Search

Background Purpose Methods Results Conclusion Achieving a clinically acceptable dose distribution with commercial vaginal applicators for brachytherapy of recurrent parauterine tumors is challenging. However, the application of three‐dimensional (3D) printing technology in brachytherapy has been widely acknowledged and can improve clinical treatment outcomes.This study aimed to introduce an individual curved‐needle interstitial template (ICIT) created using 3D printing technology for high‐dose‐rate (HDR) brachytherapy with interstitial treatment to provide a clinically feasible approach to distal parauterine and vaginal cuff tumors. The entire workflow, including the design, optimization, and application, is presented.Ten patients with pelvic cancer recurrence were examined at our center. The vaginal topography was filled with gauze strips soaked in developer solution, and images were obtained using computed tomography (CT) and magnetic resonance imaging (MRI). Curved needle paths were designed, and ICITs were 3D‐printed according to the high‐risk clinical target volume (HRCTV) and vaginal filling model. The dose and volume histogram parameters of the HRCTV (V100, V200, D90, and D98) and organs at risk (OARs) (D2cc) were recorded.All patients completed interstitial brachytherapy treatment with the 3D‐printed ICIT. One patient experienced vaginal cuff tumor recurrence, and nine patients experienced parametrial tumor recurrence (four on the left and five on the right). We used two to five interstitial needles, and the maximum angle of the curved needle was 40°. No source obstruction events occurred during treatment of these 10 patients. The doses delivered to the targets and OARs of all patients were within the dose limits and based on clinical experience at our center.The ICIT is a treatment option for patients with distal parauterine tumor recurrence. This method addresses the limitations of vaginal intracavitary and standard interstitial applicators. The ICIT has the advantages of biocompatibility, personalization, and magnetic resonance imaging compatibility. [ABSTRACT FROM AUTHOR]

Background: Electromagnetic tracking (EMT) has been researched for brachytherapy applications, showing a great potential for automating implant reconstruction, and overcoming image‐based limitations such as contrast and spatial resolution. One of the challenges of this technology is that it does not intrinsically share the same reference frame as the patient's medical imaging. Purpose: To present a novel phantom that can be used for a comprehensive quality assurance (QA) program of brachytherapy EMT systems and use this phantom to validate a novel applicator‐based registration method of EMT and image reference frames for gynecological (GYN) interstitial brachytherapy. Materials and Methods: Eleven 6F‐catheters (20 cm long), one 6F round tip catheter (29.4 cm long) and a tandem and ring gynecological applicator (Elekta, CT/MR 60°, 40 mm long tandem, 30 mm diameter ring) were placed in a rigid custom‐made phantom (Elekta Brachytherapy, Veenendaal, The Netherlands) to reconstruct their geometry using a five‐degree of freedom EMT sensor attached to an afterloader's check cable. All EMT reconstructions were done in three different environments: disturbance free (no metal nearby), computed tomography (CT)‐on‐rails brachytherapy suite and magnetic resonance imaging (MRI) brachytherapy suite. Implants were placed parallel to a magnetic field generatorand were reconstructed using two different acquisition methods: step‐and‐record and continuous motion. In all cases, the acquisition is performed at a rate of approximately 40 Hz. A CT scan of the phantom inside a water cube was obtained. In the treatment planning system (TPS), all catheters in the CT images were manually reconstructed and the applicator reconstruction was achieved by manually placing its solid 3D model, found in the applicator library of the TPS. The Iterative Closest Point and the Coherent Point Drift algorithms were used, initialized with four known points, to register both EMT and CT scan reference frames using corresponding points from the EMT and CT based reconstructions of the phantom, following three approaches: one gynecological applicator, four interstitial catheters inside four calibration plates having an S‐shaped path, and four 5 mm diameter ceramic marbles found in each of the four calibration plates. Once registered, the registration error (perpendicular distance) was computed. Results: The absolute median deviation from the expected value for EMT measurements in the disturbance free environment, CT‐on‐rails brachytherapy suite, and MRI‐brachytherapy suite are 0.41, 0.23, and 0.31 mm, respectively, while for the CT scan it is 0.18 mm. These values significantly lie below the sensor's expected accuracy of 0.70 mm (p < 0.001), suggesting that the environment did not have a significant impact on the measurements, given that care is taken in the immediate surroundings. In all three environments, the two acquisitions and three registration approaches have mean and median registration errors that lie at or below 1 mm, which is lower than the clinical acceptable threshold of 2 mm. Conclusions: The novel phantom allowed to successfully evaluate the accuracy of EMT‐based reconstructions of catheters and a GYN tandem and ring applicator in different clinical environments. A registration method based only on the applicator geometry, reconstructed withan EMT sensor and the TPS solid applicator library, was validated and shows clinically acceptable accuracy, comparable to CT‐based reconstruction but within a few minutes. Since the applicator is also visible in MRI, this method could potentially be used in clinics in an EMT‐MR interstitial GYN brachytherapy workflow. [ABSTRACT FROM AUTHOR]

Cervical cancer is the second most common cancer cause of morbidity and mortality in Filipino women; the age‐standardized annual incidence is 15.2 as of March 2023. The majority are diagnosed at a locally advanced stage and in the reproductive and working age group. This results in important treatment and productivity costs. The importance of image‐guided and interstitial brachytherapy (BRT) in local control and toxicity outcomes has been shown in recent meta‐analyses. We review the status of advanced BRT program training and implementation in the Philippines and important challenges and opportunities to move forward. [ABSTRACT FROM AUTHOR]

Background: Electromagnetic tracking (EMT) systems have been shown to provide valuable information on the geometry of catheter implants in breast cancer patients undergoing interstitial brachytherapy (iBT). In the context of an extended patient‐specific, pre‐treatment verification, EMT can play a key role in determining the potential need and, if applicable, the appropriate time for treatment adaptation. To detect dosimetric shortcomings the relative position between catheters, and target volume and critical structures must be known. Since EMT cannot provide the anatomical context and standard imaging techniques such as cone‐beam CT are not yet available in most brachytherapy suites, it is not possible to detect anatomic changes on a daily or fraction basis, so the need for adaptive planning cannot be identified. Purpose: The aim of this feasibility study is to develop and evaluate a technique capable of estimating follow‐up CTs at any time based on the initial treatment planning CT (PCT) and surrogate information about changes of the implant geometry from an EMT system. Methods: A deformation vector field is calculated from two different implant reconstructions acquired in treatment position through EMT, the first immediately after the PCT and the second at another time point during the course of treatment. The calculation is based on discrete displacement vectors of pairs of control and target points. These are extrapolated by means of different radial basis functions in order to cover the entire CT volume. The adequate parameters for the calculation of the deformation field were identified. By warping the PCT according to the deformation field, one obtains an estimated CT (ECT) that reflects the geometric changes. For the proof of concept, ECTs were computed for the time point of the clinical follow‐up CT (FCT) that is embedded in the treatment workflow after the fourth fraction. Results: ECT and clinical FCTs of 20 patients were compared to each other quantitatively in terms of absolute Hounsfield unit differences in the planning target volume (PTV) and in a convex hull (CH) enclosing the catheters. The median differences were 31.2 and 29.5 HU for the CH and the PTV, respectively. Conclusion: The proposed ECT approach was able to approximate the "anatomy of the day" and therefore, in principle, allows a dosimetric appraisal of the treatment plan quality before each fraction. In this way, it can contribute to a more detailed patient‐specific quality assurance in iBT of the breast and help to identify the timing for a potential treatment adaptation. [ABSTRACT FROM AUTHOR]

Background: Electromagnetic tracking (EMT) is a promising technology that holds great potential to advance patient‐specific pre‐treatment verification in interstitial brachytherapy (iBT). It allows easy determination of the implant geometry without line‐of‐sight restrictions and without dose exposure to the patient. What it cannot provide, however, is a link to anatomical landmarks, such as the exit points of catheters or needles on the skin surface. These landmarks are required for the registration of EMT data with other imaging modalities and for the detection of treatment errors such as incorrect indexer lengths, and catheter or needle shifts. Purpose: To develop an easily applicable method to detect reference points in the positional data of the trajectory of an EMT sensor, specifically the exit points of catheters in breast iBT, and to apply the approach to pre‐treatment error detection. Methods: Small metal objects were attached to catheter fixation buttons that rest against the breast surface to intentionally induce a local, spatially limited perturbation of the magnetic field on which the working principle of EMT relies. This perturbation can be sensed by the EMT sensor as it passes by, allowing it to localize the metal object and thus the catheter exit point. For the proof‐of‐concept, different small metal objects (magnets, washers, and bushes) and EMT sensor drive speeds were used to find the optimal parameters. The approach was then applied to treatment error detection and validated in‐vitro on a phantom. Lastly, the in‐vivo feasibility of the approach was tested on a patient cohort of four patients to assess the impact on the clinical workflow. Results: All investigated metal objects were able to measurably perturb the magnetic field, which resulted in missing sensor readings, that is two data gaps, one for the sensor moving towards the tip end and one when retracting from there. The size of the resulting data gaps varied depending on the choice of gap points used for calculation of the gap size; it was found that the start points of the gaps in both directions showed the smallest variability. The median size of data gaps was ⩽8 mm for all tested materials and sensor drive speeds. The variability of the determined object position was ⩽0.5 mm at a speed of 1.0 cm/s and ⩽0.7 mm at 2.5 cm/s, with an increase up to 2.3 mm at 5.0 cm/s. The in‐vitro validation of the error detection yielded a 100% detection rate for catheter shifts of ≥2.2 mm. All simulated wrong indexer lengths were correctly identified. The in‐vivo feasibility assessment showed that the metal objects did not interfere with the routine clinical workflow. Conclusions: The developed approach was able to successfully detect reference points in EMT data, which can be used for registration to other imaging modalities, but also for treatment error detection. It can thus advance the automation of patient‐specific, pre‐treatment quality assurance in iBT. [ABSTRACT FROM AUTHOR]

Purpose: High‐dose‐rate (HDR) interstitial brachytherapy (BT) is a common treatment technique for localized intermediate to high‐risk prostate cancer. Transrectal ultrasound (US) imaging is typically used for guiding needle insertion, including localization of the needle tip which is critical for treatment planning. However, image artifacts can limit needle tip visibility in standard brightness (B)‐mode US, potentially leading to dose delivery that deviates from the planned dose. To improve intraoperative tip visualization in visually obstructed needles, we propose a power Doppler (PD) US method which utilizes a novel wireless mechanical oscillator, validated in phantom experiments and clinical HDR‐BT cases as part of a feasibility clinical trial. Methods: Our wireless oscillator contains a DC motor housed in a 3D printed case and is powered by rechargeable battery allowing the device to be operated by one person with no additional equipment required in the operating room. The oscillator end‐piece features a cylindrical shape designed for BT applications to fit on top of the commonly used cylindrical needle mandrins. Phantom validation was completed using tissue‐equivalent agar phantoms with the clinical US system and both plastic and metal needles. Our PD method was tested using a needle implant pattern matching a standard HDR‐BT procedure as well as an implant pattern designed to maximize needle shadowing artifacts. Needle tip localization accuracy was assessed using the clinical method based on ideal reference needles as well as a comparison to computed tomography (CT) as a gold standard. Clinical validation was completed in five patients who underwent standard HDR‐BT as part of a feasibility clinical trial. Needle tips positions were identified using B‐mode US and PD US with perturbation from our wireless oscillator. Results: Absolute mean ± standard deviation tip error for B‐mode alone, PD alone, and B‐mode combined with PD was respectively: 0.3 ± 0.3 mm, 0.6 ± 0.5 mm, and 0.4 ± 0.2 mm for the mock HDR‐BT needle implant; 0.8 ± 1.7 mm, 0.4 ± 0.6 mm, and 0.3 ± 0.5 mm for the explicit shadowing implant with plastic needles; and 0.5 ± 0.2 mm, 0.5 ± 0.3 mm, and 0.6 ± 0.2 mm for the explicit shadowing implant with metal needles. The total mean absolute tip error for all five patients in the feasibility clinical trial was 0.9 ± 0.7 mm using B‐mode US alone and 0.8 ± 0.5 mm when including PD US, with increased benefit observed for needles classified as visually obstructed. Conclusions: Our proposed PD needle tip localization method is easy to implement and requires no modifications or additions to the standard clinical equipment or workflow. We have demonstrated decreased tip localization error and variation for visually obstructed needles in both phantom and clinical cases, including providing the ability to visualize needles previously not visible using B‐mode US alone. This method has the potential to improve needle visualization in challenging cases without burdening the clinical workflow, potentially improving treatment accuracy in HDR‐BT and more broadly in any minimally invasive needle‐based procedure. [ABSTRACT FROM AUTHOR]

Image-guided adaptive intracavitary/interstitial brachytherapy (IC/IS IGABT) has exhibited superior dosimetry advantage and local control for locally advanced cervical cancer (LACC). Our group designed a type of cylindrical three-dimensional (3D) printed vaginal template combining an intracavitary applicator with straight and oblique interstitial needles according to the preplan on computed tomography images. This work aimed to research the consistency of the preplan with the treatment plan at every fraction to verify the practical guiding significance of the preplan.We also investigated the difference between 3D-printed template-guided implantation compared with freehand implantation for LACC. Twenty-six patients were treated with 3D-printed individual templates (3D template group), and 20 patients were treated by using freehand insertion (freehand group). Patients in the 3D template group would take a preplan one week before treatment to design and print the individual template, while the freehand group did not. All patients accepted volumetric rotational intensitymodulated radiotherapy at a dose of 49.4 Gy in 26 fractions and subsequent brachytherapy at a dose of 26 Gy in four fractions. All analyses were performed by utilizing SPSS 26. The insertion depth was decreased in fractions 1 and 4 compared with the preplan. None of the dose volume histogram parameters of fractions 1–3, nor the D2cc of bladder and bowel at fraction 4 were barely changed compared with the preplan. The D90 and D98 of the high-risk clinical target volume in the 3D template group were statistically higher than those in the freehand group (p < 0.01). The D2cc of the rectum, bladder, bowel, and sigmoid in the 3D template group were all lower than those in the freehand group (p < 0.01). The preplan in this research is consistent with treatment plans, which is important to ensure the feasibility of applying a 3D-printed template in brachytherapy. The 3D-printed individual guidance template was an effective method in brachytherapy for locally advanced cervical cancer. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the ability of the Venezia advanced multichannel tandem and ring applicator to consistently produce dosimetrically comparable plans utilizing a reduced number of needle channels, to reduce the risk of secondary complications when boosting cervical cancer treatments with high dose rate (HDR) brachytherapy. Methods: We evaluated 26 fractions from 13 patients who were treated with HDR brachytherapy using the Venezia (Elekta) applicator. The original plans included a full load of 12–16 needles, including both parallel and 30‐degree oblique needles. We replanned each original to nine new configurations, with a reduced number of two, three, four, or six needles. Comparisons included differences in percentage dose coverage to 90% of the high‐risk clinical target volume, and percentage dose to 2 cm3 of the bladder, rectum, sigmoid, and bowel. We considered new plans "passing" if they remained within our standards (D90 > 100%; D2 cm3 < 85% bladder, <65% rectum, sigmoid, bowel) or did not perform worse than original. Results: Removing only the two most anterior or the two most posterior needles from both sides showed 80.8% and 61.5% overall passing rate. Removal of the most anterior and posterior four needles together showed 65.4% overall passing rate. Removing all oblique needles showed 19.2% overall passing rate. Removing only left‐sided or only right‐sided oblique needles showed 46.2% and 23.1% overall passing, respectively. Removing only right‐sided or only left‐sided parallel needles separately showed 19.2% and 34.6% overall passing, respectively. Removing all parallel needles showed 11.5% overall passing rate. Conclusions: As only two replans required a full needle load to maintain dosimetric quality and 40 (76.9%), 36 (34.6%), 18 (69.2%), and 10 (19.2%) replans passed with 2, 3, 4, and 6 needles removed respectively, this indicates the potential for using a lesser number of interstitial needles during combined intracavitary and interstitial HDR brachytherapy while maintaining dosimetric quality. [ABSTRACT FROM AUTHOR]

Summary: The successful application of an interstitial brachytherapy course is reported in a 14‐month‐old male Anglo European Studbook (AES) foal for the treatment of a recurrent dermal vascular hamartoma at the dorsal aspect of the pastern on the right hindlimb. The lesion was irradiated four times over 4 days to a total dose of 28 Gy. Progressive tumour shrinkage and necrosis were observed over 2 months. No significant acute side effect was reported at the end of the treatment, with excellent and long‐lasting cosmetic results observed. The only reported late effect was permanent leukotrichia within the treated area, which remained otherwise tumour‐free 1224 days after treatment. Results of this report suggest the potential use of radiation therapy (and specifically brachytherapy techniques), as an effective and safe treatment modality for vascular malformations in horses. [ABSTRACT FROM AUTHOR]

Purpose: Electromagnetic tracking (EMT) is a versatile and viable technique for various quality assurance (QA) tasks in interstitial brachytherapy (iBT). As the duration of EMT measurements in iBT is on the order of minutes, they can be strongly affected by patient motion, especially breathing, which gives rise to motion artefacts. Since the centrepiece of EMT‐related QA in iBT is to assess the geometry of the iBT implant or applicator, the absence of adequate motion compensation techniques could impede the use of EMT for QA purposes. A common way to compensate for this is to reference the data to either external or internal reference sensors (ERS, IRS) which are fixated on the patient's body or inside the applicator and therefore move with the patient. The purpose of the presented study is to provide a quantitative and in‐depth analysis on the use of reference sensors for motion compensation. Methods: First, the need for adequate motion compensation is identified both qualitatively and quantitatively using a phantom subjected to simulated breathing motion. An evaluation routine is developed to assess the influence of motion compensation using reference sensors on the acquired EMT data. The evaluation metric is based on the observed displacement of the EMT sensor from its mean position while dwelling at a dwell position (DP) for a dwell time of 1 s. After that, the routine is applied to a cohort of 54 breast cancer patients treated with iBT, and the quality of an ERS based compensation approach is assessed. In a subgroup of four patients, an IRS is inserted into the iBT implant and IRS‐based compensation is compared to the ERS‐based approach. Moreover, a correlation analysis of the ERS and IRS approach is performed, also including respiratory signals derived from the trajectories of the different reference sensors. Results: It was found that motion compensation with ERS effectively reduced the mean sensor displacement per DP to median values as low as 0.11 mm in both phantom and patient measurements, which is below the precision of the EMT system (0.48 mm). Compensation using the IRS yielded comparable results and was as good as compensation with ERS. The results obtained from both approaches showed a strong correlation. Also the respiratory signals calculated from the different reference sensors were well correlated in most cases. Conclusion: These results indicate that motion compensation with ERS can effectively remove motion artefacts in EMT data. While compensation with an IRS leads to comparable results, the IRS occupies one catheter whose geometry hence cannot be assessed. The use of ERS has proven to be both effective and practical in clinical routine. [ABSTRACT FROM AUTHOR]

Magnetic resonance imaging (MRI) offers excellent soft‐tissue contrast enabling the contouring of targets and organs at risk during gynecological interstitial brachytherapy procedure. Despite its advantage, one of the main obstacles preventing a transition to an MRI‐only workflow is that implanted plastic catheters are not reliably visualized on MR images. This study aims to evaluate the feasibility of a deep‐learning‐based algorithm for semiautomatic reconstruction of interstitial catheters during an MR‐only workflow. MR images of 20 gynecological patients were used in this study. Note that 360 catheters were reconstructed using T1‐ and T2‐weighted images by five experienced brachytherapy planners. The mean of the five reconstructed paths were used for training (257 catheters), validation (15 catheters), and testing/evaluation (88 catheters). To automatically identify and localize the catheters, a two‐dimensional (2D) U‐net algorithm was used to find their approximate location in each image slice. Once localized, thresholding was applied to those regions to find the extrema, as catheters appear as bright and dark regions in T1‐ and T2‐weighted images, respectively. The localized dwell positions of the proposed algorithm were compared to the ground truth reconstruction. Reconstruction time was also evaluated. A total of 34 009 catheter dwell positions were evaluated between the algorithm and all planners to estimate the reconstruction variability. The average variation was 0.97 ± 0.66 mm. The average reconstruction time for this approach was 11 ± 1 min, compared with 46 ± 10 min for the expert planners. This study suggests that the proposed deep learning, MR‐based framework has potential to replace the conventional manual catheter reconstruction. The adoption of this approach in the brachytherapy workflow is expected to improve treatment efficiency while reducing planning time, resources, and human errors. [ABSTRACT FROM AUTHOR]