High-dose-rate Treatment Planning Research Articles

Treatment verification in high dose rate brachytherapy using a realistic 3D printed head phantom and an imaging panel

Even though High Dose Rate (HDR) brachytherapy has good treatment outcomes in different treatment sites, treatment verification is far from widely implemented because of a lack of easily available solutions. Previously it has been shown that an imaging panel (IP) near the patient can be used to determine treatment parameters such as the dwell time and source positions in a single material pelvic phantom. In this study we will use a heterogeneous head phantom to test this IP approach, and simulate common treatment errors to assess the sensitivity and specificity of the error-detecting capabilities of the IP. A heterogeneous head-phantom consisting of soft tissue and bone equivalent materials was 3D-printed to simulate a base of tongue treatment. An High Dose Rate treatment plan with 3 different catheters was used to simulate a treatment delivery, using dwell times ranging from 0.3 s to 4 s and inter-dwell distances of 2 mm. The IP was used to measure dwell times, positions and detect simulated errors. Measured dwell times and positions were used to calculate the delivered dose. Dwell times could be determined within 0.1 s. Source positions were measured with submillimeter accuracy in the plane of the IP, and average distance accuracy of 1.7 mm in three dimensions. All simulated treatment errors (catheter swap, catheter shift, afterloader errors) were detected. Dose calculations show slightly different distributions with the measured dwell positions and dwell times (gamma pass rate for 1 mm/1% of 96.5%). Using an IP, it was possible to verify the treatment in a realistic heterogeneous phantom and detect certain treatment errors.

Feasibility of magnetic resonance-only high-dose-rate surface brachytherapy for clinical application.

In this article, we investigate the feasibility of magnetic resonance (MR)-only imaging for high-dose-rate (HDR) surface brachytherapy (SABT). We examined whether a standard CT-based planning can be replaced with an MR-only planning. For this purpose, the MRI digitization and plan quality check processes were compared against the standard CT-based processes. A prospective clinical implementation of the MR-only planning was evaluated on a clinical data set. A pointwise encoding time reduction with radial acquisition (PETRA) sequence was optimized for visualization of Freiburg flap (FF) on MR images. MR and conventional CT images were acquired with a FF applicator (Elekta, Stockholm, Sweden) placed on the following phantoms: (1) flat styrofoam (FST), FF locked-in placed with supporting structure; (2) cast-made facemask, and (3) porcine leg (PL). Catheters were digitized and activated with 10mm step size on Oncentra Brachy 4.5.3 Treatment Planning System. The CT-only and MR-only treatment plans were generated by optimizing the dose to the target defined as volume at 3mm skin depth. To compare the plans, the MRI-to-CT alignment was performed via rigid registration. Positional displacements of dwell positions between CT and MR plans were compared on the FST phantom and the relative percent dose difference in 2210 different points from CT or MR-only plans was compared. For all three phantoms, the comparabilities between CT and MR-only plans were assessed by calculating dice similarity coefficient (DSC) for volumes enclosing 150%, 125%, 100%, 95%, 90%, 80%, and 65% isodose lines (V150 -V65 ). The MR images of FF placed on the forearm of a healthy subject were acquired with this optimized PETRA sequence and used for treatment planning. The relative percent dose was calculated on 140 representative points placed at 3mm skin depth to evaluate the dose to the skin. Using the optimized PETRA sequence, MRTP digitization accuracy was<1mm in each dimension and on three-dimensional (3D) displacement for the FST phantom. In each phantom and clinical data set, it was possible to generate MR-only treatment plans with the 3mm skin depth prescription. In the FST phantom, the mean relative dose at the points was not significantly different(<0.1% difference) for CT or MR-based plans. The assessment of similarities in dose profiles between CT and MR-only plans' provided DSC values greater than 0.96, 0.92, and 0.73 for all volumes enclosing up to 100%, 125%, and 150% isodose lines, respectively. The feasibility of generating a HDR treatment plan with FF using MR-only has been evaluated in phantoms with varying geometry and for a clinical data set. The optimization of a standard MRI sequence-PETRA-implemented in this study showed that FF-based catheters can be digitized and a plan can be generated using only MRI. The resulting MR-only plans were comparable to the conventional CT-based plans, suggesting that MRI alone can generate clinically acceptable plans for FF in phantoms and on a clinical data set. Reliable MR-only treatment planning could improve treatment prescription through more accurate characterization of soft tissue targets.

Catheter position prediction using deep-learning-based multi-atlas registration for high-dose rate prostate brachytherapy.

High-dose-rate (HDR) prostate brachytherapy involves treatment catheter placement, which is currently empirical and physician dependent. The lack of proper catheter placement guidance during the procedure has left the physicians to rely on a heuristic thinking-while-doing technique, which may cause large catheter placement variation and increased plan quality uncertainty. Therefore, the achievable dose distribution could not be quantified prior to the catheter placement. To overcome this challenge, we proposed a learning-based method to provide HDR catheter placement guidance for prostate cancer patients undergoing HDR brachytherapy. The proposed framework consists of deformable registration via registration network (Reg-Net), multi-atlas ranking, and catheter regression. To model the global spatial relationship among multiple organs, binary masks of the prostate and organs-at-risk are transformed into distance maps, which describe the distance of each local voxel to the organ surfaces. For a new patient, the generated distance map is used as fixed image. Reg-Net is utilized to deformably register the distance maps from multi-atlas set to match this patient's distance map and then bring catheter maps from multi-atlas to this patient via spatial transformation. Several criteria, namely prostate volume similarity, multi-organ semantic image similarity, and catheter position criteria (far from the urethra and within the partial prostate), are used for multi-atlas ranking. The top-ranked atlas' deformed catheter positions are selected as the predicted catheter positions for this patient. Finally, catheter regression is used to refine the final catheter positions. A retrospective study on 90 patients with a fivefold cross-validation scheme was used to evaluate the proposed method's feasibility. In order to investigate the impact of plan quality from the predicted catheter pattern, we optimized the source dwell position and time for both the clinical catheter pattern and predicted catheter pattern with the same optimization settings. Comparisons of clinically relevant dose volume histogram (DVH) metrics were completed. For all patients, on average, both the clinical plan dose and predicted plan dose meet the common dose constraints when prostate dose coverage is kept at V100=95%. The plans from the predicted catheter pattern have slightly higher hotspot in terms of V150 by 5.0% and V200 by 2.9% on average. For bladder V75, rectum V75, and urethra V125, the average difference is close to zero, and the range of most patients is within ±1 cc. We developed a new catheter placement prediction method for HDR prostate brachytherapy based on a deep-learning-based multi-atlas registration algorithm. It has great clinical potential since it can provide catheter location estimation prior to catheter placement, which could reduce the dependence on physicians' experience in catheter implantation and improve the quality of prostate HDR treatment plans. This approach merits further clinical evaluation and validation as a method of quality control for HDR prostate brachytherapy.

The combined use of 2D scout and 3D axial CT images to accurately determine thecathetertips for high-dose-rate brachytherapy plans.

PurposeTo develop a method combining CT scout images with axial images to improve the localization accuracy of catheter tips in high‐dose‐rate (HDR) brachytherapy treatments.Materials and MethodsCT scout images were utilized along with conventionally reconstructed axial images to aid the localization of catheter tips used during HDR treatment planning. A method was developed to take advantage of the finer image resolution of the scout images to more precisely identify the tip coordinates. The accuracies of this method were compared with the conventional method based on the axial CT images alone, for various slice thicknesses, in a computed tomography dose index (CTDI) head phantom. A clinical case which involved multiple interstitial catheters was also selected for the evaluation of this method. Locations of the catheter tips were reconstructed with the conventional CT‐based method and this newly developed method, respectively. Location coordinates obtained via both methods were quantitatively compared.ResultsCombination of the scout and axial CT images improved the accuracy of identification and reconstruction of catheter tips along the longitudinal direction (i.e., head‐to‐foot direction, more or less parallel to the catheter tracks), compared to relying on the axial CT images alone. The degree of improvement was dependent on CT slice thickness. For the clinical patient case, the coordinate differences of the reconstructed catheter tips were 2.6 mm ± 0.9 mm in the head‐to‐foot direction, 0.4 mm ± 0.2 mm in the left‐to‐right direction, and 0.6 mm ± 0.2 mm in the anterior‐to‐posterior direction, respectively.ConclusionCombining CT scout and axial images demonstrates the ability to provide a more accurate identification and reconstruction of the interstitial catheter tips for HDR brachytherapy treatment, especially in the longitudinal direction. The method developed in this work has the potential to be implemented clinically together with automatic segmentation in modern brachytherapy treatment planning systems, in order to improve the reconstruction accuracy of HDR catheters.

Impact of High-Dose-Rate Brachytherapy Training via Telehealth in Low- and Middle-Income Countries.

PURPOSEOur objective was to demonstrate the efficacy of a telehealth training course on high-dose-rate (HDR) brachytherapy for gynecologic cancer treatment for clinicians in low- and middle-income countries (LMICs)METHODSA 12-week course consisting of 16 live video sessions was offered to 10 cancer centers in the Middle East, Africa, and Nepal. A total of 46 participants joined the course, and 22 participants, on average, attended each session. Radiation oncologists and medical physicists from 11 US and international institutions prepared and provided lectures for each topic covered in the course. Confidence surveys of 15 practical competencies were administered to participants before and after the course. Competencies focused on HDR commissioning, shielding, treatment planning, radiobiology, and applicators. Pre- and post-program surveys of provider confidence, measured by 5-point Likert scale, were administered and compared.RESULTSForty-six participants, including seven chief medical physicists, 16 senior medical physicists, five radiation oncologists, and three dosimetrists, representing nine countries attended education sessions. Reported confidence scores, both aggregate and paired, demonstrated increases in confidence in all 15 competencies. Post-curriculum score improvement was statistically significant (P < .05) for paired respondents in 11 of 15 domains. Absolute improvements were largest for confidence in applicator commissioning (2.3 to 3.8, P = .009), treatment planning system commissioning (2.2 to 3.9, P = .0055), and commissioning an HDR machine (2.2 to 4.0, P = .0031). Overall confidence in providing HDR brachytherapy services safely and teaching other providers increased from 3.1 to 3.8 and 3.0 to 3.5, respectively.CONCLUSIONA 12-week, low-cost telehealth training program on HDR brachytherapy improved confidence in treatment delivery and teaching for clinicians in 10 participating LMICs.

Automatic multi‐catheter detection using deeply supervised convolutional neural network in MRI‐guided HDR prostate brachytherapy

High-dose-rate (HDR) brachytherapy is an established technique to be used as monotherapy option or focal boost in conjunction with external beam radiation therapy (EBRT) for treating prostate cancer. Radiation source path reconstruction is a critical procedure in HDR treatment planning. Manually identifying the source path is labor intensive and time inefficient. In recent years, magnetic resonance imaging (MRI) has become a valuable imaging modality for image-guided HDR prostate brachytherapy due to its superb soft-tissue contrast for target delineation and normal tissue contouring. The purpose of this study is to investigate a deep-learning-based method to automatically reconstruct multiple catheters in MRI for prostate cancer HDR brachytherapy treatment planning. Attention gated U-Net incorporated with total variation (TV) regularization model was developed for multi-catheter segmentation in MRI. The attention gates were used to improve the accuracy of identifying small catheter points, while TV regularization was adopted to encode the natural spatial continuity of catheters into the model. The model was trained using the binary catheter annotation images offered by experienced physicists as ground truth paired with original MRI images. After the network was trained, MR images of a new prostate cancer patient receiving HDR brachytherapy were fed into the model to predict the locations and shapes of all the catheters. Quantitative assessments of our proposed method were based on catheter shaft and tip errors compared to the ground truth. Our method detected 299 catheters from 20 patients receiving HDR prostate brachytherapy with a catheter tip error of 0.37±1.68mm and a catheter shaft error of 0.93±0.50mm. For detection of catheter tips, our method resulted in 87% of the catheter tips within an error of less than±2.0mm, and more than 71% of the tips can be localized within an absolute error of no >1.0mm. For catheter shaft localization, 97% of catheters were detected with an error of <2.0mm, while 63% were within 1.0mm. In this study, we proposed a novel multi-catheter detection method to precisely localize the tips and shafts of catheters in three-dimensional MRI images of HDR prostate brachytherapy. It paves the way for elevating the quality and outcome of MRI-guided HDR prostate brachytherapy.

Fast and fully-automated multi-criterial treatment planning for adaptive HDR brachytherapy for locally advanced cervical cancer

PurposeTo develop and evaluate a fast, automated multi-criterial treatment planning approach for adaptive high-dose-rate (HDR) intracavitary + interstitial brachytherapy (BT) for locally advanced cervical cancer. Methods and materialsTwenty-two previously delivered single fraction MRI-based HDR treatment plans (SFclin) were used to guide training of our in-house system for multi-criterial autoplanning, aiming for an autoplan quality superior to the training plans, while respecting the clinically desired “pear-shaped” dose distribution. Next, the configured algorithm was used to automatically generate treatment plans for 63 other fractions (SFauto). The SFauto plans were compared to the corresponding SFclin plans in blind pairwise comparisons by an expert clinician. Then, the effect of adaptive autoplanning on total treatment (TT) plans (external beam + 3 BT fractions) was evaluated for 16 patients by simulating the clinically applied adaptive strategy to generate TTauto plans and compare them with the corresponding clinical treatments (TTclin). ResultsIn the blind comparisons, all SFauto plans were considered clinically acceptable. In 62/63 comparisons, SFauto plans were considered at least as good as, or better than the corresponding SFclin. The average optimization time for autoplanning was 20.5 ± 19.2 s (range 4.4–106.4 s) per plan. In 14 of 16 TTauto plans, the desired total dose of 90 Gy (EQD2) was obtained, compared to only 9 in the corresponding TTclin, while autoplanning also decreased bladder and rectum doses. ConclusionsFast, fully-automated multi-criterial treatment planning for adaptive HDR-BT for locally advanced cervical cancer is feasible. Autoplans were superior to corresponding clinical plans.

BrachyView: initial preclinical results for a real-time in-body HDR PBT source tracking system with simultaneous TRUS image fusion

A prototype in-body gamma camera system with integrated trans-rectal ultrasound (TRUS) and associated real-time image acquisition and analysis software was developed for intraoperative source tracking in high dose rate (HDR) brachytherapy. The accuracy and temporal resolution of the system was validated experimentally using a deformable tissue-equivalent prostate gel phantom and a full clinical HDR treatment plan. The BrachyView system was able to measure 78% of the 200 source positions with an accuracy of better than 1 mm. A minimum acquisition time of 0.28 s/frame was required to achieve this accuracy, restricting dwell times to a minimum of 0.3 s. Additionally, the performance of the BrachyView-TRUS fusion probe for mapping the spatial location of the tracked source within the prostate volume was evaluated. A global coordinate system was defined by scanning the phantom with the probe in situ using a CT scanner, and was subsequently used for co-registration of the BrachyView and TRUS fields of view (FoVs). TRUS imaging was used to segment the prostate volume and reconstruct it into a three-dimensional (3D) image. Fusion of the estimated source locations with the 3D prostate image was performed using integrated 3D visualisation software. HDR BrachyView is demonstrated to be a valuable tool for intraoperative source tracking in HDR brachytherapy, capable of resolving source dwell locations relative to the prostate anatomy when combined with TRUS.

A multi-criteria optimization approach for HDR prostate brachytherapy: II. Benchmark against clinical plans

The current iterative approach to inverse planning of high dose rate treatment planning can be time consuming. The purpose of this two-part study is to streamline the planning process while maintaining plan quality. In this second part, a multi-criteria optimization (MCO) planning algorithm is proposed and benchmarked against a standard planning algorithm.With a set of previously established regression models, a patient-specific valid solution space on the Pareto surface was predicted based on the anchor plans results. Alternative plans generated alongside the partial Pareto front were presented to the planner, and one plan was selected as the MCO plan. The dosimetric parameters results as well as the planning time were compared between the MCO plans and the physician-approved standard plans for 236 prostate cases.Results show that the urethra is better spared with MCO planning than with standard planning (a lower mean urethral D10 value of 2.25%). The overall MCO plan quality also outperforms the standard plan quality, since MCO planning is able to increase the frequency of clinically acceptable plans meeting all of RTOG criteria simultaneously without any human intervention (from 83.05% to 97.46%). Finally, the average MCO planning time is without any interventions of treatment planners.The presented MCO planning algorithm constitutes a robust and automated way to improve treatment quality in brachytherapy.

Dosimetric assessment of an air-filled balloon applicator in HDR vaginal cuff brachytherapy using the Monte Carlo method.

PurposeAs an alternative to cylindrical applicators, air‐inflated balloon applicators have been introduced into high‐dose‐rate (HDR) vaginal cuff brachytherapy to achieve sufficient dose to the vagina mucosa as well as to spare organs at risk, mainly the rectum and bladder. Commercial treatment planning systems which employ formulae in the AAPM Task Group No. 43 (TG 43) report do not take into account tissue inhomogeneity. Consequently, the low‐density air in a balloon applicator induces different doses delivered to the mucosa from planned by these planning systems. In this study, we investigated the dosimetric effects of the air in a balloon applicator using the Monte Carlo (MC) method.MethodsThe thirteen‐catheter Capri™ applicator by Varian™ for vaginal cuff brachytherapy was modeled together with the Ir‐192 radioactive source for the microSelectron™ Digital (HDR‐V3) afterloader by Elekta™ using the MCNP MC code. The validity of charged particle equilibrium (CPE) with an air balloon present was evaluated by comparing the kerma and the absorbed dose at various distances from the applicator surface. By comparing MC results with and without air cavity present, dosimetric effects of the air cavity were studied. Clinical patient cases with optimized multiple Ir‐192 source dwell positions were also explored. Four treatment plans by the Oncentra Brachy™ treatment planning system were re‐calculated with MCNP.Results CPE fails in the vicinity of the air‐water interface. One millimeter beyond the air‐water boundary the kerma and the absorbed dose are equal (0.2% difference), regardless of air cavity dimensions or iridium source locations in the balloon. The air cavity results in dose increase, due to less photon absorption in the air than in water or solid materials. The extent of the increase depends on the diameter of the air balloon. The average increment is 3.8%, 4.5% and 5.3% for 3.0, 3.5, and 4.0 cm applicators, respectively. In patient cases, the dose to the mucosa is also increased with the air cavity present. The point dose difference between Oncentra Brachy and MC at 5 mm prescription depth is 8% at most and 5% on average.ConclusionsExcept in the vicinity of the air‐mucosa interface, the dosimetric difference is not significant enough to mandate tissue inhomogeneity correction in HDR treatment planning.

SU‐F‐T‐55: Reproducibility of Interstitial HDR Brachytherapy Plans

Purpose:Treating gynecological cancers with interstitial high‐dose‐rate (HDR) brachytherapy requires precise reconstruction of catheter positions to obtain accurate dosimetric plans. In this study, we investigated the degree of reproducibility of dosimetric plans for Syed HDR brachytherapy.Methods:We randomly selected five patients having cervix‐vaginal cancer who were recently treated in our clinic with interstitial HDR brachytherapy with a prescription dose of 25–30 Gy in five fractions. Interstitial needles/catheters were placed under fluoroscopic guidance and intra‐operative 3T MRI scan was performed to confirm the desired catheter placement for adequate target volume coverage. A CT scan was performed and fused with the MRI for delineating high‐risk CTV (HR‐CTV), intermediate‐risk CTV (IR‐CTV) and OARs. HDR treatment plans were generated using Oncentra planning software. A single plan was used for all five fractions of treatment for each patient. For this study, we took the original clinical plan and removed all the reconstructed catheters from the plan keeping the original contours unchanged. Then, we manually reconstructed all the catheters and entered the same dwell time from the first original clinical plan. The dosimetric parameters studied were: D90 for HR‐CTV and IR‐CV, and D2cc for bladder, rectum, sigmoid and bowel.Results:The mean of absolute differences in dosimetric coverage (D90) were (range): 1.3% (1.0–2.0%) and 2.0% (0.9–3.6%) for HR‐CTV and IR‐CTV, respectively. In case of OARs, the mean of absolute variations in D2cc were (range): 4.7% (0.7–8.9%) for bladder, 1.60% (0.3–3.2%) for rectum, 1.6% (0–3.9%) for sigmoid, and 1.8% (0–5.1%) for bowel.Conclusion:Overall, the reproducibility of interstitial HDR plans was within clinically acceptable limit. Observed maximum variation in D2cc for bladder. If number of catchers and dwell points were relatively low or any one catheter was heavily loaded, then reproducibility of the plan was more sensitive to the accuracy of catheter reconstruction.

WE‐DE‐201‐02: A Statistical Analysis Tool for Plan Quality Verification in HDR Brachytherapy Forward Planning for Cervix Cancer

Purpose:High Dose Rate (HDR) brachytherapy forward planning is principally an iterative process; hence, plan quality is affected by planners’ experiences and limited planning time. Thus, this may lead to sporadic errors and inconsistencies in planning. A statistical tool based on previous approved clinical treatment plans would help to maintain the consistency of planning quality and improve the efficiency of second checking.Methods:An independent dose calculation tool was developed from commercial software. Thirty‐three previously approved cervical HDR plans with the same prescription dose (550cGy), applicator type, and treatment protocol were examined, and ICRU defined reference point doses (bladder, vaginal mucosa, rectum, and points A/B) along with dwell times were collected. Dose calculation tool then calculated appropriate range with a 95% confidence interval for each parameter obtained, which would be used as the benchmark for evaluation of those parameters in future HDR treatment plans. Model quality was verified using five randomly selected approved plans from the same dataset.Results:Dose variations appears to be larger at the reference point of bladder and mucosa as compared with rectum. Most reference point doses from verification plans fell between the predicted range, except the doses of two points of rectum and two points of reference position A (owing to rectal anatomical variations &amp; clinical adjustment in prescription points, respectively). Similar results were obtained for tandem and ring dwell times despite relatively larger uncertainties.Conclusion:This statistical tool provides an insight into clinically acceptable range of cervical HDR plans, which could be useful in plan checking and identifying potential planning errors, thus improving the consistency of plan quality.

Pretreatment verification of high dose rate brachytherapy plans using the ‘magic phantom’ system

High dose rate (HDR) brachytherapy treatments can be incorrectly administered to patients due to human error and equipment malfunction. While the incidence rates of these events are low, an additional redundancy check could include independent verification of the plan prior to treatment. This work describes the verification of six patient HDR treatment plans using the ‘magic phantom’ (MPh) silicon diode array, and a specialized HDR position-time gamma analysis criteria. The possibility of accelerated treatment plan verification is additionally investigated by reducing the prescription dose to shorten the total time needed for measurement. The MPh system was able to determine the measured dwell positions and times from the six patient plans to within 1.3 mm and 0.3 s, respectively. Using the position-time gamma analysis, the delivery of all measured patient plans were found to pass this metric with pass rates of 100%. The approach of decreasing prescription dose gave equal pass rates to the full dose plan when evaluated using the criteria. It was identified that the total time for treatment verification is dependent on the number of needles used, and that a substantial decrease in the total time for verification could be made by reducing the prescription dose for plans containing a low number of needles. The application of this method may have the ability to streamline pretreatment verification of the afterloader delivery within the clinical setting.

Prostate CT segmentation method based on nonrigid registration in ultrasound-guided CT-based HDR prostate brachytherapy.

The technological advances in real-time ultrasound image guidance for high-dose-rate (HDR) prostate brachytherapy have placed this treatment modality at the forefront of innovation in cancer radiotherapy. Prostate HDR treatment often involves placing the HDR catheters (needles) into the prostate gland under the transrectal ultrasound (TRUS) guidance, then generating a radiation treatment plan based on CT prostate images, and subsequently delivering high dose of radiation through these catheters. The main challenge for this HDR procedure is to accurately segment the prostate volume in the CT images for the radiation treatment planning. In this study, the authors propose a novel approach that integrates the prostate volume from 3D TRUS images into the treatment planning CT images to provide an accurate prostate delineation for prostate HDR treatment. The authors' approach requires acquisition of 3D TRUS prostate images in the operating room right after the HDR catheters are inserted, which takes 1-3 min. These TRUS images are used to create prostate contours. The HDR catheters are reconstructed from the intraoperative TRUS and postoperative CT images, and subsequently used as landmarks for the TRUS-CT image fusion. After TRUS-CT fusion, the TRUS-based prostate volume is deformed to the CT images for treatment planning. This method was first validated with a prostate-phantom study. In addition, a pilot study of ten patients undergoing HDR prostate brachytherapy was conducted to test its clinical feasibility. The accuracy of their approach was assessed through the locations of three implanted fiducial (gold) markers, as well as T2-weighted MR prostate images of patients. For the phantom study, the target registration error (TRE) of gold-markers was 0.41 ± 0.11 mm. For the ten patients, the TRE of gold markers was 1.18 ± 0.26 mm; the prostate volume difference between the authors' approach and the MRI-based volume was 7.28% ± 0.86%, and the prostate volume Dice overlap coefficient was 91.89% ± 1.19%. The authors have developed a novel approach to improve prostate contour utilizing intraoperative TRUS-based prostate volume in the CT-based prostate HDR treatment planning, demonstrated its clinical feasibility, and validated its accuracy with MRIs. The proposed segmentation method would improve prostate delineations, enable accurate dose planning and treatment delivery, and potentially enhance the treatment outcome of prostate HDR brachytherapy.

A New CT Prostate Segmentation for CT-Based HDR Brachytherapy.

High-dose-rate (HDR) brachytherapy has become a popular treatment modality for localized prostate cancer. Prostate HDR treatment involves placing 10 to 20 catheters (needles) into the prostate gland, and then delivering radiation dose to the cancerous regions through these catheters. These catheters are often inserted with transrectal ultrasound (TRUS) guidance and the HDR treatment plan is based on the CT images. The main challenge for CT-based HDR planning is to accurately segment prostate volume in CT images due to the poor soft tissue contrast and additional artifacts introduced by the catheters. To overcome these limitations, we propose a novel approach to segment the prostate in CT images through TRUS-CT deformable registration based on the catheter locations. In this approach, the HDR catheters are reconstructed from the intra-operative TRUS and planning CT images, and then used as landmarks for the TRUS-CT image registration. The prostate contour generated from the TRUS images captured during the ultrasound-guided HDR procedure was used to segment the prostate on the CT images through deformable registration. We conducted two studies. A prostate-phantom study demonstrated a submillimeter accuracy of our method. A pilot study of 5 prostate-cancer patients was conducted to further test its clinical feasibility. All patients had 3 gold markers implanted in the prostate that were used to evaluate the registration accuracy, as well as previous diagnostic MR images that were used as the gold standard to assess the prostate segmentation. For the 5 patients, the mean gold-marker displacement was 1.2 mm; the prostate volume difference between our approach and the MRI was 7.2%, and the Dice volume overlap was over 91%. Our proposed method could improve prostate delineation, enable accurate dose planning and delivery, and potentially enhance prostate HDR treatment outcome.

Evaluation of time, attendance of medical staff, and resources during interstitial brachytherapy for prostate cancer

The German Society of Radiation Oncology initiated a multicenter trial to evaluate core processes and subprocesses of radiotherapy by prospective evaluation of all important procedures in the most frequent malignancies treated by radiation therapy. The aim of this analysis was to assess the required resources for interstitial high-dose-rate (HDR) and low-dose-rate (LDR) prostate brachytherapy (BRT) based on actual time measurements regarding allocation of personnel and room occupation needed for specific procedures. Two radiotherapy centers (community hospital of Offenbach am Main and community hospital of Eschweiler) participated in this prospective study. Working time of the different occupational groups and room occupancies for the workflow of prostate BRT were recorded and methodically assessed during a 3-month period. For HDR and LDR BRT, a total of 560 and 92 measurements, respectively, were documented. The time needed for treatment preplanning was median 24min for HDR (n = 112 measurements) and 6min for LDR BRT (n = 21). Catheter implantation with intraoperative HDR real-time planning (n = 112), postimplantation HDR treatment planning (n = 112), and remotely controlled HDR afterloading irradiation (n = 112) required median 25, 39, and 50min, respectively. For LDR real-time planning (n = 39) and LDR treatment postplanning (n = 32), the assessed median duration was 91 and 11min, respectively. Room occupancy and overall mean medical staff times were 194 and 910min respectively, for HDR, and 113 and 371min, respectively, for LDR BRT. In this prospective analysis, the resource requirements for the application of HDR and LDR BRT of prostate cancer were assessed methodically and are presented for first time.

WE‐C‐WAB‐11: Improved the Accuracy of Prostate Delineation for Ultrasound‐Guided CT‐Based Treatment Planning in Prostate HDR Brachytherapy: A Pilot Study with MRI Validation

Purpose: In CT‐based prostate High‐Dose‐Rate (HDR) brachytherapy, catheter (needle) placement is commonly performed under the guidance of intra‐operative transrectal ultrasound (TRUS), while treatment planning is based on post‐operative CT images. The main challenge for CT‐based treatment planning is to accurately define target (prostate) volume in CT images due to the poor soft‐tissue contrast. To overcome this limitation, we propose a novel approach that integrates intra‐operative ultrasound‐based prostate volume into treatment planning through TRUS‐CT fusion based on the catheter locations. Methods: Our approach requires acquisition of 3D TRUS prostate images in the operating room right after the HDR catheters are inserted, which takes 1–3 minutes. These TRUS images are then used to create prostate contours. The HDR catheters are reconstructed from the intra‐operative TRUS and post‐operative CT images, and subsequently used as landmarks for the TRUS‐CT image fusion using a fuzzy‐to‐deterministic algorithm. After TRUS‐CT fusion, the TRUS‐based prostate volume is deformed to the CT images for treatment planning. This technique was evaluated through two studies: a prostate‐phantom study and a pilot study with 9 patients undergoing HDR treatment for prostate cancer. The accuracy of our approach is assessed through the locations of 3 implanted fudicial (gold) markers, as well as previous T2‐weighted MR images of patients. Results: For the phantom study, the mean gold‐marker displacement was 0.41±0.11 mm. For the 9 patients, the mean gold‐marker displacement of was 1.09±0.25mm; the prostate volume difference between our approach and the MRI‐based volume was 6.99±0.68%, and the prostate volume Dice Overlap Coefficient was 92.66±1.17%. Conclusion: We have developed a novel approach to improve prostate contours utilizing intra‐operative TRUS‐based prostate volume in CT‐based prostate HDR treatment planning, demonstrated its clinical feasibility, and validated its accuracy with MRIs. This technique will improve prostate delineation, enable accurate dose planning and delivery, and potentially enhance prostate HDR treatment outcome.

SU-E-T-186: An Automated Quality Assurance Tool for HDR Treatment Planning.

Treatment planning for high dose rate (HDR) brachytherapy requires many user inputs, all of which are potential sources of error. The goal of quality assurance (QA) is to ensure that errors are not made. In this study, we developed a software program to analyze the treatment printout from the HDR treatment planning computer and flag any suspected errors. The treatment printout from the HDR planning computer is imported by the software. The software then performs the following checks: (1) verifies that the correct source was chosen (we have multiple in our database), (2) performs an independent decay of the Ir-192 source, (3) verifies source step size, (4) verifies the offsets and indexer lengths in the catheter definitions based upon expected values for the applicator used, (4) performs an independent 2nd check of dose to a cloud of dose points surrounding the treatment region, (5) verifies that the dose per fraction and the number of fractions were entered correctly in the planning computer, and (6) verifies that the dose volume histogram (DVH) metrics were within acceptable tolerances. The software then prints this information to a PDF file, which is appended to the original treatment printout and placed in the patient's medical record. This QA tool has now been implemented for six months in our clinic, and is a critical QA tool in our HDR program. Although each plan is checked by an independent 2nd physicist, this tool provides an additional independent check on the treatment plan. A simple series of automatic 2nd checks helps reduce the risk of errors occurring in the treatment planning portion of HDR brachytherapy and can easily be implemented.

TU-D-BRB-01: PET/CT Guided Dose Redistribution for HDR Interstitial Brachytherapy of Cervical Cancer

Purpose: Advances in functional imaging may allow identification and targeting of tumor sub-volumes based on their biological characteristics, allowing selective boosting of dose to radio-resistant sub-volumes during treatment planning. The purpose of this study was to redistribute high dose regions toward the PET-hot regions as identified on PET/CT images during High-Dose-Rate (HDR) brachytherapy for cervical cancer while maintaining a clinically acceptable DVH. Material and Methods: FDG-PET and CT images were acquired and registered. The tumor volume was contoured and segmented into sub-volumes based on their Standardized Uptake Values (SUV) in PET images. The sub-volumes with higher SUV were considered metabolically active and therefore required higher radiation dose. The integral tumor was prescribed a uniform dose from external beams followed by a boost dose delivered by HDR interstitial brachytherapy. The HDR treatment plan was optimized using a home-brew software implementation of an Adaptive Simulated Annealing (ASA) algorithm. The tumor dose was then redistributed by increasing and decreasing the prescription dose to sub-volumes with higher and lower SUV respectively such that the integral tumor prescription dose was kept constant. A routine cervical cancer case with both uniform and PET-guided plans is presented. Both plans were optimized based on a generalized Equivalent Uniform Dose (gEUD) cost function and renormalized to V100=95% of prescribed dose to the integral PTV. Their isodose distributions and DVHs were compared. Results: The PET-guided plan had larger hot spots in and near the PET sub-volume while the DVH of PTV was kept the same as that of the uniformly prescribed plan. Doses to critical organs were also reduced in the PET-guided plan. Conclusions: The approach described used PET/CT imaging guiding dose redistribution within PTV so that the hot spots encompass metabolically active tumor sub-volumes. An IRB approved treatment protocol is underway to study the clinical efficiency of this approach.

Optimisation-based thermal treatment planning for catheter-based ultrasound hyperthermia

A patient-specific optimisation-based hyperthermia treatment planning program for catheter-based ultrasound technology was developed for a priori evaluation of proposed applicator implant strategies and determination of initial applied power settings. The interstitial and endocavity heating applicators, designed for delivering 3-D controllable hyperthermia within High Dose Rate (HDR) brachytherapy implants, consist of linear and sectored arrays of ultrasound transducers with variable power control in both length and angle. A 3D biothermal model, which incorporates relevant anatomical structures and implant geometries based upon HDR treatment planning, has been developed to simulate the temperature distributions induced by these ultrasound applicators within the catheter implants. A temperature-based constrained optimisation algorithm was devised and integrated within the finite-element thermal solver to determine the optimal applied power levels. A temperature-expressed objective function and constraints were employed to limit maximum temperature (Tmax), maximise target coverage (Ttarget), and minimise thermal exposure to normal tissue and surrounding organs. The optimisation-based treatment planning was applied on representative examples of clinical HDR implants for endocavity treatment of cervix (n = 3) and interstitial treatment of prostate (n = 3). Applicator positioning and orientation, Tmax, and Ttarget, were varied, and temperature volume and thermal dose volume histograms calculated for each plan. The optimisation approach provided optimal applied power levels (4–24 independent transducer sections) leading to conforming or tailored temperature distributions for all cases, as indicated with improved temperature index T90 in the target volume and negligible temperature and thermal dose (t43,max < 1 min) exposure in surrounding non-targeted tissues, such as bladder and rectum. The precision of the optimised power estimates was shown to be within <5% for a range of starting levels and were similarly convergent. The execution times of this optimisation (<16 min) and forward thermal treatment planning (<22 min) is sufficiently fast to be integrated into the clinical setting. This optimisation-based treatment planning platform for catheter-based ultrasound applicators is a useful tool to provide feedback for applicator selection (sector angle, number of transducer sections along length), positioning (angle or orientation), optimal initial power settings, and has potential to significantly improve the delivery of hyperthermia in conjunction with HDR brachytherapy.