Conjoint Professor Peter Greer

© 2016 Institute of Physics and Engineering in Medicine.In-room cine-MRI guidance can provide non-invasive target localization during radiotherapy treatment. However, in order to cope with finite imaging frequency and system latencies between target localization and dose delivery, tumour motion prediction is required. This work proposes a framework for motion prediction dedicated to cine-MRI guidance, aiming at quantifying the geometric uncertainties introduced by this process for both tumour tracking and beam gating. The tumour position, identified through scale invariant features detected in cine-MRI slices, is estimated at high-frequency (25 Hz) using three independent predictors, one for each anatomical coordinate. Linear extrapolation, auto-regressive and support vector machine algorithms are compared against systems that use no prediction or surrogate-based motion estimation. Geometric uncertainties are reported as a function of image acquisition period and system latency. Average results show that the tracking error RMS can be decreased down to a [0.2; 1.2] mm range, for acquisition periods between 250 and 750 ms and system latencies between 50 and 300 ms. Except for the linear extrapolator, tracking and gating prediction errors were, on average, lower than those measured for surrogate-based motion estimation. This finding suggests that cine-MRI guidance, combined with appropriate prediction algorithms, could relevantly decrease geometric uncertainties in motion compensated treatments.

© 2015 American Association of Physicists in Medicine.Purpose: Radiation treatments are trending toward delivering higher doses per fraction under stereotactic radiosurgery and hypofractionated treatment regimens. There is a need for accurate 3D in vivo patient dose verification using electronic portal imaging device (EPID) measurements. This work presents a model-based technique to compute full three-dimensional patient dose reconstructed from on-treatment EPID portal images (i.e., transmission images). Methods: EPID dose is converted to incident fluence entering the patient using a series of steps which include converting measured EPID dose to fluence at the detector plane and then back-projecting the primary source component of the EPID fluence upstream of the patient. Incident fluence is then recombined with predicted extra-focal fluence and used to calculate 3D patient dose via a collapsed-cone convolution method. This method is implemented in an iterative manner, although in practice it provides accurate results in a single iteration. The robustness of the dose reconstruction technique is demonstrated with several simple slab phantom and nine anthropomorphic phantom cases. Prostate, head and neck, and lung treatments are all included as well as a range of delivery techniques including VMAT and dynamic intensity modulated radiation therapy (IMRT). Results: Results indicate that the patient dose reconstruction algorithm compares well with treatment planning system computed doses for controlled test situations. For simple phantom and square field tests, agreement was excellent with a 2%/2 mm 3D chi pass rate .98.9%. On anthropomorphic phantoms, the 2%/2 mm 3D chi pass rates ranged from 79.9% to 99.9% in the planning target volume (PTV) region and 96.5% to 100% in the low dose region (>20% of prescription, excluding PTV and skin build-up region). Conclusions: An algorithm to reconstruct delivered patient 3D doses from EPID exit dosimetry measurements was presented. The method was applied to phantom and patient data sets, as well as for dynamic IMRT and VMAT delivery techniques. Results indicate that the EPID dose reconstruction algorithm presented in this work is suitable for clinical implementation.

Crown Copyright © 2015 Published by Elsevier Inc. All rights reserved.Purpose To validate automatic substitute computed tomography CT (sCT) scans generated from standard T2-weighted (T2w) magnetic resonance (MR) pelvic scans for MR-Sim prostate treatment planning. Patients and Methods A Siemens Skyra 3T MR imaging (MRI) scanner with laser bridge, flat couch, and pelvic coil mounts was used to scan 39 patients scheduled for external beam radiation therapy for localized prostate cancer. For sCT generation a whole-pelvis MRI scan (1.6 mm 3-dimensional isotropic T2w SPACE [Sampling Perfection with Application optimized Contrasts using different flip angle Evolution] sequence) was acquired. Three additional small field of view scans were acquired: T2w, T2*w, and T1w flip angle 80° for gold fiducials. Patients received a routine planning CT scan. Manual contouring of the prostate, rectum, bladder, and bones was performed independently on the CT and MR scans. Three experienced observers contoured each organ on MRI, allowing interobserver quantification. To generate a training database, each patient CT scan was coregistered to their whole-pelvis T2w using symmetric rigid registration and structure-guided deformable registration. A new multi-atlas local weighted voting method was used to generate automatic contours and sCT results. Results The mean error in Hounsfield units between the sCT and corresponding patient CT (within the body contour) was 0.6 ± 14.7 (mean ± 1 SD), with a mean absolute error of 40.5 ± 8.2 Hounsfield units. Automatic contouring results were very close to the expert interobserver level (Dice similarity coefficient): prostate 0.80 ± 0.08, bladder 0.86 ± 0.12, rectum 0.84 ± 0.06, bones 0.91 ± 0.03, and body 1.00 ± 0.003. The change in monitor units between the sCT-based plans relative to the gold standard CT plan for the same dose prescription was found to be 0.3% ± 0.8%. The 3-dimensional ¿ pass rate was 1.00 ± 0.00 (2 mm/2%). Conclusions The MR-Sim setup and automatic sCT generation methods using standard MR sequences generates realistic contours and electron densities for prostate cancer radiation therapy dose planning and digitally reconstructed radiograph generation.

The purpose of this study was to investigate performance of the couch and coil mounts designed for MR-simulation prostate scanning using data from ten volunteers. Volunteers were scanned using the standard MR scanning protocol with the MR coil directly strapped on the external body and the volunteer lying on the original scanner table. They also were scanned using a MR-simulation table top and pelvic coil mounts. MR images from both setups were compared in terms of body contour variation and image quality effects within particular organs of interest. Six-field conformal plans were generated on the two images with assigned bulk density for dose calculation. With the MR-simulation devices, the anterior skin deformation was reduced by up to 1.7 cm. The hard tabletop minimizes the posterior body deformation which can be up to 2.3 cm on the standard table, depending on the weight of volunteer. The image signal-to-noise ratio reduced by 14% and 25% on large field of view (FOV) and small FOV images, respectively, after using the coil mount; the prostate volume contoured on two images showed difference of 1.05 ± 0.66 cm³. The external body deformation caused a mean dose reduction of 0.6 ± 0.3 Gy, while the coverage reduced by 22% ± 13% and 27% ± 6% in V98 and V100, respectively. A dedicated MR simulation setup for prostate radiotherapy is essential to ensure the agreement between planning anatomy and treatment anatomy. The image signal was reduced after applying the coil mount, but no significant effect was found on prostate contouring.

© 2015 Institute of Physics and Engineering in Medicine.To clinically implement MRI simulation or MRI-alone treatment planning requires comprehensive end-to-end testing to ensure an accurate process. The purpose of this study was to design and build a geometric phantom simulating a human male pelvis that is suitable for both CT and MRI scanning and use it to test geometric and dosimetric aspects of MRI simulation including treatment planning and digitally reconstructed radiograph (DRR) generation. A liquid filled pelvic shaped phantom with simulated pelvic organs was scanned in a 3T MRI simulator with dedicated radiotherapy couch-top, laser bridge and pelvic coil mounts. A second phantom with the same external shape but with an internal distortion grid was used to quantify the distortion of the MR image. Both phantoms were also CT scanned as the gold-standard for both geometry and dosimetry. Deformable image registration was used to quantify the MR distortion. Dose comparison was made using a seven-field IMRT plan developed on the CT scan with the fluences copied to the MR image and recalculated using bulk electron densities. Without correction the maximum distortion of the MR compared with the CT scan was 7.5 mm across the pelvis, while this was reduced to 2.6 and 1.7 mm by the vendor's 2D and 3D correction algorithms, respectively. Within the locations of the internal organs of interest, the distortion was <1.5 and <1 mm with 2D and 3D correction algorithms, respectively. The dose at the prostate isocentre calculated on CT and MRI images differed by 0.01% (1.1 cGy). Positioning shifts were within 1 mm when setup was performed using MRI generated DRRs compared to setup using CT DRRs. The MRI pelvic phantom allows end-to-end testing of the MRI simulation workflow with comparison to the gold-standard CT based process. MRI simulation was found to be geometrically accurate with organ dimensions, dose distributions and DRR based setup within acceptable limits compared to CT.

© 2015 Australasian College of Physical Scientists and Engineers in Medicine To quantify the dose calculation error and resulting optimization uncertainty caused by performing inverse treatment planning on inaccurate electron density data (pseudo-CT) as needed for adaptive radiotherapy and Magnetic Resonance Imaging (MRI) based treatment planning. Planning Computer Tomography (CT) data from 10 cervix cancer patients was used to generate 4 pseudo-CT data sets. Each pseudo-CT was created based on an available method of assigning electron density to an anatomic image. An inversely modulated radiotherapy (IMRT) plan was developed on each planning CT. The dose calculation error caused by each pseudo-CT data set was quantified by comparing the dose calculated each pseudo-CT data set with that calculated on the original planning CT for the same IMRT plan. The optimization uncertainty introduced by the dose calculation error was quantified by re-optimizing the same optimization parameters on each pseudo-CT data set and comparing against the original planning CT. Dose differences were quantified by assessing the Equivalent Uniform Dose (EUD) for targets and relevant organs at risk. Across all pseudo-CT data sets and all organs, the absolute mean dose calculation error was 0.2 Gy, and was within 2 % of the prescription dose in 98.5 % of cases. Then absolute mean optimisation error was 0.3 Gy EUD, indicating that that inverse optimisation is impacted by the dose calculation error. However, the additional uncertainty introduced to plan optimisation is small compared the sources of variation which already exist. Use of inaccurate electron density data for inverse treatment planning results in a dose calculation error, which in turn introduces additional uncertainty into the plan optimization process. In this study, we showed that both of these effects are clinically acceptable for cervix cancer patients using four different pseudo-CT data sets. Dose calculation and inverse optimization on pseudo-CT is feasible for this patient cohort.

© 2014 Associazione Italiana di Fisica Medica.A new tool with the potential to verify and track jaw position during delivery has been developed. The method should be suitable for independent quality assurance for jaw position during jaw tracking dynamic IMRT and VMAT treatments. The jaw detection and tracking algorithm developed consists of five main steps. Firstly, the image is enhanced by removing a normalised predicted EPID image (that does not include the collimator transmission) from each cine EPID image. Then, using a histogram clustering technique a global intensity threshold level was determined. This threshold level was used to classify each pixel of the image as either under the jaws or under the MLC. Additionally, the collimator angle was automatically detected and used to rotate the image to vertical direction. Finally, this rotation allows the jaw positions to be determined using vertical and horizontal projection profiles. Nine IMRT fields (with static jaws) and a single VMAT clinical field (with dynamic jaws) were tested by determining the root mean square difference between planned and detected jaw positions. The test results give a detection accuracy of ±1mm RMS error for static jaw IMRT treatments and ±1.5mm RMS error for the dynamic jaw VMAT treatment. This method is designed for quality assurance and verification in modern radiation therapy; to detect the position of static jaws or verify the position of tracking jaws in more complex treatments. This method uses only information extracted from EPID images and it is therefore independent from the linear accelerator.

© 2015 Elsevier Inc. All rights reserved.Purpose Gantry-mounted megavoltage electronic portal imaging devices (EPIDs) have become ubiquitous on linear accelerators. WatchDog is a novel application of EPIDs, in which the image frames acquired during treatment are used to monitor treatment delivery in real time. We report on the preliminary use of WatchDog in a prospective study of cancer patients undergoing intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT) and identify the challenges of clinical adoption. Methods and Materials At the time of submission, 28 cancer patients (head and neck, pelvis, and prostate) undergoing fractionated external beam radiation therapy (24 IMRT, 4 VMAT) had =1 treatment fraction verified in real time (131 fractions or 881 fields). EPID images acquired continuously during treatment were synchronized and compared with model-generated transit EPID images within a frame time (~0.1 s). A ¿ comparison was performed to cumulative frames to gauge the overall delivery quality, and the resulting pass rates were reported graphically during treatment delivery. Every frame acquired (500-1500 per fraction) was saved for postprocessing and analysis. Results The system reported the mean ± standard deviation in real time ¿ 91.1% ± 11.5% (83.6% ± 13.2%) for cumulative frame ¿ analysis with 4%, 4 mm (3%, 3 mm) criteria, global over the integrated image. Conclusions A real-time EPID-based radiation delivery verification system for IMRT and VMAT has been demonstrated that aims to prevent major mistreatments in radiation therapy.

© 2014 The Authors.Methods: A custom-designed pelvic-shaped phantom was scanned by systematically increasing the anterior body-tocoil (BTC) distance from 30 to 90mm. The image quality near the organs of interest was determined in order to characterize the relationship between image quality and BTC distance at the critical organ structures. The half intensity reduction (HIR) was calculated to determine the sensitivity of each organ structure to the BTC distance change.Advances in knowledge: A method to characterize the effect on image quality due to the use of coil mounts was demonstrated. Coil mounts whose height can be adjusted individually to keep BTC distance constant are necessary to maintain a uniform image across the entire field of view.Results: As the BTC distance increased, the uniformity reduced at 3% per millimetre. The HIR value indicated that the bladder signal is most sensitive to the change in BTC distance. By maintaining a constant BTC distance set-up, the intensity uniformitywas improved by 28% along the B0 directions.Conclusion: Positioning the MRI coil on mounts can reduce body deformation but adversely degrades the image quality. The magnitude of this effect has been quantified for prostate MR simulation scanning. The coil needs to be positioned not only with a minimal but also uniform BTC distance in order to maximize image quality.Objective: To eliminate the effects of body deformation for MR-based prostate treatment planning, coil mounts are essential. In this study, we evaluated the effect of the coil set-up on image quality.

MRI-alone treatment planning and adaptive MRI-based prostate radiation therapy are two promising techniques that could significantly increase the accuracy of the curative dose delivery processes while reducing the total radiation dose. State-of-the-art methods rely on the registration of a patient MRI with a MR-CT atlas for the estimation of pseudo-CT [5]. This atlas itself is generally created by registering many CT and MRI pairs. Most registration methods are not symmetric, but the order of the images influences the result [8]. The computed transformation is therefore biased, introducing unwanted variability. This work examines how much a symmetric algorithm improves the registration. Methods: A robust symmetric registration algorithm is proposed that simultaneously optimises a half space transform and its inverse. During the registration process, the two input volumetric images are transformed to a common position in space, therefore minimising any computational bias. An asymmetrical implementation of the same algorithm was used for comparison purposes. Results: Whole pelvis MRI and CT scans from 15 prostate patients were registered, as in the creation of MR-CT atlases. In each case, two registrations were performed, with different input image orders, and the transformation error quantified. Mean residuals of 0.63±0.26 mm (translation) and (8.7±7.3) × 10-3 rad (rotation) were found for the asymmetrical implementation with corresponding values of 0.038±0.039 mm and (1.6 ± 1.3) × 10-3 rad for the proposed symmetric algorithm, a substantial improvement. Conclusions: The increased registration precision will enhance the generation of pseudo-CT from MRI for atlas based MR planning methods. © Published under licence by IOP Publishing Ltd.

Our group have been developing methods for MRI-alone prostate cancer radiation therapy treatment planning. To assist with clinical validation of the workflow we are investigating a cloud platform solution for research purposes. Benefits of cloud computing can include increased scalability, performance and extensibility while reducing total cost of ownership. In this paper we demonstrate the generation of DICOM-RT directories containing an automatic average atlas based electron density image and fast pelvic organ contouring from whole pelvis MR scans. © Published under licence by IOP Publishing Ltd.

Radiotherapy is an effective therapy in the treatment of cervix cancer. However tumor and normal tissue motion and shape deformation of the cervix, the bladder and the rectum over the course of the treatment can limit the efficacy of radiotherapy and safe delivery of the dose. A number of studies have presented the potential benefits of adaptive radiotherapy for cervix cancer with high soft tissue contrast magnetic resonance images. To enable practical implementation of adaptive radiotherapy for the cervix, computer aided segmentation is necessary. Accurate computer aided automatic or semi-automatic segmentation of the cervix is a challenging task due to inter patient shape variation, soft tissue deformation, organ motion, and anatomical changes during the course of the treatment. This article reviews the methods developed for cervix segmentation in magnetic resonance images. The objective of this work is to present different methods for cervix segmentation in the literature highlighting their similarities, differences, strengths and weaknesses. © 2013 Springer-Verlag.

The set-up variation of 11 patients treated supine with radical radiotherapy for carcinoma of the prostate was measured with an electronic portal imaging device to determine the adequacy of set-up techniques and current margins, as well as the need for immobilization. During the treatments 172 images of the anterior fields and 159 images of the left- lateral fields were taken and the errors in treatment placement were measured by template matching. The variation in the superior-inferior direction was small, 1.4-1.6 mm (1 SD), while the medio-lateral variation was 2.8 mm (1 SD). The anterior-posterior variation was largest, 4.6 mm (1 SD) with an offset of 3.3 mm anterior. This anterior offset and large anterior-posterior variation suggests that set-up techniques were not optimal for this direction. The 1 cm margin used was adequate for set-up variation except in a small number of cases, which was mainly due to the anterior trend. Random (treatment-to-treatment) variations were small (1.1-2.3 mm; 1 SD), indicating that immobilization would result in only modest improvement in reproducibility for these supine patients.