Patient In Treatment Position Research Articles

A Novel Approach for Position Verification and Dose Calculation through Local MVCT Reconstruction.

Traditional positioning verification using cone-beam computed tomography (CBCT) may incur errors due to potential misalignments between the isocenter of CBCT and the treatment beams in radiotherapy. This study introduces an innovative method for verifying patient positioning in radiotherapy. Initially, the transmission images from an electronic portal imaging device (EPID) are acquired from 10 distinct angles. Utilizing the ART-TV algorithm, a sparse reconstruction of local megavoltage computed tomography (MVCT) is performed. Subsequently, this MVCT is aligned with the planning CT via a three-dimensional mutual information registration technique, pinpointing any patient-positioning discrepancies and facilitating corrective adjustments to the treatment setup. Notably, this approach employs the same radiation source as used in treatment to obtain three-dimensional images, thereby circumventing errors stemming from misalignment between the isocenter of CBCT and the accelerator. The registration process requires only 10 EPID images, and the dose absorbed during this process is included in the total dose calculation. The results show that our method's reconstructed MVCT images fulfill the requirements for registration, and the registration algorithm accurately detects positioning errors, thus allowing for adjustments in the patient's treatment position and precise calculation of the absorbed dose.

Dosimetric Comparison of Adaptive Radiotherapy Modalities for Stereotactic Partial Breast Irradiation

An increase in the availability of adaptive radiotherapy (ART) platforms have proven to be effective in the treatment of a variety of sites. In this study, we aim to evaluate the effectiveness of non-adaptive RT and 3 different ART platforms: (1) CBCT-based, (2) CT-based, and (3) MRI-based for stereotactic partial breast irradiation (SPBI). Data were collected from 32 patients (16 left and 16 right breast) treated at a single institution. 16 patients (8 left and 8 right) treated using the non-ART platform were re-planned onto two different ART platforms, CBCT- and MRI-based. The remaining 16 patients treated using CT-based adaptive platform were not re-planned due to the prone patient treatment position (others systems supine). All cases were planned to 30 Gy in 5 fractions. Plan quality was evaluated based on pre-defined planning goals to the OARS: ipsilateral and contralateral lungs (Dmean, Dmax, V20 Gy, V9 Gy), ipsilateral (V15 Gy, V30 Gy) and contralateral breasts (Dmax), heart (Dmean, Dmax, V3 Gy, V1.5 Gy), skin (Dmax, V36.5 Gy), and rib (Dmax, V30 Gy). Target goals were defined by Dmax, Dmin, gradient index, and paddock conformality index. Re-planned cases were compared within the cohort using a paired t-test and a 2-sided t-test was used comparing to the CT-based platform. Comparing the left and right breast cohort across all platforms, the CT-based ART system showed a signification dose reduction in Dmean (p<0.001 for all platforms), Dmax (p<0.001 for left breast, p<0.03 for right breast) and V9 Gy (p<0.004 for left breast, p<0.001 for right breast) to the ipsilateral lung, V15 Gy (p<0.004 for left breast cohort) to the ipsilateral breast, and Dmax to the contralateral breast (p<0.001) and ribs (p = 0.01, p<0.001, p = 0.01 for CBCT-ART, MRI-ART, and non-ART for left breast cohort only). On average, the MR-Linac platform showed the least degree of OAR sparing across nearly all dosimetric parameters evaluated when compared to all modalities, especially for contralateral lung Dmean and Dmax (p<0.05 for all dosimetric parameters for all platforms) and contralateral breast Dmax (p<0.003 for all platforms). The CBCT-based platform showed superior dose reduction in contralateral lung mean (p<0.03 for all platforms) and heart Dmean (p = 0.065, p<0.001, p = 0.045 for non-adaptive, MRI-ART, and CT-ART for left breast and p<0.008 for right breast). PTV coverage was comparable across all platforms, averaging at approximately 95%. The CT-based ART platform showed a significantly reduced gradient index relative to the CBCT- and MRI-based platforms (p<0.001). For SPBI treatments, the CT-based ART platforms displayed a higher degree of OAR sparing for many of the dosimetric parameters recorded relative to the other ART and non-ART platforms presented. The MRI-based system typically showed less reduced OAR sparing; however, the advantage of the system is shown if soft tissue contrast is needed. PTV coverage remained comparable across all platforms.

Correlation analysis of treatment positions and body mass index on acute radiation enteritis for cervical cancer patients underwent volumetric modulated arc therapy

PurposeTo investigate the correlation of the incidence of acute radiation-induced enteritis with the factors of patient treatment position and body mass index (BMI) in cervical cancer patient treated with the volumetric modulated arc therapy (VMAT) radiotherapy. Methods96 patients with cervical cancer underwent VMAT were divided into two groups based on the BMI of the patients: the underweight (<24 kg/m2) group and the overweight (≥24 kg/m2) group. According to the treatment position during radiotherapy, all patients were divided into two groups: supine position and prone position subgroups. All the patients were further divided into four groups: Group I (prone position with underweight (n = 23)), Group II (prone position with overweight (n = 20)), group III (supine position with underweight (n = 40)) and Group IV (supine with overweight (n = 13)). The treatment volumes and normal tissues (e.g., small intestine and rectum) were delineated and confirmed by two senior radiation oncologists. Then, the treatment plans were produced and optimized by the experienced medical physicists. The correlation between the incidence of acute radiation enteritis and the dose volume measurements of the small intestine and rectum was analyzed. ResultsBinary logistic analysis showed that the dose parameter of V40 of the rectal was a risk factor for radiation proctitis (p = 0.003), and the univariate receiver operating characteristic (ROC) analysis showed a high area under curve AUC of 0.927 of this parameters for prediction of radiation proctitis. Using the nonparametric Kruskal Wallis test, the treatment position was found to be an important factor in distinguishing radiation enteritis above grade II (p = 0.003), whereas the BMI showed no significant role in predicting radiation enteritis above grade II, and there was no interaction effect between treatment position and BMI (p = 0.224). Using stratified Chi-square test, it was found that treatment position and BMI were not high-risk factors for acute radiation proctitis above grade II (P > 0.05). ConclusionFor obese cervical cancer patients underwent VAMT radiotherapy, the prone position was recommended during the beam irradiation, which can significantly reduce the radiation dose to the small intestine. To reduce the incidence of radiation proctitis, it is recommended that the V40 of rectal should be less than 45% as possible through optimizing the treatment plan.

Geometric and dosimetric consequences of intra-fractional movement in single isocenter non-coplanar stereotactic radiosurgery

PurposeTo investigate the geometric and dosimetric impacts of intra-fractional movement for patients with single or multiple brain metastasis treated using Varian Hyperarc™ mono-isocentric radiosurgery.MethodsA total of 50 single or hypo-fractionated Hyperarc™ treatment courses (118 lesions) were included in the analysis. Intra-fractional translational and rotational movements were quantified according to the post-treatment cone-beam CT (CBCT). Geometric displacements of all targets were calculated individually based on the assessed head movement in each treatment fraction and their relationships with treatment time and target-to-isocenter distances were studied. For dosimetric analysis, only single-fraction treatments (56 lesions) were included. Re-planning was performed with 0, 1, and 2 mm planning target volume (PTV) margins. Doses were then re-calculated on rotated CT images with isocenter shifted which emulate the change in patient treatment position. Target coverage, target and normal brain doses before and after intra-fractional movement were compared.ResultsThe mean 3D target displacements was 0.6 ± 0.3 (SD) mm. Target shifts for patients treated within 10 min were significantly smaller than those treated in longer sessions. No correlation was found between target shift and target-to-isocenter distance as the origin of head rotation was not located at the isocenter. Loss of target coverage and minimum Gross Tumor Volume (GTV) dose due to intra-fractional movement were apparent only when no margin was used, leading to an extra 23% of the targets violating the dose acceptance criteria, in contrast, the effects on normal brain V12Gy were negligible regardless of the margin used. The use of 1 mm PTV margin can compensate clinically significant geographical miss caused by intra-fractional movements while limiting V12Gy to within dose criteria for 88% of the cases. The plan acceptance rate (fulfillment of both target and normal brain dose criteria) after intra-fractional movement was also the highest with the 1 mm margin.ConclusionAlthough intra-fractional movements during Hyperarc™ treatments were small, there were substantial dosimetric effects due to the sharp dose fall-off near target boundaries. These effects could be mitigated by using a 1 mm PTV margin and maintaining the effective treatment time to within 10 min.

Abstract P3-19-18: Feasibility and short term toxicity of a consecutively delivered 5-fraction stereotactic body radiotherapy in early stage breast cancer patients receiving accelerated partial breast irradiation

Abstract Background: For early stage breast cancer, breast conservation is an appealing option for many women. Interest in reducing the duration and volume of RT has continued in the form of accelerated partial breast irradiation (APBI). Recent work demonstrates that for appropriately selected patients, APBI yields equivalent rates of ipsilateral breast tumor recurrence (IBTR) with improvements in patient rated cosmesis compared to whole breast radiotherapy. When using external beam radiotherapy for APBI, appropriate techniques to reduce setup uncertainty and overall treatment volume are critical to reduce long term adverse cosmesis. Stereotactic body radiotherapy (SBRT) is an attractive technique to deliver APBI because of its excellent accuracy and potentially superior sparing of uninvolved breast tissue. We report here the initial results of our IRB-approved prospective clinical trial investigating feasibility, safety, and cosmetic outcomes of daily, 5-fraction SBRT for APBI in women meeting ASTRO consensus suitability criteria for partial breast irradiation. Methods: We enrolled twenty patients with early stage breast cancer after lumpectomy who met APBI suitability. During lumpectomy, a breast surgeon placed a bioabsorbable 3D fixed array tissue marker (BioZorb™, Hologic, Marlborough, MS) for enhanced visualization of the cavity boundaries. We defined the clinical target volume (CTV) as the delineable cavity plus a 1 cm isotropic expansion. We placed a 3mm isotropic planning target volume (PTV) expansion around the CTV. We treated each woman with 3000cGy delivered in 5 consecutive, daily, free-breathed fractions in either prone or supine positioning depending on individual anatomy. Patient treatment position was free-breathing in the prone position for 17 patients and supine in 3 patients using triggered imaging and fiducial tracking. A maximum PTV of 124cc was allowed to minimize incidence of fat necrosis. Plans used 10MV flattening filter free (FFF) beams delivered on a Varian Edge linear accelerator. We documented the following: adverse events (CTCAE 4.0), causality of the event to SBRT, and nurse- and patient- scored cosmesis (i.e., 1=excellent, 2=good, 3=fair, 4=poor) at pre-treatment baseline, 1 month post-treatment, and at each proceeding 6 month interval. We also clinically surveilled for disease recurrence. Results: We completed accrual and treatment of twenty patients. At time of submission, fourteen patients had completed 6-month follow-up, and eight patients had completed 12-month follow-up. No patients experienced grade ≥3 toxicity. Adverse events reported were mostly grade 1. Eighty-five percent of patient-scored cosmesis were excellent or good at baseline, with no evidence of deterioration at 1-month post-treatment (Baseline = 1.9, 1 month = 1.9; p = 0.914). Eighty-five percent of nurse-scored cosmesis reports were excellent or good at baseline, with no evidence of deterioration between baseline and 1-month post-treatment (Baseline = 1.95, 1 month = 1.90; p = 0.564). Eighty-six percent of patients had excellent or good patient- and nurse-scored cosmesis at 6 months, with either mean score of 1.71. Eighty-eight percent of patients had excellent or good patient- and nurse-scored cosmesis at 12 months, with mean cosmesis score of 1.50 and 1.63, respectively. Local control follow-up is immature, but no patients developed IBTR. Conclusions: Our study demonstrated that consecutive daily 5-fraction breast SBRT for APBI is a safe, efficient, well-tolerated, and cosmetically favorable means of delivering partial breast irradiation in suitable women. As follow-up duration matures, we will report long term cosmetic outcome and recurrence. Citation Format: Yilan Liu, Christopher Veale, Diana Hablitz, Helen Krontiras, Michael Christian Dobelbower, Rachael Lancaster, Markus Bredel, Catherine Parker, Kimberly Keene, Evan Thomas, Drexell Hunter Boggs. Feasibility and short term toxicity of a consecutively delivered 5-fraction stereotactic body radiotherapy in early stage breast cancer patients receiving accelerated partial breast irradiation [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-18.

Patient-specific collision zones for 4π trajectory optimized radiation therapy.

The 4π methodology determines optimized noncoplanar subarcs for stereotactic radiation therapy that minimize dose to organs-at-risk. Every combination of treatment angle is examined, but some angles are not appropriate as a collision would occur between the gantry and the couch or the gantry and the patient. Those combinations of couch and gantry angles are referred to as collision zones. A major barrier to applying 4π to stereotactic body radiation therapy (SBRT) is the unknown shape of the collision zones, which are significant as patients take up a large volume within the 4π sphere. This study presents a system that determines patient-specific collision zones, without additional clinical steps, to enable safe and deliverable noncoplanar treatment trajectories for SBRTpatients. To augment patient's computed tomography (CT) scan, full body scans of patients in treatment position were acquired using an optical scanner. A library of a priori scans (N = 25) was created. Based on the patients' treatment position and their body dimensions, a library scan is selected and registered to the CT scan of the patient. Next, a model of the couch and immobilization equipment is added to the patient model. This results in a patient model that is then aligned with a model of the treatment LINAC in a "virtual treatment room," where both components can be rotated to test for collisions. To test the collision detection algorithm, an end-to-end test was performed using a cranial phantom. The registration algorithm was tested by comparing the registered patient collision zones to those generated by using the patient's matchingscan. The collision detection algorithm was found to have a 97.80% accuracy, a 99.99% sensitivity, and a 99.99% negative predictive value (NPV). Analysis of the registration algorithm determined that a 6 cm buffer was required to achieve a 99.65% mean sensitivity, where a sensitivity of unity is considered to be a requirement for safe treatment delivery. With a 6 cm buffer, the mean accuracy was 86.70% and the mean NPV was 99.33%. Our method of determining patient-specific collision zones can be accomplished with minimal user intervention based on an a priori library of body surface scans, thus enabling the safe application of 4πSBRT.

Improving generalization in MR-to-CT synthesis in radiotherapy by using an augmented cycle generative adversarial network with unpaired data.

MR-to-CT synthesis is one of the first steps in the establishment of an MRI-only workflow in radiotherapy. Current MR-to-CT synthesis methods in deep learning use unpaired MR and CT training images with a cycle generative adversarial network (CycleGAN) to minimize the effect of misalignment between paired images. However, this approach critically assumes that the underlying interdomain mapping is approximately deterministic and one-to-one. In the current study, we use an Augmented CycleGAN (AugCGAN) model to create a robust model that can be applied to different scanners and sequences using unpaired data. This study included T2-weighted MR and CT pelvic images of 38 patients in treatment position from five different centers. The AugCGAN was trained on 2D transverse slices of 19 patients from three different sites. The network was then used to generate synthetic CT (sCT) images of 19 patients from the two other sites. Mean absolute errors (MAEs) for each patient were evaluated between real and synthetic CT images. Original treatment plans of nine patients were recalculated using sCT images to assess the dose distribution in terms of voxel-wise dose difference, gamma, and dose-volume histogram analysis. The mean MAEs were Hounsfield units ( ) and 65.8HU for the first and second test sites, respectively. The maximum dose difference to the target was with a gamma pass rate using the 3%, 3mm criteria above 99%. The average time required to generate a complete sCT image for a patient on our GPU was 8.5s. This study suggests that our unpaired approach achieves good performance in generalization with respect to sCT image generation.

Analysis of characteristics of images acquired with a prototype clinical proton radiography system.

Verification of patient-specific proton stopping powers obtained in the patient's treatment position can be used to reduce the distal and proximal margins needed in particle beam planning. Proton radiography can be used as a pretreatment instrument to verify integrated stopping power consistency with the treatment planning CT. Although a proton radiograph is a pixel by pixel representation of integrated stopping powers, the image may also be of high enough quality and contrast to be used for patient alignment. This investigation quantifies the accuracy and image quality of a prototype proton radiography system on a clinical proton delivery system. We have developed a clinical prototype proton radiography system designed for integration into efficient clinical workflows. We tested the images obtained by this system for water-equivalent thickness (WET) accuracy, image noise, and spatial resolution. We evaluated the WET accuracy by comparing the average WET and rms error in several regions of interest (ROI) on a proton radiograph of a custom peg phantom. We measured the spatial resolution on a CATPHAN Line Pair phantom and a custom edge phantom by measuring the 10% value of the modulation transfer function (MTF). In addition, we tested the ability to detect proton range errors due to anatomical changes in a patient with a customized CIRS pediatric head phantom and inserts of varying WET placed in the posterior fossae of the brain. We took proton radiographs of the phantom with each insert in place and created difference maps between the resulting images. Integrated proton range was measured from an ROI in the difference maps. We measured the WET accuracy of the proton radiographic images to be ±0.2mm (0.33%) from known values. The spatial resolution of the images was 0.6lp/mm on the line pair phantom and 1.13lp/mm on the edge phantom. We were able to detect anatomical changes producing changes in WET as low as 0.6mm. The proton radiography system produces images with image quality sufficient for pretreatment range consistency verification.

A practical implementation of risk management for the clinical introduction of online adaptive Magnetic Resonance-guided radiotherapy.

Background and PurposeThe clinical introduction of on-table adaptive radiotherapy with Magnetic Resonance (MR)-guided linear accelerators (Linacs) yields new challenges and potential risks. Since the adapted plan is created within a highly interdisciplinary workflow with the patient in treatment position, time pressure or erroneous communication may lead to various possibly hazardous situations. To identify risks and implement a safe workflow, a proactive risk analysis has been conducted.Materials and MethodsA process failure mode, effects and criticality analysis (P-FMECA) was performed within a group of radiation therapy technologists, physicians and physicists together with an external moderator. The workflow for on-table adaptive MR-guided treatments was defined and for each step potentially hazardous situations were identified. The risks were evaluated within the team in order to homogenize risk assessment. The team elaborated and discussed possible mitigation strategies and carried out their implementation.ResultsIn total, 89 risks were identified for the entire MR-guided online adaptive workflow. After mitigation, all risks could be minimized to an acceptable level. Overall, the need for a standardized workflow, clear-defined protocols together with the need for checklists to ensure protocol adherence were identified among the most important mitigation measures. Moreover, additional quality assurance processes and automated plan checks were developed.ConclusionsDespite additional workload and beyond the fulfilment of legal requirements, execution of the P-FMECA within an interdisciplinary team helped all involved occupational groups to develop and foster an open culture of safety and to ensure a consensus for an efficient and safe online adaptive radiotherapy workflow.

OpenABC: An Open-Source Active Breathing Control System for Low-Resource Centers

Respiratory motion management during radiation therapy can improve delivery to a moving target and spare normal tissue. However, current gating or breath-hold motion management methods are often expensive and inaccessible to low-to-middle income countries (LMICs). We propose developing a low-cost breath-hold and gating system that provides audio visual-feedback to patients while monitoring respiratory motion. An open-source system, called open active breathing control (OpenABC), was developed consisting of a micro-processor (Raspberry Pi 3) and a motion sensor (MPU-6050, InvenSense Inc) to generate breathing traces with audiovisual projector for patient feedback and monitoring display for radiation delivery control. An algorithm was developed in Python to convert motion sensor signal to a respiratory trace for direct comparison between a commercial system (RPM™). OpenABC was demonstrated on a phantom and volunteer and univariate-linear-regression and Bland-Altman analysis was performed. A low-cost projector was used to provide visual feedback for a patient in treatment position and a web-interface will be used to provide real-time monitoring (over WiFi) for treatment control. Total cost for OpenABC system is under $100 USD. Monitoring of periodic phantom motion show excellent agreement between commercial and OpenABC (r = 0.99, p<0.0001, bias = 0.0±0.9mm, 95%-confidence-interval = -1.7 to 1.7mm) and volunteer motion shows good agreement of irregular breathing motion (r = 0.94, p<0.0001, bias = -0.2±0.5mm, 95%-confidence-interval = -1.1 to 0.7mm). Mean motion differences at maximum, average and minimum traces for the phantom were 0.2±0.1mm, 0.1±0.6mm, and 0.1±0.1mm respectively. Mean motion differences at maximum, average and minimum traces for the volunteer were 0.4±0.2mm, 0.3±0.5mm, and 0.4±0.3mm respectively. Motion period time differences for phantom and volunteer were 0.07±0.06s and 0.08±0.14s respectively. Real-time feedback was successfully provided via a projector and monitoring system. We demonstrated feasibility of an open-source accelerometer/gyroscope-based system for active breathing control for motion gating or breath-hold radiation treatments, called OpenABC. Future work will further develop OpenABC to have user friendly GUIs, standardize use protocols and showing proof-of-concept implementation, in collaboration with Rayos Contra Cancer (RCC) and Radiating Hope, in cancer centers in Bolivia that would benefit from motion management in their clinics.Tabled 1Abstract 2878; Table; Motion difference (OpenABC - RPM™)Mean ± SDPeriod (s)Max (mm)Average (mm)Min (mm)Phantom-0.07 ± 0.06-0.2 ± 0.1-0.1 ± 0.6-0.1 ± 0.1Volunteer-0.08 ± 0.140.4 ± 0.2-0.3 ± 0.5-0.4 ± 0.3 Open table in a new tab

Dosimetric Impact of the Positional Imaging Frequency for Hypofractionated Prostate Radiotherapy - A Voxel-by-Voxel Analysis.

BackgroundTo investigate deviations between planned and applied treatment doses for hypofractionated prostate radiotherapy and to quantify dosimetric accuracy in dependence of the image guidance frequency.MethodsDaily diagnostic in-room CTs were carried out in 10 patients in treatment position as image guidance for hypofractionated prostate radiotherapy. Fraction doses were mapped to the planning CTs and recalculated, and applied doses were accumulated voxel-wise using deformable registration. Non-daily imaging schedules were simulated by deriving position correction vectors from individual scans and used to rigidly register the following scans until the next repositioning before dose recalculation and accumulation. Planned and applied doses were compared regarding dose-volume indices and TCP and NTCP values in dependence of the imaging and repositioning frequency.ResultsDaily image-guided repositioning was associated with only negligible deviations of analyzed dose-volume parameters and conformity/homogeneity indices for the prostate, bladder and rectum. Average CTV T did not significantly deviate from the plan values, and rectum NTCPs were highly comparable, while bladder NTCPs were reduced. For non-daily image-guided repositioning, there were significant deviations in the high-dose range from the planned values. Similarly, CTV dose conformity and homogeneity were reduced. While TCPs and rectal NTCPs did not significantly deteriorate for non-daily repositioning, bladder NTCPs appeared falsely diminished in dependence of the imaging frequency.ConclusionUsing voxel-by-voxel dose accumulation, we showed for the first time that daily image-guided repositioning resulted in only negligible dosimetric deviations for hypofractionated prostate radiotherapy. Regarding dosimetric aberrations for non-daily imaging, daily imaging is required to adequately deliver treatment.

Head and neck cancer patient images for determining auto-segmentation accuracy in T2-weighted magnetic resonance imaging through expert manual segmentations.

The use of magnetic resonance imaging (MRI) in radiotherapy treatment planning has rapidly increased due to its ability to evaluate patient's anatomy without the use of ionizing radiation and due to its high soft tissue contrast. For these reasons, MRI has become the modality of choice for longitudinal and adaptive treatment studies. Automatic segmentation could offer many benefits for these studies. In this work, we describe a T2-weighted MRI dataset of head and neck cancer patients that can be used to evaluate the accuracy of head and neck normal tissue auto-segmentation systems through comparisons to available expert manual segmentations. T2-weighted MRI images were acquired for 55 head and neck cancer patients. These scans were collected after radiotherapy computed tomography (CT) simulation scans using a thermoplastic mask to replicate patient treatment position. All scans were acquired on a single 1.5T Siemens MAGNETOM Aera MRI with two large four-channel flex phased-array coils. The scans covered the region encompassing the nasopharynx region cranially and supraclavicular lymph node region caudally, when possible, in the superior-inferior direction. Manual contours were created for the left/right submandibular gland, left/right parotids, left/right lymph node level II, and left/right lymph node level III. These contours underwent quality assurance to ensure adherence to predefined guidelines, and were corrected if edits were necessary. The T2-weighted images and RTSTRUCT files are available in DICOM format. The regions of interest are named based on AAPM's Task Group 263 nomenclature recommendations (Glnd_Submand_L, Glnd_Submand_R, LN_Neck_II_L, Parotid_L, Parotid_R, LN_Neck_II_R, LN_Neck_III_L, LN_Neck_III_R). This dataset is available on The Cancer Imaging Archive (TCIA) by the National Cancer Institute under the collection "AAPM RT-MAC Grand Challenge 2019" (https://doi.org/10.7937/tcia.2019.bcfjqfqb). This dataset provides head and neck patient MRI scans to evaluate auto-segmentation systems on T2-weighted images. Additional anatomies could be provided at a later time to enhance the existing library of contours.

MR to CT synthesis with multicenter data in the pelvic area using a conditional generative adversarial network

The establishment of an MRI-only workflow in radiotherapy depends on the ability to generate an accurate synthetic CT (sCT) for dose calculation. Previously proposed methods have used a Generative Adversarial Network (GAN) for fast sCT generation in order to simplify the clinical workflow and reduces uncertainties. In the current paper we use a conditional Generative Adversarial Network (cGAN) framework called pix2pixHD to create a robust model prone to multicenter data.This study included T2-weighted MR and CT images of 19 patients in treatment position from 3 different sites. The cGAN was trained on 2D transverse slices of 11 patients from 2 different sites. Once trained, the network was used to generate sCT images of 8 patients coming from a third site. The Mean Absolute Errors (MAE) for each patient were evaluated between real and synthetic CTs. A radiotherapy plan was optimized on the sCT series and re-calculated on CTs to assess the dose distribution in terms of voxel-wise dose difference and Dose Volume Histograms (DVH) analysis.It takes on average of to generate a complete sCT (88 slices) for a patient on our GPU. The average MAE in HU between the sCT and actual patient CT (within the body contour) is 48.5 ± 6 HU with our method. The maximum dose difference to the target is 1.3%.This study demonstrates that an sCT can be generated in a multicentric context, with fewer pre-processing steps while being fast and accurate.

Standardization of patient modeling in hyperthermia simulation studies: introducing the Erasmus Virtual Patient Repository

Purpose Thermal dose-effect relations have demonstrated that clinical effectiveness of hyperthermia would benefit from more controlled heating of the tumor. Hyperthermia treatment planning (HTP) is a potent tool to study strategies enabling target conformal heating, but its accuracy is affected by patient modeling approximations. Homogeneous phantoms models are being used that do not match the body shape of patients in treatment position and often have unrealistic target volumes. As a consequence, simulation accuracy is affected, and performance comparisons are difficult. The aim of this study is to provide the first step toward standardization of HTP simulation studies in terms of patient modeling by introducing the Erasmus Virtual Patient Repository (EVPR): a virtual patient model database. Methods Four patients with a tumor in the head and neck or the pelvis region were selected, and corresponding models were created using a clinical segmentation procedure. Using the Erasmus University Medical Center standard procedure, HTP was applied to these models and compared to HTP for commonly used surrogate models. Results Although this study was aimed at presenting the EVPR database, our study illustrates that there is a non-negligible difference in the predicted SAR patterns between patient models and homogeneous phantom-based surrogate models. We further demonstrate the difference between actual and simplified target volumes being used today. Conclusion Our study describes the EVPR for the research community as a first step toward standardization of hyperthermia simulation studies.

Reconstruction of a high-quality volumetric image and a respiratory motion model from patient CBCT projections.

To develop and evaluate a method of reconstructing a patient- and treatment day- specific volumetric image and motion model from free-breathing cone-beam projections and respiratory surrogate measurements. This Motion-Compensated Simultaneous Algebraic Reconstruction Technique (MC-SART) generates and uses a motion model derived directly from the cone-beam projections, without requiring prior motion measurements from 4DCT, and can compensate for both inter- and intrabin deformations. The motion model can be used to generate images at arbitrary breathing points, which can be used for estimating volumetric images during treatment delivery. The MC-SART was formulated using simultaneous image reconstruction and motion model estimation. For image reconstruction, projections were first binned according to external surrogate measurements. Projections in each bin were used to reconstruct a set of volumetric images using MC-SART. The motion model was estimated based on deformable image registration between the reconstructed bins, and least squares fitting to model parameters. The model was used to compensate for motion in both projection and backprojection operations in the subsequent image reconstruction iterations. These updated images were then used to update the motion model, and the two steps were alternated between. The final output is a volumetric reference image and a motion model that can be used to generate images at any other time point from surrogate measurements. A retrospective patient dataset consisting of eight lung cancer patients was used to evaluate the method. The absolute intensity differences in the lung regions compared to ground truth were 50.8±43.9HU in peak exhale phases (reference) and 80.8±74.0 in peak inhale phases (generated). The 50th percentile of voxel registration error of all voxels in the lung regions with >5mm amplitude was 1.3mm. The MC-SART was also applied to measured patient cone-beam projections acquired with a linac-mounted CBCT system. Results from this patient data demonstrate the feasibility of MC-SART and showed qualitative image quality improvements compared to other state-of-the-art algorithms. We have developed a simultaneous image reconstruction and motion model estimation method that uses Cone-beam computed tomography (CBCT) projections and respiratory surrogate measurements to reconstruct a high-quality reference image and motion model of a patient in treatment position. The method provided superior performance in both HU accuracy and positional accuracy compared to other existing methods. The resultant reference image and motion model can be combined with respiratory surrogate measurements to generate volumetric images representing patient anatomy at arbitrary time points.

Feasibility of MRI-only photon and proton dose calculations for pediatric patients with abdominal tumors

The purpose of this study was to develop a method enabling synthetic computed tomography (sCT) generation of the whole abdomen using magnetic resonance imaging (MRI) scans of pediatric patients with abdominal tumors. The proposed method relies on an automatic atlas-based segmentation of bone and lungs followed by an MRI intensity to synthetic Hounsfield unit conversion. Separate conversion algorithms were used for bone, lungs and soft-tissue. Rigidly registered CT and T2-weighted MR images of 30 patients in treatment position and with the same field of view were used for the evaluation of the atlas and the conversion algorithms. The dose calculation accuracy of the generated sCTs was verified for volumetric modulated arc therapy (VMAT) and pencil beam scanning (PBS). VMAT and PBS plans were robust optimized on an internal target volume (ITV) against a patient set-up uncertainty of 5 mm. Average differences between CT and sCT dose calculations for the ITV V95% were 0.5% (min 0.0%; max 5.0%) and 0.0% (min −0.1%; max 0.1%) for VMAT and PBS dose distributions, respectively. Average differences for the mean dose to the organs at risk were <0.2% (min −0.6%; max 1.2%) and <0.2% (min −2.0%; max 2.6%) for VMAT and PBS dose distributions, respectively. Results show that MRI-only photon and proton dose calculations are feasible for children with abdominal tumors.

Mega Voltage Cone Beam Computed Tomography (MV- CBCT) using a Standard Medical Linear Accelerator and EPID: A feasibility study.

Introduction: The success of radiotherapy cancer treatment delivery depends on the accuracy of patient positioning for each treatment session. A number of kilovoltage x-ray volumetric imaging modalities with an additional source and detector have been developed to allow patient set-up verification based on the internal anatomy, but a significant portion of medical linacs are only equipped with electronics portal imaging device (EPID) as a planar imaging system. The aim of this study is investigating the feasibility of megavoltage cone beam computed tomography (MV-CBCT) using medical linac and EPID to obtain volumetric data for 3D representation of patient in treatment position. Materials and Methods: The MV-CBCT system consists of an amorphous silicon EPID with an active area of 41×41 cm2 attached to an Elekta Precise linac. Initially, the quality control tests were performed to evaluate the safety features, mechanical stability and quality of the megavoltage imaging system. The MV-CBCT scanning protocol was divided into three major parts. In the first part, Step and Shoot delivery mode was used to acquire projections of an anthropomorphic head phantom and quality assurance phantom in increments of 30 with 3 MU and x-rays of 6 MV energy over 3600 of gantry rotation. Afterwards, noise reduction was conducted by applying 2D adaptive wiener filter to projections. Furthermore, it is found that scatter produces cupping artifacts and increase uniformity variations across the reconstructed tomograms. Therefore, a scatter correction method which is based on a superposition of Monte Carlo generated scatter kernels was applied to the portal images. In the latest part of the research, the Feldkamp cone-beam algorithm used to reconstruct the 2D portal images to a 3D image, then, image quality characteristics such as; uniformity, contrast-to-noise ratio (CNR) and spatial resolution were investigated using the Gammex phantom Results: The safety interlocks were found to be functional. The EPID response uniformity was within 97% across the detector. Contrast resolution of the MV imaging system was found to agree with the recommended tolerance; and the value of f50 for spatial resolution was 0.41lp/mm for 6 MV. The supporting arm deviation was within ±1 mm, and corrections are required to realign the projections. Reconstructed slices from the spatial and contrast resolution modules of the Gammex phantom shown that the 4 lp/cm section was clearly resolvable, and also bone, air, polyethylene, and acrylic inserts can be clearly resolved, with bone and air having the greatest and polyethylene having the lowest contrast, which improved after scatter correction. Furthermore, the maximum uniformity variation was determined of 15.75%-pixel intensity units which reduced significantly after scatter correction. Conclusion: The result of this study has demonstrated that EPID can be used to acquire volumetric images with high enough quality to improve patient alignment prior to dose delivery.

Patterns of Inguinal Lymph Node Metastases in Anal Cancer: Recommendations for Elective Clinical Target Volume (CTV) Delineation

In the era of conformal radiotherapy for anal cancer, the optimal CTV for inguinal lymph node irradiation remains uncertain. The purpose of this study was to document the location of radiographically involved inguinal lymph nodes in patients with anal canal cancer and to propose guidelines for elective inguinal CTV delineation. Patients with squamous cell carcinoma of the anal canal with inguinal lymph node metastases presenting to our institution between 2003 and 2017 were identified from a departmental database. Inguinal lymph nodes were considered involved based on at least one of the following: >1.5 cm on computed tomography (CT) or magnetic resonance imaging (MRI), FDG avidity greater than background liver on positron emission tomography (PET), or positive histology from lymph node biopsy. Distances from the center of the involved lymph node to the closest adjacent femoral vessel and to the inferior extent of the primary tumor were measured on a pre-treatment diagnostic imaging study. Position of lymph nodes relative to the right femoral vessels was recorded on a clock face with 12:00 anterior, 3:00 medial, 6:00 posterior, and 9:00 lateral. The anatomic location of each lymph node was transferred onto a representative CT scan of a patient in treatment position and compared to the inguinal lymph node CTV in the Australasian Gastrointestinal Trials Group (AGITG) consensus guidelines for intensity-modulated radiotherapy for anal cancer. We identified 41 patients with 81 positive inguinal lymph nodes. Median lymph node size was 16.1 mm (range 7-59 mm) in short axis and 21.4 mm (range 10-65 mm) in long axis. Median distances from the nearest femoral artery and vein were 19.8 mm (range 8-40 mm) and 17.1 mm (range 8-46 mm), respectively. Median distance from the inferior aspect of the primary tumor was 47.9 mm (range 4-108 mm). Relative to the femoral vessels, lymph nodes were located at 12:00 (n=7); 1:00 (n=28); 2:00 (n=35), 3:00 (n=5); 4:00 (n=1); 10:00 (n=1); 11:00 (n=4). No lymph nodes were identified in the 5:00-9:00 positions (lateral or posterior to the vessels). Volumes contoured according to AGITG consensus guidelines covered 70% of lymph nodes anteriorly and 85% of lymph nodes medially. Margins from the nearest femoral vessel required to cover 90% and 95% of lymph nodes were 29 mm and 30 mm anteriorly and 25 mm and 26 mm medially, respectively. Inferior borders of the inguinal CTV required to cover 90% and 95% of lymph nodes were 18 mm and 12 mm, respectively, from the inferior aspect of the primary tumor. Published guidelines for CTV delineation of the inguinal lymph node region in anal cancer may result in inadequate coverage of high-risk areas. Updated contouring guidelines based on the present study would ensure coverage of areas at high risk for harboring metastatic disease and may reduce toxicity by sparing low-risk areas.

Technical Note: Adapting a GE SIGNA PET/MR scanner for radiotherapy.

Simultaneous collection of PET and MR data for radiotherapy purposes are useful for, for example, target definition and dose escalations. However, a prerequisite for using PET/MR in the radiotherapy workflow is the ability to image the patient in treatment position. The aim of this work was to adapt a GE SIGNA PET/MR scanner to image patients for radiotherapy treatment planning and evaluate the impact on signal-to-noise (SNR) of the MR images, and the accuracy of the PET attenuation correction. A flat tabletop and a coil holder were developed to image patients in the treatment position, avoid patient contour deformation, and facilitate attenuation correction of flex coils. Attenuation corrections for the developed hardware and an anterior array flex coil were also measured and implemented to the PET/MR system to minimize PET quantitation errors. The reduction of SNR in the MR images due to the added distance between the coils and the patient was evaluated using a large homogenous saline-doped water phantom, and the activity quantitation errors in PET imaging were evaluated with and without the developed attenuation corrections. We showed that the activity quantitation errors in PET imaging were within ±5% when correcting for attenuation of the flat tabletop, coil holder, and flex coil. The SNR of the MRI images were reduced to 74% using the tabletop, and 66% using the tabletop and coil holders. We present a tabletop and coil holder for an anterior array coil to be used with a GE SIGNA PET/MR scanner, for scanning patients in the radiotherapy work flow. Implementing attenuation correction of the added hardware from the radiotherapy setup leads to acceptable PET image quantitation. The drop in SNR in MR images may require adjustment of the imaging protocols.

Technical Note: Diffusion-weighted MRI with minimal distortion in head-and-neck radiotherapy using a turbo spin echo acquisition method.

Diffusion-weighted (DW) MRI, showing high contrast between tumor and background tissue, is a promising technique in radiotherapy for tumor delineation. However, its use for head-and-neck patients is hampered by poor geometric accuracy in conventional echo planar imaging (EPI) DW-MRI. An alternative turbo spin echo sequence, DW-SPLICE, is implemented and demonstrated in patients. The DW-SPLICE sequence was implemented on a 3.0 T system and evaluated in 10 patients. The patients were scanned in treatment position, using a customized head support and immobilization mask. Image distortions were quantified at the gross tumor volume (GTV) using field map analysis. The apparent diffusion coefficient (ADC) was evaluated using an ice water phantom. The DW images acquired by DW-SPLICE showed no image distortions. Field map analysis at the gross tumor volumes resulted in a median distortion of 0.2 mm for DW-SPLICE, whereas for the conventional method this was 7.2 mm. ADC values, measured using an ice water phantom were in accordance with literature values. The implementation of DW-SPLICE allows for diffusion-weighted imaging of patients in treatment position with excellent geometrical accuracy. The images can be used to facilitate target volume delineation in RT treatment planning.