A Soliman

Quantitative MRI assessment of a novel direction modulated brachytherapy tandem applicator for cervical cancer at 1.5 T

BACKGROUND AND PURPOSE The purpose of this work is to quantitatively investigate the artifacts and image distortions induced in the MR images by a recently proposed direction modulated brachytherapy (DMBT) tandem applicator prototype. This new MRI-compatible applicator allows better sparing of organs-at-risk (OAR) for cervical cancer patients, while providing conformal dose distributions to target volumes. MATERIALS AND METHODS Specific phantom and tools were designed and manufactured for this study. The phantom was filled with a tissue-like solution and MR images were acquired with clinical protocols as per GEC-ESTRO recommendations. Images were obtained at 6 different orientations that mimic possible clinical settings and full-width-at-half-maximum (FWHM) was recorded at multiple locations/angles. The accuracy of detecting the centerline of the tandem was assessed using a novel radial-fiducials mount. RESULTS FWHM from all line profiles at all angles and all orientations was 6.14±0.7mm (compared to 6mm of the actual DMBT tandem diameter). The in-plane spatial-shift observed at para-axial and para-sagittal views was less than 0.5mm. CONCLUSIONS This work demonstrated that the novel DMBT tandem applicator prototype has minimal artifact in T2-weighted images employed in clinical practice, suggesting the applicator might be a good candidate for MRI-guided adaptive brachytherapy.

Metal artefacts in MRI-guided brachytherapy of cervical cancer

The importance of assessing the metal-induced artefacts in magnetic resonance imaging (MRI)-guided brachytherapy is growing along with the increasing interest of integrating MRI into the treatment procedure of cervical cancer. Examples of metal objects in use include intracavitary cervical applicators and interstitial needles. The induced artefacts increase the uncertainties in the clinical workflow and can be a potential obstacle for the accurate delivery of the treatment. Overcoming this problem necessitates a good understanding of its originating sources. Several efforts are recorded in the literature to quantify the extent of such artefacts, in phantoms and in clinical practice. Here, we elaborate on the origin of metal-induced artefacts in the light of brachytherapy applications, while summarizing recent efforts that have been made to assess and overcome the induced distortions.

Direction modulated brachytherapy (DMBT) for treatment of cervical cancer: A planning study with 192Ir, 60Co, and 169Yb HDR sources

Purpose: To evaluate plan quality of a novel MRI‐compatible direction modulated brachytherapy (DMBT) tandem applicator using 192Ir, 60Co, and 169Yb HDR brachytherapy sources, for various cervical cancer high‐risk clinical target volumes (CTVHR). Materials and Methods: The novel DMBT tandem applicator has six peripheral grooves of 1.3‐mm diameter along a 5.4‐mm thick nonmagnetic tungsten alloy rod. Monte Carlo (MC) simulations were used to benchmark the dosimetric parameters of the 192Ir, 60Co, and 169Yb HDR sources in a water phantom against the literature data. 45 clinical cases that were treated using conventional tandem‐and‐ring applicators with 192Ir source (192Ir‐T&R) were selected consecutively from intErnational MRI‐guided BRAchytherapy in CErvical cancer (EMBRACE) trial. Then, for each clinical case, 3D dose distribution of each source inside the DMBT and conventional applicators were calculated and imported onto an in‐house developed inverse planning optimization code to generate optimal plans. All plans generated by the DMBT tandem‐and‐ring (DMBT T&R) from all three sources were compared to the respective 192Ir‐T&R plans. For consistency, all plans were normalized to the same CTVHR D90 achieved in clinical plans. The D2 cm3 for organs at risk (OAR) such as bladder, rectum, and sigmoid, and D90, D98, D10, V100, and V200 for CTVHR were calculated. Results: In general, plan quality significantly improved when a conventional tandem (Con.T) is replaced with the DMBT tandem. The target coverage metrics were similar across 192Ir‐T&R and DMBT T&R plans with all three sources (P > 0.093). 60Co‐DMBT T&R generated greater hot spots and less dose homogeneity in the target volumes compared with the 192Ir‐ and 169Yb‐DMBT T&R plans. Mean OAR doses in the DMBT T&R plans were significantly smaller (P < 0.0084) than the 192Ir‐T&R plans. Mean bladder D2 cm3 was reduced by 4.07%, 4.15%, and 5.13%, for the 192Ir‐, 60Co‐, and 169Yb‐DMBT T&R plans respectively. Mean rectum (sigmoid) D2 cm3 was reduced by 3.17% (3.63%), 2.57% (3.96%), and 4.65% (4.34%) for the 192Ir‐, 60Co‐, and 169Yb‐DMBT T&R plans respectively. The DMBT T&R plans with the 169Yb source generally resulted in the greatest OAR sparing when the CTVHR were larger and irregular in shape, while for smaller and regularly shaped CTVHR (<30 cm3), OAR sparing between the sources were comparable. Conclusions: The DMBT tandem provides a promising alternative to the Con.T design with significant improvement in the plan quality for various target volumes. The DMBT T&R plans generated with the three sources of varying energies generated superior plans compared to the conventional T&R applicators. Plans generated with the 169Yb‐DMBT T&R produced best results for larger and irregularly shaped CTVHR in terms of OAR sparing. Thus, this study suggests that the combination of the DMBT tandem applicator with varying energy sources can work synergistically to generate improved plans for cervical cancer brachytherapy.

SU-G-201-11: Exploring the Upper Limits of Dose Sculpting Capacity of the Novel Direction Modulated Brachytherapy (DMBT) Tandem Applicator

PURPOSE To explore and quantify the upper limits in dose sculpting capacity of the novel direction modulated brachytherapy (DMBT) tandem applicator compared with conventional tandem design for 192 Ir-based HDR planning. METHODS The proposed DMBT tandem applicator is designed for image-guided adaptive brachytherapy (IGABT), especially MRI, of cervical cancer. It has 6 peripheral holes of 1.3-mm width, grooved along a 5.4-mm diameter nonmagnetic tungsten alloy rod of density 18.0 g/cc, capable of generating directional dose profiles - leading to enhanced dose sculpting capacity through inverse planning. The external dimensions are identical to that of conventional tandem design to ensure clinical compatibility. To explore the expansive dose sculpting capacity, we constructed a hypothetical circular target with 20-mm radius and positioned the DMBT and conventional tandems at the center. We then incrementally shifted the positions laterally away from the center of up to 15 mm, at 1-mm steps. The in-house coded gradient projection-based inverse planning system was then used to generate inverse optimized plans ensuring identical V100=100% coverage. Conformity index (CI) was calculated for all plans. RESULTS Overall, the DMBT tandem generates more conformal dose distributions than conventional tandem for all lateral positional shifts of 0-15 mm (CI=0.91-0.52 and 0.99-0.34, respectively), with an exception at the central position due to the ideal circular dose distribution, generated by the 192 Ir, fitting tightly around the circular target (CI = 0.91 and 0.99, respectively). The DMBT tandem is able to generate dose conformity of CI>0.8 at up to 6-mm positional shift while the conventional tandem violates this past 2-mm shift. Also, the CI ratio (=DMBT/conv.) increases rapidly until about 8 mm and then stabilizes beyond. CONCLUSION A substantial enhancement in the dose sculpting capacity has been demonstrated for the novel DMBT tandem applicator. While further studies are warranted, the concept is promising for potential clinical translation.

SU-F-T-30: Comprehensive Dosimetric Characterization of the Novel Direction Modulation Brachytherapy (DMBT) Tandem Applicator Using Monte Carlo Simulations

PURPOSE To characterize the dosimetric properties/distributions of the novel proposed direction modulated brachytherapy (DMBT) tandem applicator in combination with 192Ir HDR source, and compare against conventional tandem design, using Monte Carlo simulations. METHODS The proposed DMBT tandem applicator is designed for image-guided adaptive brachytherapy, especially MRI, of cervical cancer. It has 6 peripheral holes of 1.3-mm width, grooved along a 5.4-mm diameter nonmagnetic tungsten alloy rod of density 18.0 g/cc, capable of generating directional dose profiles - leading to enhanced dose sculpting capacity through inverse planning. In-water dosimetric parameters for the DMBT and conventional tandems have been calculated for various radial distances away and around the tandems. For the DMBT tandem, the cumulative dose from the 192Ir source occupying 1) one and 2) all six holes in equal dwell times was calculated and normalized to match the dose rate of the open source (in conventional tandem) at 1 cm from the center. This is done to compare and contrast the characteristic dose distributions to that of the isotropic TG43-based 192Ir source. RESULTS All dose rates were normalized at 1-cm radius from the center of the applicators, containing source(s). The normalized dose rates at 0.5, 3.0, and 5.0-cm radiuses were then 388, 11.3, and 4.1% for conventional tandem, 657, 8.1, and 2.7% for DMBT tandem with the source in one hole at front entrance, and 436, 10.9, and 3.8% for DMBT tandem with the source in all six holes. For the DMBT tandem case with the source in one hole, the backside transmissions were 47, 2.4, and 0.9%, respectively. CONCLUSION The DMBT tandem is able to generate closely similar dosimetric characteristics as that of the single-channel conventional tandem if needed (with the source occupying all six holes), at the same time, generate directional radiation profile(s) for favorably enabling 3D dose sculpting capability.

SU‐F‐BRA‐05: Utility of the Combined Use of Two Types of HDR Sources with the Direction Modulation Brachytherapy (DMBT) Tandem Applicator for Cervical Cancer Treatment

Purpose: To maximize the dose to HRCTV while minimizing dose to the OARs, the combination of two HDR brachytherapy sources, 192-Ir and 169-Yb, used in combination with the recently-proposed novel direction modulated brachytherapy (DMBT) tandem applicator were examined. Methods: The DMBT tandem, made from nonmagnetic tungsten-alloy rod, with diameter of 5.4mm, has 6 symmetric peripheral holes of 1.3mm diameter. The 0.3mm thick bio-compatible plastic tubing wraps the tandem. MCNPX v.2.6 was used to simulate the mHDR 192-Ir V2 and 4140 HDR 169-Yb sources inside the DMBT applicator. Thought was by combining the higher energy 192-Ir (380keV) and lower energy 169-Yb (92.7keV) sources could create unprecedented level of dose conformality when combined with the high-degree intensity modulation capable DMBT tandem applicator. 3D dose matrices, with 1 mm3 resolution, were imported into an in-house-coded inverse optimization planning system to evaluate plan quality of 19 clinical patient cases. Prescription dose was 15Gy. All plans were normalized to receive the same HRCTV D90. Results: Generally, the use of dual sources produced better plans than using either of the sources alone, with significantly better performance in some patients. The mean D2cc for bladder, rectum, and sigmoid were 11.65±2.30Gy, 7.47±3.05Gy, and 9.84±2.48Gy for 192-Ir-only, respectively. For 169 -Yb-only, they were 11.67±2.26Gy, 7.44±3.02Gy, and 9.83±2.38Gy, respectively. The corresponding data for the dual sources were 11.51±2.24Gy, 7.30±3.00Gy, and 9.68 ±2.39Gy, respectively. The HRCTV D98 and V100 were 16.37±1.86Gy and 97.37±1.92Gy for Ir-192-only, respectively. For 169-Yb-only, they were 16.43±1.86Gy, and 97.51±1.91Gy, respectively. For the dual source, they were 16.42±1.87Gy and 97.47±1.93Gy, respectively. Conclusion: The plan quality improves, in some cases quite significantly, for when dual 192-Ir and 169-Yb sources are used in combination with highly intensity modulation capable DMBT tandem applicator for image guided cervical cancer brachytherapy.

A realistic phantom for validating MRI‐based synthetic CT images of the human skull

Purpose To introduce a new realistic human skull phantom for the validation of synthetic CT images of cortical bone from ultra‐short echo‐time (UTE) sequences. Methods A human skull of an adult female was utilized as a realistic representation of skull cortical bone. The skull was stabilized in a special acrylic container and was filled with contrast agents that have T1 and T2 relaxation times similar to human brain. The phantom was MR scanned at 3T with UTE and T2‐weighted sequences, followed by CT. A clustering approach was developed to extract the cortical bone signal from MR images. Symbol maps of the skull were calculated. Synthetic CT images of the bone were compared to cortical bone signal extracted from CT images and confounding factors, such as registration errors, were analyzed. Symbol. No Caption available. Results Dice similarity coefficient (DSC) of UTE‐detected cortical bone was 0.84 and gradually decreased with decreasing number of spokes. DSC did not significantly depend on echo‐time. Registration errors were found to be significant confounding factors, with 25% decrease in DSC for consistent 2 mm error at each axis. Conclusion This work introduced a new realistic human skull phantom, specifically for the evaluation and analysis of synthetic CT images of cortical bone.

SU-F-I-19: MRI Positive Contrast Visualization of Prostate Brachytherapy Seeds Using An Integrated Laplacian-Based Phase Processing

PURPOSE To propose a new method that provides a positive contrast visualization of the prostate brachytherapy seeds using the phase information from MR images. Additionally, the feasibility of using the processed phase information to distinguish seeds from calcifications is explored. METHODS A gel phantom was constructed using 2% agar dissolved in 1 L of distilled water. Contrast agents were added to adjust the relaxation times. Four iodine-125 (Eckert & Ziegler SML86999) dummy seeds were placed at different orientations with respect to the main magnetic field (B0). Calcifications were obtained from a sheep femur cortical bone due to its close similarity to human bone tissue composition. Five samples of calcifications were shaped into different dimensions with lengths ranging between 1.2 - 6.1 mm.MR imaging was performed on a 3T Philips Achieva using an 8-channel head coil. Eight images were acquired at eight echo-times using a multi-gradient echo sequence. Spatial resolution was 0.7 × 0.7 × 2 mm, TR/TE/dTE = 20.0/2.3/2.3 ms and BW = 541 Hz/pixel. Complex images were acquired and fed into a two-step processing pipeline: the first includes phase unwrapping and background phase removal using Laplacian operator (Wei et al. 2013). The second step applies a specific phase mask on the resulting tissue phase from the first step to provide the desired positive contrast of the seeds and to, potentially, differentiate them from the calcifications. RESULTS The phase-processing was performed in less than 30 seconds. The proposed method has successfully resulted in a positive contrast of the brachytherapy seeds. Additionally, the final processed phase image showed difference between the appearance of seeds and calcifications. However, the shape of the seeds was slightly distorted compared to the original dimensions. CONCLUSION It is feasible to provide a positive contrast of the seeds from MR images using Laplacian operator-based phase processing.

SU-G-IeP1-06: Estimating Relative Tissue Density From Quantitative MR Images: A Novel Perspective for MRI-Only Heterogeneity Corrected Dose Calculation

PURPOSE To explore the feasibility of extracting the relative density from quantitative MRI measurements as well as estimate a correlation between the extracted measures and CT Hounsfield units. METHODS MRI has the ability to separate water and fat signals, producing two separate images for each component. By performing appropriate corrections on the separated images, quantitative measurement of water and fat mass density can be estimated. This work aims to test this hypothesis on 1.5T.Peanut oil was used as fat-representative, while agar as water-representative. Gadolinium Chloride III and Sodium Chloride were added to the agar solution to adjust the relaxation times and the medium conductivity, respectively. Peanut oil was added to the agar solution with different percentages: 0%, 3%, 5%, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% and 100%. The phantom was scanned on 1.5T GE Optima 450W with the body coil using a multigradient echo sequences. Water/fat separation were performed while correcting for main field (B0) inhomogeneity and T2 * relaxation time. B1+ inhomogeneities were ignored. The phantom was subsequently scanned on a Philips Brilliance CT Big Bore. MR-corrected fat signal from all vials were normalized to 100% fat signal. CT Hounsfield values were then compared to those obtained from the normalized MR-corrected fat values as well as to the phantom for validation. RESULTS Good agreement were found between CT HU and the MR-extracted fat values (R2 = 0.98). CT HU also showed excellent agreement with the prepared fat fractions (R2 =0.99). Vials with 70%, 80%, and 90% fat percentages showed inhomogeneous distributions, however their results were included for completion. CONCLUSION Quantitative MRI water/fat imaging can be potentially used to extract the relative tissue density. Further in-vivo validation are required.

SU-F-T-28: Evaluation of BEBIG HDR Co-60 After-Loading System for Skin Cancer Treatment Using Conical Surface Applicator

PURPOSE To evaluate the possibility of utilizing the BEBIG HDR 60Co remote after-loading system for malignant skin surface treatment using Monte Carlo (MC) simulation technique. METHODS First TG-43 parameters of BEBIG-Co-60 and Nucletron Ir-192-mHDR-V2 brachytherapy sources were simulated using MCNP6 code to benchmark the sources against the literature. Second a conical tungsten-alloy with 3-cm diameter of Planning-Target-Volume (PTV) at surface for use with a single stepping HDR source is designed. The HDR source is modeled parallel to treatment plane at the center of the conical applicator with a source surface distance (SSD) of 1.5-cm and a removable plastic end-cap with a 1-mm thickness. Third, MC calculated dose distributions from HDR Co-60 for conical surface applicator were compared with the simulated data using HDR Ir-192 source. The initial calculations were made with the same conical surface applicator (standard-applicator) dimensions as the ones used with the Ir-192 system. Fourth, the applicator wall-thickness for the Co-60 system was increased (doubled) to diminish leakage dose to levels received when using the Ir-192 system. With this geometry, percentage depth dose (PDD), and relative 2D-dose profiles in transverse/coronal planes were normalized at 3-mm prescription-depth evaluated along the central axis. RESULTS PDD for Ir-192 and Co-60 were similar with standard and thick-walled applicator. 2D-relative dose distribution of Co-60, inside the standard-conical-applicator, generated higher penumbra (7.6%). For thick-walled applicator, it created smaller penumbra (<4%) compared to Ir-192 source in the standard-conicalapplicator. Dose leakage outside of thick-walled applicator with Co-60 source was approximately equal (≤3%) with standard applicator using Ir-192 source. CONCLUSION Skin cancer treatment with equal quality can be performed with Co-60 source and thick-walled conical applicators instead of Ir-192 with standard applicators. These conical surface applicator must be used with a protective plastic end-cap to eliminate electron contamination and over-dosage of the skin.