The management of imaging dose during imageâ guided radiotherapy: Report of the AAPM Task Group 75

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/134823/1/mp5667.pd

Recent Advances in Image-Guided Radiotherapy for Head and Neck Carcinoma

Radiotherapy has a well-established role in the management of head and neck cancers. Over the past decade, a variety of new imaging modalities have been incorporated into the radiotherapy planning and delivery process. These technologies are collectively referred to as image-guided radiotherapy and may lead to significant gains in tumor control and radiation side effect profiles. In the following review, these techniques as they are applied to head and neck cancer patients are described, and clinical studies analyzing their use in target delineation, patient positioning, and adaptive radiotherapy are highlighted. Finally, we conclude with a brief discussion of potential areas of further radiotherapy advancement

Anniversary Paper: A sampling of novel technologies and the role of medical physicists in radiation oncology

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135037/1/mp1006.pd

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

On the development of a novel detector for simultaneous imaging and dosimetry in radiotherapy

Radiotherapy uses x-ray beams to deliver prescribed radiation doses that conform to target anatomy and minimise exposure of healthy tissue. Accuracy of dose delivery is essential, thus verification of dose distributions in vivo is desirable to monitor treatments and prevent errors from compromising patient outcomes. Electronic portal imaging devices (EPIDs) are commonly used x-ray imagers, however their non water-equivalent response complicates use for dosimetry. In this thesis, a Monte Carlo (MC) model of a standard EPID was developed and extended to novel water-equivalent configurations based on prototypes in which the high atomic number components were replaced with an array of plastic scintillator fibres. The model verified that full simulation of optical transport is not necessary to predict the standard EPID dose response, which can be accurately quantified from energy deposited in the phosphor screen. By incorporating computed tomography images into the model, its capacity to predict portal dose images of humanoid anatomy was also demonstrated. The prototype EPID’s water-equivalent dose response was characterised experimentally and with the MC model. Despite exhibiting lower spatial resolution and contrast-to-noise ratio relative to the standard EPID, its image quality was sufficient to discern gross anatomical structures of an anthropomorphic phantom. Opportunities to improve imaging performance while maintaining a water-equivalent dose response were identified using the model. Longer fibres increased efficiency and use of an extra-mural absorber maximised spatial resolution. Optical coupling between the scintillator fibres and the imaging panel may further improve performance. This thesis demonstrates the feasibility of developing a next-generation EPID for simultaneous imaging and dosimetry in radiotherapy. Such a detector could monitor treatment deliveries in vivo and thereby facilitate adaptations to treatment plans in order to improve patient outcomes

On the development of a novel detector for simultaneous imaging and dosimetry in radiotherapy

Radiotherapy uses x-ray beams to deliver prescribed radiation doses that conform to target anatomy and minimise exposure of healthy tissue. Accuracy of dose delivery is essential, thus verification of dose distributions in vivo is desirable to monitor treatments and prevent errors from compromising patient outcomes. Electronic portal imaging devices (EPIDs) are commonly used x-ray imagers, however their non water-equivalent response complicates use for dosimetry. In this thesis, a Monte Carlo (MC) model of a standard EPID was developed and extended to novel water-equivalent configurations based on prototypes in which the high atomic number components were replaced with an array of plastic scintillator fibres. The model verified that full simulation of optical transport is not necessary to predict the standard EPID dose response, which can be accurately quantified from energy deposited in the phosphor screen. By incorporating computed tomography images into the model, its capacity to predict portal dose images of humanoid anatomy was also demonstrated. The prototype EPID’s water-equivalent dose response was characterised experimentally and with the MC model. Despite exhibiting lower spatial resolution and contrast-to-noise ratio relative to the standard EPID, its image quality was sufficient to discern gross anatomical structures of an anthropomorphic phantom. Opportunities to improve imaging performance while maintaining a water-equivalent dose response were identified using the model. Longer fibres increased efficiency and use of an extra-mural absorber maximised spatial resolution. Optical coupling between the scintillator fibres and the imaging panel may further improve performance. This thesis demonstrates the feasibility of developing a next-generation EPID for simultaneous imaging and dosimetry in radiotherapy. Such a detector could monitor treatment deliveries in vivo and thereby facilitate adaptations to treatment plans in order to improve patient outcomes

Developments in PET-MRI for Radiotherapy Planning Applications

The hybridization of magnetic resonance imaging (MRI) and positron emission tomography (PET) provides the benefit of soft-tissue contrast and specific molecular information in a simultaneous acquisition. The applications of PET-MRI in radiotherapy are only starting to be realised. However, quantitative accuracy of PET relies on accurate attenuation correction (AC) of, not only the patient anatomy but also MRI hardware and current methods, which are prone to artefacts caused by dense materials. Quantitative accuracy of PET also relies on full characterization of patient motion during the scan. The simultaneity of PET-MRI makes it especially suited for motion correction. However, quality assurance (QA) procedures for such corrections are lacking. Therefore, a dynamic phantom that is PET and MR compatible is required. Additionally, respiratory motion characterization is needed for conformal radiotherapy of lung. 4D-CT can provide 3D motion characterization but suffers from poor soft-tissue contrast. In this thesis, I examine these problems, and present solutions in the form of improved MR-hardware AC techniques, a PET/MRI/CT-compatible tumour respiratory motion phantom for QA measurements, and a retrospective 4D-PET-MRI technique to characterise respiratory motion. Chapter 2 presents two techniques to improve upon current AC methods that use a standard helical CT scan for MRI hardware in PET-MRI. One technique uses a dual-energy computed tomography (DECT) scan to construct virtual monoenergetic image volumes and the other uses a tomotherapy linear accelerator to create CT images at megavoltage energies (1.0 MV) of the RF coil. The DECT-based technique reduced artefacts in the images translating to improved μ-maps. The MVCT-based technique provided further improvements in artefact reduction, resulting in artefact free μ-maps. This led to more AC of the breast coil. In chapter 3, I present a PET-MR-CT motion phantom for QA of motion-correction protocols. This phantom is used to evaluate a clinically available real-time dynamic MR images and a respiratory-triggered PET-MRI protocol. The results show the protocol to perform well under motion conditions. Additionally, the phantom provided a good model for performing QA of respiratory-triggered PET-MRI. Chapter 4 presents a 4D-PET/MRI technique, using MR sequences and PET acquisition methods currently available on hybrid PET/MRI systems. This technique is validated using the motion phantom presented in chapter 3 with three motion profiles. I conclude that our 4D-PET-MRI technique provides information to characterise tumour respiratory motion while using a clinically available pulse sequence and PET acquisition method

Commissioning, Benchmarking and Clinical Application of a Novel Fiber Optic CT Scanner for Precise Three-Dimensional Radiation Dosimetry

Radiotherapy is a prominent cancer treatment modality in medicine, aiming to deliver adequate doses to the target while minimizing harm to healthy tissue. Recent advancements in computer technology, machine engineering, and imaging have facilitated intricate treatment planning and accurate radiation administration. These advancements have allowed for more precise dose distributions to be delivered to cancer patients. However, even small discrepancies in setup or delivery can result in significant dose variations. While treatment planning systems provide 3D dose calculations, there is currently a lack of 3D measurement tools in the clinic to verify the accuracy of dose calculation and delivery. Presently, medical physicists rely on 2D dose plane comparisons with treatment planning calculations using gamma index analyses. However, these results do not directly correlate with clinical dose-volume constraints, and detecting delivery errors using 1D or 2D dosimetry is challenging. The implementation of 3D dosimetry not only ensures the safety of radiation treatment but also facilitates the development of new emerging radiation treatment techniques. This study aims to commission and validate a clinically viable optical scanner for 3D dosimetry and apply the developed system to address current clinical and pre-clinical challenges, thereby advancing our understanding of treatment uncertainties in modern radiotherapy. The optical CT scanner that was developed comprises four key components: an LED illuminator, an aquarium with matching fluid, a fiber optic taper, and a CCD camera. The LED illuminator emits uniform and parallel red light at a peak wavelength of 625 nm and a full width at half maximum (FWHM) of 20 nm in continuous mode. The aquarium is constructed with transparent acrylic walls and is designed to accommodate the 3D dosimeter PRESAGE, which can be fixed on a rotation stage inside the tank. Clear acrylic has excellent optical clarity and light transmission, with a refractive index of 1.49 that is close to the average refractive index (1.54) of PRESAGE. To match the refractive index of the 3D dosimeters, a matching liquid composed of 90% Octyl Salicylate and 10% Octyl-P-Methoxy Cinnamate is filled in the tank. The fiber optic taper serves two functions: first, it demagnifies the projection images while preserving their shape, and second, it effectively reduces the acceptance angle of the light reaching the CCD camera. The CCD camera used in the system is an Allied Vision model with a resolution of 0.016 mm, capable of acquiring 2D projection images from various angles. The principle of the optical CT scanner follows that of CT imaging, where 2D projection images from different angles are used to reconstruct volumetric 3D dose images using the filtered back projection technique. To validate the dosimetric measurements and assess the uncertainties of the 3D dosimetry system, 21 benchmark experiments, including mechanical, imaging, and dosimetry tests were conducted. Furthermore, the developed system was employed for various applications, including patient-specific IMRT QA, small field dosimetry using kilovoltage and megavoltage beams, as well as end-to-end testing of stereotactic radiosurgery. A comprehensive analysis assessed uncertainties in each scanner component. Mechanical tests showed maximum uncertainties below 1%. By employing background subtraction and calibration techniques, measurement uncertainty was reduced to <1% in the optimal dose range. Background subtraction resulted in a remarkable 77% reduction in uncertainty by mitigating artifacts, ambient light, and refractive light. Reproducibility was excellent, with mean and standard deviation of dose differences below 0.4% and 1.1%, respectively, in three repeat scans. Dose distribution measurements exhibited strong agreement (passing rates: 98%-100%) between 3D measurements, treatment planning calculations, and EBT3 film dosimetry. Results confirm the optical CT scanner's robustness and accuracy for clinical 3D radiation dosimetry. The study also demonstrates that the developed 3D dosimetry system surpasses the limitations of traditional 2D gamma tests by providing clinicians with more clinically relevant information. This includes measured dose-volume histograms (DVHs) and the evaluation of gamma failing points in 3D space, enabling a comprehensive assessment of individual treatment plans. Furthermore, the study showcased the feasibility of utilizing this system to characterize a radiosurgery platform. It successfully assessed mechanical and dosimetric errors in off-axis delivery and evaluated the accuracy of treatment planning dose calculations, including modeling small fields, out-of-field dose, and multi-leaf collimator (MLC) characteristics. In addition, compelling evidence was presented that the high-resolution 3D dosimeter used in this study is capable of accurate dosimetry for both megavoltage and kilovoltage small fields. Importantly, the dosimeter exhibits no energy or dose rate dependence, further supporting its reliability and suitability for precise dosimetry measurements. The intricate and three-dimensional nature of dose distributions in modern radiotherapy necessitated the development of 3D dosimetry measurements, particularly for treatments with precise margins, such as SRS and SBRT. The newly developed 3D dosimetry system offers significant enhancements to current QA practices, delivering more clinically relevant comparison results and bolstering patient safety. Furthermore, it can be utilized for independent inspections across multiple institutions or remote dosimetry verification. Beyond its applications in clinical settings, the presented 3D dosimetry system holds the potential to expedite the development and utilization of novel radiation platforms