Optical emission-based phantom to verify coincidence of radiotherapy and imaging isocenters on an MR-linac.

PURPOSE: Demonstrate a novel phantom design using a remote camera imaging method capable of concurrently measuring the position of the x-ray isocenter and the magnetic resonance imaging (MRI) isocenter on an MR-linac. METHODS: A conical frustum with distinct geometric features was machined out of plastic. The phantom was submerged in a small water tank, and aligned using room lasers on a MRIdian MR-linac (ViewRay Inc., Cleveland, OH). The phantom physical isocenter was visualized in the MR images and related to the DICOM coordinate isocenter. To view the x-ray isocenter, an intensified CMOS camera system (DoseOptics LLC., Hanover, NH) was placed at the foot of the treatment couch, and centered such that the optical axis of the camera was coincident with the central axis of the treatment bore. Two or four 8.3mm x 24.1cm beams irradiated the phantom from cardinal directions, producing an optical ring on the conical surface of the phantom. The diameter of the ring, measured at the peak intensity, was compared to the known diameter at the position of irradiation to determine the Z-direction offset of the beam. A star-shot method was employed on the front face of the frustum to determine X-Y alignment of the MV beam. Known shifts were applied to the phantom to establish the sensitivity of the method. RESULTS: Couch translations, demonstrative of possible isocenter misalignments, on the order of 1mm were detectable for both the radiotherapy and MRI isocenters. Data acquired on the MR-linac demonstrated an average error of 0.28mm(N=10, R2 =0.997, σ=0.37mm) in established Z displacement, and 0.10mm(N=5, σ=0.34mm) in XY directions of the radiotherapy isocenter. CONCLUSIONS: The phantom was capable of measuring both the MRI and radiotherapy treatment isocenters. This method has the potential to be of use in MR-linac commissioning, and could be streamlined to be valuable in daily constancy checks of isocenter coincidence.

Comparison of surface dose during whole breast radiation therapy on Halcyon and TrueBeam using Cherenkov imaging.

The emergence of the Halcyon linear accelerator has allowed for increased patient throughput and improved treatment times for common treatment sites in radiation oncology. However, it has been shown that this can lead to increased surface dose in sites like breast cancer compared with treatments on conventional machines with flattened radiation beams. Cherenkov imaging can be used to estimate surface dose by detection of Cherenkov photons emitted in proportion to energy deposition from high energy electrons in tissue. Phantom studies were performed with both square beams in reference conditions and with clinical treatments, and dosimeter readings and Cherenkov images report higher surface dose (25% for flat phantom entrance dose, 5.9% for breast phantom treatment) from Halcyon beam deliveries than for equivalent deliveries from a TrueBeam linac. Additionally, the first Cherenkov images of a patient treated with Halcyon were acquired, and superficial dose was estimated.

Evaluation of the cumulative Cherenkov converted dose on TSET patients with multiple Cherenkov cameras.

Cherenkov images can be used for the quality assurance of dose homogeneity in total skin electron therapy (TSET). For the dose mapping purpose, this study reconstructed the patient model from 3D scans using registration algorithms and computer animation techniques. The Cherenkov light emission of the patient's surface was extracted from multi-view Cherenkov images, converted into dose distribution, and projected onto the patient's 3D model, allowing for dose cumulation and evaluation. The projected result from multiple Cherenkov cameras provides additional information about Cherenkov emission on the sides of the patients, which improves the agreement between the Cherenkov converted dose and the OSLD measurements.

Characterization of Cherenkov imaging parameters and positional constraints on an O-ring linear accelerator.

Objective. With the introduction of Cherenkov imaging technology on the Halcyon O-ring linear accelerator platform, we seek to demonstrate the imaging feasibility and optimize camera placement.Approach. Imaging parameters were probed by acquiring triggering data Cherenkov image frames for simplistic beams on the Halcyon and comparing the analyzed metrics with those from the TrueBeam platform. Camera position was analyzed by performing 3D rendering of patient treatment plans for various sites and iterating over camera positions to assess treatment area visibility.Main results. Commercial Cherenkov imaging systems are compatible with the pulse timing of the Halcyon, and this platform design favorably impacts signal to noise in Cherenkov image frames. Additionally, ideal camera placement is treatment site dependent and is always within a biconical zone of visibility centered on the isocenter. Visibility data is provided for four treatment sites, with suggestions for camera placement based on room dimensions. Median visibility values were highest for right breast plans, with values of 80.33% and 68.49% for the front and rear views respectively. Head and neck plans presented with the lowest values at 26.44% and 38.18% respectively.Significance. This work presents the first formal camera positional analysis for Cherenkov imaging on any platform and serves as a template for performing similar work for other irradiation platforms. Additionally, this study confirms the Cherenkov imaging parameters do not need to be changed for optimal imaging on the Halcyon. Lastly, the presented methodology provides a framework which could be further expanded to other optical imaging systems which rely on line of sight visibility to the patient.

One Year of Clinic-Wide Cherenkov Imaging for Discovery of Quality Improvement Opportunities in Radiation Therapy.

PURPOSE: Cherenkov imaging is clinically available as a radiation therapy treatment verification tool. The aim of this work was to discover the benefits of always-on Cherenkov imaging as a novel incident detection and quality improvement system through review of all imaging at our center. METHODS AND MATERIALS: Multicamera Cherenkov imaging systems were permanently installed in 3 treatment bunkers, imaging continuously over a year. Images were acquired as part of normal treatment procedures and reviewed for potential treatment delivery anomalies. RESULTS: In total, 622 unique patients were evaluated for this study. We identified 9 patients with treatment anomalies occurring over their course of treatment, which were only detected with Cherenkov imaging. Categorizing each event indicated issues arising in simulation, planning, pretreatment review, and treatment delivery, and none of the incidents were detected before this review by conventional measures. The incidents identified in this study included dose to unintended areas in planning, dose to unintended areas due to positioning at treatment, and nonideal bolus placement during setup. CONCLUSIONS: Cherenkov imaging was shown to provide a unique method of detecting radiation therapy incidents that would have otherwise gone undetected. Although none of the events detected in this study reached the threshold of reporting, they identified opportunities for practice improvement and demonstrated added value of Cherenkov imaging in quality assurance programs.

Fast Deformable Image Registration for Real-Time Target Tracking During Radiation Therapy Using Cine MRI and Deep Learning.

PURPOSE: We developed a deep learning (DL) model for fast deformable image registration using 2-dimensional sagittal cine magnetic resonance imaging (MRI) acquired during radiation therapy and evaluated its potential for real-time target tracking compared with conventional image registration methods. METHODS AND MATERIALS: Our DL model uses a pair of cine MRI images as input and provides a motion vector field (MVF) as output. The MVF is then applied to align the input images. A retrospective study was conducted to train and evaluate our model using cine MRI data from patients undergoing treatment for abdominal and thoracic tumors. For each treatment fraction, MR-linear accelerator delivery log files, tracking videos, and cine image files were analyzed. Individual MRI frames were temporally sampled to construct a large set of image registration pairs used to evaluate multiple methods. The DL model was optimized using 5-fold cross validation, and model outputs (transformed images and MVFs) using test set images were saved for comparison with 3 conventional registration methods (affine, b-spline, and demons). Evaluation metrics were 3-fold: (1) registration error, (2) MVF stability (both spatial and temporal), and (3) average computation time. RESULTS: We analyzed >21 hours of cine MRI (>629,000 frames) acquired during 86 treatment fractions from 21 patients. In a test set of 10,320 image registration pairs, DL registration outperformed conventional methods in both registration error (affine, b-spline, demons, DL; root mean square error: 0.067, 0.040, 0.036, 0.032; paired t test demons vs DL: t[20] = 4.2, P < .001) and computation time per frame (51, 1150, 4583, 8 ms). Among deformable methods, spatial stability of resulting MVFs was comparable; however, the DL model had significantly improved temporal consistency. CONCLUSIONS: DL-based image registration can leverage large-scale MR cine data sets to outperform conventional registration methods and is a promising solution for real-time deformable motion estimation in radiation therapy.

Color-resolved Cherenkov imaging allows for differential signal detection in blood and melanin content.

Significance: High-energy x-ray delivery from a linear accelerator results in the production of spectrally continuous broadband Cherenkov light inside tissue. In the absence of attenuation, there is a linear relationship between Cherenkov emission and deposited dose; however, scattering and absorption result in the distortion of this linear relationship. As Cherenkov emission exits the absorption by tissue dominates the observed Cherenkov emission spectrum. Spectroscopic interpretation of this effects may help to better relate Cherenkov emission to ionizing radiation dose delivered during radiotherapy. Aim: In this study, we examined how color Cherenkov imaging intensity variations are caused by absorption from both melanin and hemoglobin level variations, so that future Cherenkov emission imaging might be corrected for linearity to delivered dose. Approach: A custom, time-gated, three-channel intensified camera was used to image the red, green, and blue wavelengths of Cherenkov emission from tissue phantoms with synthetic melanin layers and varying blood concentrations. Our hypothesis was that spectroscopic separation of Cherenkov emission would allow for the identification of attenuated signals that varied in response to changes in blood content versus melanin content, because of their different characteristic absorption spectra. Results: Cherenkov emission scaled with dose linearly in all channels. Absorption in the blue and green channels increased with increasing oxy-hemoglobin in the blood to a greater extent than in the red channel. Melanin was found to absorb with only slight differences between all channels. These spectral differences can be used to derive dose from measured Cherenkov emission. Conclusions: Color Cherenkov emission imaging may be used to improve the optical measurement and determination of dose delivered in tissues. Calibration for these factors to minimize the influence of the tissue types and skin tones may be possible using color camera system information based upon the linearity of the observed signals.

Performance comparison of quantitative metrics for analysis of in vivo Cherenkov imaging incident detection during radiotherapy.

OBJECTIVES: Examine the responses of multiple image similarity metrics to detect patient positioning errors in radiotherapy observed through Cherenkov imaging, which may be used to optimize automated incident detection. METHODS: An anthropomorphic phantom mimicking patient vasculature, a biological marker seen in Cherenkov images, was simulated for a breast radiotherapy treatment. The phantom was systematically shifted in each translational direction, and Cherenkov images were captured during treatment delivery at each step. The responses of mutual information (MI) and the γ passing rate (%GP) were compared to that of existing field-shape matching image metrics, the Dice coefficient, and mean distance to conformity (MDC). Patient images containing other incidents were analyzed to verify the best detection algorithm for different incident types. RESULTS: Positional shifts in all directions were registered by both MI and %GP, degrading monotonically as the shifts increased. Shifts in intensity, which may result from erythema or bolus-tissue air gaps, were detected most by %GP. However, neither metric detected beam-shape misalignment, such as that caused by dose to unintended areas, as well as currently employed metrics (Dice and MDC). CONCLUSIONS: This study indicates that different radiotherapy incidents may be detected by comparing both inter- and intrafractional Cherenkov images with a corresponding image similarity metric, varying with the type of incident. Future work will involve determining appropriate thresholds per metric for automatic flagging. ADVANCES IN KNOWLEDGE: Classifying different algorithms for the detection of various radiotherapy incidents allows for the development of an automatic flagging system, eliminating the burden of manual review of Cherenkov images.

Clinical implementation of the first Cherenkov imaging system in a community-based hospital.

Purpose: To document experiences with one year of clinical implementation of the first Cherenkov imaging system and share the methods that we developed to utilize Cherenkov imaging to improve treatment delivery accuracy in real-time. Methods: A Cherenkov imaging system was installed commissioned and calibrated for clinical use. The optimal room lighting conditions and imaging setup protocols were developed to optimize both image quality and patient experience. The Cherenkov images were analyzed for treatment setup and beam delivery verification. Results: We have successfully implemented a clinical Cherenkov imaging system in a community-based hospital. Several radiation therapy patient setup anomalies were found in 1) exit dose to the contralateral breast, 2) dose to the chin due to head rotation for a supraclavicular field, 3) intrafractional patient motion during beam delivery, and 4) large variability (0.5 cm to 5 cm) in arm position between fractions. The system was used to deliver deep inspiration breath hold (DIBH) treatment delivery of an electron treatment beam. Clinical process and procedures were improved to mitigate the identified issues to ensure treatment delivery safety and to improve treatment accuracy. Conclusion: The Cherenkov imaging system has proven to be a valuable clinical tool for the improvement of treatment delivery safety and accuracy at our hospital. With only minimal training the therapists were able to adjust or correct treatment positions during treatment delivery as needed. With future Cherenkov software developments Cherenkov imaging systems could provide daily surface guided radiotherapy (SGRT) and real time treatment delivery quality control for all 3D and clinical setup patients without adding additional radiation image dose as in standard kV, MV and CBCT image verifications. Cherenkov imaging can greatly improve clinical efficiency and accuracy, making real time dose delivery consistency verification and SGRT a reality.

Hawai'i's Opportunity for Active Living Advancement (HO'ALA): addressing childhood obesity through safe routes to school.

Increasing active transportation to and from school may reduce childhood obesity rates in Hawai'i. A community partnership was formed to address this issue in Hawai'i's Opportunity for Active Living Advancement (HO'ALA), a quasi-experimental study of active transportation in Hawai'i County. The purpose of this study was to determine baseline rates for active transportation rates to and from school and to track changes related to macro-level (statewide) policy, locally-based Safe Routes to School (SRTS) programs and bicycle and pedestrian planning initiatives expected to improve the safety, comfort and ease of walking and bicycling to and from school. Measures included parent surveys, student travel tallies, traffic counts and safety observations. Assessments of the walking and biking environment around each school were made using the Pedestrian Environment Data Scan. Complete Streets and SRTS policy implementation was tracked through the activities of a state transportation-led Task Force and an advocacy-led coalition, respectively. Planning initiatives were tracked through citizen-based advisory committees. Thirteen volunteer schools participated as the intervention (n=8) or comparison (n=5) schools. The majority of students were Asian, Native Hawaiian, and Pacific Islander in schools located in under-resourced communities. Overall, few children walked or biked to school. The majority of children were driven to and from school by their parents. With the influence of HO'ALA staff members, two intervention schools were obligated SRTS project funding from the state, schools were identified as key areas in the pedestrian master plan, and one intervention school was slated for a bike plan priority project. As the SRTS programs are implemented in the next phase of the project, post-test data will be collected to ascertain if changes in active transportation rates occur.

Color Cherenkov imaging of clinical radiation therapy.

Color vision is used throughout medicine to interpret the health and status of tissue. Ionizing radiation used in radiation therapy produces broadband white light inside tissue through the Cherenkov effect, and this light is attenuated by tissue features as it leaves the body. In this study, a novel time-gated three-channel camera was developed for the first time and was used to image color Cherenkov emission coming from patients during treatment. The spectral content was interpreted by comparison with imaging calibrated tissue phantoms. Color shades of Cherenkov emission in radiotherapy can be used to interpret tissue blood volume, oxygen saturation and major vessels within the body.

Visual Isocenter Position Enhanced Review (VIPER): a Cherenkov imaging-based solution for MR-linac daily QA.

PURPOSE: This study demonstrates a robust Cherenkov imaging-based solution to MR-Linac daily QA, including mechanical-imaging-radiation isocenter coincidence verification. METHODS: A fully enclosed acrylic cylindrical phantom was designed to be mountable to the existing jig, indexable to the treatment couch. An ABS plastic conical structure was fixed inside the phantom, held in place with 3D-printed spacers, and filled with water allowing for high edge contrast on MR imaging scans. Both a star shot plan and a four-angle sheet beam plan were delivered to the phantom; the former allowed for radiation isocenter localization in the x-z plane (A/P and L/R directions) relative to physical landmarks on the phantom, and the latter allowed for the longitudinal position of the sheet beam to be encoded as a ring of Cherenkov radiation emitted from the phantom, allowing for isocenter localization on the y-axis (S/I directions). A custom software application was developed to perform near-real-time analysis of the data by any clinical user. RESULTS: Calibration procedures show that linearity between longitudinal position and optical ring diameter is high (R2  > 0.99), and that RMSE is low (0.184 mm). The star shot analysis showed a minimum circle radius of 0.34 mm. The final isocenter coincidence measurements in the lateral, longitudinal, and vertical directions were -0.61 mm, 0.55 mm, and -0.14 mm, respectively, and the total 3D distance coincidence was 0.83 mm, with each of these being below 2 mm tolerance. CONCLUSION: This novel system provided an efficient, MR safe, all-in-one method for acquisition and near-real-time analysis of isocenter coincidence data. This represents a direct measurement of the 3D isocentricity. The combination of this phantom and the custom analysis application makes this solution readily clinically deployable after the longitudinal analysis of performance consistency.

Initial Clinical Experience of Cherenkov Imaging in External Beam Radiation Therapy Identifies Opportunities to Improve Treatment Delivery.

PURPOSE: The value of Cherenkov imaging as an on-patient, real-time, treatment delivery verification system was examined in a 64-patient cohort during routine radiation treatments in a single-center study. METHODS AND MATERIALS: Cherenkov cameras were mounted in treatment rooms and used to image patients during their standard radiation therapy regimen for various sites, predominantly for whole breast and total skin electron therapy. For most patients, multiple fractions were imaged, with some involving bolus or scintillators on the skin. Measures of repeatability were calculated with a mean distance to conformity (MDC) for breast irradiation images. RESULTS: In breast treatments, Cherenkov images identified fractions when treatment delivery resulted in dose on the contralateral breast, the arm, or the chin and found nonideal bolus positioning. In sarcoma treatments, safe positioning of the contralateral leg was monitored. For all 199 imaged breast treatment fields, the interfraction MDC was within 7 mm compared with the first day of treatment (with only 7.5% of treatments exceeding 3 mm), and all but 1 fell within 7 mm relative to the treatment plan. The value of imaging dose through clear bolus or quantifying surface dose with scintillator dots was examined. Cherenkov imaging also was able to assess field match lines in cerebral-spinal and breast irradiation with nodes. Treatment imaging of other anatomic sites confirmed the value of surface dose imaging more broadly. CONCLUSIONS: Daily radiation therapy can be imaged routinely via Cherenkov emissions. Both the real-time images and the posttreatment, cumulative images provide surrogate maps of surface dose delivery that can be used for incident discovery and/or continuous improvement in many delivery techniques. In this initial 64-patient cohort, we discovered 6 minor incidents using Cherenkov imaging; these otherwise would have gone undetected. In addition, imaging provides automated, quantitative metrics useful for determining the quality of radiation therapy delivery.

Scintillation imaging as a high-resolution, remote, versatile 2D detection system for MR-linac quality assurance.

PURPOSE: To demonstrate the potential benefits of remote camera-based scintillation imaging for routine quality assurance (QA) measurements for magnetic resonance guided radiotherapy (MRgRT) linear accelerators. METHODS: A wall-mounted CMOS camera with a time-synchronized intensifier was used to image photons produced from a scintillation screen in response to dose deposition from a 6 MV FFF x-ray beam produced by a 0.35 T MR-linac. The oblique angle of the field of view was corrected using a projective transform from a checkerboard calibration target. Output sensitivity and constancy was measured using the scintillator and benchmarked against an A28 ion chamber. Field cross-plane and in-plane profiles were measured for field sizes ranging from 1.68 × 1.66 cm2 to 20.02 × 19.92 cm2 with both scintillation imaging and using an IC profiler. Multileaf collimator (MLC) shifts were introduced to test sensitivity of the scintillation imaging system to small spatial deviations. A picket fence test and star-shot were delivered to both the scintillator and EBT3 film to compare accuracy in measuring MLC positions and isocenter size. RESULTS: The scintillation imaging system showed comparable sensitivity and linearity to the ion chamber in response to changes in machine output down to 0.5 MU (R2  = 0.99). Cross-plane profiles show strong agreement with defined field sizes using full width half maximum (FWHM) measurement of <2 mm for field sizes below 15 cm, but the oblique viewing angle was the limiting factor in accuracy of in-plane profile widths. However, the system provided high-resolution profiles in both directions for constancy measurements. Small shifts in the field position down to 0.5 mm were detectable with <0.1 mm accuracy. Multileaf collimator positions as measured with both scintillation imaging and EBT3 film were measured within ± 1 mm tolerance and both detection systems produced similar isocenter sizes from the star-shot analysis (0.81 and 0.83 mm radii). CONCLUSIONS: Remote scintillation imaging of a two-dimensional screen provided a rapid, versatile, MR-compatible solution to many routine quality assurance procedures including output constancy, profile flatness and symmetry constancy, MLC position verification and isocenter size. This method is high-resolution, does not require post-irradiation readout, and provides simple, instantaneous data acquisition. Full automation of the readout and processing could make this a very simple but effective QA tool, and is adaptable to all medical accelerators.

Detective quantum efficiency of intensified CMOS cameras for Cherenkov imaging in radiotherapy.

In this study the metric of detective quantum efficiency (DQE) was applied to Cherenkov imaging systems for the first time, and results were compared for different detector hardware, gain levels and with imaging processing for noise suppression. Intensified complementary metal oxide semiconductor cameras using different image intensifier designs (Gen3 and Gen2+) were used to image Cherenkov emission from a tissue phantom in order to measure the modulation transfer function (MTF) and noise power spectrum (NPS) of the systems. These parameters were used to calculate the DQE for varying acquisition settings and image processing steps. MTF curves indicated that the Gen3 system had superior contrast transfer and spatial resolution than the Gen2+ system, with [Formula: see text] values of 0.52 mm-1 and 0.31 mm-1, respectively. With median filtering for noise suppression, these values decreased to 0.50 mm-1 and 0.26 mm-1. The maximum NPS values for the Gen3 and Gen2+ systems at high gain were 1.3 × 106 mm2 and 9.1 × 104 mm2 respectively, representing a 14x decrease in noise power for the Gen2+ system. Both systems exhibited increased NPS intensity with increasing gain, while median filtering lowered the NPS. The DQE of each system increased with increasing gain, and at the maximum gain levels the Gen3 system had a low-frequency DQE of 0.31%, while the Gen2+ system had a value of 1.44%. However, at a higher frequency of 0.4 mm-1, these values became 0.54% and 0.03%. Filtering improved DQE for the Gen3 system and reduced DQE for the Gen2+ system and had a mix of detrimental and beneficial qualitative effects by decreasing the spatial resolution and sharpness but also substantially lowering noise. This methodology for DQE measurement allowed for quantitative comparison between Cherenkov imaging cameras and improvements to their sensitivity, and yielded the first formal assessment of Cherenkov image formation efficiency.

Assessment of imaging Cherenkov and scintillation signals in head and neck radiotherapy.

The goal of this study was to test the utility of time-gated optical imaging of head and neck (HN) radiotherapy treatments to measure surface dosimetry in real-time and inform possible interfraction replanning decisions. The benefit of both Cherenkov and scintillator imaging in HN treatments is direct daily feedback on dose, with no change to the clinical workflow. Emission from treatment materials was characterized by measuring radioluminescence spectra during irradiation and comparing emission intensities relative to Cherenkov emission produced in phantoms and scintillation from small plastic targets. HN treatment plans were delivered to a phantom with bolus and mask present to measure impact on signal quality. Interfraction superficial tumor reduction was simulated on a HN phantom, and cumulative Cherenkov images were analyzed in the region of interest (ROI). HN human patient treatment was imaged through the mask and compared with the dose distribution calculated by the treatment planning system. The relative intensity of radioluminescence from the mask was found to be within 30% of the Cherenkov emission intensity from tissue-colored clay. A strong linear relationship between normalized cumulative Cherenkov intensity and tumor size was established ([Formula: see text]). The presence of a mask above a scintillator ROI was found to decrease mean pixel intensity by >40% and increase distribution spread. Cherenkov imaging through mask material is shown to have potential for surface field verification and tracking of superficial anatomy changes between treatment fractions. Imaging of scintillating targets provides a direct imaging of surface dose on the patient and through transparent bolus material. The first imaging of a patient receiving HN radiotherapy was achieved with a signal map which qualitatively matches the surface dose plan.