R Wiersma

Combined kV and MV imaging for real-time tracking of implanted fiducial markers

In the presence of intrafraction organ motion, target localization uncertainty can greatly hamper the advantage of highly conformal dose techniques such as intensity modulated radiation therapy (IMRT). To minimize the adverse dosimetric effect caused by tumor motion, a real-time knowledge of the tumor position is required throughout the beam delivery process. The recent integration of onboard kV diagnostic imaging together with MV electronic portal imaging devices on linear accelerators can allow for real-time three-dimensional (3D) tumor position monitoring during a treatment delivery. The aim of this study is to demonstrate a near real-time 3D internal fiducial tracking system based on the combined use of kV and MV imaging. A commercially available radiotherapy system equipped with both kV and MV imaging systems was used in this work. A hardware video frame grabber was used to capture both kV and MV video streams simultaneously through independent video channels at 30 frames per second. The fiducial locations were extracted from the kV and MV images using a software tool. The geometric tracking capabilities of the system were evaluated using a pelvic phantom with embedded fiducials placed on a moveable stage. The maximum tracking speed of the kV/MV system is approximately 9 Hz, which is primarily limited by the frame rate of the MV imager. The geometric accuracy of the system is found to be on the order of less than 1 mm in all three spatial dimensions. The technique requires minimal hardware modification and is potentially useful for image-guided radiation therapy systems.

Fast internal marker tracking algorithm for onboard MV and kV imaging systems

Intrafraction organ motion can limit the advantage of highly conformal dose techniques such as intensity modulated radiation therapy (IMRT) due to target position uncertainty. To ensure high accuracy in beam targeting, real-time knowledge of the target location is highly desired throughout the beam delivery process. This knowledge can be gained through imaging of internally implanted radio-opaque markers with fluoroscopic or electronic portal imaging devices (EPID). In the case of MV based images, marker detection can be problematic due to the significantly lower contrast between different materials in comparison to their kV-based counterparts. This work presents a fully automated algorithm capable of detecting implanted metallic markers in both kV and MV images with high consistency. Using prior CT information, the algorithm predefines the volumetric search space without manual region-of-interest (ROI) selection by the user. Depending on the template selected, both spherical and cylindrical markers can be detected. Multiple markers can be simultaneously tracked without indexing confusion. Phantom studies show detection success rates of 100% for both kV and MV image data. In addition, application of the algorithm to real patient image data results in successful detection of all implanted markers for MV images. Near real-time operational speeds of approximately 10 frames/sec for the detection of five markers in a 1024 x 768 image are accomplished using an ordinary PC workstation.

Predicting respiratory tumor motion with multi-dimensional adaptive filters and support vector regression

Intra-fraction tumor tracking methods can improve radiation delivery during radiotherapy sessions. Image acquisition for tumor tracking and subsequent adjustment of the treatment beam with gating or beam tracking introduces time latency and necessitates predicting the future position of the tumor. This study evaluates the use of multi-dimensional linear adaptive filters and support vector regression to predict the motion of lung tumors tracked at 30 Hz. We expand on the prior work of other groups who have looked at adaptive filters by using a general framework of a multiple-input single-output (MISO) adaptive system that uses multiple correlated signals to predict the motion of a tumor. We compare the performance of these two novel methods to conventional methods like linear regression and single-input, single-output adaptive filters. At 400 ms latency the average root-mean-square-errors (RMSEs) for the 14 treatment sessions studied using no prediction, linear regression, single-output adaptive filter, MISO and support vector regression are 2.58, 1.60, 1.58, 1.71 and 1.26 mm, respectively. At 1 s, the RMSEs are 4.40, 2.61, 3.34, 2.66 and 1.93 mm, respectively. We find that support vector regression most accurately predicts the future tumor position of the methods studied and can provide a RMSE of less than 2 mm at 1 s latency. Also, a multi-dimensional adaptive filter framework provides improved performance over single-dimension adaptive filters. Work is underway to combine these two frameworks to improve performance.

Real-time 3D internal marker tracking during arc radiotherapy by the use of combined MV?kV imaging

To minimize the adverse dosimetric effect caused by tumor motion, it is desirable to have real-time knowledge of the tumor position throughout the beam delivery process. A promising technique to realize the real-time image guided scheme in external beam radiation therapy is through the combined use of MV and onboard kV beam imaging. The success of this MV-kV triangulation approach for fixed-gantry radiation therapy has been demonstrated. With the increasing acceptance of modern arc radiotherapy in the clinics, a timely and clinically important question is whether the image guidance strategy can be extended to arc therapy to provide the urgently needed real-time tumor motion information. While conceptually feasible, there are a number of theoretical and practical issues specific to the arc delivery that need to be resolved before clinical implementation. The purpose of this work is to establish a robust procedure of system calibration for combined MV and kV imaging for internal marker tracking during arc delivery and to demonstrate the feasibility and accuracy of the technique. A commercially available LINAC equipped with an onboard kV imager and electronic portal imaging device (EPID) was used for the study. A custom built phantom with multiple ball bearings was used to calibrate the stereoscopic MV-kV imaging system to provide the transformation parameters from imaging pixels to 3D world coordinates. The accuracy of the fiducial tracking system was examined using a 4D motion phantom capable of moving in accordance with a pre-programmed trajectory. Overall, spatial accuracy of MV-kV fiducial tracking during the arc delivery process for normal adult breathing amplitude and period was found to be better than 1 mm. For fast motion, the results depended on the imaging frame rates. The RMS error ranged from approximately 0.5 mm for the normal adult breathing pattern to approximately 1.5 mm for more extreme cases with a low imaging frame rate of 3.4 Hz. In general, highly accurate real-time tracking of implanted markers using hybrid MV-kV imaging is achievable and the technique should be useful to improve the beam targeting accuracy of arc therapy.

A fiducial detection algorithm for real-time image guided IMRT based on simultaneous MV and kV imaging

The advantage of highly conformal dose techniques such as 3DCRT and IMRT is limited by intrafraction organ motion. A new approach to gain near real-time 3D positions of internally implanted fiducial markers is to analyze simultaneous onboard kV beam and treatment MV beam images (from fluoroscopic or electronic portal image devices). Before we can use this real-time image guidance for clinical 3DCRT and IMRT treatments, four outstanding issues need to be addressed. (1) How will fiducial motion blur the image and hinder tracking fiducials? kV and MV images are acquired while the tumor is moving at various speeds. We find that a fiducial can be successfully detected at a maximum linear speed of 1.6 cm/s. (2) How does MV beam scattering affect kV imaging? We investigate this by varying MV field size and kV source to imager distance, and find that common treatment MV beams do not hinder fiducial detection in simultaneous kV images. (3) How can one detect fiducials on images from 3DCRT and IMRT treatment beams when the MV fields are modified by a multileaf collimator (MLC)? The presented analysis is capable of segmenting a MV field from the blocking MLC and detecting visible fiducials. This enables the calculation of nearly real-time 3D positions of markers during a real treatment. (4) Is the analysis fast enough to track fiducials in nearly real time? Multiple methods are adopted to predict marker positions and reduce search regions. The average detection time per frame for three markers in a 1024 x 768 image was reduced to 0.1 s or less. Solving these four issues paves the way to tracking moving fiducial markers throughout a 3DCRT or IMRT treatment. Altogether, these four studies demonstrate that our algorithm can track fiducials in real time, on degraded kV images (MV scatter), in rapidly moving tumors (fiducial blurring), and even provide useful information in the case when some fiducials are blocked from view by the MLC. This technique can provide a gating signal or be used for intra-fractional tumor tracking on a Linac equipped with a kV imaging system. Any motion exceeding a preset threshold can warn the therapist to suspend a treatment session and reposition the patient.

Activated transport in the separate layers that form the nuT=1 exciton condensate.

We observe the total filling factor nuT=1 quantum Hall state in a bilayer two-dimensional electron system with virtually no tunneling. We find thermally activated transport in the balanced system with a monotonic increase of the activation energy with decreasing d/lB below 1.65. In the imbalanced system we find activated transport in each of the layers separately, yet the activation energies show a striking asymmetry around the balance point, implying a different excitation spectrum for the separate layers forming the condensed state.

Development of a frameless stereotactic radiosurgery system based on real-time 6D position monitoring and adaptive head motion compensation

Stereotactic radiosurgery delivers radiation with great spatial accuracy. To achieve sub-millimeter accuracy for intracranial SRS, a head ring is rigidly fixated to the skull to create a fixed reference. For some patients, the invasiveness of the ring can be highly uncomfortable and not well tolerated. In addition, placing and removing the ring requires special expertise from a neurosurgeon, and patient setup time for SRS can often be long. To reduce the invasiveness, hardware limitations and setup time, we are developing a system for performing accurate head positioning without the use of a head ring. The proposed method uses real-time 6D optical position feedback for turning on and off the treatment beam (gating) and guiding a motor-controlled 3D head motion compensation stage. The setup consists of a central control computer, an optical patient motion tracking system and a 3D motion compensation stage attached to the front of the LINAC couch. A styrofoam head cast was custom-built for patient support and was mounted on the compensation stage. The motion feedback of the markers was processed by the control computer, and the resulting motion of the target was calculated using a rigid body model. If the target deviated beyond a preset position of 0.2 mm, an automatic position correction was performed with stepper motors to adjust the head position via the couch mount motion platform. In the event the target deviated more than 1 mm, a safety relay switch was activated and the treatment beam was turned off. The feasibility of the concept was tested using five healthy volunteers. Head motion data were acquired with and without the use of motion compensation over treatment times of 15 min. On average, test subjects exceeded the 0.5 mm tolerance 86% of the time and the 1.0 mm tolerance 45% of the time without motion correction. With correction, this percentage was reduced to 5% and 2% for the 0.5 mm and 1.0 mm tolerances, respectively.

IMAGE-GUIDED RADIOTHERAPY IN NEAR REAL TIME WITH INTENSITY- MODULATED RADIOTHERAPY MEGAVOLTAGE TREATMENT BEAM IMAGING

PURPOSE To utilize image-guided radiotherapy (IGRT) in near real time by obtaining and evaluating the online positions of implanted fiducials from continuous electronic portal imaging device (EPID) imaging of prostate intensity-modulated radiotherapy (IMRT) delivery. METHODS AND MATERIALS Upon initial setup using two orthogonal images, the three-dimensional (3D) positions of all implanted fiducial markers are obtained, and their expected two-dimensional (2D) locations in the beams-eye-view (BEV) projection are calculated for each treatment field. During IMRT beam delivery, EPID images of the megavoltage treatment beam are acquired in cine mode and subsequently analyzed to locate 2D locations of fiducials in the BEV. Simultaneously, 3D positions are estimated according to the current EPID image, information from the setup portal images, and images acquired at other gantry angles (the completed treatment fields). The measured 2D and 3D positions of each fiducial are compared with their expected 2D and 3D setup positions, respectively. Any displacements larger than a predefined tolerance may cause the treatment system to suspend the beam delivery and direct the therapists to reposition the patient. RESULTS Phantom studies indicate that the accuracy of 2D BEV and 3D tracking are better than 1 mm and 1.4 mm, respectively. A total of 7330 images from prostate treatments were acquired and analyzed, showing a maximum 2D displacement of 6.7 mm and a maximum 3D displacement of 6.9 mm over 34 fractions. CONCLUSIONS This EPID-based, real-time IGRT method can be implemented on any external beam machine with portal imaging capabilities without purchasing any additional equipment, and there is no extra dose delivered to the patient.

Spatial and temporal performance of 3D optical surface imaging for real‐time head position tracking

PURPOSE The spatial and temporal tracking performance of a commercially available 3D optical surface imaging system is evaluated for its potential use in frameless stereotactic radiosurgery head tracking applications. METHODS Both 3D surface and infrared (IR) marker tracking were performed simultaneously on a head phantom mounted on an xyz motion stage and on four human subjects. To allow spatial and temporal comparison on human subjects, three points were simultaneously monitored, including the upper facial region (3D surface), a dental plate (IR markers), and upper forehead (IR markers). RESULTS For both static and dynamic phantom studies, the 3D surface tracker was found to have a root mean squared error (RMSE) of approximately 0.30 mm for region-of-interest (ROI) surface sizes greater than 1000 vertex points. Although, the processing period (1/fps) of the 3D surface system was found to linearly increase as a function of the number of ROI vertex points, the tracking accuracy was found to be independent of ROI size provided that the ROI was sufficiently large and contained features for registration. For human subjects, the RMSE between 3D surface tracking and IR marker tracking modalities was 0.22 mm left-right (x-axis), 0.44 mm superior-inferior (y-axis), 0.27 mm anterior-posterior (z-axis), 0.29° pitch (around x-axis), 0.18° roll (around y-axis), and 0.15° yaw (around z-axis). CONCLUSIONS 3D surface imaging has the potential to provide submillimeter level head motion tracking. This is provided that a highly accurate camera-to-LINAC frame of reference calibration can be performed and that the reference ROI is of sufficient size and contains suitable surface features for registration.

Improvements in dose accuracy delivered with static-MLC IMRT on an integrated linear accelerator control system.

PURPOSE Dose accuracy has been shown to vary with dose per segment and dose rate when delivered with static multileaf collimator (SMLC) intensity modulated radiation therapy (IMRT) by Varian C-series MLC controllers. The authors investigated the impact of monitor units (MUs) per segment and dose rate on the dose delivery accuracy of SMLC-IMRT fields on a Varian TrueBeam linear accelerator (LINAC), which delivers dose and manages motion of all components using a single integrated controller. METHODS An SMLC sequence was created consisting of ten identical 10 × 10 cm(2) segments with identical MUs. Beam holding between segments was achieved by moving one out-of-field MLC leaf pair. Measurements were repeated for various combinations of MU/segment ranging from 1 to 40 and dose rates of 100-600 MU/min for a 6 MV photon beam (6X) and dose rates of 800-2400 MU/min for a 10 MV flattening-filter free photon (10XFFF) beam. All measurements were made with a Farmer (0.6 cm(3)) ionization chamber placed at the isocenter in a solid-water phantom at 10 cm depth. The measurements were performed on two Varian LINACs: C-series Trilogy and TrueBeam. Each sequence was delivered three times and the dose readings for the corresponding segments were averaged. The effects of MU/segment, dose rate, and LINAC type on the relative dose variation (Δ(i)) were compared using F-tests (α = 0.05). RESULTS On the Trilogy, large Δ(i) was observed in small MU segments: at 1 MU/segment, the maximum Δ(i) was 10.1% and 57.9% at 100 MU/min and 600 MU/min, respectively. Also, the first segment of each sequence consistently overshot (Δ(i) > 0), while the last segment consistently undershot (Δ(i) < 0). On the TrueBeam, at 1 MU/segment, Δ(i) ranged from 3.0% to 4.5% at 100 and 600 MU/min; no obvious overshoot/undershoot trend was observed. F-tests showed statistically significant difference [(1 - β) =1.0000] between the Trilogy and the TrueBeam up to 10 MU/segment, at all dose rates greater than 100 MU/min. The linear trend of decreasing dose accuracy as a function of increasing dose rate on the Trilogy is no longer apparent on TrueBeam, even for dose rates as high as 2400 MU/min. Dose inaccuracy averaged over all ten segments in each beam delivery sequence was larger for Trilogy than TrueBeam, with the largest discrepancy (0.2% vs 3%) occurring for 1 MU/segment beams at both 300 and 600 MU/min. CONCLUSIONS Earlier generations of Varian LINACs exhibited large dose variations for small MU segments in SMLC-IMRT delivery. Our results confirmed these findings. The dose delivery accuracy for SMLC-IMRT is significantly improved on TrueBeam compared to Trilogy for every combination of low MU/segment (1-10) and high dose rate (200-600 MU/min), in part due to the faster sampling rate (100 vs 20 Hz) and enhanced electronic integration of the MLC controller with the LINAC. SMLC-IMRT can be implemented on TrueBeam with higher dose accuracy per beam (±0.2% vs ±3%) than previous generations of Varian C-series LINACs for 1 MU/segment delivered at 600 MU/min).