Generation of tissues outside the field of view (FOV) of radiation therapy simulation imaging based on machine learning and patient body outline (PBO).

BACKGROUND: It is not unusual to see some parts of tissues are excluded in the field of view of CT simulation images. A typical mitigation is to avoid beams entering the missing body parts at the cost of sub-optimal planning. METHODS: This study is to solve the problem by developing 3 methods, (1) deep learning (DL) mechanism for missing tissue generation, (2) using patient body outline (PBO) based on surface imaging, and (3) hybrid method combining DL and PBO. The DL model was built upon a Globally and Locally Consistent Image Completion to learn features by Convolutional Neural Networks-based inpainting, based on Generative Adversarial Network. The database used comprised 10,005 CT training slices of 322 lung cancer patients and 166 CT evaluation test slices of 15 patients. CT images were from the publicly available database of the Cancer Imaging Archive. Since existing data were used PBOs were acquired from the CT images. For evaluation, Structural Similarity Index Metric (SSIM), Root Mean Square Error (RMSE) and Peak signal-to-noise ratio (PSNR) were evaluated. For dosimetric validation, dynamic conformal arc plans were made with the ground truth images and images generated by the proposed method. Gamma analysis was conducted at relatively strict criteria of 1%/1 mm (dose difference/distance to agreement) and 2%/2 mm under three dose thresholds of 1%, 10% and 50% of the maximum dose in the plans made on the ground truth image sets. RESULTS: The average SSIM in generation part only was 0.06 at epoch 100 but reached 0.86 at epoch 1500. Accordingly, the average SSIM in the whole image also improved from 0.86 to 0.97. At epoch 1500, the average values of RMSE and PSNR in the whole image were 7.4 and 30.9, respectively. Gamma analysis showed excellent agreement with the hybrid method (equal to or higher than 96.6% of the mean of pass rates for all scenarios). CONCLUSIONS: It was first demonstrated that missing tissues in simulation imaging could be generated with high similarity, and dosimetric limitation could be overcome. The benefit of this study can be significantly enlarged when MR-only simulation is considered.

A Mathematical Model for Predicting Patient Responses to Combined Radiotherapy with CTLA-4 Immune Checkpoint Inhibitors.

The purpose of this study was to develop a cell-cell interaction model that could predict a tumor's response to radiotherapy (RT) combined with CTLA-4 immune checkpoint inhibition (ICI) in patients with hepatocellular carcinoma (HCC). The previously developed model was extended by adding a new term representing tremelimumab, an inhibitor of CTLA-4. The distribution of the new immune activation term was derived from the results of a clinical trial for tremelimumab monotherapy (NCT01008358). The proposed model successfully reproduced longitudinal tumor diameter changes in HCC patients treated with tremelimumab (complete response = 0%, partial response = 17.6%, stable disease = 58.8%, and progressive disease = 23.6%). For the non-irradiated tumor control group, adding ICI to RT increased the clinical benefit rate from 8% to 32%. The simulation predicts that it is beneficial to start CTLA-4 blockade before RT in terms of treatment sequences. We developed a mathematical model that can predict the response of patients to the combined CTLA-4 blockade with radiation therapy. We anticipate that the developed model will be helpful for designing clinical trials with the ultimate aim of maximizing the efficacy of ICI-RT combination therapy.

Quantitative Assessment of the Restoration of Original Anatomy after 3D Virtual Reduction of Long Bone Fractures.

Background: The purpose of this study was to demonstrate the usefulness of 3D image-based virtual reduction by validating the evaluation criteria according to guidelines suggested by the AO Surgery Reference. Methods: For this experiment, 19 intact radial ORTHObones (ORTHObones radius, 3B Scientific, Germany, Hamburg) without any fractures were prepared. All ORTHObones with six cortical marking holes (three points on the distal part and three points on the proximal part) were scanned using a CT scanner twice (before/after intentional fracture of the ORTHObone). After the virtual reduction of all 19 ORTHObones, accuracy evaluations using the four criteria (length variation, apposition variation, alignment variation, Rotation Variation) suggested in the AO Surgery Reference were performed. Results: The mean (M) length variation was 0.42 mm, with 0.01 mm standard deviation (SD). The M apposition variation was 0.48 mm, with 0.40 mm SD. The M AP angulation variation (for alignment variation) was 3.24°, with 2.95° SD. The M lateral angulation variation (for alignment variation) was 0.09°, with 0.13° SD. The M angle of axial rotation was 1.27° with SD: 1.19°. Conclusions: The method of accuracy evaluation used in this study can be helpful in establishing a reliable plan.

Mechanical and Biocompatibility Properties of Sintered Titanium Powder for Mimetic 3D-Printed Bone Scaffolds.

A composite comprising Ti and NaCl powders was sintered similar to a three-dimensional (3D)-printed patient-customized artificial bone scaffold. Additionally, a proper microstructure of the mimetic scaffold and the optimum processing parameters for its development were analyzed. The mechanical properties of the metal-based porous-structured framework used as an artificial bone scaffold were an optimum replacement for the human bone. Thus, it was confirmed that patient-customized scaffolds could be manufactured via 3D printing. The 3D-printed mimetic specimens were fabricated by a powder-sintering method using Ti for the metal parts, NaCl as the pore former, and polylactic acid as the biodegradable binder. Scanning electron microscopy (SEM) images showed that pores were formed homogeneously, while X-ray computed tomography confirmed that open pores were generated. The porosity and pore size distribution were measured using a mercury porosimeter, while the flexural strength and flexural elastic modulus were calculated using the three-point bending test. Based on these measurements, a pore-former content of 15 vol % optimized the density and flexural strength to 2.52 g cm-2 and 283 MPa, respectively, similar to those of the actual iliac bone. According to the 3D-printing production method, a selective laser-sintering process was applied for the fabrication of the mimetic specimen, and it was determined that the microstructure and properties similar to those of previous metal specimens could be achieved in the as-prepared specimen. Additionally, a decellularized extracellular matrix (dECM) was used to coat the surfaces and interiors of the specimens for evaluating their biocompatibilities. SEM image analysis indicated that the adipose-derived stem cells grew evenly inside the pores of the coated specimens, as compared with the bulky Ti specimens without the dECM coating. The doubling time at 65% was measured at 72, 75, and 83 h for specimens with pore-former contents of 5, 10, and 15 vol %, respectively. The doubling time without the pore former was 116 h. As compared with the specimens without the pore former (73 h), 15% of the dECM-coated specimens showed a doubling time of 64%, measured at 47 h.

A multivariate approach to determine electron beam parameters for a Monte Carlo 6 MV Linac model: Statistical and machine learning methods.

PURPOSE: This study aimed to determine the optimal initial electron beam parameters of a Linac for radiotherapy with a multivariate approach using statistical and machine-learning tools. METHODS: For MC beam commissioning, a 6 MV Varian Clinac was simulated using the Geant4 toolkit. The authors investigated the relations between simulated dose distribution and initial electron beam parameters, namely, mean energy (E), energy spread (ES), and radial beam size (RS). The goodness of simulation was evaluated by the slope of differences between the simulated and the golden beam data. The best-fit combination of the electron beam parameters that minimized the slope of dose difference was searched through multivariate methods using conventional statistical methods and machine-learning tools of the scikit-learn library. RESULTS: Simulation results with 87 combinations of the electron beam parameters were analyzed. Regardless of being univariate or multivariate, traditional statistical models did not recommend a single parameter set simultaneously minimizing slope of dose differences for percent depth dose (PDD) and lateral dose profile (LDP). Two machine learning classification modules, RandomForestClassifier and BaggingClassifier, agreed in recommending (E = 6.3 MeV, ES = ±5.0%, RS = 1.0 mm) for predicting simultaneous acceptance of PDD and LDP. CONCLUSIONS: The machine learning with random-forest and bagging classifier modules recommended a consistent result. It was possible to draw an optimal electron beam parameter set using multivariate methods for MC simulation of a radiotherapy 6 MV Linac.

Assessment of log-based fingerprinting system of Mobius3D with Elekta linear accelerators.

PURPOSE: The purpose of this study was to investigate the matching error that occurs when the Mobius3D fingerprinting system is applied in conjunction with an Elekta linear accelerator (LINAC) and to offer an acceptable and alternative method for circumventing this problem. MATERIAL AND METHODS: To avoid the multileaf collimator (MLC) conflicting error in the Mobius3D fingerprinting system, we developed an in-house program to move the MLC in the Digital Imaging and Communications in Medicine (DICOM) radiotherapy (RT)-Plan to pertinent positions, considering the relationship between log data and planned data. The re-delivered log files were calculated in the Mobius3D system, and the results were compared with those of corrected data (i.e., we analyzed a pair of re-collected log data and the previous DICOM RT-Plan data). The results were then evaluated by comparing several items, such as point dose errors, gamma index (GI) passing rates, and MLC root-mean-square (RMS) values. RESULTS: For the point dose error, the maximum difference found was below 2.0%. In the case of GI analysis of all plans, the maximum difference in the passing rates was below 1.4%. The statistical results obtained using a paired Student's t-test showed that there were no significant differences within the uncertainty. In the case of the RMS test, the maximum difference found was approximately 0.08 mm. CONCLUSIONS: Our results showed that all the mismatched log files were sufficiently acceptable within the uncertainty. We conclude that the matching error obtained when applying Mobius3D to an Elekta LINAC may be addressed using a simple modification of the fingerprinting system, and we expect that our study findings will help vendors resolve this issue in the near future.

Development of Dosimetric Verification System for Patient-Specific Quality Assurance of High-Dose-Rate Brachytherapy.

Purpose: The aim of this study was to develop a dosimetric verification system (DVS) using a solid phantom for patient-specific quality assurance (QA) of high-dose-rate brachytherapy (HDR-BT). Methods: The proposed DVS consists of three parts: dose measurement, dose calculation, and analysis. All the dose measurements were performed using EBT3 film and a solid phantom. The solid phantom made of acrylonitrile butadiene styrene (ABS, density = 1.04 g/cm3) was used to measure the dose distribution. To improve the accuracy of dose calculation by using the solid phantom, a conversion factor [CF(r)] according to the radial distance between the water and the solid phantom material was determined by Monte Carlo simulations. In addition, an independent dose calculation program (IDCP) was developed by applying the obtained CF(r). To validate the DVS, dosimetric verification was performed using gamma analysis with 3% dose difference and 3 mm distance-to-agreement criterion for three simulated cases: single dwell position, elliptical dose distribution, and concave elliptical dose distribution. In addition, the possibility of applying the DVS in the high-dose range (up to 15 Gy) was evaluated. Results: The CF(r) between the ABS and water phantom was 0.88 at 0.5 cm. The factor gradually increased with increasing radial distance and converged to 1.08 at 6.0 cm. The point doses 1 cm below the source were 400 cGy in the treatment planning system (TPS), 373.73 cGy in IDCP, and 370.48 cGy in film measurement. The gamma passing rates of dose distributions obtained from TPS and IDCP compared with the dose distribution measured by the film for the simulated cases were 99.41 and 100% for the single dwell position, 96.80 and 100% for the elliptical dose distribution, 88.91 and 99.70% for the concave elliptical dose distribution, respectively. For the high-dose range, the gamma passing rates in the dose distributions between the DVS and measurements were above 98% and higher than those between TPS and measurements. Conclusion: The proposed DVS is applicable for dosimetric verification of HDR-BT, as confirmed through simulated cases for various doses.

Four-dimensional inverse-geometry computed tomography: a preliminary study.

This study introduces and evaluates respiratory-correlated four-dimensional (4D) inverse geometry computed tomography (IGCT). The projection data of the IGCT were acquired in a single gantry rotation over 120 s. Three virtual phantoms-static Defrise, 4D Shepp-Logan, and 4D extended cardiac-torso (XCAT)-were used to obtain projection data for the IGCT and cone-beam computed tomography (CBCT). The projection acquisition parameters were determined to eliminate vacancies in the Radon space for an accurate rebinning process. Phase-based sorting was conducted within 10 phase bins, and the sorted projection data were binned into a cone beam geometry. Finally, Feldkamp-Davis-Kress reconstruction was conducted independently at each phase. The reconstructed images were compared using the structural similarity index measure (SSIM) and root mean square error (RMSE). The vertical profile of the Defrise reconstruction image was uniform, and the cone beam artefact was reduced in the IGCT image. Under an ideal projection acquisition condition, the mean coronal plane SSIMs of the Shepp-Logan and 4D XCAT phantoms were 0.899 and 0.706, respectively, which were higher than those of the CBCT (0.784 and 0.623, respectively). Similarly, the mean RMSEs of the coronal plane IGCT (0.036 and 0.158) exhibited an improvement over those of the CBCT (0.165 and 0.261, respectively). The mean standard deviations of the SSIM and RMSE were lower for IGCT than for CBCT. In particular, the SSIM and RMSE of the sagittal and coronal planes of the Shepp-Logan IGCT images were stable in all phase bins; however, those of the CBCT changed depending on the phase bins. Poor image quality was observed for IGCT under inappropriate conditions. This was caused by a vacancy in the Radon space, owing to an inappropriate scan setting. Overall, the proposed 4D IGCT exhibited better image quality than conventional CBCT.

Dose Super-Resolution in Prostate Volumetric Modulated Arc Therapy Using Cascaded Deep Learning Networks.

PURPOSE: This study proposes a cascaded network model for generating high-resolution doses (i.e., a 1 mm grid) from low-resolution doses (i.e., ≥3 mm grids) with reduced computation time. METHODS: Using the anisotropic analytical algorithm with three grid sizes (1, 3, and 5 mm) and the Acuros XB algorithm with two grid sizes (1 and 3 mm), dose distributions were calculated for volumetric modulated arc therapy plans for 73 prostate cancer patients. Our cascaded network model consisted of a hierarchically densely connected U-net (HD U-net) and a residual dense network (RDN), which were trained separately following a two-dimensional slice-by-slice procedure. The first network (HD U-net) predicted the downsampled high-resolution dose (generated through bicubic downsampling of the baseline high-resolution dose) using the low-resolution dose; subsequently, the second network (RDN) predicted the high-resolution dose from the output of the first network. Further, the predicted high-resolution dose was converted to its absolute value. We quantified the network performance using the spatial/dosimetric parameters (dice similarity coefficient, mean dose, maximum dose, minimum dose, homogeneity index, conformity index, and V95%, V70%, V50%, and V30%) for the low-resolution and predicted high-resolution doses relative to the baseline high-resolution dose. Gamma analysis (between the baseline dose and the low-resolution dose/predicted high-resolution dose) was performed with a 2%/2 mm criterion and 10% threshold. RESULTS: The average computation time to predict a high-resolution axial dose plane was <0.02 s. The dice similarity coefficient values for the predicted doses were closer to 1 when compared to those for the low-resolution doses. Most of the dosimetric parameters for the predicted doses agreed more closely with those for the baseline than for the low-resolution doses. In most of the parameters, no significant differences (p-value of >0.05) between the baseline and predicted doses were observed. The gamma passing rates for the predicted high-resolution does were higher than those for the low-resolution doses. CONCLUSION: The proposed model accurately predicted high-resolution doses for the same dose calculation algorithm. Our model uses only dose data as the input without additional data, which provides advantages of convenience to user over other dose super-resolution methods.

Simplified sigmoidal curve fitting for a 6 MV FFF photon beam of the Halcyon to determine the field size for beam commissioning and quality assurance.

BACKGROUND: An O-ring gantry-type linear accelerator (LINAC) with a 6-MV flattening filter-free (FFF) photon beam, Halcyon, includes a reference beam that contains representative information such as the percent depth dose, profile and output factor for commissioning and quality assurance. However, because it does not provide information about the field size, we proposed a method to determine all field sizes according to all depths for radiation therapy using simplified sigmoidal curve fitting (SCF). METHODS: After mathematical definition of the SCF using four coefficients, the defined curves were fitted to both the reference data (RD) and the measured data (MD). For good agreement between the fitting curve and the profiles in each data set, the field sizes were determined by identifying the maximum point along the third derivative of the fitting curve. The curve fitting included the field sizes for beam profiles of 2 × 2, 4 × 4, 6 × 6, 8 × 8, 10 × 10, 20 × 20 and 28 × 28 cm2 as a function of depth (at 1.3, 5, 10 and 20 cm). The field size results from the RD were compared with the results from the MD using the same condition. RESULTS: All fitting curves show goodness of fit, R2, values that are greater than 0.99. The differences in field size between the RD and the MD were within the range of 0 to 0.2 cm. The smallest difference in the field sizes at a depth of 10 cm, which is a surface-to-axis distance, was reported. CONCLUSION: Application of the SCF method has been proven to accurately capture the field size of the preconfigured RD and the measured FFF photon beam data for the Halcyon system. The current work can be useful for beam commissioning as a countercheck methodology to determine the field size from RD in the treatment planning system of a newly installed Halcyon system and for routine quality assurance to ascertain the correctness of field sizes for clinical use of the Halcyon system.

Development of Volumetric Independent Dose Calculation System for Verification of the Treatment Plan in Image-Guided Adaptive Brachytherapy.

Purpose: This study aimed to develop a volumetric independent dose calculation (vIDC) system for verification of the treatment plan in image-guided adaptive brachytherapy (IGABT) and to evaluate the feasibility of the vIDC in clinical practice with simulated cases. Methods: The vIDC is based on the formalism of TG-43. Four simulated cases of cervical cancer were selected to retrospectively evaluate the dose distributions in IGABT. Some reference point doses, such as points A and B and rectal points, were calculated by vIDC using absolute coordinate. The 3D dose volume was also calculated to acquire dose-volume histograms (DVHs) with grid resolutions of 1.0 × 1.0 (G1.0), 2.5 × 2.5 (G2.5), and 0.5 × 0.5 mm2 (G0.5). Dosimetric parameters such as D90% and D2cc doses covering 90% of the high-risk critical target volume (HR-CTV) and 2 cc of the organs at risk (OARs) were obtained from DVHs. D90% also converted to equivalent dose in 2-Gy fractions (EQD2) to produce the same radiobiological effect as external beam radiotherapy. In addition, D90% was obtained in two types with or without the applicator volume to confirm the effect of the applicator itself. Validation of the vIDC was also performed using gamma evaluation by comparison with Monte Carlo simulation. Results: The average percentage difference of point doses was <2.28%. The DVHs for the HR-CTV and OARs showed no significant differences between the vIDC and the treatment planning system (TPS). Without considering the applicator volume, the D90% of the HR-CTV calculated by the vIDC decreases with a decreasing calculated dose-grid size (32.4, 5.65, and -2.20 cGy in G2.5, G1.0, and G0.5, respectively). The overall D90% is higher when considering the applicator volume. The converted D90% by EQD2 ranged from -1.29 to 1.00%. The D2cc of the OARs showed that the averaged dose deviation is <10 cGy regardless of the dose-grid size. Based on gamma analysis, the passing rate was 98.81% for 3%/3-mm criteria. Conclusion: The vIDC was developed as an independent dose verification system for verification of the treatment plan in IGABT. We confirmed that the vIDC is suitable for second-check dose validation of the TPS under various conditions.

Development of a hybrid magnetic resonance/computed tomography-compatible phantom for magnetic resonance guided radiotherapy.

The purpose of the present study was to develop a hybrid magnetic resonance/computed tomography (MR/CT)-compatible phantom and tissue-equivalent materials for each MR and CT image. Therefore, the essential requirements necessary for the development of a hybrid MR/CT-compatible phantom were determined and the development process is described. A total of 12 different tissue-equivalent materials for each MR and CT image were developed from chemical components. The uniformity of each sample was calculated. The developed phantom was designed to use 14 plugs that contained various tissue-equivalent materials. Measurement using the developed phantom was performed using a 3.0-T scanner with 32 channels and a Somatom Sensation 64. The maximum percentage difference of the signal intensity (SI) value on MR images after adding K2CO3 was 3.31%. Additionally, the uniformity of each tissue was evaluated by calculating the percent image uniformity (%PIU) of the MR image, which was 82.18 ±1.87% with 83% acceptance, and the average circular-shaped regions of interest (ROIs) on CT images for all samples were within ±5 Hounsfield units (HU). Also, dosimetric evaluation was performed. The percentage differences of each tissue-equivalent sample for average dose ranged from -0.76 to 0.21%. A hybrid MR/CT-compatible phantom for MR and CT was investigated as the first trial in this field of radiation oncology and medical physics.

Development of a deformable lung phantom with 3D-printed flexible airways.

PURPOSE: Deformable lung phantoms have been proposed to investigate four-dimensional (4D) imaging and radiotherapy delivery techniques. However, most phantoms mimic only the lung and tumor without pulmonary airways. The purpose of this study was to develop a reproducible, deformable lung phantom with three-dimensional (3D)-printed airways. METHODS: The phantom consists of: (a) 3D-printed flexible airways, (b) flexible polyurethane foam infused with iodinated contrast agents, and (c) a motion platform. The airways were simulated using publicly available breath-hold computed tomography (CT) image datasets of a human lung through airway segmentation, computer-aided design modeling, and 3D printing with a rubber-like material. The lung was simulated by pouring liquid expanding foam into a mold with the 3D-printed airways attached. Iodinated contrast agents were infused into the lung phantom to emulate the density of the human lung. The lung/airways phantom was integrated into our previously developed motion platform, which allows for compression and decompression of the phantom in the superior-inferior direction. We quantified the reproducibility of the density (lung), motion/deformation (lung and airways), and position (airways) using breath-hold CT scans (with the phantom compressed and decompressed) repeated every two weeks over a 2-month period as well as 4D CT scans (with the phantom continuously compressed and decompressed) repeated twice over four weeks. The density reproducibility was quantified with a difference image (created by subtracting the rigidly registered baseline and the repeated images) in each of the compressed and decompressed states. Reproducibility of the motion/deformation was evaluated by comparing the baseline displacement vector fields (DVFs) derived from deformable image registration (DIR) between the compressed and decompressed phantom CT images with those of repeated scans and calculating the difference in the displacement vectors. Reproducibility of the airway position was quantified based on DIR between the baseline and repeated images. RESULTS: For the breath-hold CT scans, the mean difference in lung density between baseline and week 8 was -1.3 (standard deviation 33.5) Hounsfield unit (HU) in the compressed state and 0.4 (36.8) HU in the decompressed state, while large local differences were observed around the high-contrast structures (caused by small misalignments). By visual inspection, the DVFs (between the compressed and decompressed states) at baseline and last time point (week 8 for the breath-hold CT scans) demonstrated a similar pattern. The mean lengths of displacement vector differences between baseline and week 8 were 0.5 (0.4) mm for the lung and 0.3 (0.2) mm for the airways. The mean airway displacements between baseline and week 8 were 0.6 (0.5) mm in the compressed state and 0.6 (0.4) mm in the decompressed state. We also observed similar results for the 4D CT scans (week 0 vs week 4) as well as for the breath-hold CT scans at other time points (week 0 vs weeks 2, 4, and 6). CONCLUSIONS: We have developed a deformable lung phantom with 3D-printed airways based on a human lung CT image. Our findings indicate reproducible density, motion/deformation, and position. This phantom is based on widely available materials and technology, which represents advantages over other deformable phantoms.

Comparative performance analysis for abdominal phantom ROI detectability according to CT reconstruction algorithm: ADMIRE.

PURPOSE: We compared and analyzed the detectability performance pertaining to an abdominal phantom including a region of interest (ROI) according to a computed tomography (CT) reconstruction algorithm. METHODS: Three types of reconstruction algorithms (FBP, SAFIRE, and ADMIRE) were used to evaluate the detectability performance using the abdominal phantom (phantom size: 25 × 18 × 28 cm3 ). The vendor default settings for routine multi-detector computed tomography abdominal scans were used. As the quantitative evaluation method, the contrast-to-noise ratio (CNR), difference in coefficient of variation (COV) with the normalization based on the FBP data, and the noise power spectrum (NPS) were measured. RESULTS: The characteristic of the ADMIRE-3 reconstructed image was higher than those of the FBP and SAFIRE-3 reconstructed images. The CNR values of the SAFIRE and ADMIRE images were much higher than the corresponding values of the FBP images. The difference in COV values for the ADMIRE images was ~1.2 times lower than the corresponding values of the SAFIRE images. CONCLUSION: The comparative analysis of the abdominal phantom low-contrast resolution differences for each CT exposure parameters showed that ADMIRE demonstrated better results than SAFIRE and FBP in terms of contrast, CNR, COV difference, and 1D NPS. This indicates that ADMIRE can provide a clearer observation even with the same number of contrast objects as compared to SAFIRE and FBP owing to its better contrast resolution in the central part of the contrast hole at low kV.

Metal artifacts with dental implants: Evaluation using a dedicated CT/MR oral phantom with registration of the CT and MR images.

The aims of this study were to develop a computed tomography/magnetic resonance (CT/MR) oral phantom with insertable dental implants and to register CT/MR images to generate artifact-free MR images for patients undergoing teeth restorations. All measurements were done using a human MR scanner with spin echo (SE) and gradient echo (GRE) sequences image scan together with CT image. The metal regions and normal teeth parts are extracted with a suitable threshold from an initial image reconstructed with artifact from the CT images. Corrected metal projection regions of MR images and CT images are fused to produce artifact-free MR image that include dental restorations. After CT/MR registration, artifact size presented differences on the x- (SE, 12.0 mm; GRE, 18.0 mm) and y- (SE, 24.0 mm; GRE, 36.6 mm). When comparing the dental restoration with normal teeth, the structural similarity index metric (SSIM) of GRE 50 was lower than for the GRE 8 sequence and the SSIM of SE 145 shown higher than for the SE 490 sequence. The dedicated phantom provides a useful tool in head and neck research for multi-modality images. Therefore, CT/MR image-based approach for ground truth and registration offers visualization in diagnostic system and radiation treatment planning system.

A respiratory-guided 4D digital tomosynthesis.

The aim of this research was to introduce and evaluate a respiratory-guided slow gantry rotation 4D digital tomosynthesis (DTS). For each of ten volunteers, two breathing patterns were obtained for 3 min, one under free breathing conditions and the other with visual respiratory-guidance using an in-house developed respiratory monitoring system based on pressure sensing. Visual guidance was performed using a 4 s cycle sine wave with an amplitude corresponding to the average of end-inhalation peaks and end-exhalation valleys from the free-breathing pattern. The scan range was 40 degrees for each simulation, and the frame rate and gantry rotation speed were determined so that one projection per phase should be included. Both acquisition time and the number of total projections to be acquired (NPA) were calculated. Applying the obtained respiration pattern and the corresponding sequence, virtual projections were acquired under a typical geometry of Varian on-board imager for two virtual phantoms, modified Shepp-Logan (mSL) and extended cardiac-torso (XCAT). For the XCAT, two different orientations were considered, anterior-posterior (i.e. coronal) and left-right (i.e. sagittal). Projections were sorted to ten phases and image reconstruction was made using a modified filtered back-projection. Reconstructed images were compared with the planned breathing data (i.e. ideal situation) by structural similarity index (SSIM) and normalized root-mean-square error (NRMSE). For each case, simulation with guidance (SwG) showed motion-related artefact reduction compared to that under free-breathing (SuFB). SwG required less NPA but provided slightly higher SSIM and lower NRMSE values in all phantom images than SuFB did. In addition, the distribution of projections per phase was more regular in SwG. Through the proposed respiratory-guided 4D DTS, it is possible to reduce imaging dose while improving image quality. (Institutional Review Board approval: MC17DESI0086).

Investigations of line scanning proton therapy with dynamic multi-leaf collimator.

PURPOSE: Scanning proton therapy has dosimetric advantage over passive treatment, but has a large penumbra in low-energy region. This study investigates the penumbra reduction when multi-leaf collimators (MLCs) are used for line scanning proton beams and secondary neutron production from MLCs. METHODS: Scanning beam plans with and without MLC shaping were devised. Line scanning proton plan of 36 energy layers between 71.2 and 155.2 MeV was generated. The MLCs were shaped according to the cross-sectional target shape for each energy layer. The two-dimensional doses were measured through an ion-chamber array, depending on the presence of MLC field, and Monte Carlo (MC) simulations were performed. The plan, measurement, and MC data, with and without MLC, were compared at each depth. The secondary neutron dose was simulated with MC. Ambient neutron dose equivalents were computed for the line scanning with 10 × 10 × 5 cm3 volume and maximum proton energy of 150 MeV, with and without MLCs, at lateral distances of 25-200 cm from the isocenter. The neutron dose for a wobbling plan with 10 × 10 × 5 cm3 volume was also evaluated. RESULTS: The lateral penumbra width using MLC was reduced by 23.2% on average, up to a maximum of 32.2%, over the four depths evaluated. The ambient neutron dose equivalent was 18.52% of that of the wobbling beam but was 353.1% larger than the scanning open field. CONCLUSIONS: MLC field shaping with line scanning reduced the lateral penumbra and should be effective in sparing normal tissue. However, it is important to investigate the increase in neutron dose.

Dosimetric and radiobiological comparison in different dose calculation grid sizes between Acuros XB and anisotropic analytical algorithm for prostate VMAT.

To investigate feasible treatment planning parameters, we aimed to evaluate the dosimetric and radiobiological impact of the dose calculation algorithm and grid size in the volumetric modulated arc therapy (VMAT) plan for prostate cancer. Twenty patients were selected, and the treatment plans were initially generated with anisotropic analytical algorithm (AAA) and recalculated with Acuros XB (AXB) algorithm. Various dose grids were used for AXB (1, 2, and 3 mm) and AAA (1, 3, and 5 mm) plan. Dosimetric parameters such as homogeneity index (HI) and conformity index (CI), and radiobiological parameters such as tumor control probability (TCP) and normal tissue complication probability (NTCP) were calculated. Significant differences were observed in the planning target volume (PTV) coverage between both algorithms, and the V95%, HI, and CI of AAA were significantly affected by grid (p < 0.01). On 1 mm grid, the mean rectal dose difference between both algorithms was 2.87% of the prescription dose (p < 0.01), which was the highest among the critical organs. The TCP and NTCP of the AAA were higher than those of AXB (p < 0.01). Compared to AXB with 1 mm grid, the 2 mm grid showed comparable dose calculation accuracy with short calculation time. This study found that the PTV and rectum show significant differences according to dose calculation algorithm and grid. Considering the dose calculation performance for heterogeneous area, we recommend AXB with 2 mm grid for improving treatment efficiency of prostate VMAT.

To propose adding index of achievement (IOA) to IMRT QA process.

BACKGROUND: In intensity modulated radiation therapy (IMRT) quality assurance (QA), evaluation of QA result using a pass/non-pass strategy under an acceptance criterion often suffers from lack of information on how good the plan is in absolute manner. In this study, we suggested adding an index system, previously developed for dose painting technique, to current IMRT QA process for better understanding of QA result. METHODS: The index system consists of three indices, index of achievement (IOA), index of hotness (IOH) and index of coldness (IOC). As indicated by its name, IOA does measure the level of agreement. IOH and IOC, on the other hand, measure the magnitude of overdose and underdose, respectively. A systematic analysis was performed with three 1-dimensional hypothetical dose distributions to investigate the characteristics of the index system. The feasibility of the system was also assessed with clinical volumetric modulated arc therapy (VMAT) QA cases from 8 head & neck and 5 prostate patients. In both simulation studies, certain amount of errors was intentionally induced to each dose distribution. Furthermore, we applied the proposed system to compare calculated with actual measured data for a total of 60 patients (30 head & neck and 30 prostate cases). QA analysis was made using both the index system and gamma method, and results were compared. RESULTS: While the gamma evaluation showed limited sensitivity in evaluating QA result depending on the level of tolerance criteria used, the proposed indices tended to better distinguish plans in terms of the amount of errors. Hotness and coldness of prescribed dose in the plan could be evaluated quantitatively by the indices. CONCLUSIONS: The proposed index system provides information with which IMRT QA result would be better evaluated, especially when gamma pass rates are identical or similar among multiple plans. In addition, the independency of the index system on acceptance criteria would help making clear communications among readers of published articles and researchers in multi-institutional studies.

Proton range verification in inhomogeneous tissue: Treatment planning system vs. measurement vs. Monte Carlo simulation.

In particle radiotherapy, range uncertainty is an important issue that needs to be overcome. Because high-dose conformality can be achieved using a particle beam, a small uncertainty can affect tumor control or cause normal-tissue complications. From this perspective, the treatment planning system (TPS) must be accurate. However, there is a well-known inaccuracy regarding dose computation in heterogeneous media. This means that verifying the uncertainty level is one of the prerequisites for TPS commissioning. We evaluated the range accuracy of the dose computation algorithm implemented in a commercial TPS, and Monte Carlo (MC) simulation against measurement using a CT calibration phantom. A treatment plan was produced for eight different materials plugged into a phantom, and two-dimensional doses were measured using a chamber array. The measurement setup and beam delivery were simulated by MC code. For an infinite solid water phantom, the gamma passing rate between the measurement and TPS was 97.7%, and that between the measurement and MC was 96.5%. However, gamma passing rates between the measurement and TPS were 49.4% for the lung and 67.8% for bone, and between the measurement and MC were 85.6% for the lung and 100.0% for bone tissue. For adipose, breast, brain, liver, and bone mineral, the gamma passing rates computed by TPS were 91.7%, 90.6%, 81.7%, 85.6%, and 85.6%, respectively. The gamma passing rates for MC for adipose, breast, brain, liver, and bone mineral were 100.0%, 97.2%, 95.0%, 98.9%, and 97.8%, respectively. In conclusion, the described procedure successfully evaluated the allowable range uncertainty for TPS commissioning. The TPS dose calculation is inefficient in heterogeneous media with large differences in density, such as lung or bone tissue. Therefore, the limitations of TPS in heterogeneous media should be understood and applied in clinical practice.