Incidence and imaging characteristics of difficult to detect retrospectively identified brain metastases in patients receiving repeat courses of stereotactic radiosurgery.

PURPOSE: During stereotactic radiosurgery (SRS) planning for brain metastases (BM), brain MRIs are reviewed to select appropriate targets based on radiographic characteristics. Some BM are difficult to detect and/or definitively identify and may go untreated initially, only to become apparent on future imaging. We hypothesized that in patients receiving multiple courses of SRS, reviewing the initial planning MRI would reveal early evidence of lesions that developed into metastases requiring SRS. METHODS: Patients undergoing two or more courses of SRS to BM within 6 months between 2016 and 2018 were included in this single-institution, retrospective study. Brain MRIs from the initial course were reviewed for lesions at the same location as subsequently treated metastases; if present, this lesion was classified as a "retrospectively identified metastasis" or RIM. RIMs were subcategorized as meeting or not meeting diagnostic imaging criteria for BM (+ DC or -DC, respectively). RESULTS: Among 683 patients undergoing 923 SRS courses, 98 patients met inclusion criteria. There were 115 repeat courses of SRS, with 345 treated metastases in the subsequent course, 128 of which were associated with RIMs found in a prior MRI. 58% of RIMs were + DC. 17 (15%) of subsequent courses consisted solely of metastases associated with + DC RIMs. CONCLUSION: Radiographic evidence of brain metastases requiring future treatment was occasionally present on brain MRIs from prior SRS treatments. Most RIMs were + DC, and some subsequent SRS courses treated only + DC RIMs. These findings suggest enhanced BM detection might enable earlier treatment and reduce the need for additional SRS.

Local Tumor Control and Patient Outcome Using Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma: iRECIST as a Potential Substitute for Traditional Criteria.

OBJECTIVE. The purpose of this study was to investigate whether, compared with traditional criteria, the modified Response Evaluation Criteria in Solid Tumors version 1.1 for immune-based therapeutics (iRECIST) improves prediction of local tumor control and survival in patients with hepatocellular carcinoma (HCC) treated with stereotactic body radiotherapy (SBRT). MATERIALS AND METHODS. Fifty-one HCC lesions (mean size, 3.1 cm) treated with SBRT in 41 patients (mean age, 67 years) were retrospectively included. Each patient underwent CT or MRI before SBRT and at least once after SBRT. Best overall response was categorized using Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST 1.1), iRECIST, World Health Organization (WHO) criteria, modified Response Evaluation Criteria in Solid Tumors (mRECIST), and European Association for the Study of the Liver (EASL) criteria. Lesions were then classified as local tumor control (i.e., stable disease, partial response, or complete response) or local treatment failure (i.e., progressive disease) by each tumor response criteria. Proportions of local tumor control were compared using the McNemar exact test. The 1-year overall survival was estimated using the Kaplan-Meier method. RESULTS. The median follow-up after SBRT was 21.0 months. The local tumor control rate was 94.1% (48/51) by iRECIST, 88.2% (45/51) by RECIST 1.1, 72.5% (37/51) by WHO criteria, 80.4% (41/51) by mRECIST, and 72.5% (37/51) by EASL criteria. The local tumor control rate was significantly higher according to iRECIST compared with WHO (p = 0.0010) and EASL (p = 0.0225) criteria. The 1-year survival rate for patients with local tumor control according to iRECIST (86.4%) was higher (although not statistically significant) compared with the 1-year survival rate for patients with local tumor control according to the other response criteria. CONCLUSION. iRECIST may provide more robust interpretation of HCC response after SBRT, yielding improved prediction of local tumor control and 1-year survival rates compared with traditional criteria.

The role of external beam radiotherapy in the treatment of hepatocellular cancer.

Hepatocellular carcinoma (HCC) is increasing in incidence and mortality. Although the prognosis remains poor, long-term survival has improved from 3% in 1970 to an 18% 5-year survival rate today. This is likely because of the introduction of well tolerated, oral antiviral therapies for hepatitis C. Curative options for patients with HCC are often limited by underlying liver dysfunction/cirrhosis and medical comorbidities. Less than one-third of patients are candidates for surgery, which is the current gold standard for cure. Nonsurgical treatments include embolotherapies, percutaneous ablation, and ablative radiation. Technological advances in radiation delivery in the past several decades now allow for safe and effective ablative doses to the liver. Conformal techniques allow for both dose escalation to target volumes and normal tissue sparing. Multiple retrospective and prospective studies have demonstrated that hypofractionated image-guided radiation therapy, used as monotherapy or in combination with other liver-directed therapies, can provide excellent local control that is cost effective. Therefore, as the HCC treatment paradigm continues to evolve, ablative radiation treatment has moved from a palliative treatment to both a "bridge to transplant" and a definitive treatment.

A multi-institutional meningioma MRI dataset for automated multi-sequence image segmentation.

Meningiomas are the most common primary intracranial tumors and can be associated with significant morbidity and mortality. Radiologists, neurosurgeons, neuro-oncologists, and radiation oncologists rely on brain MRI for diagnosis, treatment planning, and longitudinal treatment monitoring. However, automated, objective, and quantitative tools for non-invasive assessment of meningiomas on multi-sequence MR images are not available. Here we present the BraTS Pre-operative Meningioma Dataset, as the largest multi-institutional expert annotated multilabel meningioma multi-sequence MR image dataset to date. This dataset includes 1,141 multi-sequence MR images from six sites, each with four structural MRI sequences (T2-, T2/FLAIR-, pre-contrast T1-, and post-contrast T1-weighted) accompanied by expert manually refined segmentations of three distinct meningioma sub-compartments: enhancing tumor, non-enhancing tumor, and surrounding non-enhancing T2/FLAIR hyperintensity. Basic demographic data are provided including age at time of initial imaging, sex, and CNS WHO grade. The goal of releasing this dataset is to facilitate the development of automated computational methods for meningioma segmentation and expedite their incorporation into clinical practice, ultimately targeting improvement in the care of meningioma patients.

A Deep Learning-Based Computer Aided Detection (CAD) System for Difficult-to-Detect Brain Metastases.

PURPOSE: We sought to develop a computer-aided detection (CAD) system that optimally augments human performance, excelling especially at identifying small inconspicuous brain metastases (BMs), by training a convolutional neural network on a unique magnetic resonance imaging (MRI) data set containing subtle BMs that were not detected prospectively during routine clinical care. METHODS AND MATERIALS: Patients receiving stereotactic radiosurgery (SRS) for BMs at our institution from 2016 to 2018 without prior brain-directed therapy or small cell histology were eligible. For patients who underwent 2 consecutive courses of SRS, treatment planning MRIs from their initial course were reviewed for radiographic evidence of an emerging metastasis at the same location as metastases treated in their second SRS course. If present, these previously unidentified lesions were contoured and categorized as retrospectively identified metastases (RIMs). RIMs were further subcategorized according to whether they did (+DC) or did not (-DC) meet diagnostic imaging-based criteria to definitively classify them as metastases based upon their appearance in the initial MRI alone. Prospectively identified metastases (PIMs) from these patients, and from patients who only underwent a single course of SRS, were also included. An open-source convolutional neural network architecture was adapted and trained to detect both RIMs and PIMs on thin-slice, contrast-enhanced, spoiled gradient echo MRIs. Patients were randomized into 5 groups: 4 for training/cross-validation and 1 for testing. RESULTS: One hundred thirty-five patients with 563 metastases, including 72 RIMS, met criteria. For the test group, CAD sensitivity was 94% for PIMs, 80% for +DC RIMs, and 79% for PIMs and +DC RIMs with diameter <3 mm, with a median of 2 false positives per patient and a Dice coefficient of 0.79. CONCLUSIONS: Our CAD model, trained on a novel data set and using a single common MR sequence, demonstrated high sensitivity and specificity overall, outperforming published CAD results for small metastases and RIMs - the lesion types most in need of human performance augmentation.

The ASNR-MICCAI Brain Tumor Segmentation (BraTS) Challenge 2023: Intracranial Meningioma.

Meningiomas are the most common primary intracranial tumor in adults and can be associated with significant morbidity and mortality. Radiologists, neurosurgeons, neuro-oncologists, and radiation oncologists rely on multiparametric MRI (mpMRI) for diagnosis, treatment planning, and longitudinal treatment monitoring; yet automated, objective, and quantitative tools for non-invasive assessment of meningiomas on mpMRI are lacking. The BraTS meningioma 2023 challenge will provide a community standard and benchmark for state-of-the-art automated intracranial meningioma segmentation models based on the largest expert annotated multilabel meningioma mpMRI dataset to date. Challenge competitors will develop automated segmentation models to predict three distinct meningioma sub-regions on MRI including enhancing tumor, non-enhancing tumor core, and surrounding nonenhancing T2/FLAIR hyperintensity. Models will be evaluated on separate validation and held-out test datasets using standardized metrics utilized across the BraTS 2023 series of challenges including the Dice similarity coefficient and Hausdorff distance. The models developed during the course of this challenge will aid in incorporation of automated meningioma MRI segmentation into clinical practice, which will ultimately improve care of patients with meningioma.

Effect of Large Prostate Volume on Efficacy and Toxicity of Moderately Hypofractionated Radiation Therapy in Patients With Prostate Cancer.

Purpose: To evaluate the effect of prostate volume on outcomes after moderately hypofractionated radiation therapy (mHFRT) for prostate cancer. Methods and Materials: Prostate cancer patients treated with mHFRT at a Veteran's Affairs Medical Center from August 20, 2008, to January 31, 2018, were identified. Patients were placed into a large prostate planning target volume (LPTV) cohort if their prostate PTV was in the highest quartile. Acute/late genitourinary (GU) and gastrointestinal toxicity events among patients with and without LPTV were compared. Multivariable analyses estimated the effect of factors on toxicity. Overall survival, biochemical recurrence-free survival, and freedom from late GU/gastrointestinal toxicity of patients with and without LPTV were estimated via Kaplan-Meier. Results: Four hundred and seventy-two patients were included. Ninety-three percent received 70 Gy in 2.5 Gy fractions; 75% received androgen deprivation therapy. Median follow-up was 69 months. Patients with LPTV (PTV >138.4 cm3) had a higher late 2 + GU toxicity compared with those without (59% vs 48%, P = .03). Earlier time to late 2 + GU toxicity was associated with LPTV (hazard ratio 1.36; 95% confidence interval [CI], 1.00-1.86; P = .047), androgen deprivation therapy use (hazard ratio 1.60; 95% CI, 1.13-2.27; P = .01), and higher baseline American Urologic Association symptom score (odds ratio 1.03; 95% CI, 1.02-1.05; P < .001). At 2 years, freedom from late 2 + GU toxicity was 46% (95% CI, 47%-54%) for those with LPTV versus 61% (95% CI, 55%-65%) for those without (P = .04). Late grade 3 GU toxicity was 7% for those with LPTV and 4% for those without. No differences in overall survival or biochemical recurrence-free survival were observed between patients with or without LPTV. Conclusions: LPTV did not affect efficacy of mHFRT for prostate cancer; however, it was associated with increased risk and earlier onset of late grade 2 + GU toxicity.

Impact of Race on Outcomes of High-Risk Patients With Prostate Cancer Treated With Moderately Hypofractionated Radiotherapy in an Equal Access Setting.

Background: Moderately hypofractionated radiotherapy (MHRT) is an accepted treatment for localized prostate cancer; however, limited MHRT data address high-risk prostate cancer (HRPC) and/or African American patients. We report clinical outcomes and toxicity profiles for individuals with HRPC treated in an equal access system. Methods: We identified patients with HRPC treated with MHRT at a US Department of Veterans Affairs referral center. Exclusion criteria included < 12 months follow-up and elective nodal irradiation. MHRT included 70 Gy over 28 fractions or 60 Gy over 20 fractions. Acute and late gastrointestinal (GI) and genitourinary (GU) toxicities were graded using Common Terminology Criteria for Adverse Events, version 5.0. Clinical endpoints, including biochemical recurrence-free survival (BRFS), distant metastases-free survival (DMFS), overall survival (OS), and prostate cancer-specific survival (PCSS) were estimated using Kaplan-Meier methods. Clinical outcomes, acute toxicity, and late toxicity-free survival were compared between African American and White patients with logistic regression and log-rank testing. Results: Between November 2008 and August 2018, 143 patients with HRPC were treated with MHRT and followed for a median of 38.5 months; 82 (57%) were African American and 61 were White patients. Concurrent androgen deprivation therapy (ADT) was provided for 138 (97%) patients for a median duration of 24 months. No significant differences between African American and White patients were observed for 5-year OS (73% [95% CI, 58%-83%] vs 77% [95% CI, 60%-97%]; P = .55), PCSS (90% [95% CI, 79%-95%] vs 87% [95 % CI, 70%-95%]; P = .57), DMFS (91% [95% CI, 80%-96%] vs 81% [95% CI, 62%-91%]; P = .55), or BRFS (83% [95% CI, 70%-91%] vs 71% [95% CI, 53%-82%]; P = .57), respectively. Rates of acute grade 3+ GU and GI were low overall (4% and 1%, respectively). Late toxicities were similarly favorable with no significant differences by race. Conclusions: Individuals with HRPC treated with MHRT in an equal access setting demonstrated favorable clinical outcomes that did not differ by race, alongside acceptable rates of acute and late toxicities.

A Pooled Toxicity Analysis of Moderately Hypofractionated Proton Beam Therapy and Intensity Modulated Radiation Therapy in Early-Stage Prostate Cancer Patients.

PURPOSE: Data comparing moderately hypofractionated intensity modulated radiation therapy (IMRT) and proton beam therapy (PBT) are lacking. We aim to compare late toxicity profiles of patients with early-stage prostate cancer treated with moderately hypofractionated PBT and IMRT. METHODS AND MATERIALS: This multi-institutional analysis included patients with low- or intermediate-risk biopsy-proven prostate adenocarcinoma from 7 tertiary referral centers treated from 1998 to 2018. All patients were treated with moderately hypofractionated radiation, defined as 250 to 300 cGy per daily fraction given for 4 to 6 weeks, and stratified by use of IMRT or PBT. Primary outcomes were late genitourinary (GU) and gastrointestinal (GI) toxicity. Adjusted toxicity rates were calculated using inverse probability of treatment weighting, accounting for race, National Comprehensive Cancer Network risk group, age, pretreatment International Prostate Symptom Score (GU only), and anticoagulant use (GI only). RESULTS: A total of 1850 patients were included: 1282 IMRT (median follow-up 80.0 months) and 568 PBT (median follow-up 43.9 months). Overall toxicity rates were low, with the majority of patients experiencing no late GU (56.6%, n = 1048) or late GI (74.4%, n = 1377) toxicity. No difference was seen in the rates of late toxicity between the groups, with late grade 3+ GU toxicity of 2.0% versus 3.9% (odds ratio [OR] 0.47; 95% confidence interval 0.17-1.28) and late grade 2+ GI toxicity of 14.6% versus 4.7% (OR 2.69; confidence interval 0.80-9.05) for the PBT and IMRT cohorts, respectively. On multivariable analysis, no factors were significantly predictive of GU toxicity, and only anticoagulant use was significantly predictive of GI toxicity (OR 1.90; P = .008). CONCLUSIONS: In this large, multi-institutional analysis of 1850 patients with early-stage prostate cancer, treatment with moderately hypofractionated IMRT and PBT resulted in low rates of toxicity. No difference was seen in late GI and GU toxicity between the modalities during long-term follow-up. Both treatments are safe and well tolerated.

Stochastic noise characteristics in matrix inversion tomosynthesis (MITS).

Matrix inversion tomosynthesis (MITS) uses known imaging geometry and linear systems theory to deterministically separate in-plane detail from residual tomographic blur in a set of conventional tomosynthesis ("shift-and-add") planes. A previous investigation explored the effect of scan angle (ANG), number of projections (N), and number of reconstructed planes (NP) on the MITS impulse response and modulation transfer function characteristics, and concluded that ANG = 20 degrees, N = 71, and NP = 69 is the optimal MITS imaging technique for chest imaging on our prototype tomosynthesis system. This article examines the effect of ANG, N, and NP on the MITS exposure-normalized noise power spectra (ENNPS) and seeks to confirm that the imaging parameters selected previously by an analysis of the MITS impulse response also yield reasonable stochastic properties in MITS reconstructed planes. ENNPS curves were generated for experimentally acquired mean-subtracted projection images, conventional tomosynthesis planes, and MITS planes with varying combinations of the parameters ANG, N, and NP. Image data were collected using a prototype tomosynthesis system, with 11.4 cm acrylic placed near the image receptor to produce lung-equivalent beam hardening and scattered radiation. Ten identically acquired tomosynthesis data sets (realizations) were collected for each selected technique and used to generate ensemble mean images that were subtracted from individual image realizations prior to noise power spectra (NPS) estimation. NPS curves were normalized to account for differences in entrance exposure (as measured with an ion chamber), yielding estimates of the ENNPS for each technique. Results suggest that mid- and high-frequency noise in MITS planes is fairly equivalent in magnitude to noise in conventional tomosynthesis planes, but low-frequency noise is amplified in the most anterior and posterior reconstruction planes. Selecting the largest available number of projections (N = 71) does not incur any appreciable additive electronic noise penalty compared to using fewer projections for roughly equivalent cumulative exposure. Stochastic noise is minimized by maximizing N and NP but increases with increasing ANG. The noise trend results for NP and ANG are contrary to what would be predicted by simply considering the MITS matrix conditioning and likely result from the interplay between noise correlation and the polarity of the MITS filters. From this study, the authors conclude that the previously determined optimal MITS imaging strategy based on impulse response considerations produces somewhat suboptimal stochastic noise characteristics, but is probably still the best technique for MITS imaging of the chest.

Radiation Therapy for Pancreatic Cancer: Executive Summary of an ASTRO Clinical Practice Guideline.

PURPOSE: This guideline systematically reviews the evidence for treatment of pancreatic cancer with radiation in the adjuvant, neoadjuvant, definitive, and palliative settings and provides recommendations on indications and technical considerations. METHODS AND MATERIALS: The American Society for Radiation Oncology convened a task force to address 7 key questions focused on radiation therapy, including dose fractionation and treatment volumes, simulation and treatment planning, and prevention of radiation-associated toxicities. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS: The guideline conditionally recommends conventionally fractionated or stereotactic body radiation for neoadjuvant and definitive therapy in certain patients and conventionally fractionated regimens for adjuvant therapy. The task force suggests a range of appropriate dose-fractionation schemes and provides recommendations on target volumes and sequencing of radiation and chemotherapy. Motion management, daily image guidance, use of contrast, and treatment with modulated techniques are all recommended. The task force supported prophylactic antiemetic medication, and patients may also benefit from medications to reduce acid secretion. CONCLUSIONS: The role of radiation in the management of pancreatic cancer is evolving, with many ongoing areas of active investigation. Radiation therapy is likely to become even more important as new systemic therapies are developed and there is increased focus on controlling local disease. It is important that the nuances of available data are discussed with patients and families and that care be coordinated in a multidisciplinary fashion.

On-board four-dimensional digital tomosynthesis: first experimental results.

The purpose of this study is to propose four-dimensional digital tomosynthesis (4D-DTS) for on-board analysis of motion information in three dimensions. Images of a dynamic motion phantom were reconstructed using acquisition scan angles ranging from 20 degrees (DTS) to full 360 degrees cone-beam computed tomography (CBCT). Projection images were acquired using an on-board imager mounted on a clinical linear accelerator. Three-dimensional (3D) images of the moving target were reconstructed for various scan angles. 3D respiratory correlated phase images were also reconstructed. For phase-based image reconstructions, the trajectory of a radiopaque marker was tracked in projection space and used to retrospectively assign respiratory phases to projections. The projections were then sorted according phase and used to reconstruct motion correlated images. By using two sets of projections centered about anterior-posterior and lateral axes, this study demonstrates how phase resolved coronal and sagittal DTS images can be used to obtain 3D motion information. Motion artifacts in 4D-DTS phase images are compared with those present in four-dimensional CT (4DCT) images. Due to the nature of data acquisition for the two modalities, superior-inferior motion artifacts are suppressed to a greater extent in 4D-DTS images compared with 4DCT. Theoretical derivations and experimental results are presented to demonstrate how optimal selection of image acquisition parameters including the frequency of projection acquisition and the phase window depend on the respiratory period. Two methods for acquiring projections are discussed. Preliminary results indicate that 4D-DTS can be used to acquire valuable kinetic information of internal anatomy just prior to radiation treatment.

Fast reconstruction of digital tomosynthesis using on-board images.

Digital tomosynthesis (DTS) is a method to reconstruct pseudo three-dimensional (3D) volume images from two-dimensional x-ray projections acquired over limited scan angles. Compared with cone-beam computed tomography, which is frequently used for 3D image guided radiation therapy, DTS requires less imaging time and dose. Successful implementation of DTS for fast target localization requires the reconstruction process to be accomplished within tight clinical time constraints (usually within 2 min). To achieve this goal, substantial improvement of reconstruction efficiency is necessary. In this study, a reconstruction process based upon the algorithm proposed by Feldkamp, Davis, and Kress was implemented on graphics hardware for the purpose of acceleration. The performance of the novel reconstruction implementation was tested for phantom and real patient cases. The efficiency of DTS reconstruction was improved by a factor of 13 on average, without compromising image quality. With acceleration of the reconstruction algorithm, the whole DTS generation process including data preprocessing, reconstruction, and DICOM conversion is accomplished within 1.5 min, which ultimately meets clinical requirement for on-line target localization.

Automatic registration between reference and on-board digital tomosynthesis images for positioning verification.

The authors developed a hybrid multiresolution rigid-body registration technique to automatically register reference digital tomosynthesis (DTS) images with on-board DTS images to guide patient positioning in radiation therapy. This hybrid registration technique uses a faster but less accurate static method to achieve an initial registration, followed by a slower but more accurate adaptive method to fine tune the registration. A multiresolution scheme is employed in the registration to further improve the registration accuracy, robustness, and efficiency. Normalized mutual information is selected as the criterion for the similarity measure and the downhill simplex method is used as the search engine. This technique was tested using image data both from an anthropomorphic chest phantom and from eight head-and-neck cancer patients. The effects of the scan angle and the region-of-interest (ROI) size on the registration accuracy and robustness were investigated. The necessity of using the adaptive registration method in the hybrid technique was validated by comparing the results of the static method and the hybrid method. With a 44 degrees scan angle and a large ROI covering the entire DTS volume, the average of the registration capture ranges in single-axis simulations was between -31 and +34 deg for rotations and between -89 and +78 mm for translations in the phantom study, and between -38 and +38 deg for rotations and between -58 and +65 mm for translations in the patient study. Decreasing the DTS scan angle from 44 degrees to 22 degrees mainly degraded the registration accuracy and robustness for the out-of-plane rotations. Decreasing the ROI size from the entire DTS volume to the volume surrounding the spinal cord reduced the capture ranges to between -23 and +18 deg for rotations and between -33 and +43 mm for translations in the phantom study, and between -18 and +25 deg for rotations and between -35 and +39 mm for translations in the patient study. Results also showed that the hybrid registration technique had much larger capture ranges than the static method alone in registering the out-of-plane rotations.

A novel digital tomosynthesis (DTS) reconstruction method using a deformation field map.

We developed a novel digital tomosynthesis (DTS) reconstruction method using a deformation field map to optimally estimate volumetric information in DTS images. The deformation field map is solved by using prior information, a deformation model, and new projection data. Patients' previous cone-beam CT (CBCT) or planning CT data are used as the prior information, and the new patient volume to be reconstructed is considered as a deformation of the prior patient volume. The deformation field is solved by minimizing bending energy and maintaining new projection data fidelity using a nonlinear conjugate gradient method. The new patient DTS volume is then obtained by deforming the prior patient CBCT or CT volume according to the solution to the deformation field. This method is novel because it is the first method to combine deformable registration with limited angle image reconstruction. The method was tested in 2D cases using simulated projections of a Shepp-Logan phantom, liver, and head-and-neck patient data. The accuracy of the reconstruction was evaluated by comparing both organ volume and pixel value differences between DTS and CBCT images. In the Shepp-Logan phantom study, the reconstructed pixel signal-to-noise ratio (PSNR) for the 60 degrees DTS image reached 34.3 dB. In the liver patient study, the relative error of the liver volume reconstructed using 60 degrees projections was 3.4%. The reconstructed PSNR for the 60 degrees DTS image reached 23.5 dB. In the head-and-neck patient study, the new method using 60 degrees projections was able to reconstruct the 8.1 degrees rotation of the bony structure with 0.0 degrees error. The reconstructed PSNR for the 60 degrees DTS image reached 24.2 dB. In summary, the new reconstruction method can optimally estimate the volumetric information in DTS images using 60 degrees projections. Preliminary validation of the algorithm showed that it is both technically and clinically feasible for image guidance in radiation therapy.

Digital tomosynthesis of the chest for lung nodule detection: interim sensitivity results from an ongoing NIH-sponsored trial.

The authors report interim clinical results from an ongoing NIH-sponsored trial to evaluate digital chest tomosynthesis for improving detectability of small lung nodules. Twenty-one patients undergoing computed tomography (CT) to follow up lung nodules were consented and enrolled to receive an additional digital PA chest radiograph and digital tomosynthesis exam. Tomosynthesis was performed with a commercial CsI/a-Si flat-panel detector and a custom-built tube mover. Seventy-one images were acquired in 11 s, reconstructed with the matrix inversion tomosynthesis algorithm at 5-mm plane spacing, and then averaged (seven planes) to reduce noise and low-contrast artifacts. Total exposure for tomosynthesis imaging was equivalent to that of 11 digital PA radiographs (comparable to a typical screen-film lateral radiograph or two digital lateral radiographs). CT scans (1.25-mm section thickness) were reviewed to confirm presence and location of nodules. Three chest radiologists independently reviewed tomosynthesis images and PA chest radiographs to confirm visualization of nodules identified by CT. Nodules were scored as: definitely visible, uncertain, or not visible. 175 nodules (diameter range 3.5-25.5 mm) were seen by CT and grouped according to size: < 5, 5-10, and > 10 mm. When considering as true positives only nodules that were scored definitely visible, sensitivities for all nodules by tomosynthesis and PA radiography were 70% (+/- 5%) and 22% (+/- 4%), respectively, (p < 0.0001). Digital tomosynthesis showed significantly improved sensitivity of detection of known small lung nodules in all three size groups, when compared to PA chest radiography.

Digital tomosynthesis of the chest.

Digital tomosynthesis is a technique that generates an arbitrary number of section images of a patient from a single pass of the x-ray tube. It is under investigation for application to a number of clinical detection tasks, and has recently been implemented in commercial devices for chest radiography. Tomosynthesis provides improved visibility of structures in the chest, such as pulmonary nodules, airways, and spine. This review article outlines the components of a typical tomosynthesis system, and presents examples of improved pulmonary nodule detection from a clinical trial in human subjects. Possible implementation strategies for use in chest imaging are discussed.

On-board patient positioning for head-and-neck IMRT: comparing digital tomosynthesis to kilovoltage radiography and cone-beam computed tomography.

PURPOSE: High-precision intensity-modulated radiotherapy demands high patient positioning accuracy. On-board digital tomosynthesis (DTS) provides three-dimensional (3D) image guidance for daily positioning with a lower imaging dose, faster acquisition, and more geometric flexibility than 3D cone-beam computed tomography (CBCT). This clinical study evaluated DTS as a daily imaging technique for patient positioning and compared the results with 3D CBCT and two-dimensional (2D) radiography. METHODS AND MATERIALS: Head and neck cancer patients undergoing intensity-modulated radiotherapy were studied. For each session, the patient was positioned using laser marks. On-board imaging data sets, including 2D kilovoltage radiographs, DTS, and CBCT, were obtained to measure the daily patient positioning variations. The mean and standard deviations of the positioning variations in the translational and rotational directions were calculated. The positioning differences among 2D radiography, DTS, and CBCT were analyzed. RESULTS: Image data sets were collected from 65 treatment fractions for 10 patients. The systematic patient positioning variation was <0.10 cm and 1.0 degrees one dimensionally. The random variations were 0.27-0.34 cm in the translational and 0.93 degrees -1.99 degrees in the rotational direction. The mean vector isocenter variation was 0.48 cm. DTS with 40 degrees and 20 degrees scan angles in the coronal or sagittal directions yielded the same results for patient positioning. DTS performance was comparable to that of CBCT, with positioning differences of <0.1 cm and 0.5 degrees . The positioning difference between 2D radiography and DTS was approximately 0.1 cm and 0.2 cm in the vertical/longitudinal and lateral directions. CONCLUSION: Our results have demonstrated that DTS is a comparable 3D imaging technique to CBCT for daily patient positioning of head-and-neck patients as determined by manual registration of bony anatomy.

Accelerating reconstruction of reference digital tomosynthesis using graphics hardware.

The successful implementation of digital tomosynthesis (DTS) for on-board image guided radiation therapy (IGRT) requires fast DTS image reconstruction. Both target and reference DTS image sets are required to support an image registration application for IGRT. Target images are usually DTS image sets reconstructed from on-board projections, which can be accomplished quickly using the conventional filtered backprojection algorithm. Reference images are DTS image sets reconstructed from digitally reconstructed radiographs (DRRs) previously generated from conventional planning CT data. Generating a set of DRRs from planning CT is relatively slow using the conventional ray-casting algorithm. In order to facilitate DTS reconstruction within a clinically acceptable period of time, we implemented a high performance DRR reconstruction algorithm on a graphics processing unit of commercial PC graphics hardware. The performance of this new algorithm was evaluated and compared with that which is achieved using the conventional software-based ray-casting algorithm. DTS images were reconstructed from DRRs previously generated by both hardware and software algorithms. On average, the DRR reconstruction efficiency using the hardware method is improved by a factor of 67 over the software method. The image quality of the DRRs was comparable to those generated using the software-based ray-casting algorithm. Accelerated DRR reconstruction significantly reduces the overall time required to produce a set of reference DTS images from planning CT and makes this technique clinically practical for target localization for radiation therapy.

Evaluation of three types of reference image data for external beam radiotherapy target localization using digital tomosynthesis (DTS).

Digital tomosynthesis (DTS) is a fast, low-dose three-dimensional (3D) imaging approach which yields slice images with excellent in-plane resolution, though low plane-to-plane resolution. A stack of DTS slices can be reconstructed from a single limited-angle scan, with typical scan angles ranging from 10 degrees to 40 degrees and acquisition times of less than 10 s. The resulting DTS slices show soft tissue contrast approaching that of full cone-beam CT. External beam radiotherapy target localization using DTS requires the registration of on-board DTS images with corresponding reference image data. This study evaluates three types of reference volume: original reference CT, exact reference DTS (RDTS), and a more computationally efficient approximate reference DTS (RDTSapprox), as well as three different DTS scan angles (22 degrees, 44 degrees, and 65 degrees) for the DTS target localization task. Three-dimensional mutual information (MI) shared between reference and onboard DTS volumes was computed in a region surrounding the spine of a chest phantom, as translations spanning +/-5 mm and rotations spanning +/-5 degrees were simulated along each dimension in the reference volumes. The locations of the MI maxima were used as surrogates for registration accuracy, and the width of the MI peaks were used to characterize the registration robustness. The results show that conventional treatment planning CT volumes are inadequate reference volumes for direct registration with on-board DTS data. The efficient RDTSapprox method also appears insufficient for MI-based registration without further refinement of the technique, though it may be suitable for manual registration performed by a human observer. The exact RDTS volumes, on the other hand, delivered a 3D DTS localization accuracy of 0.5 mm and 0.50 along each axis, using only a single 44 degrees coronal on-board DTS scan of the chest phantom.