Modeling Elekta VersaHD using the Varian Eclipse treatment planning system for photon beams: A single-institution experience.

The aim of this study was to report a single-institution experience and commissioning data for Elekta VersaHD linear accelerators (LINACs) for photon beams in the Eclipse treatment planning system (TPS). Two VersaHD LINACs equipped with 160-leaf collimators were commissioned. For each energy, the percent-depth-dose (PDD) curves, beam profiles, output factors, leaf transmission factors and dosimetric leaf gaps (DLGs) were acquired in accordance with the AAPM task group reports No. 45 and No. 106 and the vendor-supplied documents. The measured data were imported into Eclipse TPS to build a VersaHD beam model. The model was validated by creating treatment plans spanning over the full-spectrum of treatment sites and techniques used in our clinic. The quality assurance measurements were performed using MatriXX, ionization chamber, and radiochromic film. The DLG values were iteratively adjusted to optimize the agreement between planned and measured doses. Mobius, an independent LINAC logfile-based quality assurance tool, was also commissioned both for routine intensity-modulated radiation therapy (IMRT) QA and as a secondary check for the Eclipse VersaHD model. The Eclipse-generated VersaHD model was in excellent agreement with the measured PDD curves and beam profiles. The measured leaf transmission factors were less than 0.5% for all energies. The model validation study yielded absolute point dose agreement between ionization chamber measurements and Eclipse within ±4% for all cases. The comparison between Mobius and Eclipse, and between Mobius and ionization chamber measurements lead to absolute point dose agreement within ±5%. The corresponding 3D dose distributions evaluated with 3%global/2mm gamma criteria resulted in larger than 90% passing rates for all plans. The Eclipse TPS can model VersaHD LINACs with clinically acceptable accuracy. The model validation study and comparisons with Mobius demonstrated that the modeling of VersaHD in Eclipse necessitates further improvement to provide dosimetric accuracy on par with Varian LINACs.

Classification and evaluation strategies of auto-segmentation approaches for PET: Report of AAPM task group No. 211.

PURPOSE: The purpose of this educational report is to provide an overview of the present state-of-the-art PET auto-segmentation (PET-AS) algorithms and their respective validation, with an emphasis on providing the user with help in understanding the challenges and pitfalls associated with selecting and implementing a PET-AS algorithm for a particular application. APPROACH: A brief description of the different types of PET-AS algorithms is provided using a classification based on method complexity and type. The advantages and the limitations of the current PET-AS algorithms are highlighted based on current publications and existing comparison studies. A review of the available image datasets and contour evaluation metrics in terms of their applicability for establishing a standardized evaluation of PET-AS algorithms is provided. The performance requirements for the algorithms and their dependence on the application, the radiotracer used and the evaluation criteria are described and discussed. Finally, a procedure for algorithm acceptance and implementation, as well as the complementary role of manual and auto-segmentation are addressed. FINDINGS: A large number of PET-AS algorithms have been developed within the last 20 years. Many of the proposed algorithms are based on either fixed or adaptively selected thresholds. More recently, numerous papers have proposed the use of more advanced image analysis paradigms to perform semi-automated delineation of the PET images. However, the level of algorithm validation is variable and for most published algorithms is either insufficient or inconsistent which prevents recommending a single algorithm. This is compounded by the fact that realistic image configurations with low signal-to-noise ratios (SNR) and heterogeneous tracer distributions have rarely been used. Large variations in the evaluation methods used in the literature point to the need for a standardized evaluation protocol. CONCLUSIONS: Available comparison studies suggest that PET-AS algorithms relying on advanced image analysis paradigms provide generally more accurate segmentation than approaches based on PET activity thresholds, particularly for realistic configurations. However, this may not be the case for simple shape lesions in situations with a narrower range of parameters, where simpler methods may also perform well. Recent algorithms which employ some type of consensus or automatic selection between several PET-AS methods have potential to overcome the limitations of the individual methods when appropriately trained. In either case, accuracy evaluation is required for each different PET scanner and scanning and image reconstruction protocol. For the simpler, less robust approaches, adaptation to scanning conditions, tumor type, and tumor location by optimization of parameters is necessary. The results from the method evaluation stage can be used to estimate the contouring uncertainty. All PET-AS contours should be critically verified by a physician. A standard test, i.e., a benchmark dedicated to evaluating both existing and future PET-AS algorithms needs to be designed, to aid clinicians in evaluating and selecting PET-AS algorithms and to establish performance limits for their acceptance for clinical use. The initial steps toward designing and building such a standard are undertaken by the task group members.

An alternative approach to histopathological validation of PET imaging for radiation therapy image-guidance: a proof of concept.

PURPOSE: In radiotherapy, PET images can be used to guide the delivery of selectively escalated doses to biologically relevant tumour subvolumes. Validation of PET for such applications requires demonstration of spatial coincidence between PET tracer uptake pattern and the histopathologically confirmed target. This study introduces a novel approach to histopathological validation of PET image segmentation for radiotherapy guidance. METHODS AND MATERIALS: Sequential tissue sections from surgically excised whole-tumour specimens were used to acquire full 3D-sets of both histopathological images (microscopy) and PET tracer distribution images (autoradiography). After these datasets were accurately registered, a full 3D autoradiographic distribution of PET tracer was reconstructed and used to obtain synthetic PET images (sPET) by simulating the image deterioration induced by processes involved in PET image formation. To illustrate the method, sPET images were used in this study to investigate spatial coincidence between high FDG uptake areas and the distribution of viable tissue in two small animal tumour models. RESULTS: The reconstructed 3D autoradiographic distribution of the PET tracer was spatially coherent, as indicated by the high average value of the normalised pixel-by-pixel correlation of intensities between successive slices (0.84 ± 0.05 and 0.94 ± 0.02). The loss of detail in the sPET images versus the 3D autoradiography was significant as indicated by Dice coefficient values corresponding to the two tumours (0 and 0.1 at 70% threshold). The maximum overlap between the FDG segmented volumes and the extent of the viable tissue as indicated by Dice coefficient values, was 0.8 for one tumour (for the image thresholded at 22% of max intensity) and 0.88 for the other (threshold of 14% of max intensity). CONCLUSION: It was demonstrated that the use of synthetic PET images for histopathological validation allows for bypassing a technically challenging and error-prone step of registering non-invasive PET images with histopathology.

Single-fraction simulation of relative cell survival in response to uniform versus hypoxia-targeted dose escalation.

The purpose of this study was to investigate the increase in cell kill that can be achieved by tumor irradiation with heterogeneous dose distributions targeting hypoxic regions that can be visualized with non-invasive imaging. Starting with a heterogeneous distribution of microvessels, a microscopic two-dimensional model of tumor oxygenation was developed using planar simulation of oxygen diffusion. Non-invasive imaging of hypoxia was simulated taking partial volume effect into account. A dose-modulation scheme was implemented with the goal of delivering higher doses to the hypoxic pixels, as seen in simulated hypoxia images. To determine the relative cell kill in response to hypoxia-targeting irradiation, tumor cell survival fractions were compared to those resulting from treatments delivering the same average dose to the lesion in a spatially uniform fashion. It was shown that hypoxia-targeting dose modulation may be better suited for tumors with low α/ß, low hypoxic fraction and spatially aggregated hypoxic features. Most importantly, it was determined that at low fraction doses there is no cell kill increase from targeting hypoxic regions alone versus escalating the total tumor dose. However, for higher doses per fraction (≥8 Gy/fraction), the effectiveness of hypoxia-targeting irradiation increases, resulting in the tumoricidal effect of up to 30% higher than that of uniform tumor irradiation delivering the same average tumor dose.

Tumour microenvironment heterogeneity affects the perceived spatial concordance between the intratumoural patterns of cell proliferation and 18F-fluorothymidine uptake.

BACKGROUND AND PURPOSE: PET imaging with (18)F-fluorothymidine ((18)F-FLT) can potentially be used to identify tumour subvolumes for selective dose escalation in radiation therapy. The purpose of this study is to analyse the co-localization of intratumoural patterns of cell proliferation with (18)F-FLT tracer uptake. MATERIALS AND METHODS: Mice bearing FaDu or SQ20B xenograft tumours were injected with (18)F-FLT, and bromodeoxyuridine (proliferation marker). Ex vivo images of the spatial pattern of intratumoural (18)F-FLT uptake and that of bromodeoxyuridine DNA incorporation were obtained from thin tumour tissue sections. These images were segmented by thresholding and Relative Operating Characteristic (ROC) curves and Dice similarity indices were evaluated. RESULTS: The thresholds at which maximum overlap occurred between FLT-segmented areas and areas of active cell proliferation were significantly different for the two xenograft tumour models, whereas the median Dice values were not. However, ROC analysis indicated that segmented FLT images were more specific at detecting the proliferation pattern in FaDu tumours than in SQ20B tumours. CONCLUSION: Highly dispersed patterns of cell proliferation observed in certain tumours can affect the perceived spatial concordance between the spatial pattern of (18)F-FLT uptake and that of cell proliferation even when high-resolution ex vivo autoradiography imaging is used for (18)F-FLT imaging.

Comprehensive approach to coregistration of autoradiography and microscopy images acquired from a set of sequential tissue sections.

UNLABELLED: Histopathologic validation of a PET tracer requires assessment of colocalization of the tracer with its intended biologic target. Using thin tissue section autoradiography, it is possible to visualize the spatial distribution of the PET tracer uptake and compare it with the distribution of the intended biologic target (as visualized with immunohistochemistry). The purpose of this study was to develop and evaluate an objective methodology for deformable coregistration of autoradiography and microscopy images acquired from a set of sequential tissue sections. METHODS: Tumor-bearing animals were injected with 3'-deoxy-3'-(18)F-fluorothymidine ((18)F-FLT), (14)C-FDG, and other markers of tumor microenvironment including Hoechst 33342 (blood-flow surrogate). After sacrifice, tumors were excised, frozen, and sectioned. Multiple stacks of sequential 8 µm sections were collected from each tumor. From each stack, the middle (reference) sections were used to obtain images of (18)F-FLT and (14)C-FDG uptake distributions using dual-tracer autoradiography. Sections adjacent to the reference were used to acquire all histopathologic data (e.g., images of cell proliferation, hematoxylin and eosin). Hoechst images were acquired from all sections. To correct for deformations and misalignments induced by tissue processing and image acquisition, the Hoechst image of each nonreference section was deformably registered to the reference Hoechst image. This transformation was then applied to all images acquired from the same tissue section. In this way, all microscopy images were registered to the reference Hoechst image. The Hoechst-to-autoradiography image registration was done using rigid point-set registration based on external markers visible in both images. RESULTS: The mean error of Hoechst to (18)F-FLT autoradiography registration (both images acquired from the same section) was 30.8 ± 20.1 µm. The error of Hoechst-based deformable registration of histopathologic images (acquired from sequential tissue sections) was 23.1 ± 17.9 µm. Total error of registration of autoradiography images to the histopathologic images acquired from adjacent sections was evaluated at 44.9 µm. This coregistration precision supersedes current rigid registration methods with reported errors of 100-200 µm. CONCLUSION: Deformable registration of autoradiography and histopathology images acquired from sequential sections is feasible and accurate when performed using corresponding Hoechst images.

In vivo characterization of a reporter gene system for imaging hypoxia-induced gene expression.

PURPOSE: To characterize a tumor model containing a hypoxia-inducible reporter gene and to demonstrate utility by comparison of reporter gene expression to the uptake and distribution of the hypoxia tracer (18)F-fluoromisonidazole ((18)F-FMISO). METHODS: Three tumors derived from the rat prostate cancer cell line R3327-AT were grown in each of two rats as follows: (1) parental R3327-AT, (2) positive control R3327-AT/PC in which the HSV1-tkeGFP fusion reporter gene was expressed constitutively, (3) R3327-AT/HRE in which the reporter gene was placed under the control of a hypoxia-inducible factor-responsive promoter sequence (HRE). Animals were coadministered a hypoxia-specific marker (pimonidazole) and the reporter gene probe (124)I-2'-fluoro-2'-deoxy-1-beta-d-arabinofuranosyl-5-iodouracil ((124)I-FIAU) 3 h prior to sacrifice. Statistical analysis of the spatial association between (124)I-FIAU uptake and pimonidazole fluorescent staining intensity was then performed on a pixel-by-pixel basis. Utility of this system was demonstrated by assessment of reporter gene expression versus the exogenous hypoxia probe (18)F-FMISO. Two rats, each bearing a single R3327-AT/HRE tumor, were injected with (124)I-FIAU (3 h before sacrifice) and (18)F-FMISO (2 h before sacrifice). Statistical analysis of the spatial association between (18)F-FMISO and (124)I-FIAU on a pixel-by-pixel basis was performed. RESULTS: Correlation coefficients between (124)I-FIAU uptake and pimonidazole staining intensity were: 0.11 in R3327-AT tumors, -0.66 in R3327-AT/PC and 0.76 in R3327-AT/HRE, confirming that only in the R3327-AT/HRE tumor was HSV1-tkeGFP gene expression associated with hypoxia. Correlation coefficients between (18)F-FMISO and (124)I-FIAU uptakes in R3327-AT/HRE tumors were r=0.56, demonstrating good spatial correspondence between the two tracers. CONCLUSIONS: We have confirmed hypoxia-specific expression of the HSV1-tkeGFP fusion gene in the R3327-AT/HRE tumor model and demonstrated the utility of this model for the evaluation of radiolabeled hypoxia tracers.

Dependence of FDG uptake on tumor microenvironment.

PURPOSE: To investigate the factors affecting the (18)F-fluorodeoxyglucose ((18)F-FDG) uptake in tumors at a microscopic level, by correlating it with tumor hypoxia, cellular proliferation, and blood perfusion. METHODS AND MATERIALS: Nude mice bearing Dunning prostate tumors (R3327-AT) were injected with (18)F-FDG and pimonidazole, bromodeoxyuridine, and, 1 min before sacrifice, with Hoechst 33342. Selected tumor sections were imaged by phosphor plate autoradiography, while adjacent sections were used to obtain the images of the spatial distribution of Hoechst 33342, pimonidazole, and bromodeoxyuridine. The images were co-registered and analyzed on a pixel-by-pixel basis. RESULTS: Statistical analysis of the data obtained from these tumors demonstrated that (18)F-FDG uptake was positively correlated with pimonidazole staining intensity in each data set studied. Correlation of FDG uptake with bromodeoxyuridine staining intensity was always negative. In addition, FDG uptake was always negatively correlated with the staining intensity of Hoechst 33342. CONCLUSIONS: For the Dunning prostate tumors studied, FDG uptake was always positively correlated with hypoxia and negatively correlated with both cellular proliferation and blood flow. Therefore, for the tumor model studied, higher FDG uptake is indicative of tumor hypoxia, but neither blood flow nor cellular proliferation.

Assessment of regional tumor hypoxia using 18F-fluoromisonidazole and 64Cu(II)-diacetyl-bis(N4-methylthiosemicarbazone) positron emission tomography: Comparative study featuring microPET imaging, Po2 probe measurement, autoradiography, and fluorescent microscopy in the R3327-AT and FaDu rat tumor models.

PURPOSE: To compare two potential positron emission tomography (PET) tracers of tumor hypoxia in an animal model. METHODS AND MATERIALS: The purported hypoxia imaging agents (18)F-fluoromisonidazole (FMISO) and (64)Cu(II)-diacetyl-bis(N4-methylthiosemicarbazone) (Cu-ATSM) were compared by serial microPET imaging of Fisher-Copenhagen rats bearing the R3327-AT anaplastic rat prostate tumor. Probe measurements of intratumoral Po(2) were compared with the image data. At the microscopic level, the relationship between the spatial distributions of (64)Cu (assessed by digital autoradiography) and tumor hypoxia (assessed by immunofluorescent detection of pimonidazole) was examined. (18)F-FMISO and (64)Cu-ATSM microPET images were also acquired in nude rats bearing xenografts derived from the human squamous cell carcinoma cell line, FaDu. RESULTS: In R3327-AT tumors, the intratumoral distribution of (18)F-FMISO remained relatively constant 1-4 h after injection. However, that of (64)Cu-ATSM displayed a significant temporal evolution for 0.5-20 h after injection in most tumors. In general, only when (64)Cu-ATSM was imaged at later times (16-20 h after injection) did it correspond to the distribution of (18)F-FMISO. Oxygen probe measurements were broadly consistent with (18)F-FMISO and late (64)Cu-ATSM images but not with early (64)Cu-ATSM images. At the microscopic level, a negative correlation was found between tumor hypoxia and (64)Cu distribution when assessed at early times and a positive correlation when assessed at later times. For the FaDu tumor model, the early and late (64)Cu-ATSM microPET images were similar and were in general concordance with the (18)F-FMISO scans. CONCLUSION: The difference in behavior between the R3327-AT and FaDu tumor models suggests a tumor-specific dependence of Cu-ATSM uptake and retention under hypoxic conditions.

Incorporating prior knowledge into beam orientation optimization in IMRT.

PURPOSE: Selection of beam configuration in currently available intensity-modulated radiotherapy (IMRT) treatment planning systems is still based on trial-and-error search. Computer beam orientation optimization has the potential to improve the situation, but its practical implementation is hindered by the excessive computing time associated with the calculation. The purpose of this work is to provide an effective means to speed up the beam orientation optimization by incorporating a priori geometric and dosimetric knowledge of the system and to demonstrate the utility of the new algorithm for beam placement in IMRT. METHODS AND MATERIALS: Beam orientation optimization was performed in two steps. First, the quality of each possible beam orientation was evaluated using beam's-eye-view dosimetrics (BEVD) developed in our previous study. A simulated annealing algorithm was then employed to search for the optimal set of beam orientations, taking into account the BEVD scores of different incident beam directions. During the calculation, sampling of gantry angles was weighted according to the BEVD score computed before the optimization. A beam direction with a higher BEVD score had a higher probability of being included in the trial configuration, and vice versa. The inclusion of the BEVD weighting in the stochastic beam angle sampling process made it possible to avoid spending valuable computing time unnecessarily at "bad" beam angles. An iterative inverse treatment planning algorithm was used for beam intensity profile optimization during the optimization process. The BEVD-guided beam orientation optimization was applied to an IMRT treatment of paraspinal tumor. The advantage of the new optimization algorithm was demonstrated by comparing the calculation with the conventional scheme without the BEVD weighting in the beam sampling. RESULTS: The BEVD tool provided useful guidance for the selection of the potentially good directions for the beams to incident and was used to guide the search for the optimal beam configuration. The BEVD-guided sampling improved both optimization speed and convergence of the calculation. A comparison of several five-field IMRT treatment plans obtained with and without BEVD guidance indicated that the computational efficiency was increased by a factor of approximately 10. CONCLUSION: Incorporation of BEVD information allows for development of a more robust tool for beam orientation optimization in IMRT planning. It enables us to more effectively use the angular degree of freedom in IMRT without paying the excessive computing overhead and brings us one step closer to the goal of automated selection of beam orientations in a clinical environment.

Examination of the effect of increasing the number of radiation beams on a radiation treatment plan.

Within the confines of least-squares operations, it is possible to quantify the effect of the addition of treatment fields or beamlets to a treatment plan. Using linear algebra and eigenvalue perturbation theory, the effect of the increase in number of treatments is shown to be equivalent to adding a perturbation operator. The effect of adding additional fields will be negligible if the perturbation operator is small. The correspondence of this approach to an earlier work in beam-orientation optimization is also demonstrated. Results are presented for prostate, spinal and head and neck cases, and the connection to beam-orientation optimization is examined.