3D ultrasound can contribute to planning CT to define the target for partial breast radiotherapy.

PURPOSE: The role of three-dimensional breast ultrasound (3D US) in planning partial breast radiotherapy (PBRT) is unknown. This study evaluated the accuracy of coregistration of 3D US to planning computerized tomography (CT) images, the seroma contouring consistency of radiation oncologists using the two imaging modalities and the clinical situations in which US was associated with improved contouring consistency compared to CT. MATERIALS AND METHODS: Twenty consecutive women with early-stage breast cancer were enrolled prospectively after breast-conserving surgery. Subjects underwent 3D US at CT simulation for adjuvant RT. Three radiation oncologists independently contoured the seroma on separate CT and 3D US image sets. Seroma clarity, seroma volumes, and interobserver contouring consistency were compared between the imaging modalities. Associations between clinical characteristics and seroma clarity were examined using Pearson correlation statistics. RESULTS: 3D US and CT coregistration was accurate to within 2 mm or less in 19/20 (95%) cases. CT seroma clarity was reduced with dense breast parenchyma (p = 0.035), small seroma volume (p < 0.001), and small volume of excised breast tissue (p = 0.01). US seroma clarity was not affected by these factors (p = NS). US was associated with improved interobserver consistency compared with CT in 8/20 (40%) cases. Of these 8 cases, 7 had low CT seroma clarity scores and 4 had heterogeneously to extremely dense breast parenchyma. CONCLUSION: 3D US can be a useful adjunct to CT in planning PBRT. Radiation oncologists were able to use US images to contour the seroma target, with improved interobserver consistency compared with CT in cases with dense breast parenchyma and poor CT seroma clarity.

Daily quality assurance phantom for ultrasound image guided radiation therapy.

A simple phantom was designed, constructed, tested, and clinically implemented for daily quality assurance (QA) of an ultrasound-image-guided radiation therapy (US-IGRT) system, the Restitu Ultrasound system (Resonant Medical, Montreal, QC). The phantom consists of a high signal echogenic background gel surrounding a low signal hypoechoic egg-shaped target. Daily QA checks involve ultrasound imaging of the phantom and segmenting of the embedded target using the automated tools available on the US-IGRT system. This process serves to confirm system hardware and software functions and, in particular, accurate determination of the target position. Experiments were conducted to test the stability of the phantom at room temperature, its tissue-mimicking properties, the reproducibility of target position measurements, and the usefulness of the phantom as a daily QA device. The phantom proved stable at room temperature, exhibited no evidence of bacterial or fungal invasion in 9 months, and showed limited desiccation (resulting in a monthly reduction in ultrasound-measured volume of approximately 0.2 cm3). Furthermore, the phantom was shown to be nearly tissue-mimicking, with speed of sound in the phantom estimated to be 0.8% higher than that assumed by the scanner calibration. The phantom performs well in a clinical setting, owing to its light weight and ease of operation. It provides reproducible measures of target position even with multiple users. At our center, the phantom is being used for daily QA of the US-IGRT system with clinically acceptable tolerances of +/-1 cm3 on target volume and +/-2 mm on target position. For routine daily QA, this phantom is a good alternative to the manufacturer-supplied calibration phantom, and we recommended that that larger phantom be reserved for less frequent, more detailed QA checks and system calibration.

Comparison of three image segmentation techniques for target volume delineation in positron emission tomography.

Incorporation of positron emission tomography (PET) data into radiotherapy planning is currently under investigation for numerous sites including lung, brain, head and neck, breast, and prostate. Accurate tumor-volume quantification is essential to the proper utilization of the unique information provided by PET. Unfortunately,target delineation within PET currently remains a largely unaddressed problem. We therefore examined the ability of three segmentation methods-thresholding, Sobel edge detection, and the watershed approach-to yield accurate delineation of PET target cross-sections. A phantom study employing well-defined cylindrical and spherical volumes and activity distributions provided an opportunity to assess the relative efficacy with which the three approaches could yield accurate target delineation in PET. Results revealed that threshold segmentation can accurately delineate target cross-sections, but that the Sobel and watershed techniques both consistently fail to correctly identify the size of experimental volumes. The usefulness of threshold-based segmentation is limited, however, by the dependence of the correct threshold (that which returns the correct area at each image slice) on target size.

Iterative threshold segmentation for PET target volume delineation.

The purpose of this work is to create a rigorous method of segmenting PET images using an automated iterative technique. To this end a phantom study employing spherical targets was used to determine local (slice specific) threshold levels which produce correct cross-sections based on the contrast between target and background. Numerous target to background activity concentration ratios were investigated but found to have minimal effect in comparison to the influence of target size. Functions were fit to this data and used to construct an iterative threshold segmentation algorithm. In all cases this approach yielded convergence within ten iterations. Iterative threshold segmentation was applied using both an axial and tri-axial approach to the spherical targets and also to two irregularly shaped volumes. Of these two approaches, the tri-axial method proved less susceptible to image noise and better at dealing with partial volume effects at the interface between target and background. For comparative purposes, single thresholds of 28% and 40% were also applied to the spherical data sets. The tri-axial iterative method was found capable of delineating cross sections with areas greater than 250 mm2 to within the maximum resolution possible (1 pixel width). Cross sections of less than 250 mm2 in area were resolved by the tri-axial method to within 2 pixel widths of their true physical extent. Local contrast based iterative threshold segmentation shows promise as a method of rigorously delineating PET target volumes with good accuracy subject to the limitations imposed by the image resolution which currently characterizes this modality.

A local contrast based approach to threshold segmentation for PET target volume delineation.

Current radiation therapy techniques, such as intensity modulated radiation therapy and three-dimensional conformal radiotherapy rely on the precise delivery of high doses of radiation to well-defined volumes. CT, the imaging modality that is most commonly used to determine treatment volumes cannot, however, easily distinguish between cancerous and normal tissue. The ability of positron emission tomography (PET) to more readily differentiate between malignant and healthy tissues has generated great interest in using PET images to delineate target volumes for radiation treatment planning. At present the accurate geometric delineation of tumor volumes is a subject open to considerable interpretation. The possibility of using a local contrast based approach to threshold segmentation to accurately delineate PET target cross sections is investigated using well-defined cylindrical and spherical volumes. Contrast levels which yield correct volumetric quantification are found to be a function of the activity concentration ratio between target and background, target size, and slice location. Possibilities for clinical implementation are explored along with the limits posed by this form of segmentation.

Virtual micro MLC commissioning.

The resolution of multileaf collimators (MLCs) is limited by their finite leaf width. A commercial package (HD-270) uses 3D couch translation and leaf adjustments to emulate smaller leaf widths. In this paper, we report on the commissioning of this feature using software testing, dial gauge measurements, and film dosimetry. We also identify a variety of limitations: software bugs and truncation artifacts, MLC leaf positioning uncertainties (random variations, systematic gantry dependence and backlash), and uncertainties in couch positioning. These reduce the capabilities of this implementation below that achievable theoretically.