Daily Megavoltage Computed Tomography Images Research Articles

Reproducibility and Repeatability of Pelvic Radiomics Features with Daily Imaging on a Novel Biology-Guided Radiotherapy Machine Compared to Daily Imaging on Other Radiotherapy Delivery Systems

Radiomics features extracted from computed tomography (CT) images have the potential of being used as imaging biomarkers in diagnostic and prognostic models for prostate cancer. This study aims to evaluate reproducibility and repeatability of radiomics features using daily CT images from a novel biology-guided radiotherapy (BgRT)-capable machine compared to other daily CT imaging modalities from other radiotherapy delivery systems. We retrospectively selected thirty male patients treated to the pelvic region at our institution. Among the thirty patients, ten patients were treated on a BgRT-capable machine with daily fan-beam kilovoltage CT (kVCT) scans, ten patients were treated on a conventional Linac with daily cone-beam CT (CBCT) scans, and ten patients were treated on helical tomotherapy with daily megavoltage CT (MVCT) scans. The prostate gland and femoral heads were delineated on planning CT images and on CT images at the first treatment fraction. After all the CT images were resampled to have an identical voxel size, 107 radiomics features were calculated for the prostate and femoral heads on both the planning CT images and daily CT images. Concordance correlation coefficient (CCC) and Pearson's correlation coefficient (r) were calculated to evaluate radiomics feature reproducibility between the planning CT images and pre-treatment CT scans at the first treatment fraction. To evaluate radiomics feature repeatability with kVCT images on the BgRT-capable machine, a total of ten treatment sessions with repeat kVCT scans on the BgRT-capable machine were retrieved and radiomics features were compared between the first and the second kVCT scans. For the prostate gland volume, high concordance (CCC > 0.8) was found for 8, 6, and 0 radiomics features with the first-fraction kVCT, CBCT, and MVCT images, respectively, in relation to the planning CT images, while there was strong correlation (r > 0.8) in 38, 22, and 5 radiomics features in the kVCT, CBCT, and MVCT images, respectively, in relation to the planning CT images. For the left and right femoral heads, high concordance (CCC > 0.8) was found in no more than two radiomics features with the kVCT, CBCT, or MVCT images in relation to the planning CT images. Based on repeat kVCT scan data, 97 (90.7%) radiomics features showed high concordance (CCC > 0.8) in repeat kVCT scans with 98 (91.6%) features showing high correlation (Pearson's correlation coefficient > 0.8) for the prostate gland volume. A small number of radiomics features were found to show strong reproducibility between daily CT images on the first fraction and the planning CT images with the three IGRT CT modalities in this study. On the other hand, our results indicated that strong reproducibility was found with more radiomics features with daily kVCT images from the BgRT-capable machine compared to daily CBCT and MVCT images for the prostate gland. Strong repeatability was also found with most radiomics features in daily kVCT images.

Feasibility of artificial intelligence-driven interfractional monitoring of organ changes by mega-voltage computed tomography in intensity-modulated radiotherapy of prostate cancer.

High-dose radiotherapy (RT) for localized prostate cancer requires careful consideration of target position changes and adjacent organs-at-risk (OARs), such as the rectum and bladder. Therefore, daily monitoring of target position and OAR changes is crucial in minimizing interfractional dosimetric uncertainties. For efficient monitoring of the internal condition of patients, we assessed the feasibility of an auto-segmentation of OARs on the daily acquired images, such as megavoltage computed tomography (MVCT), via a commercial artificial intelligence (AI)-based solution in this study. We collected MVCT images weekly during the entire course of RT for 100 prostate cancer patients treated with the helical TomoTherapy system. Based on the manually contoured body outline, the bladder including prostate area, and rectal balloon regions for the 100 MVCT images, we trained the commercially available fully convolutional (FC)-DenseNet model and tested its auto-contouring performance. Based on the optimally determined hyperparameters, the FC-DenseNet model successfully auto-contoured all regions of interest showing high dice similarity coefficient (DSC) over 0.8 and a small mean surface distance (MSD) within 1.43 mm in reference to the manually contoured data. With this well-trained AI model, we have efficiently monitored the patient's internal condition through six MVCT scans, analyzing DSC, MSD, centroid, and volume differences. We have verified the feasibility of utilizing a commercial AI-based model for auto-segmentation with low-quality daily MVCT images. In the future, we will establish a fast and accurate auto-segmentation and internal organ monitoring system for efficiently determining the time for adaptive replanning.

Acute toxicity of hypofractionated intensity-modulated radiotherapy for prostate cancer.

Dose-escalated hypofractionated radiotherapy (hfrt) using intensity-modulated radiotherapy (imrt), with inclusion of the pelvic lymph nodes (plns), plus androgen suppression therapy (ast) in high-risk prostate cancer patients should improve patient outcomes, but acute toxicity could limit its feasibility. Our single-centre phase ii prospective study enrolled 40 high-risk prostate cancer patients. All patients received hfrt using imrt with daily mega-voltage computed tomography imaging guidance, with 95% of planning target volumes (ptv68 and ptv50) receiving 68 Gy and 50 Gy (respectively) in 25 daily fractions. The boost volume was targeted to the involved plns and the prostate (minus the urethra plus 3 mm and minus 3 mm from adjacent rectal wall) and totalled up to 75 Gy in 25 fractions. Acute toxicity scores were recorded weekly during and 3 months after radiotherapy (rt) administration. For the 37 patients who completed rt and the 3-month follow-up, median age was 65.5 years (range: 50-76 years). Disease was organ-confined (T1c-T2c) in 23 patients (62.1%), and node-positive in 5 patients (13.5%). All patients received long-term ast. Maximum acute genitourinary (gu) and gastrointestinal (gi) toxicity peaked at grade 2 in 6 of 36 evaluated patients (16.6%) and in 4 of 31 evaluated patients (12.9%) respectively. Diarrhea and urinary frequency were the chief complaints. Dose-volume parameters demonstrated no correlation with toxicity. The ptv treatment objectives were met in 36 of the 37 patients. This hfrt dose-escalation trial in high-risk prostate cancer has demonstrated the feasibility of administering 75 Gy in 25 fractions with minimal acute gi and gu toxicities. Further follow-up will report late toxicities and outcomes.

Assessment of Three-dimensional Set-up Errors using Megavoltage Computed Tomography (MVCT) during Image-guided Intensity-modulated Radiation Therapy (IMRT) for Craniospinal Irradiation (CSI) on Helical Tomotherapy (HT)

The purpose of this study was to assess three-dimensional (3D) set-up errors using megavoltage computed tomography (MVCT) during image-guided intensity-modulated radiation therapy (IMRT) for supine craniospinal irradiation (CSI) on helical tomotherapy (HT). Patients were immobilized in a customized 4-clamp thermoplastic head mask with or without whole-body vacuum cradle. Set-up was based primarily on a set of cranial fiducial markers. MVCT scans were acquired and co-registered with planning scan separately at three different levels (brain, upper, and lower spine) at every fraction. Only translational displacements were analysed, wherein positive sign denotes deviation in anterior, left, and superior direction; while negative sign denotes deviation in posterior, right, and inferior direction. Mean displacements, systematic, and random errors of the study population were calculated at all three levels separately. Local residual uncertainty of the upper and lower spine was also derived assuming perfect co-registration of the skull. Set-up margins for clinical target volume (CTV) to planning target volume (PTV) were derived at these three levels separately using published margin recipes. Data from 1868 co-registrations in 674 fractions on 33 patients was included. The mean displacements in the lateral, longitudinal, and vertical directions were -1.21, -1.36, and 1.38 mm; -1.25, -0.34, and 0.65 mm; and -1.47, -2.78, and 0.22 mm for the brain; upper spine; and lumbar spine respectively. The corresponding 3D vector of displacement was 2.28; 1.45; and 3.15 mm respectively. There was a distinct systematic trend towards increasing inaccuracy from the brain towards the lower spine. Using Stroom's formula, the minimum recommended CTV to PTV margins in absence of daily image-guidance were 6.5; 7.0; and 9.5 mm for the brain; upper spine; and lower spine respectively. This increased to 7.5; 8.5; and 11.5 mm using van Herk's formula. Subset and sensitivity analyses could not identify any factor predictive of increased inaccuracy. Residual uncertainty of the spinal column was lesser after daily co-registration referenced to the skull, suggesting that smaller set-up margins maybe appropriate while using daily image-guidance with an online correction protocol. Daily MVCT imaging during supine CSI on HT provides volumetric verification of the set-up process. There is substantial site-dependent variability in translational displacements that increases systematically from brain towards the lower spine with implications for differential set-up -margins for the brain, upper, and lower spine.

Daily setup uncertainty analysis for craniospinal irradiation using helical tomotherapy

PurposeSetup deviations of a craniospinal irradiation (CSI) patient cohort previously treated with helical tomotherapy were used to derive the optimal planning target volume (PTV) margin for CSI patients treated in the supine position. Methods and MaterialsThe daily setup shifts of 27 CSI tomotherapy patients as determined using pretreatment megavoltage computed tomography verification for a total of 454 fractions were evaluated. Translational displacements in the mediolateral (ML), craniocaudal (CC), and anteroposterior (AP) directions were used to assess the systematic and random setup errors, and to derive the PTV margin required when daily image guidance is unavailable. ResultsThe individual patient mean shifts and the corresponding standard deviations in the ML, CC, and AP directions were −0.5 ± 2.1 mm, 1.0 ± 2.7 mm, and 0.7 ± 1.1 mm, respectively. The random errors in the corresponding directions were 1.9 mm, 1.9 mm, and 2.2 mm. The PTV margins required in the absence of daily imaging were 3.7 mm to the right, 4.7 mm to the left, 4.4 mm inferior, 6.4 mm superior, 1.6 mm posterior, and 3.0 mm anterior. ConclusionsThe current PTV margin of 3.0 mm is sufficient to ensure clinical target volume coverage for CSI tomotherapy patients treated with daily megavoltage computed tomography imaging. When pretreatment verification imaging is not used to lower the setup uncertainty, a larger PTV margin of up to 6.4 mm in the CC direction will be needed.

Daily Megavoltage Computed Tomography in Lung Cancer Radiotherapy: Correlation Between Volumetric Changes and Local Outcome

To assess the predictive or comparative value of volumetric changes, measured on daily megavoltage computed tomography during radiotherapy for lung cancer. We included 80 patients with locally advanced non-small-cell lung cancer treated with image-guided intensity-modulated radiotherapy. The radiotherapy was combined with concurrent chemotherapy, combined with induction chemotherapy, or given as primary treatment. Patients entered two parallel studies with moderately hypofractionated radiotherapy. Tumor volume contouring was done on the daily acquired images. A regression coefficient was derived from the volumetric changes on megavoltage computed tomography, and its predictive value was validated. Logarithmic or polynomial fits were applied to the intratreatment changes to compare the different treatment schedules radiobiologically. Regardless of the treatment type, a high regression coefficient during radiotherapy predicted for a significantly prolonged cause-specific local progression free-survival (p = 0.05). Significant differences were found in the response during radiotherapy. The significant difference in volumetric treatment response between radiotherapy with concurrent chemotherapy and radiotherapy plus induction chemotherapy translated to a superior long-term local progression-free survival for concurrent chemotherapy (p = 0.03). An enhancement ratio of 1.3 was measured for the used platinum/taxane doublet in comparison with radiotherapy alone. Contouring on daily megavoltage computed tomography images during radiotherapy enabled us to predict the efficacy of a given treatment. The significant differences in volumetric response between treatment strategies makes it a possible tool for future schedule comparison.

Standard and Nonstandard Craniospinal Radiotherapy Using Helical TomoTherapy

To show the advantages of planning and delivering craniospinal radiotherapy with helical TomoTherapy (TomoTherapy Inc., Madison, WI) by presenting 4 cases treated at our institution. We first present a standard case of craniospinal irradiation in a patient with recurrent myxopapillary ependymoma (MPE) and follow this with 2 cases requiring differential dosing to multiple target volumes. One of these, a patient with recurrent medulloblastoma, required a lower dose to be delivered to the posterior fossa because the patient had been previously irradiated to the full dose, and the other required concurrent boosts to leptomeningeal metastases as part of his treatment for newly diagnosed MPE. The final case presented is a patient with pronounced scoliosis who required spinal irradiation for recurrent MPE. The four cases presented were planned and treated successfully with Helical Tomotherapy. Helical TomoTherapy delivers continuous arc-based intensity-modulated radiotherapy that gives high conformality and excellent dose homogeneity for the target volumes. Increased healthy tissue sparing is achieved at higher doses albeit at the expense of larger volumes of tissue receiving lower doses. Helical TomoTherapy allows for differential dosing of multiple targets, resulting in very elegant dose distributions. Daily megavoltage computed tomography imaging allows for precision of patient positioning, permitting a reduction in planning margins and increased healthy tissue sparing in comparison with standard techniques.

Image Guidance is Most Critical in the First Two Weeks for Patients Treated by Radiation Therapy for Head and Neck Cancer: Implications for Adaptive Radiotherapy

Daily Megavoltage computed tomography (MVCT) images are acquired at our institution as part of the patient setup for radiation therapy. The purpose of this study was to analyze temporal trends in the gross tumor volume (GTV) to better understand tumor remodeling secondary to radiation therapy for head and neck cancer. We used daily MVCT images from six patients with intact tumors involving the base of the tongue, oropharynx, nasopharynx, and/or hypopharynx to determine the changes in GTV and airway volumes throughout treatment. To assess the tissue changes to radiation therapy, the GTV was compared with the initial simulation images and systematically recontoured on weekly IGRT scans. Additionally, the volume of the oropharynx and hypopharynx was measured using several of the bony aspects of the head and neck as boundaries. These were chosen for consistency in contouring these volumes from week to week. In all cases it was necessary that the daily MV-CT images incorporated enough of the airway to make a measurement. Variables measured weekly included the volume of the GTV and the volume of the luminous airway. Graphical software was used to visually depict and analyze trends in volume changes. In all cases, the most pronounced losses in GTV (shrinkage) occurred in the first two weeks of treatment, after which time the response was markedly variable from patient to patient. Similarly, the airway volume in all of the patients increased during the first two weeks, but then could shrink again, stabilize, or continue to expand. The mean initial volumes of the GTV was 52.3 cc (range, 12.7 to 93.4 cc). The mean change in volume for the GTV over the first two weeks was 14.1 cc (range, 1.8 to 30.0 cc). This corresponded to a mean change of 1.0 cc daily over the first two weeks. On average, each patient's GTV shrank by approximately 23% (range of ΔV, +4.4% to -39%) during the first 2 weeks. During this time, the airway opened by 1.6 to 38.1 cc (relative ΔV of 8% to 580%). In contrast, documented changes in volume of both GTV and the airway slowed dramatically in the last four weeks of treatment at -7% and +7%, respectively. Our results confirm that tumor shrinkage during radiation therapy for head and neck cancer is a dynamic process. The greatest remodeling in GTV and adjacent tissues occur within the first two weeks. These results suggest that IGRT is most beneficial during this time. Additionally, adaptive planning may be most useful after the third week of treatment when changes in internal anatomy level off and stabilize.

A Comparison of Soft-Tissue Implanted Markers and Bony Anatomy Alignments for Image-Guided Treatments of Head-and-Neck Cancers

To compare the geometric alignments of soft-tissue implanted markers to the traditional bony-based alignments in head-and-neck cancers, on the basis of daily image guidance. Dosimetric impact of the two alignment techniques on target coverage is presented. A total of 330 retrospective alignments (5 patients) were performed on daily megavoltage computed tomography (MVCT) image sets using both alignment techniques. Intermarker distances were tracked for all fractions to assess marker interfractional stability. Using a deformable image registration algorithm, target cumulative doses were calculated according to generated shifts on daily MVCT image sets. Target D95 was used as a dosimetric endpoint to evaluate each alignment technique. Intermarker distances overall were stable, with a standard deviation of <1.5 mm for all fractions and no observed temporal trends. Differences in shift magnitudes between both alignment techniques were found to be statistically significant, with a maximum observed difference of 8 mm in a given direction. Evaluation of technique-specific dose coverage based on D95 of target clinical target volume and planning target volume shows small differences (within +/-5%) compared with the kilovoltage CT plan. The use of daily MVCT imaging demonstrates that implanted markers in oral tongue and soft-palate cancers are stable localization surrogates. Alignments based on implanted markers generate shifts comparable overall to the traditional bony-based alignment, with no observed systematic difference in magnitude or direction. The cumulative dosimetric impact on target clinical target volume and planning target volume coverage was found to be similar, despite large observed differences in daily alignment shifts between the two techniques.

Volumetric response analysis during chemoradiation as predictive tool for optimizing treatment strategy in locally advanced unresectable NSCLC

Purpose To study the feasibility of measuring volumetric changes in the primary tumor on megavoltage-computed tomography (MVCT) during chemoradiation and to examine the correlation with local response. Patients and methods Fifteen consecutive patients with stage III, inoperable, locally advanced non-small cell lung cancer (NSCLC) were treated in a prospective dose escalation study protocol of concurrent chemoradiation. They were monitored for acute toxicity and evaluated with daily MVCT imaging. The volumetric changes were fitted to a negative exponential resulting in a regression coefficient (RC). Local response evaluation was done with positron emission tomography using the radio-labeled glucose analogue F18 fluorodeoxyglucose (FDG-PET). Results The mean volume decrease (±standard deviation) was 73% (±18%). With a mean treatment time of 42 days this treatment schedule resulted in a mean decrease of 1.74%/day. Of the 13 evaluable patients seven developed a metabolic complete remission (MCR). The mean RC of the patients with MCR is 0.050 versus a mean RC of 0.023 in non-responders ( p = 0.0074). Using a proposed cut-off value for the RC of 0.03 80% of the non-responders will be detected correctly while misclassifying 16.4% of patients who will eventually achieve an MCR. The total cumulative percentage of esophageal grade 3 or more toxicity was 46.7%. Conclusion The RC derived from volumetric analysis of daily MVCT is prognostic and predictive for local response in patients treated with chemoradiation for a locally advanced NSCLC. Because this treatment schedule is toxic in nearly half of the patient population, MVCT is a tool in the implementation of patient-individualized treatment strategies.

Assessment of Parotid Gland Dose Changes During Head and Neck Cancer Radiotherapy Using Daily Megavoltage Computed Tomography and Deformable Image Registration

To analyze changes in parotid gland dose resulting from anatomic changes throughout a course of radiotherapy in a cohort of head-and-neck cancer patients. The study population consisted of 10 head-and-neck cancer patients treated definitively with intensity-modulated radiotherapy on a helical tomotherapy unit. A total of 330 daily megavoltage computed tomography images were retrospectively processed through a deformable image registration algorithm to be registered to the planning kilovoltage computed tomography images. The process resulted in deformed parotid contours and voxel mappings for both daily and accumulated dose-volume histogram calculations. The daily and cumulative dose deviations from the original treatment plan were analyzed. Correlations between dosimetric variations and anatomic changes were investigated. The daily parotid mean dose of the 10 patients differed from the plan dose by an average of 15%. At the end of the treatment, 3 of the 10 patients were estimated to have received a greater than 10% higher mean parotid dose than in the original plan (range, 13-42%), whereas the remaining 7 patients received doses that differed by less than 10% (range, -6-8%). The dose difference was correlated with a migration of the parotids toward the high-dose region. The use of deformable image registration techniques and daily megavoltage computed tomography imaging makes it possible to calculate daily and accumulated dose-volume histograms. Significant dose variations were observed as result of interfractional anatomic changes. These techniques enable the implementation of dose-adaptive radiotherapy.

Initial experience in treating lung cancer with helical tomotherapy

Helical tomotherapy is a new form of image-guided radiation therapy that combines features of a linear accelerator and a helical computed tomography (CT) scanner. Megavoltage CT (MVCT) data allow the verification and correction of patient setup on the couch by comparison and image registration with the kilovoltage CT multi-slice images used for treatment planning. An 84-year-old male patient with Stage III bulky non-small cell lung cancer was treated on a Hi-ART II tomotherapy unit. Daily MVCT imaging was useful for setup corrections and signaled the need to adapt the delivery plan when the patient’s anatomy changed significantly.