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Prospectively measure change in vaginal length after definitive chemoradiation (C-EBRT) with Intracavitary Brachytherapy (ICBT) for locally advanced cervix cancer (LACC) and correlate with vaginal dose (VD). Twenty one female patients with LACC receiving C-EBRT and ICBT underwent serial vaginal length (VL) measurements. An initial measurement was made at the time of the first ICBT procedure and subsequently at 3 month intervals up to 1 year post radiation. The vagina was contoured as a 3-dimensional structure for each brachytherapy plan. The difference in VL before and at least 6 months after the last fraction of brachytherapy was considered as an indicator of toxicity. The mean initial VL was 8.7 cm (6.5–12) with median value of 8.5 cm. The mean VL after 6 months was 8.6 cm (6.5–12) and VL change was not found to be statistically significant. The median values (interquartile ranges) for vaginal D0.1cc, D1cc, and D2cc were 129.2 Gy (99.6–252.2), 96.9 Gy (84.2–114.9), and 89.6 Gy (82.4–102.2), respectively. No significant correlation was found between vaginal length change and the dosimetric parameters calculated for all patients. Definitive C-EBRT and ICBT did not significantly impact VL in this prospective cohort probably related to acceptable doses per ICRU constraints. Estimate of vaginal stenosis and sexual function was not performed in this cohort which is a limitation of this study and which we hope to study prospectively going forward. [ABSTRACT FROM AUTHOR]

Purpose: Suitable commissioning and quality control (QC) tests for high-dose-rate brachytherapy (HDR-BT) is necessary to ensure dosimetric and geometric accuracy of the treatment. This study aimed to present the methodology of developing a novel multi-purpose QC phantom (AQuA-BT) and examples of its' application in 3D image-based (particularly magnetic resonance imaging [MRI]-based) planning for cervix BT. Material and methods: Design criteria led to a phantom with sufficient size waterproof box for dosimetry and capability for inserting other components inside the phantom for: (A) Validating dose calculation algorithms in treatment planning systems (TPSs) using a small-volume ionization chamber; (B) Testing volume calculation accuracy in TPSs for bladder, rectum, and sigmoid organs at risk (OARs) constructed by 3D printing; (C) Quantification of MRI distortions using 17 semi-elliptical plates with 4,317 control points to mimic a realistic female's pelvis size; and (D) Quantification of image distortions and artifacts induced by MRI-compatible applicators using a specific radial fiducial marker. The utility of the phantom was tested in various QC procedures. Results: The phantom was successfully implemented for examples of intended QC procedures. The maximum deviation between the absorbed doses to water assessed with our phantom and those calculated by SagiPlan TPS was 1.7%. The mean discrepancy in volumes of TPS-calculated OARs was 1.1%. The differences between known distances within the phantom on MR imaging were within 0.7 mm compared with computed tomography. Conclusions: This phantom is a promising useful tool for dosimetric and geometric quality assurance (QA) in MRIbased cervix BT. [ABSTRACT FROM AUTHOR]

Prospectively measure change in vaginal length after definitive Chemoradiation (C-EBRT) with Intracavitary Brachytherapy (ICBT) for locally advanced cervix cancer (LACC) and correlate with vaginal dose (VD) 21 female patients with LACC receiving C-EBRT and ICBT underwent serial vaginal length (VL) measurements. 6 of these women had Hybrid interstitial/intracavitary brachytherapy, the rest had Tandem and ovoid alone. Initial measurement was made at time of first ICBT procedure and subsequently at 3 month intervals till one year post radiation. For consistency the length was defined as distance between external cervical os and the introitus. All patients underwent radiation per ASTRO cervix cancer guidelines. Education regarding the use of vaginal dilator was given to all but compliance was less than 50%. For VD co-relation, the vagina was contoured as a 3- dimensional structure for each brachytherapy plan. All contouring was performed on CT (with MR fusion- if available) using a 0.5-cm fixed brush to outline the vagina around applicator and/or packing, expanded to include any grossly visible vagina. The surface of the cervix was specifically excluded from the contour, but the fornices were included. High-dose-rate (HDR) doses were converted to the equivalent dose in 2-Gy fractions using an α/β of 3 for late effects and added to the dose received by vagina in external beam radiotherapy. The parameters D0.1cc, D1cc, and D2cc and ICRU rectovaginal point dose were calculated for all patients. The difference in VL before and at least 6 months after the last fraction of brachytherapy was considered as an indicator of toxicity. Linear regressions were performed for the generation of Pearson correlation coefficients to explore VD with changes in VL. A Holm-Bonferroni correction was used for all correlations. The mean initial VL was 8.7 (6.5 - 12cm) with median value of 8.5. The mean VL after six months was 8.6 (6.5 - 12cm) and VL change was not found to be statistically significant. The median values (interquartile ranges) for vaginal D0.1cc, D1cc, and D2cc were 129.2 (99.6-252.2) Gy, 96.9 (84.2-114.9) Gy, and 89.6 (82.4-102.2) Gy, respectively. No significant correlation was found between vaginal length change and the dosimetric parameters calculated for all patients. The values were within normal range (ICRU 89), ICRU rectovaginal point was higher than 65Gy in 12 of patients but this did not significantly correlate with change in VL. Definitive C-EBRT and ICBT did not significantly impact VL in this prospective cohort probably related to acceptable doses per ICRU constraints. Estimate of vaginal stenosis and sexual function was not performed in this cohort which is a limitation of this study and which we hope to study prospectively going forward. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Over the past decade, the application of magnetic resonance imaging (MRI) has increased, and there is growing evidence to suggest that improvements in accuracy of target delineation in MRI-guided brachytherapy may improve clinical outcomes in cervical cancer. To implement a high quality image guided brachytherapy program, a multidisciplinary team is required with appropriate expertise as well as an adequate patient load to ensure a sustainable program. It is imperative to know that the most important source of uncertainty in the treatment process is related to target delineation and therefore, the necessity of training and expertise as well as quality assurance should be emphasized. A short review of concepts and techniques that have been developed for implementation and/or improvement of workflow of a MRI-guided brachytherapy program are provided in this document, so that institutions can use and optimize some of them based on their resources to minimize their procedure times. [ABSTRACT FROM AUTHOR]

The variations of depth and surface dose on the bone heterogeneity and beam angle were compared between unflattened and flattened photon beams using Monte Carlo simulations. Phase-space files of the 6MV photon beams with field size of 10×10cm2 were generated with and without the flattening filter based on a Varian TrueBeam linac. Depth and surface doses were calculated in a bone and water phantoms using Monte Carlo simulations (the EGSnrc-based code). Dose calculations were repeated with angles of the unflattened and flattened beams turned from 0° to 15°, 30°, 45°, 60°, 75° and 90° in the bone and water phantoms. Monte Carlo results of depth doses showed that compared to the flattened beam the unflattened photon beam had a higher dose in the build-up region but lower dose beyond the depth of maximum dose. Dose ratios of the unflattened to flattened beams were calculated in the range of 1.6–2.6 with beam angle varying from 0° to 90° in water. Similar results were found in the bone phantom. In addition, higher surface doses of about 2.5 times were found with beam angles equal to 0° and 15° in the bone and water phantoms. However, surface dose deviation between the unflattened and flattened beams became smaller with increasing beam angle. Dose enhancements due to the bone backscatter were also found at the water–bone and bone–water interfaces for both the unflattened and flattened beams in the bone phantom. With Monte Carlo beams cross-calibrated to the monitor unit in simulations, variations of depth and surface dose on the bone heterogeneity and beam angle were investigated and compared using Monte Carlo simulations. For the unflattened and flattened photon beams, the surface dose and range of depth dose ratios (unflattened to flattened beam) decreased with increasing beam angle. The dosimetric comparison in this study is useful in understanding the characteristics of unflattened photon beam on the depth and surface dose with bone heterogeneity. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to quantitatively evaluate the relationship between short echo time pulmonary 1H magnetic resonance imaging (MRI) signal intensity (SI) and 3He MRI apparent diffusion coefficients (ADC), high-resolution computed tomography (CT) measurements of emphysema, and pulmonary function measurements. Materials and methods: Nine healthy never-smokers and 11 COPD subjects underwent same-day plethysmography, spirometry, short echo time ((TE)=1.2ms) 1H and diffusion-weighted hyperpolarized 3He MRI (b =1.6s/cm2) at 3.0T. In addition, for COPD subjects only, CT densitometry was also performed. Results: Mean 1H SI was significantly greater for never-smokers (12.1±1.1 arbitrary units (AU)) compared to COPD subjects (10.9±1.3AU, p =0.04). The 1H SI AP-gradient was also significantly greater for never-smokers (0.40AU/cm, R 2 =0.94) compared to COPD subjects (0.29AU/cm, R 2 =0.968, p =0.05). There was a significant correlation between 1H SI and 3He ADC (r =−0.58, p =0.008) and significant correlations between 1H MR SI and CT measurements of emphysema (RA950, r =−0.69, p =0.02 and HU15, r =0.66, p =0.03). Conclusions: The significant and moderately strong relationship between 1H SI and 3He ADC, as well as between 1H SI and CT measurements of emphysema suggests that these imaging methods and measurements may be quantifying similar tissue changes in COPD and that pulmonary 1H SI may be used to monitor emphysema as a complement to CT and noble gas MRI. [ABSTRACT FROM AUTHOR]

Background: The functional effects of abnormal diffusing capacity for carbon monoxide (DLCO) in ex-smokers without chronic obstructive pulmonary disease (COPD) are not well understood. Objective: We aimed to evaluate and compare well established clinical, physiological and emerging imaging measurements in ex-smokers with normal spirometry and abnormal DLCO with a group of ex-smokers with normal spirometry and DLCO and ex-smokers with Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage I COPD. Methods We enrolled 38 ex-smokers and 15 subjects with stage I COPD who underwent spirometry, plethysmography, St George's Respiratory Questionnaire (SGRQ), 6 min Walk Test (6MWT), x-ray CT and hyperpolarised helium-3 (³He) MRI. The 6MWT distance (6MWD), SGRQ scores, ³He MRI apparent diffusion coefficients (ADC) and CT attenuation values below -950 HU (RA950) were evaluated. Results: Of 38 ex-smokers without COPD, 19 subjects had abnormal DLCO with significantly worse ADC ( p=0.01), 6MWD ( p=0.008) and SGRQ (p=0.01) but not RA950 ( p=0.53) compared with 19 ex-smokers with normal DLCO. Stage I COPD subjects showed significantly worse ADC (p=0.02), RA950 (p=0.0008) and 6MWD (p=0.005), but not SGRQ (p=0.59) compared with subjects with abnormal DLCO. There was a significant correlation for ³He ADC with SGRQ (r=0.34, p=0.02) and 6MWD (r=-0.51, p=0.0002). Conclusions: In ex-smokers with normal spirometry and CT but abnormal DLCO, there were significantly worse symptoms, 6MWD and ³He ADC compared with exsmokers with normal DLCO, providing evidence of the impact of mild or early stage emphysema and a better understanding of abnormal DLCO and hyperpolarised ³He MRI in ex-smokers without COPD. [ABSTRACT FROM AUTHOR]

Abstract: Dependences of mucosal dose in the oral or nasal cavity on the beam energy, beam angle, multibeam configuration, and mucosal thickness were studied for small photon fields using Monte Carlo simulations (EGSnrc-based code), which were validated by measurements. Cylindrical mucosa phantoms (mucosal thickness = 1, 2, and 3 mm) with and without the bone and air inhomogeneities were irradiated by the 6- and 18-MV photon beams (field size = 1 × 1 cm2) with gantry angles equal to 0°, 90°, and 180°, and multibeam configurations using 2, 4, and 8 photon beams in different orientations around the phantom. Doses along the central beam axis in the mucosal tissue were calculated. The mucosal surface doses were found to decrease slightly (1% for the 6-MV photon beam and 3% for the 18-MV beam) with an increase of mucosal thickness from 1–3 mm, when the beam angle is 0°. The variation of mucosal surface dose with its thickness became insignificant when the beam angle was changed to 180°, but the dose at the bone-mucosa interface was found to increase (28% for the 6-MV photon beam and 20% for the 18-MV beam) with the mucosal thickness. For different multibeam configurations, the dependence of mucosal dose on its thickness became insignificant when the number of photon beams around the mucosal tissue was increased. The mucosal dose with bone was varied with the beam energy, beam angle, multibeam configuration and mucosal thickness for a small segmental photon field. These dosimetric variations are important to consider improving the treatment strategy, so the mucosal complications in head-and-neck intensity-modulated radiation therapy can be minimized. [Copyright &y& Elsevier]

Purpose: Manual segmentation of lung tumors is observer dependent and time-consuming but an important component of radiology and radiation oncology workflow. The objective of this study was to generate an automated lung tumor measurement tool for segmentation of pulmonary metastatic tumors from x-ray computed tomography (CT) images to improve reproducibility and decrease the time required to segment tumor boundaries. Methods: The authors developed an automated lung tumor segmentation algorithm for volumetric image analysis of chest CT images using shape constrained Otsu multithresholding (SCOMT) and sparse field active surface (SFAS) algorithms. The observer was required to select the tumor center and the SCOMT algorithm subsequently created an initial surface that was deformed using level set SFAS to minimize the total energy consisting of mean separation, edge, partial volume, rolling, distribution, background, shape, volume, smoothness, and curvature energies. Results: The proposed segmentation algorithm was compared to manual segmentation whereby 21 tumors were evaluated using one-dimensional (1D) response evaluation criteria in solid tumors (RECIST), two-dimensional (2D) World Health Organization (WHO), and 3D volume measurements. Linear regression goodness-of-fit measures (r2 = 0.63, p < 0.0001; r2 = 0.87, p < 0.0001; and r2 = 0.96, p < 0.0001), and Pearson correlation coefficients (r = 0.79, p < 0.0001; r = 0.93, p < 0.0001; and r = 0.98, p < 0.0001) for 1D, 2D, and 3D measurements, respectively, showed significant correlations between manual and algorithm results. Intra-observer intraclass correlation coefficients (ICC) demonstrated high reproducibility for algorithm (0.989-0.995, 0.996-0.997, and 0.999-0.999) and manual measurements (0.975-0.993, 0.985-0.993, and 0.980-0.992) for 1D, 2D, and 3D measurements, respectively. The intra-observer coefficient of variation (CV%) was low for algorithm (3.09%-4.67%, 4.85%-5.84%, and 5.65%-5.88%) and manual observers (4.20%-6.61%, 8.14%-9.57%, and 14.57%-21.61%) for 1D, 2D, and 3D measurements, respectively. Conclusions: The authors developed an automated segmentation algorithm requiring only that the operator select the tumor to measure pulmonary metastatic tumors in 1D, 2D, and 3D. Algorithm and manual measurements were significantly correlated. Since the algorithm segmentation involves selection of a single seed point, it resulted in reduced intra-observer variability and decreased time, for making the measurements. [ABSTRACT FROM AUTHOR]

This study evaluated the dosimetry of electron backscatter when Solid Water is used to substitute water as phantom in electron radiotherapy. Monte Carlo simulation (EGSnrc-based code) was employed to predict electron energy spectra and depth doses for the 0.5 and 1 cm of Solid Water and water slabs above 3 mm of lead (Pb) layers using electron beams with energies of 4 and 6 MeV. For comparison, Monte Carlo simulations were repeated with Pb layers taken out from the phantoms using the same experimental configuration. Analyses on electron energy spectra for the 4 and 6 MeV electron beams showed that deviations of electron energy distributions between the Solid Water and water phantom were more significant in the high-energy range (i.e., close to the maximal electron energy) than the lower range corresponding to the electron backscatter. These deviations of electron energy spectra varied with depth and were mainly due to the electron fluence or beam attenuation. Dosimetry results from Monte Carlo simulations showed that the Solid Water phantom had lower depth dose compared to water with the same experimental setup. For the 4 MeV electron beams with 0.5 cm of Solid Water, depth doses were 1.8%–3.9% and 2.3%–4.4% lower than those in water, with and without the Pb layer underneath, respectively. Thicker Solid Water of 1 cm resulted in different decreases in depth doses of 1.8%–4.6% (with Pb) and 2.3%–4.4% (without Pb) compared to water. For higher nominal electron beam energy of 6 MeV with 0.5 cm of Solid Water, depth doses decreased 1.7%–2.9% (with Pb) and 1.6%–2.1% (without Pb) compared to water. These decreases in depth doses changed to 1.7%–3.7% (with Pb) and 1.7%–3% (without Pb) when the thickness of Solid Water was increased to 1 cm. The dosimetry data in this study are useful in determining the correction factor when using Solid Water to substitute water for the electron backscatter measurement in electron radiotherapy. [ABSTRACT FROM AUTHOR]

This study investigated the depth dependence of electron backscatter from a layer of lead (Pb) for clinical electron beams. The change in the electron backscatter with variation in the water depth above the Pb was determined. Electron energy spectra and relative depth doses as a function of depth in water over the Pb layer were calculated using a Monte Carlo simulation and studied. Phase-space files for 4 and 9 MeV electron beams (10×10 cm2 applicator and cutout) based on the Varian 21 EX linear accelerator were generated using the EGSnrc-based BEAMNRC code. 3 mm of Pb, at depths of 0.5 and 1 cm in water, was irradiated with electrons. The source-to-surface distance is equal to 100 cm. Electron energy spectra and relative depth doses with and without the presence of the Pb layer at different depths in water were determined using the BEAMNRC code. For the 4 MeV electron energy spectra at a depth of 0.5 cm in water, electron backscatter was found to originate at the Pb-water interface and extend to 0.5 cm above the Pb insert. However, at a depth of 1 cm in water, electron backscatter almost disappeared at 0.5 and 1 cm above th ePb insert. This is due to the increased attenuation of the incident 4 MeV electron beam in a thicker layer of water as well as increased attenuation of the electron backscatter above the Pb. This resulted in a 23% decrease in relative dose at a measurement point of 0.5 cm depth, when the depth of the Pb insert was changed from 1 to 0.5 cm. For the electron energy spectra of the 9 MeV beams with a 0.5 cm depth of water, only a small amount of electron backscatter was observed. However, more electron backscatter was found when the water depth was increased to 1 cm. This is because the electron beam energy was decreased more due to the increase in attenuation from the increased depth of water compared to 0.5 cm. Since the electron energy spectrum and relative depth dose above the Pb layer vary with depth of water on top of the Pb, the electron backscatter depends significantly on the thickness of water, or water equivalent bolus, or critical tissue over the Pb shield in electron radiotherapy. [ABSTRACT FROM AUTHOR]

To evaluate an iterative metal-artifact reduction (iMAR) algorithm, dual-energy CT (DECT) through virtual monoenergetic images (VMI), and a combination of iMAR and DECT for reducing metal artifact severity (AS) induced by Fletcher titanium applicators used in cervix brachytherapy, the efficacy of which are hitherto unreported. 120 kV p single-energy CT (SECT) (Siemens) of BEBIG tandem applicators, varying in shape (straight or curved) and diameter (3.5 mm or 5 mm) in a custom-made water-filled phantom, and their DECT images obtained from extrapolation of 80 kVp and 140 kVp, were reconstructed using four methods: DECT through VMI±iMAR, and SECT±iMAR. The DECT images were reconstructed monoenergetically at 70, 150, and 190 keV. AS was evaluated using measured values and statistical analysis. iMAR, DECT, and combined DECT and iMAR reduced AS (p < 0.05). DECT had a lower AS than SECT, even without iMAR (p < 0.025). SECT+iMAR was more effective than DECT-iMAR with VMI at 70 and 190 keV (p < 0.05), whereas showing no statistically significant difference at 150 keV. With DECT and iMAR combined, AS was reduced more effectively compared to the SECT+iMAR or DECT alone. It also reduced the mean interobserver uncertainty by 0.2 mm. These findings indicate that iMAR reduces the AS caused by Fletcher titanium applicators for both SECT and DECT, a combination of iMAR and DECT is superior to either strategy alone, and at low energies, DECT+iMAR also produces similar artifact reduction. These practical strategies promise more accurate source-position and structure definitions in CT-based gynecological brachytherapy treatment planning. [ABSTRACT FROM AUTHOR]

The author reflects on a study which investigates the effect of high-field chest magnetic resonance imaging (MRI) is being compared with computed tomography (CT) among children with non-cystic fibrosis (CF) lung disease. The author notes that the group has used a direct MRI protocol accessible on most hospital scanners without the use of extra programming which enables a practical comparison between two methods. The author adds that chest MRI is a major concern in children with lung disease.

Background: MRI‐only radiotherapy planning (MROP) is beneficial to patients by avoiding MRI/CT registration errors, simplifying the radiation treatment simulation workflow and reducing exposure to ionizing radiation. MRI is the primary imaging modality for soft tissue delineation. Treatment planning CTs (i.e., CT simulation scan) are redundant if a synthetic CT (sCT) can be generated from the MRI to provide the patient positioning and electron density information. Unsupervised deep learning (DL) models like CycleGAN are widely used in MR‐to‐sCT conversion, when paired patient CT and MR image datasets are not available for model training. However, compared to supervised DL models, they cannot guarantee anatomic consistency, especially around bone. Purpose: The purpose of this work was to improve the sCT accuracy generated from MRI around bone for MROP. Methods: To generate more reliable bony structures on sCT images, we proposed to add bony structure constraints in the unsupervised CycleGAN model's loss function and leverage Dixon constructed fat and in‐phase (IP) MR images. Dixon images provide better bone contrast than T2‐weighted images as inputs to a modified multi‐channel CycleGAN. A private dataset with a total of 31 prostate cancer patients were used for training (20) and testing (11). Results: We compared model performance with and without bony structure constraints using single‐ and multi‐channel inputs. Among all the models, multi‐channel CycleGAN with bony structure constraints had the lowest mean absolute error, both inside the bone and whole body (50.7 and 145.2 HU). This approach also resulted in the highest Dice similarity coefficient (0.88) of all bony structures compared with the planning CT. Conclusion: Modified multi‐channel CycleGAN with bony structure constraints, taking Dixon‐constructed fat and IP images as inputs, can generate clinically suitable sCT images in both bone and soft tissue. The generated sCT images have the potential to be used for accurate dose calculation and patient positioning in MROP radiation therapy. [ABSTRACT FROM AUTHOR]

Abstract: Objective: We developed a semi-automated tool to quantify emphysema from thoracic X-ray multi-detector (64-slice) computed tomography (CT) for training purposes and multi-reader studies. Materials and Methods: Thoracic X-ray CT was acquired in 93 ex-smokers, who were evaluated by six trainees with little or no expertise (trainees) and a single experienced thoracic radiologist (expert). A graphic user interface (GUI) was developed for emphysema quantification based on the percentile of lung where a score of 0=no abnormalities, 1=1–25%, 2=26–50%, 3=51–75% and 4=76–100% for each lung side/slice. Trainees blinded to subject characteristics scored randomized images twice; accuracy was determined by comparison to expert scores, density histogram 15th percentile (HU15), relative area at −950HU (RA950), low attenuation clusters at −950HU (LAC950), −856HU (LAC856) and the diffusing capacity for carbon monoxide (DLCO%pred). Intra- and inter-observer reproducibility was evaluated using coefficients-of-variation (COV), intra-class (ICC) and Pearson correlations. Results: Trainee–expert correlations were significant (r =0.85–0.97, p <0.0001) and a significant trainee bias (0.15±0.22) was observed. Emphysema score was correlated with RA950 (r =0.88, p <0.0001), HU15 (r =−0.77, p <0.0001), LAC950 (r =0.76, p <0.0001), LAC856 (r =0.74, p =0.0001) and DLCO%pred (r =−0.71, p <0.0001). Intra-observer reproducibility (COV=4–27%; ICC=0.75–0.94) was moderate to high for trainees; intra- and inter-observer COV were negatively and non-linearly correlated with emphysema score. Conclusion: We developed a GUI for rapid and interactive emphysema scoring that allows for comparison of multiple readers with clinical and radiological standards. [Copyright &y& Elsevier]

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. [ABSTRACT FROM AUTHOR]

Intracavitary cervical brachytherapy (BT) has transitioned from a two-dimensional nonvolumetric (NV) dosimetry system to three-dimensional computed tomography (CT) and/or magnetic resonance imaging (MRI)-based planning techniques. The purpose of this study is to retrospectively evaluate the relative improvements in image-guided planning strategies over time with regards to dosimetry, survival, and toxicity. A single site retrospective review of 95 locally advanced cervical cancer patients treated with concurrent chemoradiation and high dose rate BT from 2009 to 2016 were divided into three BT planning groups: point-A based NV dosimetry using CT imaging (n = 37), CT-based volumetric dosimetry (n = 33), and MRI-based volumetric dosimetry (n = 25). Overall survival (OS), progression free survival (PFS), and pelvic control (PC) at 5 years were plotted using Kaplan–Meier curves. Univariate and multivariate (MVA) cox proportional-hazards models calculated hazard-ratios (HZ). Finally, acute and late grade 3–4 toxicities were compared between the cohorts. Both MRI and CT had significantly less D2cc to bowel (p < 0.001) and sigmoid (p < 0.001) compared to NV-based planning. On MVA, age (<60 vs. ≥60 years) was significant for worse 5-year OS (HZ: 2.48) and PC (HZ: 5.25). MRI, with NV as the reference, had significantly improved 5-year OS (HZ: 0.26), PFS (HZ: 0.34) and PC (HZ: 0.16). There was no significant difference in grade ≥3 toxicities between the cohorts. CT and MRI-based 3D planning had significantly less D2cc to bowel and sigmoid. MRI-based planning had significant improvement in 5-year OS, PFS, and LC compared to NV on MVA. [ABSTRACT FROM AUTHOR]

Purpose: The beam model in a three dimensional treatment planning system (TPS) defines virtually the mechanical and dosimetric characteristics of a treatment unit. The manual optimization of a beam model during commissioning can be a time consuming task due to its iterative nature. Furthermore, the quality of the beam model commissioning depends on the user’s ability to manage multiple parameters and assess their impact on the agreement between measured and calculated dose. The objective of this work is to develop and validate the performance of an automated beam model optimization system (ABMOS) based on intensity modulated radiotherapy (IMRT) beam measurements to improve beam model accuracy while streamlining the commissioning process. Methods: The ABMOS was developed to adjust selected TPS beam model parameters iteratively to maximize the agreement between measured and calculated 2D dose maps obtained for an IMRT beam pattern. A 2D diode array with high spatial resolution detectors was used to sample the entire IMRT beam pattern in a single dose measurement. The use of an IMRT beam pattern with large number of monitor units was selected to highlight the difference between planned and delivered dose and improve the signal to noise ratio in the low dose regions. ABMOS was applied to the optimization of a beam model for an Elekta Synergy S treatment unit. The optimized beam model was validated for two anatomical sites (25 paraspinal and 25 prostate cases) using two independent patient-specific IMRT quality control (QC) methods based on ion chamber and 2D diode array measurements, respectively. The conventional approach of comparing calculated and measured beam profiles and percent-depth dose curves was also used to assess improvement in beam model after ABMOS optimization. Elements of statistical process control were applied to the process of patient-specific QC performed with the ion chamber and the 2D array to complement the model comparison. Results: After beam model optimization with ABMOS, improvement in planned to delivered dose agreement was demonstrated with both patient-specific IMRT QC methods and the calculated to measured profile comparison. In terms of ion chamber measurements, the largest improvement was observed for the paraspinal cases with the mean measured to calculated dose difference at the low dose points decreasing from -13.8% to 2.0% with the optimized beam model. The 2D diode array patient-specific QC also demonstrated clearly the improvement in beam model for both paraspinal and prostate cases with, on average, more than 96% of the diodes satisfying tolerances of 3% of dose difference or 2 mm of distance to agreement after ABMOS optimization. The capability index (Cpk) for both patient-specific QC methods also increased with the optimized beam model. Conclusions: In this work, ABMOS was developed to use 2D diode array measurements of an IMRT beam pattern for the automated multivariable optimization of a TPS beam model. Based on the observed improvements in patient-specific QC results for 25 paraspinal and 25 prostate plans, optimization of the remaining clinical beam models using ABMOS is now ongoing in the institution. [ABSTRACT FROM AUTHOR]

The purpose of this study is to compare the predicted rate of local control and bladder and rectum toxicity rates for image-guided adaptive brachytherapy plans using a tandem and ovoid (T/O) applicator versus using a simulated hybrid intracavitary/interstitial tandem and ring applicator with needles (T/R + N) for patients with locally advanced cervical cancer (LACC). Patients with ≥ FIGO Stage IIB locally advanced cervical cancer treated with T/O from a single institution were included. Simulated treatment plans were created with a T/R + N applicator for the best high-risk clinical target volume (CTV) coverage and minimal dose to organs at risk. Three-year local control rate was estimated using published dose-volume effect relationships. Next, the high-risk CTV EQD2 D90 of T/R + N plans were calculated, and bladder and rectum toxicity rates were estimated. Analysis was performed in subpatient groups defined based on tumor volume and ratio of maximal and minimal tumor radii (RR) that reflects tumor shape asymmetry. Improvements in predicted local control rate for the T/R + N were 0.8, 4.1, 1.6, and 3.9% for groups with tumor volume <35 cc, ≥35 cc, RR < 2.0, and ≥2.0, respectively, with the latter three being statistically significant. Predicted reductions in Grade 2–4 toxicity rates of bladder and rectum were significant in all groups except bladder toxicity in tumor volume <35 cc, when T/R + N plans were normalized to the same CTV coverage as the T/O plans. Comparing unnormalized T/R + N plans and T/O plans, predicted toxicity reductions were significant in all groups except rectum toxicity in RR ≥ 2.0. Predicted reduction of toxicity rate was larger for patients with large tumor or large tumor RR, although some reductions were relatively small. Cases with large tumor (volume ≥35 cc) or large tumor asymmetry (RR ≥ 2.0) would probably benefit more from the use of hybrid applicators. [ABSTRACT FROM AUTHOR]

• CT and MR images from 77 brain patients who underwent brain tumor radiotherapy are used in this work. • This work demonstrated an accurate and reproducible synthetic CT generation using a GAN model that can distinguish between air and bone regions. • The developed model can reduce radiation dose, patient time, and imaging costs image related to CT simulation and may be a step toward the implementation brain MRI-only radiotherapy. This study assessed the dosimetric accuracy of synthetic CT images generated from magnetic resonance imaging (MRI) data for focal brain radiation therapy, using a deep learning approach. We conducted a study in 77 patients with brain tumors who had undergone both MRI and computed tomography (CT) imaging as part of their simulation for external beam treatment planning. We designed a generative adversarial network (GAN) to generate synthetic CT images from MRI images. We used Mutual Information (MI) as the loss function in the generator to overcome the misalignment between MRI and CT images (unregistered data). The model was trained using all MRI slices with corresponding CT slices from each training subject's MRI/CT pair. The proposed GAN method produced an average mean absolute error (MAE) of 47.2 ± 11.0 HU over 5-fold cross validation. The overall mean Dice similarity coefficient between CT and synthetic CT images was 80% ± 6% in bone for all test data. Though training a GAN model may take several hours, the model only needs to be trained once. Generating a complete synthetic CT volume for each new patient MRI volume using a trained GAN model took only one second. The GAN model we developed produced highly accurate synthetic CT images from conventional, single-sequence MRI images in seconds. Our proposed method has strong potential to perform well in a clinical workflow for MRI-only brain treatment planning. [ABSTRACT FROM AUTHOR]

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 int Ernational 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. [ABSTRACT FROM AUTHOR]

Purpose: To perform a comprehensive comparative planning study evaluating the utility of the proposed direction modulated brachytherapy (DMBT) tandem applicator against standard applicators, in the setting of image guided adaptive brachytherapy of cervical cancer.Methods and Materials: A detailed conceptual article was published in 2014. The proposed DMBT tandem applicator has 6 peripheral grooves of 1.3-mm width, along a 5.4-mm-thick nonmagnetic tungsten alloy rod of density 18.0 g/cm(3), capable of generating directional dose profiles. We performed a comparative planning study with 45 cervical cancer patients enrolled consecutively in the prospective observational EMBRACE study. In all patients, MRI-based planning was performed while utilizing various tandem-ring (27 patients) and tandem-ring-needles (18 patients) applicators, in accordance with the Groupe Européen de Curiethérapie-European Society for Radiotherapy and Oncology recommendations. For unbiased comparisons, all cases were replanned with an in-house-developed inverse optimization code while enforcing a uniform set of constraints that are reflective of the clinical practice. All plans were normalized to the same high-risk clinical target volume D90 values achieved in the original clinical plans.Results: In general, if the standard tandem was replaced with the DMBT tandem while maintaining all other planning conditions the same, there was consistent improvement in the plan quality. For example, among the 18 tandem-ring-needles cases, the average D2cm(3) reductions achieved were -2.48% ± 11.03%, -4.45% ± 5.24%, and -5.66% ± 6.43% for the bladder, rectum, and sigmoid, respectively. An opportunity may also exist in avoiding use of needles altogether for when the total number of needles required is small (approximately 2 to 3 needles or less), if DMBT tandem is used.Conclusions: Integrating the novel DMBT tandem onto both intracavitary and intracavitary-interstitial applicator assembly enabled consistent improvement in the sparing of the OARs, over a standard "single-channel" tandem, though individual variations in benefit were considerable. Although at an early stage of development, the DMBT concept design is demonstrated to be useful and pragmatic for potential clinical translation. [ABSTRACT FROM AUTHOR]

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 ± 0.7 mm (compared to 6 mm of the actual DMBT tandem diameter). The in-plane spatial-shift observed at para-axial and para-sagittal views was less than 0.5 mm. Conclusions This work demonstrated that the novel DMBT tandem applicator prototype has minimal artifact in T 2 -weighted images employed in clinical practice, suggesting the applicator might be a good candidate for MRI-guided adaptive brachytherapy. [ABSTRACT FROM AUTHOR]

Noble gas pulmonary magnetic resonance imaging ( MRI) is transitioning away from 3He to 129Xe gas, but the physiological/clinical relevance of 129Xe apparent diffusion coefficient ( ADC) parenchyma measurements is not well understood. Therefore, our objective was to generate 129Xe MRI ADC for comparison with 3He ADC and with well-established measurements of alveolar structure and function in older never-smokers and ex-smokers with chronic obstructive pulmonary disease ( COPD). In four never-smokers and 10 COPD ex-smokers, 3He ( b = 1.6 sec/cm2) and 129Xe ( b = 12, 20, and 30 sec/cm2) ADC, computed tomography ( CT) density-threshold measurements, and the diffusing capacity for carbon monoxide (DLCO) were measured. To understand regional differences, the anterior-posterior ( APG) and superior-inferior (∆ SI) ADC differences were evaluated. Compared to never-smokers, COPD ex-smokers showed greater 3He ADC ( P = 0.006), 129Xe ADCb12 ( P = 0.006), and ADCb20 ( P = 0.006), but not for ADCb30 ( P > 0.05). Never-smokers and COPD ex-smokers had significantly different APG for 3He ADC ( P = 0.02), 129Xe ADCb12 ( P = 0.006), and ADCb20 ( P = 0.01), but not for ADCb30 ( P > 0.05). ∆ SI for never- and ex-smokers was significantly different for 3He ADC ( P = 0.046), but not for 129Xe ADC ( P > 0.05). There were strong correlations for DLCO with 3He ADC and 129Xe ADCb12 (both r = −0.95, P < 0.05); in a multivariate model 129Xe ADCb12 was the only significant predictor of DLCO ( P = 0.049). For COPD ex-smokers, CT relative area <−950 HU ( RA950) correlated with 3He ADC ( r = 0.90, P = 0.008) and 129Xe ADCb12 ( r = 0.85, P = 0.03). In conclusion, while 129Xe ADCb30 may be appropriate for evaluating subclinical or mild emphysema, in this small group of never-smokers and ex-smokers with moderate-to-severe emphysema, 129Xe ADCb12 provided a physiologically appropriate estimate of gas exchange abnormalities and alveolar microstructure. [ABSTRACT FROM AUTHOR]