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External beam radiotherapy (EBRT) is one of the curative treatment options for prostate cancer patients. The aim of this treatment option is to irradiate tumor tissue, while sparing normal tissue as much as possible. Frequent imaging during the course of the treatment (image guided radiotherapy) allows for determination of the location and shape of the prostate (target) and of the organs at risk. This information is used to increase accuracy in radiation dose delivery resulting in better tumor control and lower toxicity. Ultrasound imaging is harmless for the patient, it is cost-effective, and it allows for real-time volumetric organ tracking. For these reasons, it is an ideal technique for image guidance during EBRT workflows. Review papers have been published in which the use of ultrasound imaging in EBRT workflows for different cancer sites (prostate, breast, etc.) was extensively covered. This new review paper aims at providing the readers with an update on the current status for prostate cancer ultrasound guided EBRT treatments.

In many medical fields, spatial localization of devices is of paramount importance to e.g. deliver treatments correctly or to perform accurate diagnostic evaluations. Among the different technologies available, optical localization in the visible band of the spectrum offers many advantages: minimum interference with other instruments, flexibility in position of the devices used and extra features such as patient/operator surface tracking or vital signs monitoring. Its application in the domain of radiotherapy is novel, and potentially very beneficial. In this work we introduced a workflow to test the reliability of one of these systems, developed in house, to localize an ultrasound transducer for ultrasound guided radiation therapy (USgRT). Accuracy, precision, latency, sensitive volume and sensitivity to light intensity were evaluated. The workflow we proposed allowed us to establish that, while all the clinically relevant parameters of the system are acceptable, accuracy in locating the transducer could be as poor as 7-8 mm, therefore not acceptable for the intended purpose of the system.

Purpose: Imaging of patient anatomy during treatment is a necessity for position verification and for adaptive radiotherapy based on daily dose recalculation. Ultrasound (US) image guided radiotherapy systems are currently available to collect US images at the simulation stage (USsim), coregistered with the simulation computed tomography (CT), and during all treatment fractions. The authors hypothesize that a deformation field derived from US-based deformable image registration can be used to create a daily pseudo-CT (CTps) image that is more representative of the patients' geometry during treatment than the CT acquired at simulation stage (CTsim). Methods: The three prostate patients, considered to evaluate this hypothesis, had coregistered CT and US scans on various days. In particular, two patients had two US-CT datasets each and the third one had five US-CT datasets. Deformation fields were computed between pairs of US images of the same patient and then applied to the corresponding USsim scan to yield a new deformed CTps scan. The original treatment plans were used to recalculate dose distributions in the simulation, deformed and ground truth CT (CTgt) images to compare dice similarity coefficients, maximum absolute distance, and mean absolute distance on CT delineations and gamma index (gamma) evaluations on both the Hounsfield units (HUs) and the dose. Results: In the majority, deformation did improve the results for all three evaluation methods. The change in gamma failure for dose (gamma(Dose), 3%, 3 mm) ranged from an improvement of 11.2% in the prostate volume to a deterioration of 1.3% in the prostate and bladder. The change in gamma failure for the CT images (gamma(CT), 50 HU, 3 mm) ranged from an improvement of 20.5% in the anus and rectum to a deterioration of 3.2% in the prostate. Conclusions: This new technique may generate CTps images that are more representative of the actual patient anatomy than the CTsim scan.