Towards automated ultrasound imaging-robotic image acquisition in liver and prostate for long-term motion monitoring.

Real-time volumetric (4D) ultrasound has shown high potential for diagnostic and therapy guidance tasks. One of the main drawbacks of ultrasound imaging to date is the reliance on manual probe positioning and the resulting user dependence. Robotic assistance could help overcome this issue and facilitate the acquisition of long-term image data to observe dynamic processesin vivoover time. The aim of this study is to assess the feasibility of robotic probe manipulation and organ motion quantification during extended imaging sessions. The system consists of a collaborative robot and a 4D ultrasound system providing real-time data access. Five healthy volunteers received liver and prostate scans during free breathing over 30 min. Initial probe placement was performed with real-time remote control with a predefined contact force of 10 N. During scan acquisition, the probe position was continuously adjusted to the body surface motion using impedance control. Ultrasound volumes, the pose of the end-effector and the estimated contact forces were recorded. For motion analysis, one anatomical landmark was manually annotated in a subset of ultrasound frames for each experiment. Probe contact was uninterrupted over the entire scan duration in all ten sessions. Organ drift and imaging artefacts were successfully compensated using remote control. The median contact force along the probe's longitudinal axis was 10.0 N with maximum values of 13.2 and 21.3 N for liver and prostate, respectively. Forces exceeding 11 N only occurred in 0.3% of the time. Probe and landmark motion were more pronounced in the liver, with median interquartile ranges of 1.5 and 9.6 mm, compared to 0.6 and 2.7 mm in the prostate. The results show that robotic ultrasound imaging with dynamic force control can be used for stable, long-term imaging of anatomical regions affected by motion. The system facilitates the acquisition of 4D image datain vivoover extended scanning periods for the first time and holds the potential to be used for motion monitoring for therapy guidance as well as diagnostic tasks.

Medical Robotics for Ultrasound Imaging: Current Systems and Future Trends.

PURPOSE OF REVIEW: This review provides an overview of the most recent robotic ultrasound systems that have contemporary emerged over the past five years, highlighting their status and future directions. The systems are categorized based on their level of robot autonomy (LORA). RECENT FINDINGS: Teleoperating systems show the highest level of technical maturity. Collaborative assisting and autonomous systems are still in the research phase, with a focus on ultrasound image processing and force adaptation strategies. However, missing key factors are clinical studies and appropriate safety strategies. Future research will likely focus on artificial intelligence and virtual/augmented reality to improve image understanding and ergonomics. SUMMARY: A review on robotic ultrasound systems is presented in which first technical specifications are outlined. Hereafter, the literature of the past five years is subdivided into teleoperation, collaborative assistance, or autonomous systems based on LORA. Finally, future trends for robotic ultrasound systems are reviewed with a focus on artificial intelligence and virtual/augmented reality.

A visual probe positioning tool for 4D ultrasound-guided radiotherapy.

Ultrasound (US) guidance is a rapidly growing area in image-guided radiotherapy. For motion compensation, the therapy target needs to be visualized with the US probe to continuously determine its position and adapt for shifts. While US has obvious benefits such as real-time capability and proven safety, one of the main drawbacks to date is its user dependency - high quality results require long years of clinical experience. To provide positioning assistance for the setup of US equipment by non-experts, we developed a visual guidance tool combining real-time US volume and CT visualization in a geometrically calibrated setup. By using a 4D US station with real-time data access and an optical tracking system, we achieved a calibration accuracy of 1.2 mm and a mean 2D contour distance of 1.7 mm between organ boundaries identified in US and CT. With this low calibration error as well as the good visual alignment of the structures, the developed probe positioning tool could be a valuable aid for ultrasound-guided radiotherapy and other interventions by guiding the user to a suitable acoustic window while potentially improving setup reproducibility.

Investigating multi-leaf collimator tracking in stereotactic arrhythmic radioablation (STAR) treatments for atrial fibrillation.

Stereotactic arrhythmia radioablation (STAR) is an emerging treatment option for atrial fibrillation (AF). However, it faces possibly the most challenging motion compensation scenario: both respiratory and cardiac motion. Multi-leaf collimator (MLC) tracking is clinically used for lung cancer treatments but its capabilities with intracardiac targets is unknown. We report the first experimental results of MLC tracking for intracardiac targets. Five AF STAR plans of varying complexity were created. All delivered 5 × 10 Gy to both pulmonary vein antra. Three healthy human target motion trajectories were acquired with ultrasound and programmed into a motion platform. Plans were delivered with a linac to a dosimeter placed on the motion platform. For each motion trace, each plan was delivered with no MLC tracking and with MLC tracking with and without motion prediction. Dosimetric accuracy was assessed with γ-tests and dose metrics. MLC tracking improved the dosimetric accuracy in all measurements compared to non-tracking experiments. The average 2%/2 mm γ-failure rate was improved from 13.1% with no MLC tracking to 5.9% with MLC tracking (p < 0.001) and 7.2% with MLC tracking and no motion prediction (p < 0.001). MLC tracking significantly improved the consistency between planned and delivered target dose coverage. The 95% target coverage with the prescription dose (V100) was improved from 60% of deliveries with no MLC tracking to 80% of deliveries with MLC tracking (p = 0.03). MLC tracking was successfully implemented for the first time for intracardiac motion compensation. MLC tracking provided significant dosimetric accuracy improvements in AF STAR experiments, even with challenging cardiac and respiratory-induced target motion and complex treatment plans. These results warrant further investigation and optimisation of MLC tracking for intracardiac target motion compensation.

Investigation of the XCAT phantom as a validation tool in cardiac MRI tracking algorithms.

PURPOSE: To describe our magnetic resonance imaging (MRI) simulated implementation of the 4D digital extended cardio torso (XCAT) phantom to validate our previously developed cardiac tracking techniques. Real-time tracking will play an important role in the non-invasive treatment of atrial fibrillation with MRI-guided radiosurgery. In addition, to show how quantifiable measures of tracking accuracy and patient-specific physiology could influence MRI tracking algorithm design. METHODS: Twenty virtual patients were subjected to simulated MRI scans that closely model the proposed real-world scenario to allow verification of the tracking technique's algorithm. The generated phantoms provide ground-truth motions which were compared to the target motions output from our tracking algorithm. The patient-specific tracking error, ep, was the 3D difference (vector length) between the ground-truth and algorithm trajectories. The tracking errors of two combinations of new tracking algorithm functions that were anticipated to improve tracking accuracy were studied. Additionally, the correlation of key physiological parameters with tracking accuracy was investigated. RESULTS: Our original cardiac tracking algorithm resulted in a mean tracking error of 3.7 ±â€¯0.6 mm over all virtual patients. The two combinations of tracking functions demonstrated comparable mean tracking errors however indicating that the optimal tracking algorithm may be patient-specific. CONCLUSIONS: Current and future MRI tracking strategies are likely to benefit from this virtual validation method since no time-resolved 4D ground-truth signal can currently be derived from purely image-based studies.

Online 4D ultrasound guidance for real-time motion compensation by MLC tracking.

PURPOSE: With the trend in radiotherapy moving toward dose escalation and hypofractionation, the need for highly accurate targeting increases. While MLC tracking is already being successfully used for motion compensation of moving targets in the prostate, current real-time target localization methods rely on repeated x-ray imaging and implanted fiducial markers or electromagnetic transponders rather than direct target visualization. In contrast, ultrasound imaging can yield volumetric data in real-time (3D + time = 4D) without ionizing radiation. The authors report the first results of combining these promising techniques-online 4D ultrasound guidance and MLC tracking-in a phantom. METHODS: A software framework for real-time target localization was installed directly on a 4D ultrasound station and used to detect a 2 mm spherical lead marker inside a water tank. The lead marker was rigidly attached to a motion stage programmed to reproduce nine characteristic tumor trajectories chosen from large databases (five prostate, four lung). The 3D marker position detected by ultrasound was transferred to a computer program for MLC tracking at a rate of 21.3 Hz and used for real-time MLC aperture adaption on a conventional linear accelerator. The tracking system latency was measured using sinusoidal trajectories and compensated for by applying a kernel density prediction algorithm for the lung traces. To measure geometric accuracy, static anterior and lateral conformal fields as well as a 358° arc with a 10 cm circular aperture were delivered for each trajectory. The two-dimensional (2D) geometric tracking error was measured as the difference between marker position and MLC aperture center in continuously acquired portal images. For dosimetric evaluation, VMAT treatment plans with high and low modulation were delivered to a biplanar diode array dosimeter using the same trajectories. Dose measurements with and without MLC tracking were compared to a static reference dose using 3%/3 mm and 2%/2 mm γ-tests. RESULTS: The overall tracking system latency was 172 ms. The mean 2D root-mean-square tracking error was 1.03 mm (0.80 mm prostate, 1.31 mm lung). MLC tracking improved the dose delivery in all cases with an overall reduction in the γ-failure rate of 91.2% (3%/3 mm) and 89.9% (2%/2 mm) compared to no motion compensation. Low modulation VMAT plans had no (3%/3 mm) or minimal (2%/2 mm) residual γ-failures while tracking reduced the γ-failure rate from 17.4% to 2.8% (3%/3 mm) and from 33.9% to 6.5% (2%/2 mm) for plans with high modulation. CONCLUSIONS: Real-time 4D ultrasound tracking was successfully integrated with online MLC tracking for the first time. The developed framework showed an accuracy and latency comparable with other MLC tracking methods while holding the potential to measure and adapt to target motion, including rotation and deformation, noninvasively.

Treatment Planning Considerations for Robotic Guided Cardiac Radiosurgery for Atrial Fibrillation.

PURPOSE: Robotic guided stereotactic radiosurgery has recently been investigated for the treatment of atrial fibrillation (AF). Before moving into human treatments, multiple implications for treatment planning given a potential target tracking approach have to be considered. MATERIALS & METHODS: Theoretical AF radiosurgery treatment plans for twenty-four patients were generated for baseline comparison. Eighteen patients were investigated under ideal tracking conditions, twelve patients under regional dose rate (RDR = applied dose over a certain time window) optimized conditions (beam delivery sequence sorting according to regional beam targeting), four patients under ultrasound tracking conditions (beam block of the ultrasound probe) and four patients with temporary single fiducial tracking conditions (differential surrogate-to-target respiratory and cardiac motion). RESULTS: With currently known guidelines on dose limitations of critical structures, treatment planning for AF radiosurgery with 25 Gy under ideal tracking conditions with a 3 mm safety margin may only be feasible in less than 40% of the patients due to the unfavorable esophagus and bronchial tree location relative to the left atrial antrum (target area). Beam delivery sequence sorting showed a large increase in RDR coverage (% of voxels having a larger dose rate for a given time window) of 10.8-92.4% (median, 38.0%) for a 40-50 min time window, which may be significant for non-malignant targets. For ultrasound tracking, blocking beams through the ultrasound probe was found to have no visible impact on plan quality given previous optimal ultrasound window estimation for the planning CT. For fiducial tracking in the right atrial septum, the differential motion may reduce target coverage by up to -24.9% which could be reduced to a median of -0.8% (maximum, -12.0%) by using 4D dose optimization. The cardiac motion was also found to have an impact on the dose distribution, at the anterior left atrial wall; however, the results need to be verified. CONCLUSION: Robotic AF radiosurgery with 25 Gy may be feasible in a subgroup of patients under ideal tracking conditions. Ultrasound tracking was found to have the lowest impact on treatment planning and given its real-time imaging capability should be considered for AF robotic radiosurgery. Nevertheless, advanced treatment planning using RDR or 4D respiratory and cardiac dose optimization may be still advised despite using ideal tracking methods.