Expanding the use of real-time electromagnetic tracking in radiation oncology.

In the past 10 years, techniques to improve radiotherapy delivery, such as intensity-modulated radiation therapy (IMRT), image-guided radiation therapy (IGRT) for both inter- and intrafraction tumor localization, and hypofractionated delivery techniques such as stereotactic body radiation therapy (SBRT), have evolved tremendously. This review article focuses on only one part of that evolution, electromagnetic tracking in radiation therapy. Electromagnetic tracking is still a growing technology in radiation oncology and, as such, the clinical applications are limited, the expense is high, and the reimbursement is insufficient to cover these costs. At the same time, current experience with electromagnetic tracking applied to various clinical tumor sites indicates that the potential benefits of electromagnetic tracking could be significant for patients receiving radiation therapy. Daily use of these tracking systems is minimally invasive and delivers no additional ionizing radiation to the patient, and these systems can provide explicit tumor motion data. Although there are a number of technical and fiscal issues that need to be addressed, electromagnetic tracking systems are expected to play a continued role in improving the precision of radiation delivery

Multivariate Statistical Techniques for Accurately and Noninvasively Localizing Tumors Subject to Respiration-Induced Motion

Tumors in the lung, liver, and pancreas can move considerably with normal respiration. The tumor motion extent, path, and baseline position change over time. This creates a complex "moving target" for external beam radiation and is a major obstacle to treating cancer. Real-time tumor motion compensation systems have emerged, but device performance is limited by tumor localization accuracy. Direct tumor tracking is not feasible for these tumors, but tumor displacement can be predicted from surrogate measurements of respiration. In this dissertation, we have developed a series of multivariate statistical techniques for reliably and accurately localizing tumors from respiratory surrogate markers affixed to the torso surface. Our studies utilized radiographic tumor localizations measured concurrently with optically tracked respiratory surrogates during 176 lung, liver, and pancreas radiation treatment and dynamic MR imaging sessions. We identified measurement precision, tumor-surrogate correlation, training data selection, inter-patient variations, and algorithm design as factors impacting localization accuracy. Training data timing was particularly important, as tumor localization errors increased over time in 63% of 30-min treatments. This was a result of the changing relationship between surrogate signals and tumor motion. To account for these changes, we developed a method for detecting and correcting large localization errors. By monitoring the surrogate-to-surrogate and surrogate-to-model relationships, tumor localization errors exceeding 3 mm could be detected at a sensitivity of 95%. The method that we have proposed and validated in this dissertation leads to 69% fewer treatment interruptions than conventional respiratory surrogate model monitoring techniques. Finally, we extended respiratory surrogate-based tumor motion prediction to the otherwise time-consuming process of contouring respiratory-correlated computed tomography scans. This dissertation clarifies the scope and significance of problems underlying existing surrogate-based tumor localization models. Furthermore, it presents novel solutions that make it possible to improve radiation delivery to tumors without increasing the time required to plan and deliver radiation treatments

Advances in real-time thoracic guidance systems

Substantial tissue motion: \u3e1cm) arises in the thoracic/abdominal cavity due to respiration. There are many clinical applications in which localizing tissue with high accuracy: \u3c1mm) is important. Potential applications include radiation therapy, radio frequency ablation, lung/liver biopsies, and brachytherapy seed placement. Recent efforts have made highly accurate sub-mm 3D localization of discrete points available via electromagnetic: EM) position monitoring. Technology from Calypso Medical allows for simultaneous tracking of up to three implanted wireless transponders. Additionally, Medtronic Navigation uses wired electromagnetic tracking to guide surgical tools for image guided surgery: IGS). Utilizing real-time EM position monitoring, a prototype system was developed to guide a therapeutic linear accelerator to follow a moving target: tumor) within the lung/abdomen. In a clinical setting, electromagnetic transponders would be bronchoscopically implanted into the lung of the patient in or near the tumor. These transponders would ax to the lung tissue in a stable manner and allow real-time position knowledge throughout a course of radiation therapy. During each dose of radiation, the beam is either halted when the target is outside of a given threshold, or in a later study the beam follows the target in real-time based on the EM position monitoring. We present quantitative analysis of the accuracy and efficiency of the radiation therapy tumor tracking system. EM tracking shows promise for IGS applications. Tracking the position of the instrument tip allows for minimally invasive intervention and alleviates the trauma associated with conventional surgery. Current clinical IGS implementations are limited to static targets: e.g. craniospinal, neurological, and orthopedic intervention. We present work on the development of a respiratory correlated image guided surgery: RCIGS) system. In the RCIGS system, target positions are modeled via respiratory correlated imaging: 4DCT) coupled with a breathing surrogate representative of the patient\u27s respiratory phase/amplitude. Once the target position is known with respect to the surrogate, intervention can be performed when the target is in the correct location. The RCIGS system consists of imaging techniques and custom developed software to give visual and auditory feedback to the surgeon indicating both the proper location and time for intervention. Presented here are the details of the IGS lung system along with quantitative results of the system accuracy in motion phantom, ex-vivo porcine lung, and human cadaver environments

Electromagnetic Tracking for Medical Imaging

This thesis explores the novel use of a wireless electromagnetic: EM) tracking device in a Computed Tomography: CT) environment. The sources of electromagnetic interference inside a Philips Brilliant Big Bore CT scanner are analyzed. A research version of the Calypso wireless tracking system was set up inside the CT suite, and a set of three Beacon transponders was bonded to a plastic fixture. The tracking system was tested under different working parameters including orientation of tracking beacons, the gain level of the frontend amplifier, the distance between the transponders and the sensor array, the rotation speed of the CT gantry, and the presence/absence of the CT X-ray source. The performance of the tracking system reveals two obvious factors which bring in electromagnetic interference: 1) metal like effect brought in by carbon fiber patient couch and 2) electromagnetic disturbance due to spinning metal inside the CT gantry. The accuracy requirements for electromagnetic tracking in the CT environment are a Root Mean Square: RMS) error of \u3c2 mm in stationary position tracking. Within a working volume of 120×120×120 mm3 centered 200 mm below the sensor array, the tracking system achieves the desired clinical goal

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

A precision translation stage for reproducing measured target volume motions

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135505/1/acm20111.pd

Clinical practice vs. state-of-the-art research and future visions:Report on the 4D treatment planning workshop for particle therapy - Edition 2018 and 2019

The 4D Treatment Planning Workshop for Particle Therapy, a workshop dedicated to the treatment of moving targets with scanned particle beams, started in 2009 and since then has been organized annually. The mission of the workshop is to create an informal ground for clinical medical physicists, medical physics researchers and medical doctors interested in the development of the 4D technology, protocols and their translation into clinical practice. The 10th and 11th editions of the workshop took place in Sapporo, Japan in 2018 and Krakow, Poland in 2019, respectively. This review report from the Sapporo and Krakow workshops is structured in two parts, according to the workshop programs. The first part comprises clinicians and physicists review of the status of 4D clinical implementations. Corresponding talks were given by speakers from five centers around the world: Maastro Clinic (The Netherlands), University Medical Center Groningen (The Netherlands), MD Anderson Cancer Center (United States), University of Pennsylvania (United States) and The Proton Beam Therapy Center of Hokkaido University Hospital (Japan). The second part is dedicated to novelties in 4D research, i.e. motion modelling, artificial intelligence and new technologies which are currently being investigated in the radiotherapy field

Real-time intrafraction motion monitoring in external beam radiotherapy

© 2019 Institute of Physics and Engineering in Medicine. Radiotherapy (RT) aims to deliver a spatially conformal dose of radiation to tumours while maximizing the dose sparing to healthy tissues. However, the internal patient anatomy is constantly moving due to respiratory, cardiac, gastrointestinal and urinary activity. The long term goal of the RT community to 'see what we treat, as we treat' and to act on this information instantaneously has resulted in rapid technological innovation. Specialized treatment machines, such as robotic or gimbal-steered linear accelerators (linac) with in-room imaging suites, have been developed specifically for real-time treatment adaptation. Additional equipment, such as stereoscopic kilovoltage (kV) imaging, ultrasound transducers and electromagnetic transponders, has been developed for intrafraction motion monitoring on conventional linacs. Magnetic resonance imaging (MRI) has been integrated with cobalt treatment units and more recently with linacs. In addition to hardware innovation, software development has played a substantial role in the development of motion monitoring methods based on respiratory motion surrogates and planar kV or Megavoltage (MV) imaging that is available on standard equipped linacs. In this paper, we review and compare the different intrafraction motion monitoring methods proposed in the literature and demonstrated in real-time on clinical data as well as their possible future developments. We then discuss general considerations on validation and quality assurance for clinical implementation. Besides photon RT, particle therapy is increasingly used to treat moving targets. However, transferring motion monitoring technologies from linacs to particle beam lines presents substantial challenges. Lessons learned from the implementation of real-time intrafraction monitoring for photon RT will be used as a basis to discuss the implementation of these methods for particle RT

A comparison of gantry-mounted x-ray-based real-time target tracking methods.

PURPOSE: Most modern radiotherapy machines are built with a 2D kV imaging system. Combining this imaging system with a 2D-3D inference method would allow for a ready-made option for real-time 3D tumor tracking. This work investigates and compares the accuracy of four existing 2D-3D inference methods using both motion traces inferred from external surrogates and measured internally from implanted beacons. METHOD: Tumor motion data from 160 fractions (46 thoracic/abdominal patients) of Synchrony traces (inferred traces), and 28 fractions (7 lung patients) of Calypso traces (internal traces) from the LIGHT SABR trial (NCT02514512) were used in this study. The motion traces were used as the ground truth. The ground truth trajectories were used in silico to generate 2D positions projected on the kV detector. These 2D traces were then passed to the 2D-3D inference methods: interdimensional correlation, Gaussian probability density function (PDF), arbitrary-shape PDF, and the Kalman filter. The inferred 3D positions were compared with the ground truth to determine tracking errors. The relationships between tracking error and motion magnitude, interdimensional correlation, and breathing periodicity index (BPI) were also investigated. RESULTS: Larger tracking errors were observed from the Calypso traces, with RMS and 95th percentile 3D errors of 0.84-1.25 mm and 1.72-2.64 mm, compared to 0.45-0.68 mm and 0.74-1.13 mm from the Synchrony traces. The Gaussian PDF method was found to be the most accurate, followed by the Kalman filter, the interdimensional correlation method, and the arbitrary-shape PDF method. Tracking error was found to strongly and positively correlate with motion magnitude for both the Synchrony and Calypso traces and for all four methods. Interdimensional correlation and BPI were found to negatively correlate with tracking error only for the Synchrony traces. The Synchrony traces exhibited higher interdimensional correlation than the Calypso traces especially in the anterior-posterior direction. CONCLUSION: Inferred traces often exhibit higher interdimensional correlation, which are not true representation of thoracic/abdominal motion and may underestimate kV-based tracking errors. The use of internal traces acquired from systems such as Calypso is advised for future kV-based tracking studies. The Gaussian PDF method is the most accurate 2D-3D inference method for tracking thoracic/abdominal targets. Motion magnitude has significant impact on 2D-3D inference error, and should be considered when estimating kV-based tracking error

Improving Radiotherapy Targeting for Cancer Treatment Through Space and Time

Radiotherapy is a common medical treatment in which lethal doses of ionizing radiation are preferentially delivered to cancerous tumors. In external beam radiotherapy, radiation is delivered by a remote source which sits several feet from the patient\u27s surface. Although great effort is taken in properly aligning the target to the path of the radiation beam, positional uncertainties and other errors can compromise targeting accuracy. Such errors can lead to a failure in treating the target, and inflict significant toxicity to healthy tissues which are inadvertently exposed high radiation doses. Tracking the movement of targeted anatomy between and during treatment fractions provides valuable localization information that allows for the reduction of these positional uncertainties. Inter- and intra-fraction anatomical localization data not only allows for more accurate treatment setup, but also potentially allows for 1) retrospective treatment evaluation, 2) margin reduction and modification of the dose distribution to accommodate daily anatomical changes (called `adaptive radiotherapy\u27), and 3) targeting interventions during treatment (for example, suspending radiation delivery while the target it outside the path of the beam). The research presented here investigates the use of inter- and intra-fraction localization technologies to improve radiotherapy to targets through enhanced spatial and temporal accuracy. These technologies provide significant advancements in cancer treatment compared to standard clinical technologies. Furthermore, work is presented for the use of localization data acquired from these technologies in adaptive treatment planning, an investigational technique in which the distribution of planned dose is modified during the course of treatment based on biological and/or geometrical changes of the patient\u27s anatomy. The focus of this research is directed at abdominal sites, which has historically been central to the problem of motion management in radiation therapy