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PurposeTo develop and clinically evaluate a volumetric imaging technique for assessing intrafraction geometric and dosimetric accuracy of stereotactic ablative radiation therapy (SABR).Methods and materialsTwenty patients received SABR for lung tumors using volumetric modulated arc therapy (VMAT). At the beginning of each fraction, pretreatment cone beam computed tomography (CBCT) was used to align the soft-tissue tumor position with that in the planning CT. Concurrent with dose delivery, we acquired fluoroscopic radiograph projections during VMAT using the Varian on-board imaging system. Those kilovolt projections acquired during millivolt beam-on were automatically extracted, and intrafraction CBCT images were reconstructed using the filtered backprojection technique. We determined the time-averaged target shift during VMAT by calculating the center of mass of the tumor target in the intrafraction CBCT relative to the planning CT. To estimate the dosimetric impact of the target shift during treatment, we recalculated the dose to the GTV after shifting the entire patient anatomy according to the time-averaged target shift determined earlier.ResultsThe mean target shift from intrafraction CBCT to planning CT was 1.6, 1.0, and 1.5 mm; the 95th percentile shift was 5.2, 3.1, 3.6 mm; and the maximum shift was 5.7, 3.6, and 4.9 mm along the anterior-posterior, left-right, and superior-inferior directions. Thus, the time-averaged intrafraction gross tumor volume (GTV) position was always within the planning target volume. We observed some degree of target blurring in the intrafraction CBCT, indicating imperfect breath-hold reproducibility or residual motion of the GTV during treatment. By our estimated dose recalculation, the GTV was consistently covered by the prescription dose (PD), that is, V100% above 0.97 for all patients, and minimum dose to GTV >100% PD for 18 patients and >95% PD for all patients.ConclusionsIntrafraction CBCT during VMAT can provide geometric and dosimetric verification of SABR valuable for quality assurance and potentially for treatment adaptation.

Purpose: Four-dimensional cone-beam computed tomography (4D-CBCT) imaging is sensitive to parameters such as gantry rotation speed, number of gantry rotations, X-ray pulse rate, and tube current, as well as a patient’s breathing pattern. The aim of this study is to optimize the image acquisition on a patient-specific basis while minimizing the scan time and the radiation dose. Methods and Materials: More than 60 sets of 4D-CBCT images, each with a temporal resolution of 10 phases, were acquired using multiple-gantry rotation and slow-gantry rotation techniques. The image quality was quantified with a relative root mean-square error (RE) and correlated with various acquisition settings; specifically, varying gantry rotation speed, varying both the rotation speed and the number of rotations, and varying both the rotation speed and tube current to keep the radiation exposure constant. These experiments were repeated for three different respiratory periods. Results: With similar radiation dose, 4D-CBCT images acquired with low current and low rotation speed have better quality over images obtained with high current and high rotation speed. In general, a one-rotation low-speed scan is superior to a two-rotation double-speed scan, even though they provide the same number of projections. Furthermore, it is found that the image quality behaves monotonically with the relative speed as defined by the gantry rotation speed and the patient respiratory period. Conclusions: The RE curves established in this work can be used to predict the 4D-CBCT image quality before a scan. This allows the acquisition protocol to be optimized individually to balance the desired quality with the associated scanning time and patient radiation dose. [Copyright &y& Elsevier]

Recent advances in radiation delivery techniques, such as intensity-modulated radiation therapy, provide unprecedented ability to exquisitely control three-dimensional dose distribution. Development of on-board imaging and other image-guidance methods significantly improved our ability to better target a radiation beam to the tumor volume. However, in reality, accurate definition of the location and boundary of the tumor target is still problematic. Biologic and physiologic imaging promises to solve the problem in a fundamental way and has a more and more important role in patient staging, treatment planning, and therapeutic assessment in radiation therapy clinics. The last decade witnessed a dramatic increase in the use of positron emission tomography and computed tomography in radiotherapy practice. To ensure safe and effective use of nuclide imaging, a rigorous quality assurance (QA) protocol of the imaging tools and integration of the imaging data must be in place. The application of nuclide imaging in radiation oncology occurs at different levels of sophistication. Quantitative use of the imaging data in treatment planning through image registration and standardized uptake value calculation is often involved. Thus, QA should not be limited to the performance of the scanner, but should also include the process of implementing image data in treatment planning, such as data transfer, image registration, and quantitation of data for delineation of tumors and sensitive structures. This presentation discusses various aspects of nuclide imaging as applied to radiotherapy and describes the QA procedures necessary for the success of biologic image-guided radiation therapy. [Copyright &y& Elsevier]

Purpose: Head-and-neck (HN) cone-beam computed tomography (CBCT) can be exploited to probe the IMRT dose delivered to a patient taking into account the interfraction anatomic variation and any potential inaccuracy in the IMRT delivery. The aim of this work is to reconstruct the intensity-modulated radiation therapy dose delivered to an HN patient using the CBCT and multileaf collimator (MLC) log-files. Methods and Materials: A cylindrical CT phantom was used for calibrating the electron density and validating the procedures of the dose reconstruction. Five HN patients were chosen, and for each patient, CBCTs were performed on three separate fractions spaced every 2 weeks starting from the first fraction. The respective MLC log-files were retrieved and converted into fluence maps. The dose was then reconstructed on the corresponding CBCT with the regenerated fluence maps. The reconstructed dose distribution, dosimetric endpoints, and DVHs were compared with that of the treatment plan. Results: Phantom study showed that HN CBCT can be directly used for dose reconstruction. For most treatment sessions, the CBCT-based dose reconstructions yielded DVHs of the targets close (within 3%) to that of the original treatment plans. However, dosimetric changes (within 10%) due to anatomic variations caused by setup inaccuracy, organ deformation, tumour shrinkage, or weight loss (or a combination of these) were observed for the critical organs. Conclusions: The methodology we established affords an objective dosimetric basis for the clinical decision on whether a replanning is necessary during the course of treatment and provides a valuable platform for adaptive therapy in future. [Copyright &y& Elsevier]

Purpose: To develop a method for deriving the phase-binned four-dimensional computed tomography (4D CT) image sets through interpolation of the images acquired at some known phases. Methods and Materials: Four-dimensional computed tomography data sets for 3 patients were acquired. For each patient, the correlation between inhale and exhale phases was studied and quantified using a BSpline deformable model. Images at an arbitrary phase were deduced by an interpolation of the deformation coefficients. The accuracy of the proposed scheme was assessed by comparing marker trajectories and by checkerboard/difference display of the interpolated and acquired images. Results: The images at intermediate phases could be derived by an interpolation of the deformation field. An analysis of marker movements indicated that 3 mm accuracy is achievable by the interpolation. The subtraction of image analysis indicated a similar level of success. The proposed technique was useful also for automatically mapping the organ contours in a known phase to other phases, and for designing patient-specific margins in the presence of respiratory motion. Finally, the technique led to a 90% reduction in the acquired data, because in the BSpline model, a lattice of only a few thousand values is sufficient to describe a CT data set of 25 million pixels. Conclusions: Organ deformation can be well modeled by using a BSpline model. The proposed technique may offer useful means for radiation dose reduction, binning artifacts removal, and disk storage improvement in 4D imaging. [ABSTRACT FROM AUTHOR]

Purpose: To report the characteristics of prostate motion as tracked by the stereoscopic X-ray images of the implanted fiducials during hypofractionated radiotherapy with CyberKnife. Methods and Materials: Twenty-one patients with prostate cancer who were treated with CyberKnife between January 2005 and September 2007 were selected for this retrospective study. The CyberKnife uses a stereoscopic X-ray system to obtain the position of the prostate target through the monitoring of implanted gold fiducial markers. If there is a significant deviation, the treatment is paused while the patient is repositioned by moving the couch. The deviations calculated from X-ray images acquired within the time interval between two consecutive couch motions constitute a data set. Results: Included in the analysis were 427 data sets and 4,439 time stamps of X-ray images. The mean duration for each data set was 697 sec. At 30 sec, a motion >2 mm exists in about 5% of data sets. The percentage is increased to 8%, 11%, and 14% at 60 sec, 90 sec, and 120 sec, respectively. A similar trend exists for other values of prostate motion. Conclusions: With proper monitoring and intervention during treatment, the prostate shifts observed among patients can be kept within the tracking range of the CyberKnife. On average, a sampling rate of ∼40 sec between consecutive X-rays is acceptable to ensure submillimeter tracking. However, there is significant movement variation among patients, and a higher sampling rate may be necessary in some patients. [Copyright &y& Elsevier]

Purpose: Newly emerged four-dimensional (4D) imaging techniques such as 4D-computed tomography (CT), 4D-cone beam CT, 4D-magnetic resonance imaging, and 4D-positron emission tomography are effective tools to reveal the spatiotemporal details of patients'' anatomy. To use the 4D data acquired under different conditions or using different modalities, an algorithm for registering 4D images must be in place. We developed an automated 4D-4D registration method to take advantage of 4D information. Methods and Materials: We used 4D-4D matching to find the appropriate three-dimensional anatomy in the fixed image for each phase of the moving image and spatially register them. A search algorithm was implemented to simultaneously find the best phase and spatial match of two 4D inputs. An interpolation scheme capable of deriving an image set based on temporally adjacent three-dimensional data sets was developed to deal with the situation in which the discrete temporal points of the two inputs do not coincide or correspond. Results: In a phantom study, our technique was able to reproduce the known “ground truth” with high spatial fidelity. The technique regenerated all deliberately introduced “missing” three-dimensional images at different phases of the input using temporal interpolation. In the registration of gated-magnetic resonance imaging and 4D-CT, the algorithm was able to select the appropriate CT phase. The technique was also able to register 4D-CT with 4D-cone beam CT and two 4D-CT scans acquired at different times. A spatial accuracy of <3 mm was achieved in 98% of voxels in all cases. Conclusion: Automated 4D-4D registration can find the best possible spatiotemporal match between two 4D data sets and is useful for image-guided radiotherapy applications. [Copyright &y& Elsevier]

Purpose: To develop a regional narrow-band algorithm to auto-propagate the contour surface of a region of interest (ROI) from one phase to other phases of four-dimensional computed tomography (4D-CT). Methods and Materials: The ROI contours were manually delineated on a selected phase of 4D-CT. A narrow band encompassing the ROI boundary was created on the image and used as a compact representation of the ROI surface. A BSpline deformable registration was performed to map the band to other phases. A Mattes mutual information was used as the metric function, and the limited memory Broyden-Fletcher-Goldfarb-Shanno algorithm was used to optimize the function. After registration the deformation field was extracted and used to transform the manual contours to other phases. Bidirectional contour mapping was introduced to evaluate the proposed technique. The new algorithm was tested on synthetic images and applied to 4D-CT images of 4 thoracic patients and a head-and-neck Cone-beam CT case. Results: Application of the algorithm to synthetic images and Cone-beam CT images indicates that an accuracy of 1.0 mm is achievable and that 4D-CT images show a spatial accuracy better than 1.5 mm for ROI mappings between adjacent phases, and 3 mm in opposite-phase mapping. Compared with whole image–based calculations, the computation was an order of magnitude more efficient, in addition to the much-reduced computer memory consumption. Conclusions: A narrow-band model is an efficient way for contour mapping and should find widespread application in future 4D treatment planning. [Copyright &y& Elsevier]

Purpose: To evaluate indirect magnetic resonance lymphangiography (MR-LAG) using interstitial injection of conventional gadolinium contrast (gadoteridol and gadopentetate dimeglumine) for delineating the primary lymphatic drainage of head-and-neck sites. Methods and Materials: We performed head-and-neck MR-LAG in 5 healthy volunteers, with injection of dermal and mucosal sites. We evaluated the safety of the procedure, the patterns of enhancement categorized by injection site and nodal level, the time course of enhancement, the optimal concentration and volume of contrast, and the optimal imaging sequence. Results: The worst side effects of interstitial contrast injection were brief, mild pain and swelling at the injected sites that were self-limited. MR-LAG resulted in consistent visualization of the primary lymphatic drainage pattern specific to each injected site, which was reproducible on repeated examinations. The best enhancement was obtained with injection of small volumes (0.3-0.5 mL) of either agent diluted, imaging within 5-15 min of injection, and a three-dimensional fast spoiled gradient echo sequence with magnetization transfer. Conclusions: We found head-and-neck MR-LAG to be a safe, convenient imaging method that provides functional information about the lymphatic drainage of injected sites. Applied to head-and-neck cancer, it has the potential to identify sites at highest risk of occult metastatic spread for radiotherapy or surgical planning, and possibly to visualize micrometastases. [ABSTRACT FROM AUTHOR]