T. Fox

A quality assurance program for the on-board imager ®

To develop a quality assurance (QA) program for the On-Board Imager (OBI) system and to summarize the results of these QA tests over extended periods from multiple institutions. Both the radiographic and cone-beam computed tomography (CBCT) mode of operation have been evaluated. The QA programs from four institutions have been combined to generate a series of tests for evaluating the performance of the On-Board Imager. The combined QA program consists of three parts: (1) safety and functionality, (2) geometry, and (3) image quality. Safety and functionality tests evaluate the functionality of safety features and the clinical operation of the entire system during the tube warm-up. Geometry QA verifies the geometric accuracy and stability of the OBI/CBCT hardware/software. Image quality QA monitors spatial resolution and contrast sensitivity of the radiographic images. Image quality QA for CBCT includes tests for Hounsfield Unit (HU) linearity, HU uniformity, spatial linearity, and scan slice geometry, in addition. All safety and functionality tests passed on a daily basis. The average accuracy of the OBI isocenter was better than 1.5mm with a range of variation of less than 1mm over 8 months. The average accuracy of arm positions in the mechanical geometry QA was better than 1mm, with a range of variation of less than 1mm over 8 months. Measurements of other geometry QA tests showed stable results within tolerance throughout the test periods. Radiographic contrast sensitivity ranged between 2.2% and 3.2% and spatial resolution ranged between 1.25 and 1.6lp∕mm. Over four months the CBCT images showed stable spatial linearity, scan slice geometry, contrast resolution (1%; <7mm disk) and spatial resolution (>6lp∕cm). The HU linearity was within ±40HU for all measurements. By combining test methods from multiple institutions, we have developed a comprehensive, yet practical, set of QA tests for the OBI system. Use of the tests over extended periods show that the OBI system has reliable mechanical accuracy and stable image quality. Nevertheless, the tests have been useful in detecting performance deficits in the OBI system that needed recalibration. It is important that all tests are performed on a regular basis.

Case study of anti-1-amino-3-F-18 fluorocyclobutane-1-carboxylic acid (anti-[F-18] FACBC) to guide prostate cancer radiotherapy target design.

Purpose of the Report: Anti-1-amino-3-F-18 fluorocyclobutane-1-carboxylic acid (FACBC) is a novel radiotracer, which has shown some promise for use with positron emission tomography (PET)/computed tomography (CT) for visualizing prostate cancer. Here we describe a case of a prostate cancer patient who underwent radiation treatment and had an FACBC scan obtained as part of a pilot study. Methods: We explored the potential impact of FACBC on treatment planning. We registered the FACBC acquisition with the PET/CT, which required a simple translation. Then, we did a deformable image registration of the PET/CT with the planning CT—this process allowed the FACBC-defined gross tumor volume (GTVFACBC) to be projected into the planning CT. An intensity-modulated radiotherapy (IMRT) plan (plan A) not including GTVFACBC (with final dose to 81.0 Gy) was generated, as was an IMRT plan including the GTVFACBC to a final dose of 86.4 Gy (plan B). Target coverage and normal tissue dose volume histogram (DVH) endpoints were tabulated. Results: In this particular patient, bladder constraints could not be met on any plan due to anatomic limitations. However, the impact on the rectal DVH could be assessed, and inclusion of the GTVFACBC did permit rectal DVH constraints to be met in plan B while maintaining target coverage and inhomogeneity constraints. Conclusion: In our test case, it was feasible to use FACBC to guide IMRT, and highlights the role of deformable image registration of the PET/CT with the planning CT. These findings can guide future studies incorporating FACBC into treatment planning.

A critical look at currently available radiation oncology information management systems

Many complicated technical factors are involved in selecting a radiation oncology information management system. This report presents a discussion of some important information systems components and concepts which should be considered when evaluating vendor options. Network operating systems, database management systems, network infrastructure, and client issues are all presented. The current marketplace of products is analyzed from both a features and a systems standpoint. Because selection of an appropriate system is a highly site-specific matter taking into account may important factors, general recommendations are difficult. Nonetheless, current market leadership by certain vendors and a broad sense of the future direction are indicated in the conclusions.

PET Lesion Segmentation Using Automated Iso-intensity Contouring in Head and Neck Cancer

To improve the objectivity of the integration of positron emission tomography (PET), we used the conformality index (CI) to measure the goodness of fit of a given PET iso-SUV (standardized uptake value) level with the GTV defined on PET (GTVPET) and CT (GTVCT). Twenty-two datasets involving 20 head and neck cancer patients were identified. GTVPET and GTVCT were delineated manually. An iso-intensity method was developed to automatically segment GTVPET-ISO using (a) SUV and (b) maximum intensity thresholding (%Max), over a range of intensities. For each intensity, GTVPET-ISO was compared to GTVPET using the conformality index CIPET (and, similarly, to GTVCT using CICT). Comparing GTVPET to GTVPET-ISO vs comparing GTVCT to GTVPET-ISO, the average peak CI was 0.68 ± 0.09 vs 0.49 ± 0.12 (p<0.001), the optimum iso-SUV was 2.7 ± 0.7 vs 2.9 ± 1.0 (p=0. 253), and the %Max SUV was 21.8% ± 7.6% vs 23.8% ± 8.6% (p=0. 310), respectively. The radiation oncologists volumes corresponded to a lower iso-SUV (3.02 ± 0.58 vs 4.36 ± 0.77, p < 0.001) and lower %Max SUV (24.1 ± 9.1% vs 34.3 ± 11.2%, p<0.001) than those drawn by the nuclear medicine physician. Though manual editing may still be necessary, PET iso-contouring is one method to improve the objectivity of GTV definition in head and neck cancer patients. Iso-SUVs can also be used to study the differences between PETs role as a nuclear medicine diagnostic test versus a radiation oncology treatment planning tool.

SU‐E‐J‐189: The Kullback‐Leiber Divergence for Quantifying Changes in Radiotherapy Treatment Response

PURPOSE Repeated imaging is an extremely powerful tool in current radiotherapy practice since it allows advanced tumor detection and personalized treatment assessment by quantify tumor response. Change detection algorithms have been developed for remote sensing images to mathematically quantify relevant modifications occurring between datasets of the same subject acquired at different times. We propose usage of change detectors in radiotherapy for an automated quantification of clinical changes occurring in repeated imaging. METHODS We explore usage of the Kullback-Leiber divergence as indicator of tumor change and quantification of treatment response. The Kullbach-Leiber divergence uses the likelihood theory to measures the distance between two statistical distributions and thus does not assume consistency in imaging. By its general nature, it can accommodate the presence of noise and variations in imaging acquisition parameters that usually hinder automated identification of clinically-relevant features. RESULTS In a comparison of simple difference maps and the Kullbach-Leiber divergence operator, the difference maps were affected by noise and did not consistently detect changes of low intensity. In contrast, the proposed operator discerned noise by considering regional statistics around each voxel, and marked both regions with low and high contrast changes. CONCLUSIONS Statistical comparison through Kullback-Leiber divergence provides a reliable means to automatically quantify changes in repeated radiotherapy imaging.

Pelvic shape and prostate motion: implications for target volume design and analysis of acute toxicity.

Objectives:To study the impact of pelvic shape on prostate motion and the implications for radiotherapy target design and treatment outcomes. Methods:A total of 3741 measurements (daily shift moves in the 3 principal directions) on 29 consecutive prostate cancer patients were reviewed. All patients had 3 prostatic fiducials placed and were tracked using kilovoltage on-board imaging. Pelvic shape was categorized into android (n = 21; 2580 measurements) and gynecoid (n = 8; 1161 measurements) (defined geometrically by postoutlet to preoutlet ratio). Multivariate analyses of means/standard deviations in each principal direction were performed using major demographic, disease, anatomic, and treatment factors as covariates. Toxicity rates were compared using Fisher exact test. Results:On simple t test comparisons, no mean/standard deviation reached significance, although there was a nonsignificant (0.38 vs. 0.31 cm, P = 0.083) larger mean antero-posterior (AP) movement in the gynecoid group. On multivariate analyses, gynecoid shape (P = 0.032) significantly predicted for mean AP movement, and gynecoid shape (P = 0.045) significantly predicted for standard deviation of AP movement. Pelvic AP and RL dimensions also correlated with mean and standard movement along the respective axes. There were no differences between rates of acute (GI or GU) toxicity (P = 0.456) between the android and gynecoid groups. Conclusions:Treatment strategies that do not employ daily motion tracking may require wider planning target volume margins in gynecoid patients. Tracking the prostate daily, as done in our case using fiducials/on-board imaging, can counter differences in pelvic shape to produce similar treatment outcomes.

TU‐C‐332‐02: Concomitant Segmentation and Registration of Liver Anatomy Using SPECT‐CT Imaging

Purpose: To develop an automatic and accurate technique for concomitant segmentations and registration of liveranatomy using SPECT and CTimages for unsealed sourceradiotherapy.Method and Materials: The link between segmentation and registration is given by the using the level set of a liver segmentation into the registration process. In the combined approach, the liver is automatically segmented from the CTimage by evolving an initial seed with a level set until it locks to the livers border as observed in the CTimages. The time‐crossing map of the level set is then used to match gradients in the SPECTimage to the level set by using a data structure containing the signed distance values at a small band of neighboring pixels. Results: The technique was applied to three cases of metastatic liver disease treated with unsealed source therapy. Results indicated that the speed map of the level set plays an importance role in obtainng an accurate registration and produce a segmentation that is superior in registration time and accuracy over manual segmentation or the standard registration approach using mutual information. Accuracy measured with the convergence analysis method was of less than 0.5 mm rotation and 1 degree rotation. Conclusion: With the proposed combined segmentation‐registration technique, the uncertainty of soft‐tissue target localization could be greatly reduced ensuring accurate therapy assessment to be precisely delivered as planned. The combined all‐in‐one approach is automated and provides excellent accuracy over manual segmentation and mutual information approaches.

SU‐FF‐J‐122: Deformable Image Registration Using FDG‐PET/MRI for Metastatic Breast Cancer Detection

Introduction: Diagnostic imaging techniques using fluoro‐deoxy‐glucose (FDG) — positron emission tomography(PET) and magnetic resonance imaging(MRI) offer tumor‐specific imaging capabilities for breast cancerimaging. Combining PET‐MRI systems may provide synergistic information on abnormal soft tissue processes useful for discriminating tumor from other soft tissue abnormalities that may mimic tumor. We propose a deformable image registration method able to align MRI series over an FDG‐PET dataset which may improve metastatic for breast cancerimaging.Method: To more precisely replicate presentation of FDG‐PET when analyzing FDG‐PET/MRI, a deformable registration method was devised to correct locally defined posture changes. To mathematically represent the deformations, we use a BSpline model whose coefficients are iteratively calculated in small steps using a gradient‐based optimization algorithm under the guidance of a mutual information metric. The deformable BSpline approach technique was evaluated using checkerboard views and compared to a rigid body registration. Results: Comparison of rigid versus deformable registration of checkerboard FDG‐PET and MRIimages revealed superior results for deformable registration. The deformable registration was feasible and showed exact anatomical correlation between FDG‐PET and MRimages in a checkerboard. Increased activity from the FDG‐PET scan clearly corresponded to anatomical structures on the MRimages. Clinically, the deformable registration of FDG‐PET and MRI revealed the complimentary information. Regions of increased FDG activity on PET‐CT, which was initially rated as possible tumor disease, were evaluated based on the additional soft tissue information available from the MRI. In one patient case, MRI revealed a benign uterine fibroid which was not definitive on PET‐CT. Conclusion: Deformable image registration of PET‐CT and MRI using a BSpline algorithm is feasible for metastatic breast cancer detection.

SU-D-BRD-06: Automated Population-Based Planning for Whole Brain Radiation Therapy

PURPOSE Treatment planning for whole brain radiation treatment is technically a simple process but in practice it takes valuable clinical time of repetitive and tedious tasks. This report presents a method that automatically segments the relevant target and normal tissues and creates a treatment plan in only a few minutes after patient simulation. METHODS Segmentation is performed automatically through morphological operations on the soft tissue. The treatment plan is generated by searching a database of previous cases for patients with similar anatomy. In this search, each database case is ranked in terms of similarity using a customized metric designed for sensitivity by including only geometrical changes that affect the dose distribution. The database case with the best match is automatically modified to replace relevant patient info and isocenter position while maintaining original beam and MLC settings. RESULTS Fifteen patients were used to validate the method. In each of these cases the anatomy was accurately segmented to mean Dice coefficients of 0.970 ± 0.008 for the brain, 0.846 ± 0.009 for the eyes and 0.672 ± 0.111 for the lens as compared to clinical segmentations. Each case was then subsequently matched against a database of 70 validated treatment plans and the best matching plan (termed auto-planned), was compared retrospectively with the clinical plans in terms of brain coverage and maximum doses to critical structures. Maximum doses were reduced by a maximum of 20.809 Gy for the left eye (mean 3.533), by 13.352 (1.311) for the right eye, and by 27.471 (4.856), 25.218 (6.315) for the left and right lens. Time from simulation to auto-plan was 3-4 minutes. CONCLUSION Automated database- based matching is an alternative to classical treatment planning that improves quality while providing a cost-effective solution to planning through modifying previous validated plans to match a current patients anatomy.

SU-E-T-369: Experience of Using 6D Robotic Couch Top in the Treatment of Intracranial Tumors Utilizing Frameless Stereotactic Radiosurgery (SRS) Technique

PURPOSE To investigate the extent and necessity of 6 DOF corrections for intracranial frameless Stereotactic Radiosurgery METHODS: Civco Protura 6D robotic couch top was fitted to the Novalis TX in 2012. The couch enables ± 3 ° rotations in pitch, roll and yaw, ±50 mm in lateral and longitudinal shifts and ±25 mm in vertical shifts. Patient sets up using the room laser; then two orthogonal kV images are taken for confirmation. A CBCT is acquired and registered to the planning CT using two independent systems. The calculated rotational and translational shifts are applied. A second CBCT is acquired to assess the residual translational and rotational errors. The treatment will be carried out if residual rotational shifts are ≤ 0.3 degrees. We treated 113 patients utilizing 6D couch to align a total of 160 targets. Some of the targets were fractionated, with total alignments of 252. Geometrical analysis is performed to assess the systems accuracy and extent of shifts. RESULTS After the planar kV images alignment, a CBCT was acquired and registered to the planning CT, the average required rotational shifts were (yaw=1.03 °± 0.8, roll=1.16°± 0.9 and Pitch= 0.9°± 0.7). A second CBCT was taken to verify the match and the previous shifts, the residual rotational errors on average were 0.37°± 0.6, 0.27°± 0.28 and 0.24°± 0.29 in the yaw, roll, and pitch directions, respectively. The translational residual shifts (mm) were 0.68 ± 0.57, 0.68 ± 0.57, 0.68 ± 0.57 in lateral, vertical, and longitudinal directions, respectively. CONCLUSION The 6D couch is capable of aligning targets with an accuracy of ≤ 0.4 ° in any rotational direction and ≤ 0.7 mm in any translational directions, and not applying the rotational corrections could lead to compromised target dose coverage and may lead to excessive dose to OARs.