A multi-institution study: comparison of the heating patterns of five different MR-guided deep hyperthermia systems using an anthropomorphic phantom.

INTRODUCTION: Within the hyperthermia community, consensus exists that clinical outcome of the treatment radiotherapy and/or chemotherapy plus hyperthermia (i.e. elevating tumor temperature to 40 - 44 °C) is related to the applied thermal dose; hence, treatment quality is crucial for the success of prospective multi-institution clinical trials. Currently, applicator quality assurance (QA) measurements are implemented independently at each institution using basic cylindrical phantoms. A multi-institution comparison of heating quality using magnetic resonance thermometry (MRT) and anatomical representative anthropomorphic phantoms provides a unique opportunity to obtain novel QA insights to facilitate multi-institution trial evaluation. OBJECTIVE: Perform a systematic QA procedure to compare the performance of MR-compatible hyperthermia systems in five institutions. METHODS AND MATERIALS: Anthropomorphic phantoms, including pelvic and spinal bones, were produced. Clinically relevant power of 600 watts was applied for ∼12 min to allow for 8 sequential MR-scans. The 3D-heating distribution, steering capabilities, and presence of off-target heating were analyzed. RESULTS: The evaluated devices show comparable heating profiles for centric and eccentric targets. The differences observed in the 3D-heating profiles are the result of variations in the exact phantom positioning and applicator characteristics, whereby positioning of the phantom followed current ESHO-QA guidelines. CONCLUSION: Anthropomorphic phantoms were used to perform QA-measurements of MR-guided hyperthermia systems operating in MR-scanners of different brands. Comparable heating profiles are shown for the five evaluated institutions. Subcentimeter differences in position substantially affected the results when evaluating the heating patterns. Integration of advanced phantoms and precise positioning in QA-guidelines should be evaluated to guarantee the best quality patient care.

Simultaneous PET/MR imaging: MR-based attenuation correction of local radiofrequency surface coils.

PURPOSE: In simultaneous positron emission tomography/magnetic resonance (PET/MR) imaging, local receiver surface radiofrequency (RF) coils are positioned in the field-of-view (FOV) of the PET detector during PET/MR data acquisition and potentially attenuate the PET signal. For flexible body RF surface coils placed on top of the patient's body, MR-based attenuation correction (AC) is an unsolved problem since the RF coils are not inherently visible in MR images and their individual position in the FOV is patient specific and not known a priori. The aim of this work was to quantify the effect of local body RF coils used in the Biograph mMR hybrid PET/MR system on PET emission data and to present techniques for MR-based position determination of these specific local RF coils. METHODS: Acquisitions of a homogeneous phantom were performed on a whole-body PET/MRI scanner. Two different PET emission scans were performed, with and without the local body matrix RF coil placed on the top of the phantom. For position determination of the coil, two methods were applied. First, cod liver oil capsules were attached to the surface of the coil and second, an ultrashort echo time (UTE) sequence was used. PET images were reconstructed in five different ways: (1) PET reference scan without the coil, (2) PET scan with the coil, but omitting the coil in AC (PET/MR scanning conditions), (3) AC of the coil using a CT scan of the same phantom setup and registration via capsules, (4) same setup as 3, but registration was done using UTE images, neglecting the capsules, and (5) registration using the capsules, but the CT was performed with the coil placed flat on the CT table and the outer regions of the coil were cropped. The activity concentrations were then compared to the reference scan. For clinical evaluation of the concept, the presented methods were also evaluated on a patient. RESULTS: The oil capsules were visible in the MR and CT images and image registration was straightforward. The UTE images show only parts of the coil's plastic housing and image registration was more difficult. The overall loss of true counts due to the presence of the surface coil is 4.7%. However, a spatially dependent analysis shows larger deviation (10%-15% attenuation) of the activity concentration in the top part of the phantom close to the coil. When accounting for the RF coil for PET AC, attenuation due to the RF coil could mostly be corrected. These results of the phantom studies were confirmed by the patient measurements. CONCLUSIONS: Disregarding local coils in PET AC can lead to a bias of the AC PET images that is regional dependent. The closer the analyzed region is located to the coil, the higher the bias. Cod liver oil capsules or the UTE sequence can be used for RF coil position determination. The middle part of the examined RF coil hosting the preamplifiers and electronic components provides the highest attenuating part. Consequently, emphasis should be put on correcting for this portion of the RF coils with the suggested methods.

Quantitative, Multi-institutional Evaluation of MR Thermometry Accuracy for Deep-Pelvic MR-Hyperthermia Systems Operating in Multi-vendor MR-systems Using a New Anthropomorphic Phantom.

Clinical outcome of hyperthermia depends on the achieved target temperature, therefore target conformal heating is essential. Currently, invasive temperature probe measurements are the gold standard for temperature monitoring, however, they only provide limited sparse data. In contrast, magnetic resonance thermometry (MRT) provides unique capabilities to non-invasively measure the 3D-temperature. This study investigates MRT accuracy for MR-hyperthermia hybrid systems located at five European institutions while heating a centric or eccentric target in anthropomorphic phantoms with pelvic and spine structures. Scatter plots, root mean square error (RMSE) and Bland-Altman analysis were used to quantify accuracy of MRT compared to high resistance thermistor probe measurements. For all institutions, a linear relation between MRT and thermistor probes measurements was found with R2 (mean ± standard deviation) of 0.97 ± 0.03 and 0.97 ± 0.02, respectively for centric and eccentric heating targets. The RMSE was found to be 0.52 ± 0.31 °C and 0.30 ± 0.20 °C, respectively. The Bland-Altman evaluation showed a mean difference of 0.46 ± 0.20 °C and 0.13 ± 0.08 °C, respectively. This first multi-institutional evaluation of MR-hyperthermia hybrid systems indicates comparable device performance and good agreement between MRT and thermistor probes measurements. This forms the basis to standardize treatments in multi-institution studies of MR-guided hyperthermia and to elucidate thermal dose-effect relations.

Regional deep hyperthermia: impact of observer variability in CT-based manual tissue segmentation on simulated temperature distribution.

The aim of this study was to systematically investigate the influence of the inter- and intra-observer segmentation variation of tumors and organs at risk on the simulated temperature coverage of the target. CT scans of six patients with tumors in the pelvic region acquired for radiotherapy treatment planning were used for hyperthermia treatment planning. To study the effect of inter-observer variation, three observers manually segmented in the CT images of each patient the following structures: fat, muscle, bone and the bladder. The gross tumor volumes (GTV) were contoured by three radiation oncology residents and used as the hyperthermia target volumes. For intra-observer variation, one of the observers of each group contoured the structures of each patient three times with a time span of one week between the segmentations. Moreover, the impact of segmentation variations in organs at risk (OARs) between the three inter-observers was investigated on simulated temperature distributions using only one GTV. The spatial overlap between individual segmentations was assessed by the Dice similarity coefficient (DSC) and the mean surface distance (MSD). Additionally, the temperatures T90/T10 delivered to 90%/10% of the GTV, respectively, were assessed for each observer combination. The results of the segmentation similarity evaluation showed that the DSC of the inter-observer variation of fat, muscle, the bladder, bone and the target was 0.68 ± 0.12, 0.88 ± 0.05, 0.73 ± 0.14, 0.91 ± 0.04 and 0.64 ± 0.11, respectively. Similar results were found for the intra-observer variation. The MSD results were similar to the DSCs for both observer variations. A statistically significant difference (p < 0.05) was found for T90 and T10 in the predicted target temperature due to the observer variability. The conclusion is that intra- and inter-observer variations have a significant impact on the temperature coverage of the target. Furthermore, OARs, such as bone and the bladder, may essentially influence the homogeneity of the simulated target temperature distribution.

Influence of patient mispositioning on SAR distribution and simulated temperature in regional deep hyperthermia.

Patient positioning plays an important role in regional deep hyperthermia to obtain a successful hyperthermia treatment. In this study, the influence of possible patient mispositioning was systematically assessed on specific absorption rate (SAR) and temperature distribution. With a finite difference time domain approach, the SAR and temperature distributions were predicted for six patients at 312 positions. Patient displacements and rotations as well as the combination of both were considered inside the Sigma-Eye applicator. Position sensitivity is assessed for hyperthermia treatment planning -guided steering, which relies on model-based optimization of the SAR and temperature distribution. The evaluation of the patient mispositioning was done with and without optimization. The evaluation without optimization was made by creating a treatment plan for the patient reference position in the center of the applicator and applied for all other positions, while the evaluation with optimization was based on creating an individual plan for each position. The parameter T90 was used for the temperature evaluation, which was defined as the temperature that covers 90% of the gross tumor volume (GTV). Furthermore, the hotspot tumor quotient (HTQ) was used as a goal function to assess the quality of the SAR and temperature distribution. The T90 was shown considerably dependent on the position within the applicator. Without optimization, the T90 was clearly decreased below 40 °C by patient shifts and the combination of shifts and rotations. However, the application of optimization for each positon led to an increase of T90 in the GTV. Position inaccuracies of less than 1 cm in the X-and Y-directions and 2 cm in the Z-direction, resulted in an increase of HTQ of less than 5%, which does not significantly affect the SAR and temperature distribution. Current positioning precision is sufficient in the X (right-left)-direction, but position accuracy is required in the Y-and Z-directions.

Impact of Point-Spread Function Modeling on PET Image Quality in Integrated PET/MR Hybrid Imaging.

UNLABELLED: The aim of this study was to systematically assess the quantitative and qualitative impact of including point-spread function (PSF) modeling into the process of iterative PET image reconstruction in integrated PET/MR imaging. METHODS: All measurements were performed on an integrated whole-body PET/MR system. Three substudies were performed: an (18)F-filled Jaszczak phantom was measured, and the impact of including PSF modeling in ordinary Poisson ordered-subset expectation maximization reconstruction on quantitative accuracy and image noise was evaluated for a range of radial phantom positions, iteration numbers, and postreconstruction smoothing settings; 5 representative datasets from a patient population (total n = 20, all oncologic (18)F-FDG PET/MR) were selected, and the impact of PSF on lesion activity concentration and image noise for various iteration numbers and postsmoothing settings was evaluated; and for all 20 patients, the influence of PSF modeling was investigated on visual image quality and number of detected lesions, both assessed by clinical experts. Additionally, the influence on objective metrics such as changes in SUVmean, SUVpeak, SUVmax, and lesion volume was assessed using the manufacturer-recommended reconstruction settings. RESULTS: In the phantom study, PSF modeling significantly improved activity recovery and reduced the image noise at all radial positions. This effect was measurable only at a high number of iterations (>10 iterations, 21 subsets). In the patient study, again, PSF increased the detected activity in the patient's lesions at concurrently reduced image noise. Contrary to the phantom results, the effect was notable already at a lower number of iterations (>1 iteration, 21 subsets). Lastly, for all 20 patients, when PSF and no-PSF reconstructions were compared, an identical number of congruent lesions was found. The overall image quality of the PSF reconstructions was rated better when compared with no-PSF data. The SUVs of the detected lesions with PSF were substantially increased in the range of 6%-75%, 5%-131%, and 5%-148% for SUVmean, SUVpeak, and SUVmax, respectively. A regression analysis showed that the relative increase in SUVmean/peak/max decreases with increasing lesion size, whereas it increases with the distance from the center of the PET field of view. CONCLUSION: In whole-body PET/MR hybrid imaging, PSF-based PET reconstructions can improve activity recovery and image noise, especially at lateral positions of the PET field of view. This has been demonstrated quantitatively in phantom experiments as well as in patient imaging, for which additionally an improvement of image quality could be observed.

Integrated PET/MR imaging: automatic attenuation correction of flexible RF coils.

PURPOSE: Flexible radiofrequency (RF) surface coils used in simultaneous PET/MR imaging are currently disregarded in PET attenuation correction (AC) since their position and individual geometry are unknown in whole-body patient scans. The attenuation of PET emission data due to the presence of RF surface coils has been investigated by several research groups but so far no automatic approach for the incorporation of RF surface coils into PET AC has been described. In this work, an algorithm is presented and evaluated which automatically determines the position of multiple RF surface coils and corrects for their attenuation of the PET emission data. METHODS: The presented algorithm nonrigidly registers pre-acquired CT-based three-dimensional attenuation templates of RF surface coils into attenuation maps used for PET AC. Transformation parameters are obtained by nonrigid B-spline landmark registration of marker positions in the CT-based attenuation templates of the RF surface coils to marker positions in the current MR images of the patient. The use of different marker patterns enables the registration algorithm to distinguish multiple partly overlapping RF surface coils. To evaluate the registration algorithm, two different PET emission scans of a NEMA standard body phantom with six active lesions and of a large rectangular body phantom were performed on an integrated whole-body PET/MR scanner. The phantoms were scanned with and without one (NEMA phantom scan) or three (large body phantom scan) flexible six-channel RF surface coils placed on top. Additionally, the accuracy and performance of the algorithm were evaluated on volunteer scans (n=5) and on a patient scan using a typical clinical setup of three RF surface coils. RESULTS: Overall loss of true counts due to the presence of the RF surface coils was 5.1% for the NEMA phantom, 3.6% for the large body phantom, and 2.1% for the patient scan. Considerable local underestimation of measured activity concentration up to 15.4% in the top part of the phantoms and 15.5% for a lesion near the body surface of the patient was measured close to the high attenuating hardware components of the RF coils. The attenuation maps generated by the registration algorithm reduced the quantification errors due to the RF surface coils to values ranging from -3.9% to 4.3%. Concerning the volunteer examinations, the attenuation templates of the three RF surface coils were registered to their correct positions with an overall accuracy of about 3 mm. CONCLUSIONS: The presence of flexible RF surface coils leads to considerable local errors in the simultaneously measured PET activity concentration up to 15.5% especially in regions close to the coils. The presented automatic algorithm accurately and reliably reduces the PET quantification errors caused by multiple partly overlapping flexible RF surface coils to values of 4.3% or better.

Toward simultaneous PET/MR breast imaging: systematic evaluation and integration of a radiofrequency breast coil.

PURPOSE: With the recent introduction of integrated whole-body hybrid positron emission tomography/magnetic resonance (PET/MR) scanners, simultaneous PET/MR breast imaging appears to be a potentially attractive new clinical application. In this study, the technical groundwork toward performing simultaneous PET/MR breast imaging was developed and systematically evaluated in phantom experiments and breast cancer patient hybrid imaging. METHODS: Measurements were performed on a state-of-the-art whole-body simultaneous PET/MR system (Biograph mMR, Siemens AG, Erlangen, Germany). The PET signal attenuating effects of a MR-only four-channel radiofrequency (RF) breast coil that is present in the PET field-of-view (FoV) during a simultaneous PET/MR data acquisition has been investigated and quantified. For this purpose, a dedicated PET/MR visible breast phantom featuring four modular inserts with various structures (no insert, MR insert, PET insert, and PET/MR insert) was developed. In addition to a systematic evaluation of MR-only image quality, the following phantom scans were performed using (18)F radio tracer: (1) PET emission scan with only the homogeneous breast phantom; (2) PET emission scan additionally with the RF breast coil in the PET FoV. Attenuation correction (AC) of PET data was performed with CT-based three-dimensional (3D) hardware attenuation maps (µ-maps) of the RF coil and breast phantom. Finally, a simultaneous PET/MR breast imaging was performed in two breast cancer patients. RESULTS: The modular breast phantom allowed for systematic evaluation of various MR, PET, and PET/MR image quality parameters. The RF breast coil provided MR images of good image quality, unaffected by PET imaging. The global attenuation of the RF breast coil on the PET emission data was approximately 11%. This hardware attributed PET signal attenuation was successfully corrected by using an appropriate CT-based 3D µ-map of the RF breast coil. Imaging of two breast cancer patients confirmed the successful integration of the RF breast coil into the concept of simultaneous PET/MR breast imaging. CONCLUSIONS: The successful integration of a four-channel RF breast coil with a defined table position together with the CT-based µ-maps provides a technical basis for future clinical PET/MR breast imaging applications.