Dose to the penile bulb and individual patient anatomy are predictive of erectile dysfunction in men treated with 125I low dose rate brachytherapy for localized prostate cancer.

Background: To evaluate the occurrence of erectile dysfunction at 3 years (3yED) after prostate brachytherapy (BT) and to predict 3yED after treatment based on patients and treatments characteristics. Material and methods: From September 2007 to July 2015, 117 men with mild or no ED [International Index of Erectile Function (IIEF-5) > 16] underwent 125Iodine real-time ultrasound-guided low-dose rate BT to a total dose of 160 Gy for low-risk or favorable intermediate-risk prostate adenocarcinoma, and were followed prospectively during 3 years. Median age was 63 years (51-79). The post-implant dosimetric parameters on the postoperative computer tomography were derived from the dose-volume histogram of the prostate and the penile bulb (PB), crura, neurovascular bundles (NVBs) and internal pudendal arteries (IPAs). Potential clinical confounding factors were collected. Additionally, anatomical indexes reflecting the prostate anatomical location within the pelvis were studied. These variables were compared between patients with and without 3yED. 3yED was defined as an IIEF-5 score change to the lower category between baseline, with or without medication. Results: The 3yED rate was 59% (62% maintained an IIEF-5 > 16). On multivariate analysis, prostate D90% (p > .5) and pretreatment characteristics including age (p > .5), pre-implant potency (p > .5), diabetes (p = .08) and high cardiovascular risk rates (p = .1) did not influence the occurrence of 3yED. Only the PB dose especially the D10% > 51 Gy was associated with 3yED (p = .005). Conversely, dose to the crura, IPAs or NVBs did not seem to impact the erectile function. The prostate position, especially the apex location varied significantly between potent and impotent patients and 3yED was significantly associated with close position of the prostate apex to PB (p = .008). Conclusion: The most predictive factor of 3yED was the dose to the PB. This may be explained by variation in individual patients' anatomy and this could allow for the development of better strategies to prevent ED.

Monte-Carlo dosimetry for intraoperative radiotherapy using a low energy x-ray source.

UNLABELLED: Intraoperative radiotherapy (IORT) is continuously gaining ground in cancer treatment. However, there is currently no planning system associated with these devices, which precludes patient-specific dose delivery optimization. The objective of this study was the development and validation of a Monte Carlo simulation (MCS)-based dosimetry platform using the Intrabeam™ system. METHODS: After surgical resection of the tumor this system delivers a single dose fraction at the surface of an applicator irradiating the tumor bed through a 50 kV x-ray beam. The GATE MCS platform was used in this study combining the phase space obtained by modeling the x-ray source and the detailed modeling of the additional parts of the Intrabeam™ system. The model was validated by comparing simulated versus experimental measurements of depth dose curves (DDC) and isotropy. A clinical validation study was also carried out using patient computed tomography images. RESULTS: The mean deviation between measured and simulated DDC was 2.9% ± 4.4% and 5.9% ± 5.7% for the bare needle and the use of applicators, respectively. A good agreement with experimental measurements was also found in terms of dose isotropy with a maximum difference of 2.04% for the 40 mm diameter applicator. A patient study revealed a mean absolute deviation of 0.06 Gy between simulated and thermoluminescent dosimeters (TLD) measured skin doses. CONCLUSION: This study shows the potential of using the GATE MCS platform to model three-dimensional dose distributions of the Intrabeam™ system for use in IORT.

Cross-modal tumor segmentation using generative blending augmentation and self-training.

OBJECTIVES: Data scarcity and domain shifts lead to biased training sets that do not accurately represent deployment conditions. A related practical problem is cross-modal image segmentation, where the objective is to segment unlabelled images using previously labelled datasets from other imaging modalities. METHODS: We propose a cross-modal segmentation method based on conventional image synthesis boosted by a new data augmentation technique called Generative Blending Augmentation (GBA). GBA leverages a SinGAN model to learn representative generative features from a single training image to diversify realistically tumor appearances. This way, we compensate for image synthesis errors, subsequently improving the generalization power of a downstream segmentation model. The proposed augmentation is further combined to an iterative self-training procedure leveraging pseudo labels at each pass. RESULTS: The proposed solution ranked first for vestibular schwannoma (VS) segmentation during the validation and test phases of the MICCAI CrossMoDA 2022 challenge, with best mean Dice similarity and average symmetric surface distance measures. CONCLUSION AND SIGNIFICANCE: Local contrast alteration of tumor appearances and iterative self-training with pseudo labels are likely to lead to performance improvements in a variety of segmentation contexts.

Predicting the Tumour Response to Radiation by Modelling the Five Rs of Radiotherapy Using PET Images.

Despite the intensive use of radiotherapy in clinical practice, its effectiveness depends on several factors. Several studies showed that the tumour response to radiation differs from one patient to another. The non-uniform response of the tumour is mainly caused by multiple interactions between the tumour microenvironment and healthy cells. To understand these interactions, five major biologic concepts called the "5 Rs" have emerged. These concepts include reoxygenation, DNA damage repair, cell cycle redistribution, cellular radiosensitivity and cellular repopulation. In this study, we used a multi-scale model, which included the five Rs of radiotherapy, to predict the effects of radiation on tumour growth. In this model, the oxygen level was varied in both time and space. When radiotherapy was given, the sensitivity of cells depending on their location in the cell cycle was taken in account. This model also considered the repair of cells by giving a different probability of survival after radiation for tumour and normal cells. Here, we developed four fractionation protocol schemes. We used simulated and positron emission tomography (PET) imaging with the hypoxia tracer 18F-flortanidazole (18F-HX4) images as input data of our model. In addition, tumour control probability curves were simulated. The result showed the evolution of tumours and normal cells. The increase in the cell number after radiation was seen in both normal and malignant cells, which proves that repopulation was included in this model. The proposed model predicts the tumour response to radiation and forms the basis for a more patient-specific clinical tool where related biological data will be included.

Impact of age on the Quadrella index assessing oncological and functional results after prostate brachytherapy: A 6-year analysis.

Purpose: As the oncological results of prostate brachytherapy (BT) are excellent for low-risk (LR) or favorable intermediate-risk (FIR) prostate cancer (PCa), evaluating the side effects has become a major issue, especially for young men. The objective of the study was to compare the oncologic and functional results of BT using Quadrella index for patients aged 60 or less compared with older patients. Material and methods: From June, 2007 to June, 2017, 222 patients, including 70 ≤ 60 years old and 152 > 60 years old, underwent BT for LR-FIR PCa, with good erectile function at baseline according to International Index of Erectile Function-5 (IIEF-5) > 16. Quadrella index was achieved under the following circumstances: 1) Absence of biological recurrence (Phoenix criteria); 2) Absence of erectile dysfunction (ED) (IIEF-5 > 16); 3) No urinary toxicity (international prostate score symptom) IPSS < 15 or IPSS > 15, and ΔIPSS < 5; 4) No rectal toxicity (RT) (Radiation Therapy Oncology Group, RTOG = 0). Patients were treated on demand with phosphodiesterase inhibitors (PDE5i) post-operatively. Results: The Quadrella index was satisfied for about 40-80% of patients ≤ 60 years vs. 33-46% for older patients during 6-year follow-up (significant difference from the second year). At year 5, 100% of evaluable patients aged ≤ 60 and 91.8% > 60 (p = 0.29) reached Phoenix criteria. The criterion of ED (IIEF-5 < 16) largely explained the validity rate of Quadrella alone. There was no ED for 67.2-81.4% of patients ≤ 60 years compared with 40.0-56.1% for patients > 60 (significant difference since year 4 in favor of young men). After two years of follow-up, more than 90% of patients in both the groups showed neither urinary nor rectal toxicities. Conclusions: For young men displaying LR-FIR PCa, BT appears to be a first-class therapeutic option, as the oncological results were at least equivalent to those of older patients with good long-term tolerance.

Evaluation of a 3D local multiresolution algorithm for the correction of partial volume effects in positron emission tomography.

PURPOSE: Partial volume effects (PVEs) are consequences of the limited spatial resolution in emission tomography leading to underestimation of uptake in tissues of size similar to the point spread function (PSF) of the scanner as well as activity spillover between adjacent structures. Among PVE correction methodologies, a voxel-wise mutual multiresolution analysis (MMA) was recently introduced. MMA is based on the extraction and transformation of high resolution details from an anatomical image (MR/CT) and their subsequent incorporation into a low-resolution PET image using wavelet decompositions. Although this method allows creating PVE corrected images, it is based on a 2D global correlation model, which may introduce artifacts in regions where no significant correlation exists between anatomical and functional details. METHODS: A new model was designed to overcome these two issues (2D only and global correlation) using a 3D wavelet decomposition process combined with a local analysis. The algorithm was evaluated on synthetic, simulated and patient images, and its performance was compared to the original approach as well as the geometric transfer matrix (GTM) method. RESULTS: Quantitative performance was similar to the 2D global model and GTM in correlated cases. In cases where mismatches between anatomical and functional information were present, the new model outperformed the 2D global approach, avoiding artifacts and significantly improving quality of the corrected images and their quantitative accuracy. CONCLUSIONS: A new 3D local model was proposed for a voxel-wise PVE correction based on the original mutual multiresolution analysis approach. Its evaluation demonstrated an improved and more robust qualitative and quantitative accuracy compared to the original MMA methodology, particularly in the absence of full correlation between anatomical and functional information.

A machine-learning approach based on 409 treatments to predict optimal number of iodine-125 seeds in low-dose-rate prostate brachytherapy.

PURPOSE: Low-dose-rate brachytherapy is a key treatment for low-risk or favorable intermediate-risk prostate cancer. The number of radioactive seeds inserted during the procedure depends on prostate volume, and is not easy to predict without pre-planning. Consequently, a large number of unused seeds may be left after treatment. The objective of the present study was to predict the exact number of seeds for future patients using machine learning and a database of 409 treatments. MATERIAL AND METHODS: Database consisted of 18 dosimetric and efficiency parameters for each of 409 cases. Nine predictive algorithms based on machine-learning were compared in this database, which was divided into training group (80%) and test group (20%). Ten-fold cross-validation was applied to obtain robust statistics. The best algorithm was then used to build an abacus able to predict number of implanted seeds from expected prostate volume only. As an evaluation, the abacus was also applied on an independent series of 38 consecutive patients. RESULTS: The best coefficients of determination R 2 were given by support vector regression, with values attaining 0.928, 0.948, and 0.968 for training set, test set, and whole set, respectively. In terms of predicted seeds in test group, mean square error, median absolute error, mean absolute error, and maximum error were 2.55, 0.92, 1.21, and 7.29, respectively. The use of obtained abacus in 38 additional patients resulted in saving of 493 seeds (393 vs. 886 remaining seeds). CONCLUSIONS: Machine-learning-based abacus proposed in this study aims at estimating the necessary number of seeds for future patients according to past experience. This new abacus, based on 409 treatments and successfully tested in 38 new patients, is a good alternative to non-specific recommendations.

Dosimetric Validation of a GAN-Based Pseudo-CT Generation for MRI-Only Stereotactic Brain Radiotherapy.

PURPOSE: Stereotactic radiotherapy (SRT) has become widely accepted as a treatment of choice for patients with a small number of brain metastases that are of an acceptable size, allowing for better target dose conformity, resulting in high local control rates and better sparing of organs at risk. An MRI-only workflow could reduce the risk of misalignment between magnetic resonance imaging (MRI) brain studies and computed tomography (CT) scanning for SRT planning, while shortening delays in planning. Given the absence of a calibrated electronic density in MRI, we aimed to assess the equivalence of synthetic CTs generated by a generative adversarial network (GAN) for planning in the brain SRT setting. METHODS: All patients with available MRIs and treated with intra-cranial SRT for brain metastases from 2014 to 2018 in our institution were included. After co-registration between the diagnostic MRI and the planning CT, a synthetic CT was generated using a 2D-GAN (2D U-Net). Using the initial treatment plan (Pinnacle v9.10, Philips Healthcare), dosimetric comparison was performed using main dose-volume histogram (DVH) endpoints in respect to ICRU 91 guidelines (Dmax, Dmean, D2%, D50%, D98%) as well as local and global gamma analysis with 1%/1 mm, 2%/1 mm and 2%/2 mm criteria and a 10% threshold to the maximum dose. t-test analysis was used for comparison between the two cohorts (initial and synthetic dose maps). RESULTS: 184 patients were included, with 290 treated brain metastases. The mean number of treated lesions per patient was 1 (range 1-6) and the median planning target volume (PTV) was 6.44 cc (range 0.12-45.41). Local and global gamma passing rates (2%/2 mm) were 99.1 CI95% (98.1-99.4) and 99.7 CI95% (99.6-99.7) respectively (CI: confidence interval). DVHs were comparable, with no significant statistical differences regarding ICRU 91's endpoints. CONCLUSIONS: Our study is the first to compare GAN-generated CT scans from diagnostic brain MRIs with initial CT scans for the planning of brain stereotactic radiotherapy. We found high similarity between the planning CT and the synthetic CT for both the organs at risk and the target volumes. Prospective validation is under investigation at our institution.

Minimal channel GreenLight photovaporization before permanent implant prostate brachytherapy for patients with obstructive symptoms: Technically feasible and safe.

PURPOSE: Brachytherapy (BrT) is a standard treatment for low-risk to favorable-intermediate-risk prostate cancer but is a relative contraindication for patients with obstructive symptoms. We aimed to assess the feasibility and urinary toxicity of a minimal photovaporization (mPVP) before implantation. MATERIALS AND METHODS: Between 04/2009 and 08/2016, 50 patients candidates for BrT but with International Prostate Symptom Score (IPSS)>15, uroflowmetry <15 mL/s, obstructive prostate or large median lobe underwent a mPVP (GreenLight Laser) at least 6 weeks (median 8.5) before permanent seed implantation (loose seeds, 125I, 160 Gy). RESULTS: Two patients (4%) did not have sufficient improvement and did not undergo BrT, although it would have been possible at 3 months. For the 48 (96%) other patients, at the baseline, mean IPSS was 15.5 (±5.3), vs. 8.6 (±4.4) after mPVP (p = 1 × 10-6), and uroflowmetry 11.7 mL/s (±4), vs. 17.4 (±5.4) (p = 1.4 × 10-5). We did not experience any difficulty for BrT. Mean IPSS did not significantly increase 1, 3, or 6 months after BrT. With a median followup of 60 months [30-120], (92% assessed at last followup), only 4 patients (4/48 = 8.3%) experienced urinary retention and 5 (10.4%) needed surgery for urinary toxicity. In addition, only 2 patients (4%) needed medical treatment at last followup. Considering the 8 patients with de novo incontinence at 1 year, only 2 (4%) had persistent mild symptoms at last followup (36 months) (ICS1-2). CONCLUSIONS: These results suggest that a two-step approach with an mPVP at least 6 weeks before BrT is feasible, with no excessive urinary toxicity, and may be a good strategy for obstructive patients seeking BrT.

Toxicity in patients treated with permanent prostate brachytherapy using intraoperatively built custom-linked seeds versus loose seeds.

PURPOSE: Low-dose-rate brachytherapy (BT) with permanent iodine-125 radioactive seeds is a highly effective treatment option for low- and favorable intermediate-risk prostate cancer. However, optimal implantation is not always achieved due to edema or seeds loss. One way to improve seed placement is the use of stranded seeds called "intraoperatively built custom-linked seeds (IBCLS)" in an opposition to loose seeds (LS). To date, there are few data comparing toxicity rates between these two techniques. The aim of this study was to compare dosimetric parameters and toxicity rates at 2 years between both procedures in a matched-paired population. MATERIAL AND METHODS: Patients were considered for BT according to European guidelines. Among 548 patients treated at our institution, 105 patients in the loose seeds cohort were individually matched to 105 patients in the IBCLS group according to age, prostate volume, pre-operative international prostate symptom score (IPSS), clinical stage, and Gleason score. Erectile function was scored using the five-item international index of erectile function (IIEF-5) score. A multivariable linear mixed-effects model was applied to examine the association between total and individual scores (repeated measures) and covariates. RESULTS: Overall, 61 (29%) patients presented with a favorable intermediate-risk prostate cancer. There were no significant changes in IPSS over time (p = 0.57). During follow-up, the IIEF-5 was similar in the two groups, except at one month, where it was lower in the IBCLS group (10.9 vs. 6.9, p = 0.029). Also, there was no difference in grade ≥ 2 rectal toxicity. At 1 month, D90Gy, V150%, and V100% were higher in the LS group compared to the IBCLS group. CONCLUSIONS: Low-dose-rate prostate brachytherapy using IBCLS is a safe technique, with comparable toxicity profiles at 2 years compared to LS brachytherapy.

Functional and structural synergy for resolution recovery and partial volume correction in brain PET.

PURPOSE: Positron Emission Tomography (PET) has the unique capability of measuring brain function but its clinical potential is affected by low resolution and lack of morphological detail. Here we propose and evaluate a wavelet synergistic approach that combines functional and structural information from a number of sources (CT, MRI and anatomical probabilistic atlases) for the accurate quantitative recovery of radioactivity concentration in PET images. When the method is combined with anatomical probabilistic atlases, the outcome is a functional volume corrected for partial volume effects. METHODS: The proposed method is based on the multiresolution property of the wavelet transform. First, the target PET image and the corresponding anatomical image (CT/MRI/atlas-based segmented MRI) are decomposed into several resolution elements. Secondly, high-resolution components of the PET image are replaced, in part, with those of the anatomical image after appropriate scaling. The amount of structural input is weighted by the relative high frequency signal content of the two modalities. The method was validated on a digital Zubal phantom and clinical data to evaluate its quantitative potential. RESULTS: Simulation studies showed the expected relationship between functional recovery and the amount of correct structural detail provided, with perfect recovery achieved when true images were used as anatomical reference. The use of T1-MRI images brought significant improvements in PET image resolution. However improvements were maximized when atlas-based segmented images as anatomical references were used; these results were replicated in clinical data sets. CONCLUSION: The synergistic use of functional and structural data, and the incorporation of anatomical probabilistic information in particular, generates morphologically corrected PET images of exquisite quality.

Prostate Volume Segmentation in TRUS Using Hybrid Edge-Bhattacharyya Active Surfaces.

OBJECTIVE: We present a new hybrid edge and region-based parametric deformable model, or active surface, for prostate volume segmentation in transrectal ultrasound (TRUS) images. METHODS: Our contribution is threefold. First, we develop a new edge detector derived from the radial bas-relief approach, allowing for better scalar prostate edge detection in low contrast configurations. Second, we combine an edge-based force derived from the proposed edge detector with a new region-based force driven by the Bhattacharyya gradient flow and adapted to the case of parametric active surfaces. Finally, we develop a quasi-automatic initialization technique for deformable models by analyzing the profiles of the proposed edge detector response radially to obtain initial landmark points toward which an initial surface model is warped. RESULTS: We validate our method on a set of 36 TRUS images for which manual delineations were performed by two expert radiation oncologists, using a wide variety of quantitative metrics. The proposed hybrid model achieved state-of-the-art segmentation accuracy. CONCLUSION: Results demonstrate the interest of the proposed hybrid framework for accurate prostate volume segmentation. SIGNIFICANCE: This paper presents a modular framework for accurate prostate volume segmentation in TRUS, broadening the range of available strategies to tackle this open problem.

PET image denoising using a synergistic multiresolution analysis of structural (MRI/CT) and functional datasets.

UNLABELLED: PET allows the imaging of functional properties of the living tissue, whereas other modalities (CT, MRI) provide structural information at significantly higher resolution and better image quality. Constraints for injected radioactivity, technologic limitations of current instrumentation, and inherent spatial uncertainties on the decaying process affect the quality of PET images. In this article we illustrate how structural information of matched anatomic images can be used in a multiresolution model to enhance the signal-to-noise ratio of PET images. The model states a flexible relation between function and structure in the brain and replaces high-resolution information of PET images with appropriately scaled MRI or CT local detail. The method can be naturally extended to other functional imaging modalities (SPECT, functional MRI). METHODS: The methodology is based on the multiresolution property of the wavelet transform (WT). First, the coregistered structural image (MRI/CT) is downgraded to the resolution of the PET volume through appropriate filtering. Second, a redundant version of the WT is applied to both volumes. Third, a linear model is applied to the set of local coefficients of both image volumes and resulting parameters are recorded. The overall set of linear coefficients is then modeled as a mixture of multivariate gaussian distributions and fitted through a k-means algorithm. Finally, the local wavelet coefficients of the PET image are substituted by the corresponding values of the MRI/CT set calibrated according to the resulting clustering. The methodology was validated on digital simulated images and clinical data to evaluate its quantitative potential for individual as well as group analysis. RESULTS: Application to real and simulated datasets shows very effective noise reduction (15% SD) while resolution is preserved. CONCLUSION: The methodology is robust to errors in the coregistration parameters, practical to implement, and computationally fast.

Multi-Scale Modeling and Oxygen Impact on Tumor Temporal Evolution: Application on Rectal Cancer During Radiotherapy.

We present a multi-scale approach of tumor modeling in order to predict its evolution during radiotherapy. Within this context we focus on three different scales of tumor modeling: microscopic (individual cells in a voxel), mesoscopic (population of cells in a voxel) and macroscopic (whole tumor), with transition interfaces between these three scales. At the cellular level, the description is based on phase transfer probabilities in the cellular cycle. At the mesoscopic scale we represent populations of cells according to different stages in a cell cycle. Finally, at the macroscopic scale, the tumor description is based on the use of FDG PET image voxels. These three scales exist naturally: biological data are collected at the macroscopic scale, but the pathological behavior of the tumor is based on an abnormal cell-cycle at the microscopic scale. On the other hand, the introduction of a mesoscopic scale is essential in order to reduce the gap between the two extreme, in terms of resolution, description levels. It also reduces the computational burden of simulating a large number of individual cells. As an application of the proposed multi-scale model, we simulate the effect of oxygen on tumor evolution during radiotherapy. Two consecutive FDG PET images of 17 rectal cancer patients undergoing radiotherapy are used to simulate the tumor evolution during treatment. The simulated results are compared with those obtained on a third FDG PET image acquired two weeks after the beginning of the treatment.

Evaluation of the "Quadrella" at 3 years: New index to assess functional and oncological performance specific to prostate brachytherapy.

PURPOSE: "Quadrella" index has been recently developed to assess oncological and functional outcomes after prostate brachytherapy (PB). We aimed to evaluate this index at 1, 2, and 3 years, using validated questionnaires, assessed prospectively. METHODS AND MATERIALS: From 08/2007 to 01/2013, 193 patients underwent 125Iodine PB for low-risk or favorable intermediate-risk prostate adenocarcinoma. Inclusion criteria were as follows: no incontinence (International Continence Society Index initial score = 0) and good erectile function (International Index of Erectile Function-5 items: >16). One hundred patients were included (mean age: 64 y). Postimplantation intake of phosphodiesterase inhibitors was not considered as failure. The "Quadrella" index was defined by the absence of biochemical recurrence (Phoenix criteria), significant erectile dysfunction (ED) (Index of Erectile Function-5 items: >16), urinary toxicity (UT) (International Prostate Score Symptom [IPSS] <15 or IPSS> 15 with ΔIPSS <5), and rectal toxicity (RT) (Radiation Therapy Oncology Group = 0). RESULTS: At 12 months, 90 patients were evaluable: 42/90 (46.7%) achieved Quadrella. The main criteria for failure were as follows: ED in 77.1% (37/48) of cases, RT in 20.8% (10/48) of cases, and UT in 12.5% (9/57) of cases. At 24 and 36 months, 59.3% (48/81) and 61.1% (44/72) of patients achieved Quadrella, respectively. The main cause of failure was ED in 69.7% (23/33) and 85.7% (24/28) of cases, while RT was involved in 21.2% (7/33) and in 3.6% (1/28) of cases, and UT in 9.1% (3/33) and 3.6% (1/28) of cases. Only one case of biochemical recurrence was observed (i.e., 1/28 = 3.6% at 3 y). CONCLUSIONS: The Quadrella can be used at 1, 2, and 3 years after PB. It allows to take into account the urinary and RT specific to PB. ED was the main cause of failure. This index will be useful to assess midterm and long-term results.

Optimization of spatial resolution for peripheral magnetic resonance angiography.

RATIONALE AND OBJECTIVES: To determine optimum spatial resolution when imaging peripheral arteries with magnetic resonance angiography (MRA). MATERIALS AND METHODS: Eight vessel diameters ranging from 1.0 to 8.0 mm were simulated in a vascular phantom. A total of 40 three-dimensional flash MRA sequences were acquired with incremental variations of fields of view, matrix size, and slice thickness. The accurately known eight diameters were combined pairwise to generate 22 "exact" degrees of stenosis ranging from 42% to 87%. Then, the diameters were measured in the MRA images by three independent observers and with quantitative angiography (QA) software and used to compute the degrees of stenosis corresponding to the 22 "exact" ones. The accuracy and reproducibility of vessel diameter measurements and stenosis calculations were assessed for vessel size ranging from 6 to 8 mm (iliac artery), 4 to 5 mm (femoro-popliteal arteries), and 1 to 3 mm (infrapopliteal arteries). Maximum pixel dimension and slice thickness to obtain a mean error in stenosis evaluation of less than 10% were determined by linear regression analysis. RESULTS: Mean errors on stenosis quantification were 8.8% +/- 6.3% for 6- to 8-mm vessels, 15.5% +/- 8.2% for 4- to 5-mm vessels, and 18.9% +/- 7.5% for 1- to 3-mm vessels. Mean errors on stenosis calculation were 12.3% +/- 8.2% for observers and 11.4% +/- 15.1% for QA software (P = .0342). To evaluate stenosis with a mean error of less than 10%, maximum pixel surface, the pixel size in the phase direction, and the slice thickness should be less than 1.56 mm2, 1.34 mm, 1.70 mm, respectively (voxel size 2.65 mm3) for 6- to 8-mm vessels; 1.31 mm2, 1.10 mm, 1.34 mm (voxel size 1.76 mm3), for 4- to 5-mm vessels; and 1.17 mm2, 0.90 mm, 0.9 mm (voxel size 1.05 mm3) for 1- to 3-mm vessels. CONCLUSION: Higher spatial resolution than currently used should be selected for imaging peripheral vessels.

Fully automatic deformable registration of pretreatment MRI/CT for image-guided prostate radiotherapy planning.

PURPOSE: In prostate radiotherapy, dose distribution may be calculated on CT images, while the MRI can be used to enhance soft tissue visualization. Therefore, a registration between MR and CT images could improve the overall treatment planning process, by improving visualization with a demonstrated interobserver delineation variability when segmenting the prostate, which in turn can lead to a more precise planning. This registration must compensate for prostate deformations caused by changes in size and form between the acquisitions of both modalities. METHODS: We present a fully automatic MRI/CT nonrigid registration method for prostate radiotherapy treatment planning. The proposed registration methodology is a two-step registration process involving both a rigid and a nonrigid registration step. The registration is constrained to volumes of interest in order to improve robustness and computational efficiency. The method is based on the maximization of the mutual information in combination with a deformation field parameterized by cubic B-Splines. RESULTS: The proposed method was validated on eight clinical patient datasets. Quantitative evaluation, using Hausdorff distance between prostate volumes in both images, indicated that the overall registration errors is 1.6 ± 0.2 mm, with a maximum error of less than 2.3 mm, for all patient datasets considered in this study. CONCLUSIONS: The proposed approach provides a promising solution for an effective and accurate prostate radiotherapy treatment planning since it satisfies the desired clinical accuracy.

DEMAT: A multi-institutional dosimetry audit of rotational and static intensity-modulated radiotherapy.

PURPOSE: Static beam intensity-modulated-radiation-therapy (IMRT) and/or Volumetric-Modulated-Arc-Therapy (VMAT) are now available in many regional radiotherapy departments. The aim of this multi-institutional audit was to design a new methodology based on radiochromic films to perform an independent quality control. METHODS: A set of data were sent to all participating centres for two clinical localizations: prostate and Head and Neck (H&N) cancers. The agreement between calculations and measurements was verified in the Octavius phantom (PTW) by point measurements using ionization chambers and by 2D measurements using EBT3 radiochromic films. Due to uncertainties in the whole procedure, criteria were set to 5% and 3% in local dose and 3mm in distance excluding doses lower than 10% of the maximum doses. No normalization point or area was used for the quantitative analysis. RESULTS: 13 radiotherapy centres participated in this audit involving 28 plans (12 IMRT, 16 VMAT). For point measurements, mean errors were -0.18±1.54% and 0.00±1.58% for prostate and H&N cases respectively. For 2D measurements with 5%/3mm criteria, gamma map analysis showed a pixel pass rate higher than 95% for prostate and H&N. Mean gamma index was lower than 0.4 for prostate and 0.5 for H&N. Both techniques yielded similar results. CONCLUSION: This study showed the feasibility of an independent quality control by peers for conventional IMRT and VMAT. Results from all participating centres were found to be in good agreement. This regional study demonstrated the feasibility of our new methodology based on radiochromic films without dose normalization on a specific point.

GGEMS-Brachy: GPU GEant4-based Monte Carlo simulation for brachytherapy applications.

In brachytherapy, plans are routinely calculated using the AAPM TG43 formalism which considers the patient as a simple water object. An accurate modeling of the physical processes considering patient heterogeneity using Monte Carlo simulation (MCS) methods is currently too time-consuming and computationally demanding to be routinely used. In this work we implemented and evaluated an accurate and fast MCS on Graphics Processing Units (GPU) for brachytherapy low dose rate (LDR) applications. A previously proposed Geant4 based MCS framework implemented on GPU (GGEMS) was extended to include a hybrid GPU navigator, allowing navigation within voxelized patient specific images and analytically modeled (125)I seeds used in LDR brachytherapy. In addition, dose scoring based on track length estimator including uncertainty calculations was incorporated. The implemented GGEMS-brachy platform was validated using a comparison with Geant4 simulations and reference datasets. Finally, a comparative dosimetry study based on the current clinical standard (TG43) and the proposed platform was performed on twelve prostate cancer patients undergoing LDR brachytherapy. Considering patient 3D CT volumes of 400 × 250 × 65 voxels and an average of 58 implanted seeds, the mean patient dosimetry study run time for a 2% dose uncertainty was 9.35 s (≈500 ms 10(-6) simulated particles) and 2.5 s when using one and four GPUs, respectively. The performance of the proposed GGEMS-brachy platform allows envisaging the use of Monte Carlo simulation based dosimetry studies in brachytherapy compatible with clinical practice. Although the proposed platform was evaluated for prostate cancer, it is equally applicable to other LDR brachytherapy clinical applications. Future extensions will allow its application in high dose rate brachytherapy applications.

Automated detection of local normalization areas for ictal-interictal subtraction brain SPECT.

UNLABELLED: Whole-brain activity is often chosen to quantitatively normalize peri-ictal and interictal SPECT scans before their subtraction. This use is not justified, because significant and extended modification of the cerebral blood flow can occur during a seizure. We validated and compared 2 automatic methods able to determine the optimal reference region, using simulation and clinical data. METHODS: In the first method, the selected reference region is the intersection of peri-ictal-interictal areas with no significantly different z values. The other method relies on a 3-dimensional iterative voxel aggregation. The increase of the selected volume is stopped by using 2 different variance tests (Levene and SE). These algorithms were tested on 39 epileptic patients and were validated using 1 interictal and 10 peri-ictal scans simulated from the mean image of 22 healthy subjects. RESULTS: In the patient studies, the mean relative activity of the selected regions, compared with whole-brain activity (classic normalization), was 122.6%. Their average relative size (compared with the size of the whole brain) was 33.2% for the z map method, 22.8% for the SE test, and 11.8% for the Levene test. After application of our automatic processes, subtraction of the simulated images revealed a recovery of abnormal regions up to 45% larger than the region obtained with classic normalization. CONCLUSION: These results illustrate the role of normalization on the subtracted peri-ictal and interictal images. Our methods are automatic and objective and give good results on various simulated images. The z map construction is worth considering because it is simple, selects large parts of the brain, and requires little computation time.