Impact of a novel multilayer imager on metal artifacts in MV-CBCT.

Objective. Megavoltage cone-beam computed tomography (MV-CBCT) imaging offers several advantages including reduced metal artifacts and accurate electron density mapping for adaptive or emergent situations. However, MV-CBCT imaging is limited by the poor efficiency of current detectors. Here we examine a new MV imager and compare CBCT reconstructions under clinically relevant scenarios.Approach. A multilayer imager (MLI), consisting of four vertically stacked standard flat-panel imagers, was mounted to a clinical linear accelerator. A custom anthropomorphic pelvis phantom with replaceable femoral heads was imaged using MV-CBCT and kilovoltage CBCT (kV-CBCT). Bone, aluminum, and titanium were used as femoral head inserts. 8 MU 2.5 MV scans were acquired for all four layers and (as reference) the top layer. Prostate and bladder were contoured on a reference CT and transferred to the other scans after rigid registration, from which the structural similarity index measure (SSIM) was calculated. Prostate and bladder were also contoured on CBCT scans without guidance, and Dice coefficients were compared to CT contours.Main results. kV-CBCT demonstrated the highest SSIMs with bone inserts (prostate: 0.86, bladder: 0.94) and lowest with titanium inserts (0.32, 0.37). Four-layer MV-CBCT SSIMs were preserved with bone (0.75, 0.80) as compared to titanium (0.67, 0.74), outperforming kV-CBCT when metal is present. One-layer MV-CBCT consistently underperformed four-layer results across all phantom configurations. Unilateral titanium inserts and bilateral aluminum insert results fell between the bone and bilateral titanium results. Dice coefficients trended similarly, with four-layer MV-CBCT reducing metal artifact impact relative to KV-CBCT to provide better soft-tissue identification.Significance. MV-CBCT with a four-layer MLI showed improvement over single-layer MV scans, approaching kV-CBCT quality for soft-tissue contrast. In the presence of artifact-producing metal implants, four-layer MV-CBCT scans outperformed kV-CBCT by eliminating artifacts and single-layer MV-CBCT by reducing noise. MV-CBCT with a novel multi-layer imager may be a valuable alternative to kV-CBCT, particularly in the presence of metal.

Improvements in beam's eye view fiducial tracking using a novel multilayer imager.

Purpose.Electronic portal image devices (EPIDs) have been investigated previously for beams-eye view (BEV) applications such as tumor tracking but are limited by low contrast-to-noise ratio and detective quantum efficiency. A novel multilayer imager (MLI), consisting of four stacked flat-panels was used to measure improvements in fiducial tracking during liver stereotactic body radiation therapy (SBRT) procedures compared to a single layer EPID.Methods.The prototype MLI was installed on a clinical TrueBeam linac in place of the conventional DMI single-layer EPID. The panel was extended during volumetric modulated arc therapy SBRT treatments in order to passively acquire data during therapy. Images were acquired for six patients receiving SBRT to liver metastases over two fractions each, one with the MLI using all 4 layers and one with the MLI using the top layer only, representing a standard EPID. The acquired frames were processed by a previously published tracking algorithm modified to identify implanted radiopaque fiducials. Truth data was determined using respiratory traces combined with partial manual tracking. Results for 4- and 1-layer mode were compared against truth data for tracking accuracy and efficiency. Tracking and noise improvements as a function of gantry angle were determined.Results. Tracking efficiency with 4-layers improved to 82.8% versus 58.4% for the 1-layer mode, a relative improvement of 41.7%. Fiducial tracking with 1-layer returned a root mean square error (RMSE) of 2.1 mm compared to 4-layer RMSE of 1.5 mm, a statistically significant (p < 0.001) improvement of 0.6 mm. The reduction in noise correlated with an increase in successfully tracked frames (r = 0.913) and with increased tracking accuracy (0.927).Conclusion. Increases in MV photon detection efficiency by utilization of a MLI results in improved fiducial tracking for liver SBRT treatments. Future clinical applications utilizing BEV imaging may be enhanced by including similar noise reduction strategies.

Clinical translation of a new flat-panel detector for beam's-eye-view imaging.

Electronic portal imaging devices (EPIDs) lend themselves to beams-eye view clinical applications, such as tumor tracking, but are limited by low contrast and detective quantum efficiency (DQE). We characterize a novel EPID prototype consisting of multiple layers and investigate its suitability for use under clinical conditions. A prototype multi-layer imager (MLI) was constructed utilizing four conventional EPID layers, each consisting of a copper plate, a Gd2O2S:Tb phosphor scintillator, and an amorphous silicon flat panel array detector. We measured the detector's response to a 6 MV photon beam with regards to modulation transfer function, noise power spectrum, DQE, contrast-to-noise ratio (CNR), signal-to-noise ratio (SNR), and the linearity of the detector's response to dose. Additionally, we compared MLI performance to the single top layer of the MLI and the standard Varian AS-1200 detector. Pre-clinical imaging was done on an anthropomorphic phantom, and the detector's CNR, SNR and spatial resolution were assessed in a clinical environment. Images obtained from spine and liver patient treatment deliveries were analyzed to verify CNR and SNR improvements. The MLI has a DQE(0) of 9.7%, about 5.7 times the reference AS-1200 detector. Improved noise performance largely drives the increase. CNR and SNR of clinical images improved three-fold compared to reference. A novel MLI was characterized and prepared for clinical translation. The MLI substantially improved DQE and CNR performance while maintaining the same resolution. Pre-clinical tests on an anthropomorphic phantom demonstrated improved performance as predicted theoretically. Preliminary patient data were analyzed, confirming improved CNR and SNR. Clinical applications are anticipated to include more accurate soft tissue tracking.

Automated MV markerless tumor tracking for VMAT.

Tumor tracking during radiotherapy treatment can improve dose accuracy, conformity and sparing of healthy tissue. Many methods have been introduced to tackle this challenge utilizing multiple imaging modalities, including a template matching based approach using the megavoltage (MV) on-board portal imager demonstrated on 3D conformal treatments. However, the complexity of treatments is evolving with the introduction of VMAT and IMRT, and successful motion management is becoming more important due to a trend towards hypofractionation. We have developed a markerless lung tumor tracking algorithm, utilizing the electronic portal imager (EPID) of the treatment machine. The algorithm has been specifically adapted to track during complex treatment deliveries with gantry and MLC motion. The core of the algorithm is an adaptive template matching method that relies on template stability metrics and local relative orientations to perform multiple feature tracking simultaneously. Only a single image is required to initialize the algorithm and features are automatically added, modified or removed in response to the input images. This algorithm was evaluated against images collected during VMAT arcs of a dynamic thorax phantom. Dynamic phantom images were collected during radiation delivery for multiple lung SBRT breathing traces and an example patient data set. The tracking error was 1.34 mm for the phantom data and 0.68 mm for the patient data. A multi-region, markerless tracking algorithm has been developed, capable of tracking multiple features simultaneously without requiring any other a priori information. This novel approach delivers robust target localization during complex treatment delivery. The reported tracking error is similar to previous reports for 3D conformal treatments.

SU-D-BRA-03: Simultaneous MV-KV Imaging for Intra-Fractional Motion Management during Volume Modulated Arc Therapy (VMAT) Delivery on the Varian TrueBeam.

PURPOSE: To evaluate a MV-kV intra-fractional imaging technique for use during volume modulated arc therapy (VMAT) with the Varian TrueBeam. METHODS: MV-kV image pairs were acquired intra-fractionally during VMAT delivery. kV images (11 fps) were acquired throughout delivery using a standard pre-programmed imaging template. MV images (9.5 fps) were acquired simultaneously by deploying the EPID and passively collecting the resulting images using Varian proprietary software, iTools Capture. Localization accuracy was evaluated by imaging a Rando phantom implanted with 3 fiducials while moving the couch according to XML- programmed trajectories simulating typical prostate and respiratory motion. VMAT delivery was done using a single 360 degree arc in TrueBeam Developer mode. The effect on accuracy of total MU and gantry speed was studied. To improve image quality, MV frame averaging was performed and the MV and kV images were then registered to their corresponding DRRs using in-house registration software. From these 2D registrations, the 3D position at each MV-kV acquisition point was determined. RESULTS: Between 130 and 390 MV-kV pairs were acquired for each delivery. The mean difference between planned couch and measured fiducial 3D positions with prostate motion was less than 0.03 cm in each direction (SD 0.03 cm). Neither gantry speed nor MU significantly impacted accuracy. for respiratory motion, the mean difference between planned and measured position was less than 0.04 cm. Standard deviation averaged 0.06 cm but increased to 0.12 cm with large instantaneous motion and less MV dose per frame. MV frame averaging and inaccuracies in MV image gantry angle determination also affected accuracy, particularly with significant motion. CONCLUSIONS: With high quality MV imaging, MV-kV localization techniques can be highly accurate, even in the presence of significant motion. As clinical MV-kV methods become available, such techniques can provide an efficient and accurate method for monitoring intra-fractional motion. This work was partially supported through a research agreement with Varian Medical Systems, Palo Alto, CA.

Patient satisfaction with anaesthesia care: development of a psychometric questionnaire and benchmarking among six hospitals in Switzerland and Austria.

BACKGROUND: We describe the development and comparison of a psychometric questionnaire on patient satisfaction with anaesthesia care among six hospitals. METHODS: We used a rigorous protocol: generation of items, construction of the pilot questionnaire, pilot study, statistical analysis (construct validity, factor analysis, reliability analysis), compilation of the final questionnaire, main study, repeated analysis of construct validity and reliability. We compared the mean total problem score and the scores for the dimensions: 'Information/Involvement in decision-making', and 'Continuity of personal care by anaesthetist'. The influence of potential confounding variables was tested (multiple linear regression). RESULTS: The average problem score from all hospitals was 18.6%. Most problems are mentioned in the dimensions 'Information/Involvement in decision-making' (mean problem score: 30.9%) and 'Continuity of personal care by anaesthetist' (mean problem score: 32.2%). The overall assessment of the quality of anaesthesia care was good to excellent in 98.7% of cases. The most important dimension was 'Information/Involvement in decision-making'. The mean total problem score was significantly lower for two hospitals than the total mean for all hospitals (significantly higher at two hospitals) (P<0.05). Amongst the confounding variables considered, age, sex, subjective state of health, type of anaesthesia and level of education had an influence on the total problem score and the two dimensions mentioned. There were only marginal differences with and without the influence of the confounding variables for the different hospitals. CONCLUSIONS: A psychometric questionnaire on patient satisfaction with anaesthesia care must cover areas such as patient information, involvement in decision-making, and contact with the anaesthetist. The assessment using summed scores for dimensions is more informative than a global summed rating. There were significant differences between hospitals. Moreover, the high problem scores indicate a great potential for improvement at all hospitals.