CTC-ask: a new algorithm for conversion of CT numbers to tissue parameters for Monte Carlo dose calculations applying DICOM RS knowledge

One of the building blocks in Monte Carlo (MC) treatment planning is to convert patient CT data to MC compatible phantoms, consisting of density and media matrices. The resulting dose distribution is highly influenced by the accuracy of the conversion. Two major contributing factors are precise conversion of CT number to density and proper differentiation between air and lung. Existing tools do not address this issue specifically. Moreover, their density conversion may depend on the number of media used. Differentiation between air and lung is an important task in MC treatment planning and misassignment may lead to local dose errors on the order of 10%. A novel algorithm, CTC-ask, is presented in this study. It enables locally confined constraints for the media assignment and is independent of the number of media used for the conversion of CT number to density. MC compatible phantoms were generated for two clinical cases using a CT-conversion scheme implemented in both CTC-ask and the DICOM-RT toolbox. Full MC dose calculation was subsequently conducted and the resulting dose distributions were compared. The DICOM-RT toolbox inaccurately assigned lung in 9.9% and 12.2% of the voxels located outside of the lungs for the two cases studied, respectively. This was completely avoided by CTC-ask. CTC-ask is able to reduce anatomically irrational media assignment. The CTC-ask source code can be made available upon request to the authors

Determining intrafractional prostate motion using four dimensional ultrasound system

BACKGROUND: In prostate radiotherapy, it is essential that the prostate position is within the planned volume during the treatment delivery. The aim of this study is to investigate whether intrafractional motion of the prostate is of clinical consequence, using a novel 4D autoscan ultrasound probe. METHODS: Ten prostate patients were ultrasound (US) scanned at the time of CT imaging and once a week during their course of radiotherapy treatment in an ethics-approved study, using the transperineal Clarity autoscan system (Clarity®, Elekta Inc., Stockholm, Sweden). At each US scanning session (fraction) the prostate was monitored for 2 to 2.5 min, a typical beam-on time to deliver a RapidArc® radiotherapy fraction. The patients were instructed to remain motionless in supine position throughout the US scans. They were also requested to comply with a bladder-filling protocol. In total, 51 monitoring curves were acquired. Data of the prostate motion in three orthogonal directions were analyzed. Finally, the BMI value was calculated to investigate correlation between BMI and the extent of prostate displacement. RESULTS: The patients were cooperative, despite extra time for applying the TPUS scan. The mean (±1SD) of the maximal intrafractional displacements were [mm]; I(+)/S: (0.2 ± 0.9); L(+)/R: (−0.2 ± 0.8); and A(+)/P: (−0.2 ± 1.1), respectively. The largest displacement was 2.8 mm in the posterior direction. The percentage of fractions with displacements larger than 2.0 mm was 4 %, 2 %, and 10 % in the IS, LR, and AP directions, respectively. The mean of the maximal intrafractional Euclidean distance (3D vector) was 0.9 ± 0.6 mm. For 12 % of the fractions the maximal 3D vector displacements were larger than 2.0 mm. At only two fractions (4 %) displacements larger than 3.0 mm were observed. There was no correlation between BMI and the extent of the prostate displacement. CONCLUSIONS: The prostate intrafractional displacement is of no clinically consequence for treatment times in the order of 2 – 2.5 min, which is typical for a RapidArc radiotherapy fraction. However, prostate motion should be considered for longer treatment times eg if applying conventional or IMRT radiotherapy

Evaluation of uterine ultrasound imaging in cervical radiotherapy; a comparison of autoscan and conventional probe

OBJECTIVE: In cervical radiotherapy, it is essential that the uterine position is correctly determined prior to treatment delivery. The aim of this study was to evaluate an autoscan ultrasound (A-US) probe, a motorized transducer creating three-dimensional (3D) images by sweeping, by comparing it with a conventional ultrasound (C-US) probe, where manual scanning is required to acquire 3D images. METHODS: Nine healthy volunteers were scanned by seven operators, using the Clarity(®) system (Elekta, Stockholm, Sweden). In total, 72 scans, 36 scans from the C-US and 36 scans from the A-US probes, were acquired. Two observers delineated the uterine structure, using the software-assisted segmentation in the Clarity workstation. The data of uterine volume, uterine centre of mass (COM) and maximum uterine lengths, in three orthogonal directions, were analyzed. RESULTS: In 53% of the C-US scans, the whole uterus was captured, compared with 89% using the A-US. F-test on 36 scans demonstrated statistically significant differences in interobserver COM standard deviation (SD) when comparing the C-US with the A-US probe for the inferior–superior (p < 0.006), left–right (p < 0.012) and anteroposterior directions (p < 0.001). The median of the interobserver COM distance (Euclidean distance for 36 scans) was reduced from 8.5 (C-US) to 6.0 mm (A-US). An F-test on the 36 scans showed strong significant differences (p < 0.001) in the SD of the Euclidean interobserver distance when comparing the C-US with the A-US scans. The average Dice coefficient when comparing the two observers was 0.67 (C-US) and 0.75 (A-US). The predictive interval demonstrated better interobserver delineation concordance using the A-US probe. CONCLUSION: The A-US probe imaging might be a better choice of image-guided radiotherapy system for correcting for daily uterine positional changes in cervical radiotherapy. ADVANCES IN KNOWLEDGE: Using a novel A-US probe might reduce the uncertainty in interoperator variability during ultrasound scanning

Adaptation requirements due to anatomical changes in free-breathing and deep-inspiration breath-hold for standard and dose-escalated radiotherapy of lung cancer patients

<div><p>ABSTRACT</p><p><b>Background.</b> Radiotherapy of lung cancer patients is subject to uncertainties related to heterogeneities, anatomical changes and breathing motion. Use of deep-inspiration breath-hold (DIBH) can reduce the treated volume, potentially enabling dose-escalated (DE) treatments. This study was designed to investigate the need for adaptation due to anatomical changes, for both standard (ST) and DE plans in free-breathing (FB) and DIBH.</p><p><b>Material and methods.</b> The effect of tumor shrinkage (TS), pleural effusion (PE) and atelectasis was investigated for patients and for a CIRS thorax phantom. Sixteen patients were computed tomography (CT) imaged both in FB and DIBH. Anatomical changes were simulated by CT information editing and re-calculations, of both ST and DE plans, in the treatment planning system. PE was systematically simulated by adding fluid in the dorsal region of the lung and TS by reduction of the tumor volume.</p><p><b>Results.</b> Phantom simulations resulted in maximum deviations in mean dose to the GTV-T (_GTV-T) of −1% for 3 cm PE and centrally located tumor, and + 3% for TS from 5 cm to 1 cm diameter for an anterior tumor location. For the majority of the patients, simulated PE resulted in a decreasing _GTV-T with increasing amount of fluid and increasing _GTV-T for decreasing tumor volume. Maximum change in _GTV-T of -3% (3 cm PE in FB for both ST and DE plans) and + 10% (2 cm TS in FB for DE plan) was observed. Large atelectasis reduction increased the _GTV-T with 2% for FB and had no effect for DIBH.</p><p><b>Conclusion.</b> Phantom simulations provided potential adaptation action levels for PE and TS. For the more complex patient geometry, individual assessment of the dosimetric impact is recommended for both ST and DE plans in DIBH as well as in FB. However, DIBH was found to be superior over FB for DE plans, regarding robustness of _GTV-T to TS.</p></div

Model simulations on the long-term dispersal of 137Cs released into the Pacific Ocean off Fukushima

A sequence of global ocean circulation models, with horizontal mesh sizes of 0.5°, 0.25° and 0.1°, are used to estimate the long-term dispersion by ocean currents and mesoscale eddies of a slowly decaying tracer (half-life of 30 years, comparable to that of 137Cs) from the local waters off the Fukushima Dai-ichi Nuclear Power Plants. The tracer was continuously injected into the coastal waters over some weeks; its subsequent spreading and dilution in the Pacific Ocean was then simulated for 10 years. The simulations do not include any data assimilation, and thus, do not account for the actual state of the local ocean currents during the release of highly contaminated water from the damaged plants in March–April 2011. An ensemble differing in initial current distributions illustrates their importance for the tracer patterns evolving during the first months, but suggests a minor relevance for the large-scale tracer distributions after 2–3 years. By then the tracer cloud has penetrated to depths of more than 400 m, spanning the western and central North Pacific between 25°N and 55°N, leading to a rapid dilution of concentrations. The rate of dilution declines in the following years, while the main tracer patch propagates eastward across the Pacific Ocean, reaching the coastal waters of North America after about 5–6 years. Tentatively assuming a value of 10 PBq for the net 137Cs input during the first weeks after the Fukushima incident, the simulation suggests a rapid dilution of peak radioactivity values to about 10 Bq m−3 during the first two years, followed by a gradual decline to 1–2 Bq m−3 over the next 4–7 years. The total peak radioactivity levels would then still be about twice the pre-Fukushima values

Prevalence, Enabling Factors, and Clinical Outcome

Background: Striatocapsular infarcts (SCIs) are defined as large subcortical infarcts involving the territory of more than one lenticulostriate artery. SCI without concomitant ischemia in the more distal middle cerebral artery (MCA) territory [isolated SCI (iSCI)] has been described as a rare infarct pattern. The purpose of this study was to assess the prevalence of iSCI in patients treated with endovascular thrombectomy (ET), to evaluate baseline and procedural parameters associated with this condition, and to describe the clinical course of iSCI patients. Methods: A retrospective analysis of 206 consecutive patients with an isolated MCA occlusion involving the lenticulostriate arteries and treated with ET was performed. Baseline patient and procedural characteristics and ischemic involvement of the striatocapsular and distal MCA territory [iSCI, as opposed to non-isolated SCI (niSCI)] were analyzed using multivariate logistic regression models. Prevalence of iSCI was assessed, and clinical course was determined with the rates of substantial neurological improvement and good functional short- and mid-term outcome (discharge/day 90 Modified Rankin Scale ≤2). Results: iSCI was detected in 53 patients (25.7%), and niSCI was detected in 153 patients (74.3%). Successful reperfusion [thrombolysis in cerebral infarction (TICI) 2b/3] [adjusted odds ration (aOR) 8.730, 95% confidence interval (95% CI) 1.069–71.308] and good collaterals (aOR 2.100, 95% CI 1.119–3.944) were associated with iSCI. In successfully reperfused patients, TICI 3 was found to be an additional factor associated with iSCI (aOR 5.282, 1.759–15.859). Patients with iSCI had higher rates of substantial neurological improvement (71.7 vs. 37.9%, p < 0.001) and higher rates of good functional short- and mid-term outcome (58.3 vs. 23.7%, p < 0.001 and 71.4 vs. 41.7%, p < 0.001). However, while iSCI patients, in general, had a more favorable outcome, considerable heterogeneity in outcome was observed. Conclusion: High rates of successful reperfusion (TICI 2b/3) and in particular, complete reperfusion (TICI 3) are associated with iSCIs. The high prevalence of iSCI in successfully reperfused patients with good collaterals corroborates previous concepts of iSCI pathogenesis. iSCI, once considered a rare pattern of cerebral ischemia, is likely to become more prevalent with increases in endovascular stroke therapy. This may have implications for patient rehabilitation and pathophysiological analyses of ischemic damage confined to subcortical regions of the MCA territory