided positioning accuracy and/or dose accuracy in "water-like" condition.

METHODS AND RESULTS

English speaking manuscripts published since 2008 were searched in 5 databases (Google Scholar, Scopus, PubMed, IEEE Xplore, and Web of Science). A significant increase in publications over the 10 years was observed with imaging and dosimetry phantoms about the same total number (52 vs 50). Key features of additive manufacturing are the customization with creation of realistic pathology as well as the ability to vary density and as such contrast. Commonly used printing materials, such as polylactic acid, acrylonitrile butadiene styrene, high-impact polystyrene and many more, are utilized to achieve a wide range of achievable X-ray attenuation values from -1000 HU to 500 HU and higher. Not surprisingly, multimaterial printing using the polymer jetting technology is emerging as an important printing process with its ability to create heterogeneous phantoms for dosimetry in radiotherapy.

CONCLUSION

Given the flexibility and increasing availability and low cost of additive manufacturing, it can be expected that its applications for radiation medicine will continue to increase.

Persistent collection of antibiotic ointment masquerading as a lipoma arising at a surgical site

Antibiotic ointments are often used to treat or prevent infections in surgical wounds. However, due to a dearth of reports on adverse effects, the complications of the use of such ointments, especially possible long-term effects, are largely unknown. We experienced a unique case of a cystic lesion that developed after surgical site infection treated with gentamicin ointment in a 62-year-old man who underwent subtotal glossectomy for tongue cancer. The antibiotic ointment that was applied following abscess drainage remained there, replacing the abscess cavity and forming an oval mass. The lesion was found incidentally on follow-up MR examination to monitor cancer recurrence. On both T1- and T2-weighted images, it showed high-intensity reflecting oily base material, constituting the ointment, which appeared to be a fat-containing tumor such as a lipoma that had arisen at the surgical site. Echo-guided drainage extracted the ointment, which was seemingly unaltered from the time it was applied 11 months before. We describe the clinical course and imaging findings to acknowledge this potential adverse effect associated with topical antibiotic treatment for surgical site infection.

3D printing with MRI in pediatric applications

3D printing (3DP) applications for clinical evaluation, preoperative planning, patient and trainee education, and simulation has increased in the past decade. Most of the applications are found in cardiovascular, head and neck, orthopedic, neurological, urological, and oncological surgical cases. This review has three parts. The first part discusses the technical pathway to realizing a physical model, 3DP considerations in pediatric MRI image acquisition, data and resolution requirements, and related structural segmentation and postprocessing steps needed to generalize both virtual and physical models. Standard practices and processing software used in these processes will be assessed. The second part discusses complementary examples in pediatric applications, including cases from cardiology, neuroradiology, neurology, and neurosurgery, head and neck, orthopedics, pelvic and urological applications, oncological applications, and fetal imaging. The third part explores other 3D printing applications and considerations such as using 3DP to develop tissue-specific phantoms and devices for testing in the MR environment, to educate patients and their families, to train clinicians and students, and facility requirements for building a 3DP program. Level of Evidence: 5 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2020;51:1641-1658.

Absolute dosimetry with polymer gels-a TLD reference system

BACKGROUND AND PURPOSE

Absolute dosimetry in 3D with polymer gels (PG) is generally complicated and usually requires a second independent measurement with conventional detectors. This is why, PG are often used only for relative dosimetry. To overcome this drawback, we combine PG with a 1D thermoluminescence (TL) detector within the same measurement. The TL detector information is then used as additional information for calibration of the gel.

MATERIALS AND METHODS

The PAGAT dosimetry gel was used in combination with TLD600 (LiF:Mg,Ti). TL detectors were attached on the surface of the PG container placed inside a cylindrical phantom. To test the usability of this setup, two irradiation geometries were carried out: (a) homogeneous target coverage and (b) small-field irradiation. PG was evaluated with magnetic resonance imaging (MRI) and the TL detectors with a Harshaw 5500 hot gas reader.

RESULTS

PG dosimetry alone showed deviations of up to 4% as compared to calculations. Including additionally the dose information of the TL detectors for PG calibration, this deviation was decreased to less than 1% for both irradiation geometries. This is also reflected by the very high [Formula: see text]-passing rates of  >  96% (3%/3 mm) and  >93% (2%/2 mm), respectively.

CONCLUSION

This study presents a novel method combining 3D PG and TL dose measurements for the purpose of absolute 3D dose measurements that can also be applied in complex anthropomorphic phantoms using only a single measurement. The method was validated for two different irradiation geometries including a homogeneous large field as well as a small field irradiation with sharp dose gradients.

Development and evaluation of a novel MR-compatible pelvic end-to-end phantom

MR-only treatment planning and MR-IGRT leverage MRI's powerful soft tissue contrast for high-precision radiation therapy. However, anthropomorphic MR-compatible phantoms are currently limited. This work describes the development and evaluation of a custom-designed, modular, pelvic end-to-end (PETE) MR-compatible phantom to benchmark MR-only and MR-IGRT workflows. For construction considerations, subject data were assessed for phantom/skeletal geometry and internal organ kinematics to simulate average male pelvis anatomy. Various materials for the bone, bladder, and rectum were evaluated for utility within the phantom. Once constructed, PETE underwent CT-SIM, MR-Linac, and MR-SIM imaging to qualitatively assess organ visibility. Scans were acquired with various bladder and rectal volumes to assess component interactions, filling capabilities, and filling reproducibility via volume and centroid differences. PETE simulates average male pelvis anatomy and comprises an acrylic body oval (height/width = 23.0/38.1 cm) and a cast-mold urethane skeleton, with silicone balloons simulating bladder and rectum, a silicone sponge prostate, and hydrophilic poly(vinyl alcohol) foam to simulate fat/tissue separation between organs. Access ports enable retrofitting the phantom with other inserts including point/film-based dosimetry options. Acceptable contrast was achievable in CT-SIM and MR-Linac images. However, the bladder was challenging to distinguish from background in CT-SIM. The desired contrast for T1-weighted and T2-weighted MR-SIM (dark and bright bladders, respectively) was achieved. Rectum and bone exhibited no MR signal. Inputted volumes differed by <5 and <10 mL from delineated rectum (CT-SIM) and bladder (MR-SIM) volumes. Increasing bladder and rectal volumes induced organ displacements and shape variations. Reproduced volumes differed by <4.5 mL, with centroid displacements <1.4 mm. A point dose measurement with an MR-compatible ion chamber in an MR-Linac was within 1.5% of expected. A novel, modular phantom was developed with suitable materials and properties that accurately and reproducibly simulate status changes with multiple dosimetry options. Future work includes integrating more realistic organ models to further expand phantom options.

Fabrication of an anthropomorphic heterogeneous mouse phantom for multimodality medical imaging

This work presents a comprehensive methodology for constructing a tissue equivalent mouse phantom using image modeling and 3D printing technology. The phantom can be used in multimodality imaging and irradiation experiments, quality control, and management. Computed tomography (CT) images of a mouse were acquired and imported into 3D modeling software. A skeleton and skin shell models were segmented in the modeling software and manufactured using 3D printing technology. The bone model was constructed with VERO-WHITE printing material with additional ingredients, including a photosensitive resin, polyurethane epoxy resin, and acrylate. Acrylonitrile butadiene styrene resin material was used to construct the skin shell. The skin shell was attached to the skeleton and filled with a specially formulated gel to act as a soft tissue substitute. The gel consisted of agarose, micro-pearl powder, sodium chloride, and magnevist solution (gadopentetate dimeglumine). A micro-container filled with ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) radioactive tracer was placed in the abdomen for micro and human positron emission tomography (PET)/CT imaging. The mouse phantom had tissue equivalency in dose attenuation with x-rays and relaxation times with magnetic resonance imaging (MRI). The CT Hounsfield Unit (HU) range for the gel soft tissue material was 31-36 HU. The 3D printed bone mimetic material had equivalent tissue/bone contrast compared with in vivo mouse measurements with a mean value of 130  ±  10 HU. At different magnetic field strengths, the T ₁ relaxation time of the soft tissue was 382.75-506.48 ms, and T ₂ was 51.11-70.76 ms. ¹⁸F-FDG tracer could be clearly observed in PET imaging. The 3D printed mouse phantom was successfully constructed with tissue-equivalent materials. Our model can be used for CT, MRI, and PET as a standard device for small-animal imaging and quality control.

Recent advances on the development of phantoms using 3D printing for imaging with CT, MRI, PET, SPECT, and ultrasound

PURPOSE

Printing technology, capable of producing three-dimensional (3D) objects, has evolved in recent years and provides potential for developing reproducible and sophisticated physical phantoms. 3D printing technology can help rapidly develop relatively low cost phantoms with appropriate complexities, which are useful in imaging or dosimetry measurements. The need for more realistic phantoms is emerging since imaging systems are now capable of acquiring multimodal and multiparametric data. This review addresses three main questions about the 3D printers currently in use, and their produced materials. The first question investigates whether the resolution of 3D printers is sufficient for existing imaging technologies. The second question explores if the materials of 3D-printed phantoms can produce realistic images representing various tissues and organs as taken by different imaging modalities such as computer tomography (CT), positron emission tomography (PET), single-photon emission computed tomography (SPECT), magnetic resonance imaging (MRI), ultrasound (US), and mammography. The emergence of multimodal imaging increases the need for phantoms that can be scanned using different imaging modalities. The third question probes the feasibility and easiness of "printing" radioactive or nonradioactive solutions during the printing process.

METHODS

A systematic review of medical imaging studies published after January 2013 is performed using strict inclusion criteria. The databases used were Scopus and Web of Knowledge with specific search terms. In total, 139 papers were identified; however, only 50 were classified as relevant for this paper. In this review, following an appropriate introduction and literature research strategy, all 50 articles are presented in detail. A summary of tables and example figures of the most recent advances in 3D printing for the purposes of phantoms across different imaging modalities are provided.

RESULTS

All 50 studies printed and scanned phantoms in either CT, PET, SPECT, mammography, MRI, and US-or a combination of those modalities. According to the literature, different parameters were evaluated depending on the imaging modality used. Almost all papers evaluated more than two parameters, with the most common being Hounsfield units, density, attenuation and speed of sound.

CONCLUSIONS

The development of this field is rapidly evolving and becoming more refined. There is potential to reach the ultimate goal of using 3D phantoms to get feedback on imaging scanners and reconstruction algorithms more regularly. Although the development of imaging phantoms is evident, there are still some limitations to address: One of which is printing accuracy, due to the printer properties. Another limitation is the materials available to print: There are not enough materials to mimic all the tissue properties. For example, one material can mimic one property-such as the density of real tissue-but not any other property, like speed of sound or attenuation.

Developing and characterizing MR/CT-visible materials used in QA phantoms for MRgRT systems

PURPOSE

Synthetic tissue equivalent (STE) materials currently used to simulate tumor and surrounding tissues for IROC-Houston's anthropomorphic head and thorax QA phantoms cannot be visualized using magnetic resonance (MR) imaging. The purpose of this study was to characterize dual MR/CT-visible STE materials that can be used in an end-to-end QA phantom for MR-guided radiotherapy (MRgRT) modalities.

METHODS

Over 80 materials' MR, CT, and dosimetric STE properties were investigated for use in MRgRT QA phantoms. The materials tested included homogeneous and heterogeneous materials to simulate soft tissue/tumor and lung tissues. Materials were scanned on a Siemens' Magnetom Espree 1.5 T using four sequences, which showed the materials visual contrast between T1- and T2-weighted images. Each material's Hounsfield number and electron density data was collected using a GE's CT Lightspeed Simulator. Dosimetric properties were examined by constructing a 10 × 10 × 20 cm³ phantom of the selected STE materials that was divided into three sections: anterior, middle, and posterior. Anterior and posterior pieces were composed of polystyrene, whereas the middle section was substituted with the selected STE materials. EBT3 film was inserted into the phantom's midline and was irradiated using an Elekta's Versa 6 MV beam with a prescription of 6 Gy at 1.5 cm and varying field size of: 10 × 10 cm² , 6 × 6 cm² , and 3 × 3 cm² . Measured film PDD curves were compared to planning system calculations and conventional STE materials' percent depth dose (PDD) curves.

RESULTS

The majority of the tested materials showed comparable CT attenuation properties to their respective organ site; however, most of the tested materials were not visible on either T1- or T2-weighted MR images. Silicone, hydrocarbon, synthetic gelatin, and liquid PVC plastic-based materials showed good MR image contrast. In-house lung equivalent materials made with either silicone- or hydrocarbon-based materials had HUs ranging from: -978 to -117 and -667 to -593, respectively. Synthetic gelatin and PVC plastic-based materials resembled soft tissue/tumor equivalent materials and had HUs of: -175 to -170 and -29 to 32, respectively. PDD curves of the selected MR/CT-visible materials were comparable to IROC-Houston's conventional phantom STE materials. The smallest field size showed the largest disagreements, where the average discrepancies between calculated and measured PDD curves were 1.8% and 5.9% for homogeneous and heterogeneous testing materials, respectively.

CONCLUSIONS

Gelatin, liquid plastic, and hydrocarbon-based materials were determined as alternative STE substitutes for MRgRT QA phantoms.