C Liu

Contouring variability of human- and deformable-generated contours in radiotherapy for prostate cancer

This study was designed to evaluate contouring variability of human-and deformable-generated contours on planning CT (PCT) and CBCT for ten patients with low-or intermediate-risk prostate cancer. For each patient in this study, five radiation oncologists contoured the prostate, bladder, and rectum, on one PCT dataset and five CBCT datasets. Consensus contours were generated using the STAPLE method in the CERR software package. Observer contours were compared to consensus contour, and contour metrics (Dice coefficient, Hausdorff distance, Contour Distance, Center-of-Mass [COM] Deviation) were calculated. In addition, the first day CBCT was registered to subsequent CBCT fractions (CBCTn: CBCT2-CBCT5) via B-spline Deformable Image Registration (DIR). Contours were transferred from CBCT1 to CBCTn via the deformation field, and contour metrics were calculated through comparison with consensus contours generated from human contour set. The average contour metrics for prostate contours on PCT and CBCT were as follows: Dice coefficient-0.892 (PCT), 0.872 (CBCT-Human), 0.824 (CBCT-Deformed); Hausdorff distance-4.75 mm (PCT), 5.22 mm (CBCT-Human), 5.94 mm (CBCT-Deformed); Contour Distance (overall contour)-1.41 mm (PCT), 1.66 mm (CBCT-Human), 2.30 mm (CBCT-Deformed); COM Deviation-2.01 mm (PCT), 2.78 mm (CBCT-Human), 3.45 mm (CBCT-Deformed). For human contours on PCT and CBCT, the difference in average Dice coefficient between PCT and CBCT (approx. 2%) and Hausdorff distance (approx. 0.5 mm) was small compared to the variation between observers for each patient (standard deviation in Dice coefficient of 5% and Hausdorff distance of 2.0 mm). However, additional contouring variation was found for the deformable-generated contours (approximately 5.0% decrease in Dice coefficient and 0.7 mm increase in Hausdorff distance relative to human-generated contours on CBCT). Though deformable contours provide a reasonable starting point for contouring on CBCT, we conclude that contours generated with B-Spline DIR require physician review and editing if they are to be used in the clinic.

A novel approach for evaluation of prostate deformation and associated dosimetric implications in IGRT of the prostate

PURPOSE Prostate deformation is assumed to be a secondary correction and is typically ignored in the planning target volume (PTV) margin calculations. This assumption needs to be tested, especially when planning margins are reduced with daily image-guidance. In this study, deformation characteristics of the prostate and seminal vesicles were determined, and the dosimetric impact on treatment plans with different PTV margins was investigated. METHODS Ten prostate cancer patients were retrospectively selected for the study, each with three fiducial markers implanted in the prostate. Two hundred CBCT images were registered to respective planning CT images using a B-spline-based deformable image registration (DIR) software. A manual bony anatomy-based match was first applied based on the alignment of the pelvic bones and fiducial landmarks. DIR was then performed. For each registration, deformation vector fields (DVFs) of the prostate and seminal vesicles (SVs) were quantified using deformation-volume histograms. In addition, prostate rotation was evaluated and compared with prostate deformation. For a patient demonstrating small and large prostate deformations, target coverage degradation was analyzed in each of three treatment plans with PTV margins of 10 mm (6 mm at the prostate/rectum interface), as well as 5, and 3 mm uniformly. RESULTS Deformation of the prostate was most significant in the anterior direction. Maximum prostate deformation of greater than 10, 5, and 3 mm occurred in 1%, 17%, and 76% of the cases, respectively. Based on DVF-histograms, DVF magnitudes greater than 5 and 3 mm occurred in 2% and 27% of the cases, respectively. Deformation of the SVs was most significant in the posterior direction, and it was greater than 5 and 3 mm in 7.5% and 44.9% of the cases, respectively. Prostate deformation was found to be poorly correlated with rotation. Fifty percent of the cases showed rotation with negligible deformation and 7% of the cases showed significant deformation with minimal rotation (<3°). Average differences in the D95 dose to the prostate+SVs between the planning CT and CBCT images was 0.4%±0.5%, 3.0%±2.8%, and 6.6%±6.1%, respectively, for the plans with 10/6, 5, and 3 mm margins. For the case with both a large degree of prostate deformation (≈10% of the prostate volume) and rotation (≈8°), D95 was reduced by 0.5%±0.1%, 6.8%±0.6%, and 20.9%±1.6% for 10/6, 5, and 3 mm margin plans, respectively. For the case with large prostate deformation but negligible rotation (<1°), D95 was reduced by 0.4±0.3, 3.9±1.0, and 11.5±2.5 for 10/6, 5, and 3 mm margin plans, respectively. CONCLUSIONS Prostate deformation over a course of fractionated prostate radiotherapy may not be insignificant and may need to be accounted for in the planning margin design. A consequence of these results is that use of highly reduced planning margins must be viewed with caution.

Optimization of Treatment Geometry to Reduce Normal Brain Dose in Radiosurgery of Multiple Brain Metastases with Single–Isocenter Volumetric Modulated Arc Therapy

Treatment of patients with multiple brain metastases using a single-isocenter volumetric modulated arc therapy (VMAT) has been shown to decrease treatment time with the tradeoff of larger low dose to the normal brain tissue. We have developed an efficient Projection Summing Optimization Algorithm to optimize the treatment geometry in order to reduce dose to normal brain tissue for radiosurgery of multiple metastases with single-isocenter VMAT. The algorithm: (a) measures coordinates of outer boundary points of each lesion to be treated using the Eclipse Scripting Application Programming Interface, (b) determines the rotations of couch, collimator, and gantry using three matrices about the cardinal axes, (c) projects the outer boundary points of the lesion on to Beam Eye View projection plane, (d) optimizes couch and collimator angles by selecting the least total unblocked area for each specific treatment arc, and (e) generates a treatment plan with the optimized angles. The results showed significant reduction in the mean dose and low dose volume to normal brain, while maintaining the similar treatment plan qualities on the thirteen patients treated previously. The algorithm has the flexibility with regard to the beam arrangements and can be integrated in the treatment planning system for clinical application directly.

Tuning of AcurosXB source size setting for small intracranial targets

&NA; This study details a method to evaluate the source size selection for small field intracranial stereotactic radiosurgery (SRS) deliveries in Eclipse treatment planning system (TPS) for AcurosXB dose calculation algorithm. Our method uses end‐to‐end dosimetric data to evaluate a total of five source size selections (0.50 mm, 0.75 mm, 1.00 mm, 1.25 mm, and 1.50 mm). The dosimetric leaf gap (DLG) was varied in this analysis (three DLG values were tested for each scenario). We also tested two MLC leaf designs (standard and high‐definition MLC) and two delivery types for intracranial SRS (volumetric modulated arc therapy [VMAT] and dynamic conformal arc [DCA]). Thus, a total of 10 VMAT plans and 10 DCA plans were tested for each machine type (TrueBeam [standard MLC] and Edge [high‐definition MLC]). Each plan was mapped to a solid water phantom and dose was calculated with each iteration of source size and DLG value (15 total dose calculations for each plan). To measure the dose, Gafchromic film was placed in the coronal plane of the solid water phantom at isocenter. The phantom was localized via on‐board CBCT and the plans were delivered at planned gantry, collimator, and couch angles. The planned and measured film dose was compared using Gamma (3.0%, 0.3 mm) criteria. The vendor‐recommended 1.00 mm source size was suitable for TrueBeam planning (both VMAT and DCA planning) and Edge DCA planning. However, for Edge VMAT planning, the 0.50 mm source size yielded the highest passing rates. The difference in dose calculation among the source size variations manifested primarily in two regions of the dose calculation: (1) the shoulder of the high‐dose region, and (2) for small targets (volume ≤ 0.30 cc), in the central portion of the high‐dose region. Selection of a larger than optimal source size can result in increased blurring of the shoulder for all target volume sizes tested, and can result in central axis dose discrepancies in excess of 10% for target volumes sizes ≤ 0.30 cc. Our results indicate a need for evaluation of the source size when AcurosXB is used to model intracranial SRS delivery, and our methods represent a feasible process for many clinics to perform tuning of the AcurosXB source size parameter.

Evaluation of a magnetic resonance guided linear accelerator for stereotactic radiosurgery treatment

INTRODUCTION The purpose of this study was to investigate the systematic localization accuracy, treatment planning capability, and delivery accuracy of an integrated magnetic resonance imaging guided Linear Accelerator (MR-Linac) platform for stereotactic radiosurgery. MATERIALS AND METHODS The phantom for the end-to-end test comprises three different compartments: a rectangular MR/CT target phantom, a Winston-Lutz cube, and a rectangular MR/CT isocenter phantom. Hidden target tests were performed at gantry angles of 0, 90, 180, and 270 degrees to quantify the systematic accuracy. Five patient plans with a total of eleven lesions were used to evaluate the dosimetric accuracy. Single-isocenter IMRT treatment plans using 10-15 coplanar beams were generated to treat the multiple metastases. RESULTS The end-to-end localization accuracy of the system was 1.0 ± 0.1 mm. The conformity index, homogeneity index and gradient index of the plans were 1.26 ± 0.22, 1.22 ± 0.10, and 5.38 ± 1.44, respectively. The average absolute point dose difference between measured and calculated dose was 1.64 ± 1.90%, and the mean percentage of points passing the 3%/1 mm gamma criteria was 96.87%. CONCLUSIONS Our experience demonstrates that excellent plan quality and delivery accuracy was achievable on the MR-Linac for treating multiple brain metastases with a single isocenter.

SU-D-204-07: Retrospective Correlation of Dose Accuracy with Regions of Local Failure for Early Stage Lung Cancer Patients Treated with Stereotactic Body Radiotherapy

PURPOSE To correlate dose distributions computed using six algorithms for recurrent early stage non-small cell lung cancer (NSCLC) patients treated with stereotactic body radiotherapy (SBRT), with outcome (local failure). METHODS Of 270 NSCLC patients treated with 12Gyx4, 20 were found to have local recurrence prior to the 2-year time point. These patients were originally planned with 1-D pencil beam (1-D PB) algorithm. 4D imaging was performed to manage tumor motion. Regions of local failures were determined from follow-up PET-CT scans. Follow-up CT images were rigidly fused to the planning CT (pCT), and recurrent tumor volumes (Vrecur) were mapped to the pCT. Dose was recomputed, retrospectively, using five algorithms: 3-D PB, collapsed cone convolution (CCC), anisotropic analytical algorithm (AAA), AcurosXB, and Monte Carlo (MC). Tumor control probability (TCP) was computed using the Marsden model (1,2). Patterns of failure were classified as central, in-field, marginal, and distant for Vrecur ≥95% of prescribed dose, 95-80%, 80-20%, and ≤20%, respectively (3). RESULTS Average PTV D95 (dose covering 95% of the PTV) for 3-D PB, CCC, AAA, AcurosXB, and MC relative to 1-D PB were 95.3±2.1%, 84.1±7.5%, 84.9±5.7%, 86.3±6.0%, and 85.1±7.0%, respectively. TCP values for 1-D PB, 3-D PB, CCC, AAA, AcurosXB, and MC were 98.5±1.2%, 95.7±3.0, 79.6±16.1%, 79.7±16.5%, 81.1±17.5%, and 78.1±20%, respectively. Patterns of local failures were similar for 1-D and 3D PB plans, which predicted that the majority of failures occur in centraldistal regions, with only ∼15% occurring distantly. However, with convolution/superposition and MC type algorithms, the majority of failures (65%) were predicted to be distant, consistent with the literature. CONCLUSION Based on MC and convolution/superposition type algorithms, average PTV D95 and TCP were ∼15% lower than the planned 1-D PB dose calculation. Patterns of failure results suggest that MC and convolution/superposition type algorithms predict different outcomes for patterns of failure relative to PB algorithms. Work supported in part by Varian Medical Systems, Palo Alto, CA.

MO-F-CAMPUS-T-01: Radiosurgery of Multiple Brain Metastases with Single-Isocenter VMAT: Optimizing Treatment Geometry to Reduce Normal Brain Dose

Purpose: To develop an optimization algorithm to reduce normal brain dose by optimizing couch and collimator angles for single isocenter multiple targets treatment of stereotactic radiosurgery. Methods: Three metastatic brain lesions were retrospectively planned using single-isocenter volumetric modulated arc therapy (VMAT). Three matrices were developed to calculate the projection of each lesion on Beam’s Eye View (BEV) by the rotating couch, collimator and gantry respectively. The island blocking problem was addressed by computing the total area of open space between any two lesions with shared MLC leaf pairs. The couch and collimator angles resulting in the smallest open areas were the optimized angles for each treatment arc. Two treatment plans with and without couch and collimator angle optimization were developed using the same objective functions and to achieve 99% of each target volume receiving full prescription dose of 18Gy. Plan quality was evaluated by calculating each target’s Conformity Index (CI), Gradient Index (GI), and Homogeneity index (HI), and absolute volume of normal brain V8Gy, V10Gy, V12Gy, and V14Gy. Results: Using the new couch/collimator optimization strategy, dose to normal brain tissue was reduced substantially. V8, V10, V12, and V14 decreased by 2.3%, 3.6%, 3.5%, and 6%, respectively. There were no significant differences in the conformity index, gradient index, and homogeneity index between two treatment plans with and without the new optimization algorithm. Conclusion: We have developed a solution to the island blocking problem in delivering radiation to multiple brain metastases with shared isocenter. Significant reduction in dose to normal brain was achieved by using optimal couch and collimator angles that minimize total area of open space between any of the two lesions with shared MLC leaf pairs. This technique has been integrated into Eclipse treatment system using scripting API.

SU‐C‐17A‐03: Evaluation of Deformable Image Registration Methods Between MRI and CT for Prostate Cancer Radiotherapy

PURPOSE We evaluated the performance of two commercially available and one open source B-Spline deformable image registration (DIR) algorithms between T2-weighted MRI and treatment planning CT using the DICE indices. METHODS CT simulation (CT-SIM) and MR simulation (MR-SIM) for four prostate cancer patients were conducted on the same day using the same setup and immobilization devices. CT images (120 kVp, 500 mAs, voxel size = 1.1×1.1×3.0 mm3) were acquired using an open-bore CT scanner. T2-weighted Turbo Spine Echo (T2W-TSE) images (TE/TR/α = 80/4560 ms/90°, voxel size = 0.7×0.7×2.5 mm3) were scanned on a 1.0T high field open MR-SIM. Prostates, seminal vesicles, rectum and bladders were delineated on both T2W-TSE and CT images by the attending physician. T2W-TSE images were registered to CT images using three DIR algorithms, SmartAdapt (Varian), Velocity AI (Velocity) and Elastix (Klein et al 2010) and contours were propagated. DIR results were evaluated quantitatively or qualitatively by image comparison and calculating organ DICE indices. RESULTS Significant differences in the contours of prostate and seminal vesicles were observed between MR and CT. On average, volume changes of the propagated contours were 5%, 2%, 160% and 8% for the prostate, seminal vesicles, bladder and rectum respectively. Corresponding mean DICE indices were 0.7, 0.5, 0.8, and 0.7. The intraclass correlation coefficient (ICC) was 0.9 among three algorithms for the Dice indices. CONCLUSION Three DIR algorithms for CT/MR registration yielded similar results for organ propagation. Due to the different soft tissue contrasts between MRI and CT, organ delineation of prostate and SVs varied significantly, thus efforts to develop other DIR evaluation metrics are warranted. CONFLICT OF INTEREST Submitting institution has research agreements with Varian Medical System and Philips Healthcare.

SU‐E‐J‐206: Delivered Dose to Organs From CBCT‐Based IGRT of the Prostate

Purpose: To estimate the actual delivered dose to organs from CBCT‐based image‐guided radiation therapy for localized prostate cancer treatments. Methods: Seven localized prostate cancer treatments were retrospectively selected, each with ∼40 CBCT images. All patients were treated with 9 IMRT beams. The PTV margin was 6 mm in the posterior direction, and 10 mm otherwise around the prostate. For each patient, the original plan was used to calculate treatment dose on each CBCT image at treatment position. The calculated daily dose was then warped back to the original planning CT via an intensity‐based B‐spline deformable image registration (DIR) algorithm. The DIR algorithm employed mutual information with a multi‐resolution and multi‐stage scheme. From the transferred total cumulative dose, dosimetric parameters were recorded for comparison with the original plan. The quality of prostate registration was quantified using three implanted fiducial markers. Only those cases with < 2mm error were included in the dose analysis. Results: The overall marker displacement was 1.8±1.8 mm after registrations. 75 of 281 registrations (27%) exceeded the 2 mm error threshold. The primary causes were the excessive noise level on CBCT images especially for large patients, presence of rectum gas, and lower abdominal motion artifacts. Excluding these cases, a total of 206 CBCT images were included in dosimetric analysis. Changes in dose coverage to the prostate was minimal (<1%). Dose deviations for rectum (Dmax, V50, V65, V75) were (0.5±1.0%, 2.6±2.5%, 3.5±3.7%, 2.3±4.2%) and (−1.1−0.9%, −2.5±5.3%, −3.0±5.3%, −3.8±4.9%) for bladder, respectively. Conclusion: With the conventional PTV margins, deviations in dose coverage of the prostate in the face of daily anatomic changes were minor However, relatively larger deviations were observed for rectum and bladder (1SD=∼4.3%). Reduced margins may lower dose to critical organs while maintaining target coverage. However, margin reduction must be viewed cautiously and with consideration of clinical outcomes.

Principal Component Analysis (PCA) modeling of Head-and-Neck anatomy using daily CBCT images

PURPOSE To model Head-and-Neck anatomy from daily Cone Beam-CT (CBCT) images over the course of fractionated radiotherapy using principal component analysis (PCA). METHODS AND MATERIALS Eighteen oropharyngeal Head-and-Neck cancer patients, treated with volumetric modulated arc therapy (VMAT), were included in this retrospective study. Normal organs, including the parotid and submandibular glands, mandible, pharyngeal constrictor muscles (PCMs), and spinal cord were contoured using daily CBCT image datasets. PCA models for each organ were developed for individual patients (IP) and the entire patient cohort/population (PP). The first 10 principal components (PCs) were extracted for all models. Analysis included cumulative and individual PCs for each organ and patient, as well as the aggregate organ/patient population; comparisons were made using the root-mean-square (RMS) of the percentage predicted spatial displacement for each PC. RESULTS Overall, spatial displacement prediction was achieved at the 95% confidence level (CL) for the first three to four PCs for all organs, based on IP models. For PP models, the first four PCs predicted spatial displacement at the 80%-89% CL. Differences in percentage predicted spatial displacement between mean IP models for each organ ranged from 2.8% ± 1.8% (1st PC) to 0.6% ± 0.4% (4th PC). Differences in percentage predicted spatial displacement between IP models vs the mean IP model for each organ based on the 1st PC were <12.9% ± 6.9% for all organs. Differences in percentage predicted spatial displacement between IP and PP models based on all organs and patients for the 1st and 2nd PC were <11.7% ± 2.2%. CONCLUSION Tissue changes during fractionated radiotherapy observed on daily CBCT in patients with Head-and-Neck cancers, were modeled using PCA. In general, spatial displacement for organs-at-risk was predicted for the first 4 principal components at the 95% confidence levels (CL), for individual patient (IP) models, and at the 80%-89% CL for population-based patient (PP) models. The IP and PP models were most predictive of changes in glandular organs and pharyngeal constrictor muscles, respectively.