The effects of computed tomography image characteristics and knot spacing on the spatial accuracy of B-spline deformable image registration in the head and neck geometry

Objectives: To explore the effects of computed tomography (CT) image characteristics and B-spline knot spacing (BKS) on the spatial accuracy of a B-spline deformable image registration (DIR) in the head-and-neck geometry. Methods: The effect of image feature content, image contrast, noise, and BKS on the spatial accuracy of a B-spline DIR was studied. Phantom images were created with varying feature content and varying contrast-to-noise ratio (CNR), and deformed using a known smooth B-spline deformation. Subsequently, the deformed images were repeatedly registered with the original images using different BKSs. The quality of the DIR was expressed as the mean residual displacement (MRD) between the known imposed deformation and the result of the B-spline DIR. Finally, for three patients, head-and-neck planning CT scans were deformed with a realistic deformation field derived from a rescan CT of the same patient, resulting in a simulated deformed image and an a-priori known deformation field. Hence, a B-spline DIR was performed between the simulated image and the planning CT at different BKSs. Similar to the phantom cases, the DIR accuracy was evaluated by means of MRD. Results: In total, 162 phantom registrations were performed with varying CNR and BKSs. MRD-values = +/- 250 HU and noise <+/- 200 HU. Decreasing the image feature content resulted in increased MRD-values at all BKSs. Using BKS = 15 mm for the three clinical cases resulted in an average MRD <1.0 mm. Conclusions: For synthetically generated phantoms and three real CT cases the highest DIR accuracy was obtained for a BKS between 10-20 mm. The accuracy decreased with decreasing image feature content, decreasing image contrast, and higher noise levels. Our results indicate that DIR accuracy in clinical CT images (typical noise levels <+/- 100 HU) will not be effected by the amount of image noise

Reproducibility of the lung anatomy under Active Breathing Coordinator control: Dosimetric consequences for scanned proton treatments.

Purpose/Objective The treatment of moving targets with scanning proton beams is challenging. By controlling lung volumes, Active Breathing Control (ABC) assists breath-holding for motion mitigation. The delivery of proton treatment fractions often exceeds feasible breath-hold durations, requiring high breath-hold reproducibility. Therefore, we investigated dosimetric consequences of anatomical reproducibility uncertainties in the lung under ABC, evaluating robustness of scanned proton treatments during breath-hold. Material/Methods T1-weighted MRIs of five volunteers were acquired during ABC, simulating image acquisition during four subsequent breath-holds within one treatment fraction. Deformation vector fields obtained from these MRIs were used to deform 95% inspiration phase CTs of 3 randomly selected non-small-cell lung cancer patients (Figure 1). Per patient, an intensity-modulated proton plan was recalculated on the 3 deformed CTs, to assess the dosimetric influence of anatomical breath-hold inconsistencies. Results Dosimetric consequences were negligible for patient 1 and 2 (Figure 1). Patient 3 showed a decreased volume (95.2%) receiving 95% of the prescribed dose for one deformed CT. The volume receiving 105% of the prescribed dose increased from 0.0% to 9.9%. Furthermore, the heart volume receiving 5 Gy varied by 2.3%. Figure 2 shows dose volume histograms for all relevant structures in patient 3. Conclusion Based on the studied patients, our findings suggest that variations in breath-hold have limited effect on the dose distribution for most lung patients. However, for one patient, a significant decrease in target coverage was found for one of the deformed CTs. Therefore, further investigation of dosimetric consequences from intra-fractional breath-hold uncertainties in the lung under ABC is needed

Head and neck IMPT probabilistic dose accumulation:Feasibility of a 2 mm setup uncertainty setting

OBJECTIVE: To establish optimal robust optimization uncertainty settings for clinical head and neck cancer (HNC) patients undergoing 3D image-guided pencil beam scanning (PBS) proton therapy. METHODS: We analyzed ten consecutive HNC patients treated with 70 and 54.25 GyRBE to the primary and prophylactic clinical target volumes (CTV) respectively using intensity-modulated proton therapy (IMPT). Clinical plans were generated using robust optimization with 5 mm/3% setup/range uncertainties (RayStation v6.1). Additional plans were created for 4, 3, 2 and 1 mm setup and 3% range uncertainty and for 3 mm setup and 3%, 2% and 1% range uncertainty. Systematic and random error distributions were determined for setup and range uncertainties based on our quality assurance program. From these, 25 treatment scenarios were sampled for each plan, each consisting of a systematic setup and range error and daily random setup errors. Fraction doses were calculated on the weekly verification CT closest to the date of treatment as this was considered representative of the daily patient anatomy. RESULTS: Plans with a 2 mm/3% setup/range uncertainty setting adequately covered the primary and prophylactic CTV (V95≥ 99% in 98.8% and 90.8% of the treatment scenarios respectively). The average organ-at-risk dose decreased with 1.1 GyRBE/mm setup uncertainty reduction and 0.5 GyRBE/1% range uncertainty reduction. Normal tissue complication probabilities decreased by 2.0%/mm setup uncertainty reduction and by 0.9%/1% range uncertainty reduction. CONCLUSION: The results of this study indicate that margin reduction below 3 mm/3% is possible but requires a larger cohort to substantiate clinical introduction

Selection of head and neck cancer patients for adaptive radiotherapy to decrease xerostomia

AbstractBackground and purposeThe aim of this study was to develop and validate a method to select head and neck cancer patients for adaptive radiotherapy (ART) pre-treatment. Potential pre-treatment selection criteria presented in recent literature were included in the analysis.Materials and methodsDeviations from the planned parotid gland mean dose (PG ΔDmean) were estimated for 113 head and neck cancer patients by re-calculating plans on repeat CT scans. Uni- and multivariable linear regression analyses were performed to select pre-treatment parameters, and ROC curve analysis was used to determine cut off values, for selecting patients with a PG dose deviation larger than 3Gy. The patient selection method was validated in a second patient cohort of 43 patients.ResultsAfter multivariable analysis, the planned PG Dmean remained the only significant parameter for PG ΔDmean. A sensitivity of 91% and 80% could be obtained using a threshold of PG Dmean of 22.2Gy, for the development and validation cohorts, respectively. This would spare 38% (development cohort) and 24% (validation cohort) of patients from the labour-intensive ART procedure.ConclusionsThe presented method to select patients for ART pre-treatment reduces the labour of ART, contributing to a more effective allocation of the department resources

Reproducibility of the lung anatomy under active breathing coordinator control:Dosimetric consequences for scanned proton treatments

Purpose The treatment of moving targets with scanned proton beams is challenging. For motion mitigation, an Active Breathing Coordinator (ABC) can be used to assist breath-holding. The delivery of pencil beam scanning fields often exceeds feasible breath-hold durations, requiring high breath-hold reproducibility. We evaluated the robustness of scanned proton therapy against anatomical uncertainties when treating nonsmall-cell lung cancer (NSCLC) patients during ABC controlled breath-hold. Methods Four subsequent MRIs of five healthy volunteers (3 male, 2 female, age: 25-58, BMI: 19-29) were acquired under ABC controlled breath-hold during two simulated treatment fractions, providing both intrafractional and interfractional information about breath-hold reproducibility. Deformation vector fields between these MRIs were used to deform CTs of five NSCLC patients. Per patient, four or five cases with different tumor locations were modeled, simulating a total of 23 NSCLC patients. Robustly optimized (3 and 5 mm setup uncertainty respectively and 3% density perturbation) intensity-modulated proton plans (IMPT) were created and split into subplans of 20 s duration (assumed breath-hold duration). A fully fractionated treatment was recalculated on the deformed CTs. For each treatment fraction the deformed CTs representing multiple breath-hold geometries were alternated to simulate repeated ABC breath-holding during irradiation. Also a worst-case scenario was simulated by recalculating the complete treatment plan on the deformed CT scan showing the largest deviation with the first deformed CT scan, introducing a systematic error. Both the fractionated breath-hold scenario and worst-case scenario were dosimetrically evaluated. Results Looking at the deformation vector fields between the MRIs of the volunteers, up to 8 mm median intra- and interfraction displacements (without outliers) were found for all lung segments. The dosimetric evaluation showed a median difference in D-98% between the planned and breath-hold scenarios of -0.1 Gy (range: -4.1 Gy to 2.0 Gy). D-98% target coverage was more than 57.0 Gy for 22/23 cases. The D-1 cc of the CTV increased for 21/23 simulations, with a median difference of 0.9 Gy (range: -0.3 to 4.6 Gy). For 14/23 simulations the increment was beyond the allowed maximum dose of 63.0 Gy, though remained under 66.0 Gy (110% of the prescribed dose of 60.0 Gy). Organs at risk doses differed little compared to the planned doses (difference in mean doses <0.9 Gy for the heart and lungs, <1.4% difference in V-35 [%] and V-20 [%] to the esophagus and lung). Conclusions When treating under ABC controlled breath-hold, robustly optimized IMPT plans show limited dosimetric consequences due to anatomical variations between repeated ABC breath-holds for most cases. Thus, the combination of robustly optimized IMPT plans and the delivery under ABC controlled breath-hold presents a safe approach for PBS lung treatments