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Title: SU-F-P-30: Clinical Assessment of Auto Beam-Hold Triggered by Fiducial Localization During Prostate RapidArc Delivery

Abstract

Purpose: To assess the clinical efficacy of auto beam hold during prostate RapidArc delivery, triggered by fiducial localization on kV imaging with a Varian True Beam. Methods: Prostate patients with four gold fiducials were candidates in this study. Daily setup was accomplished by aligning to fiducials using orthogonal kV imaging. During RapidArc delivery, a kV image was automatically acquired with a momentary beam hold every 60 degrees of gantry rotation. The position of each fiducial was identified by a search algorithm and compared to a predetermined 1.4 cm diameter target area. Treatment continued if all the fiducials were within the target area. If any fiducial was outside the target area the beam hold was not released, and the operators determined if the patient needed re-alignment using the daily setup method. Results: Four patients were initially selected. For three patients, the auto beam hold performed seamlessly. In one instance, the system correctly identified misaligned fiducials, stopped treatment, and the patient was re-positioned. The fourth patient had a prosthetic hip which sometimes blocked the fiducials and caused the fiducial search algorithm to fail. The auto beam hold was disabled for this patient and the therapists manually monitored the fiducial positions during treatment.more » Average delivery time for a 2-arc fraction was increased by 59 seconds. Phantom studies indicated the dose discrepancy related to multiple beam holds is <0.1%. For a plan with 43 fractions, the additional imaging increased dose by an estimated 68 cGy. Conclusion: Automated intrafraction kV imaging can effectively perform auto beam holds due to patient movement, with the exception of prosthetic hip patients. The additional imaging dose and delivery time are clinically acceptable. It may be a cost-effective alternative to Calypso in RapidArc prostate patient delivery. Further study is warranted to explore its feasibility under various clinical conditions.« less

Authors:
;  [1]
  1. Flower Hospital, Sylvania, OH (United States)
Publication Date:
OSTI Identifier:
22624469
Resource Type:
Journal Article
Resource Relation:
Journal Name: Medical Physics; Journal Volume: 43; Journal Issue: 6; Other Information: (c) 2016 American Association of Physicists in Medicine; Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
60 APPLIED LIFE SCIENCES; 61 RADIATION PROTECTION AND DOSIMETRY; ALGORITHMS; ALIGNMENT; BEAMS; BIOMEDICAL RADIOGRAPHY; DELIVERY; IMAGES; PATIENTS; PHANTOMS; PROSTATE; RADIATION DOSES; RADIOTHERAPY

Citation Formats

Atkinson, P, and Chen, Q. SU-F-P-30: Clinical Assessment of Auto Beam-Hold Triggered by Fiducial Localization During Prostate RapidArc Delivery. United States: N. p., 2016. Web. doi:10.1118/1.4955737.
Atkinson, P, & Chen, Q. SU-F-P-30: Clinical Assessment of Auto Beam-Hold Triggered by Fiducial Localization During Prostate RapidArc Delivery. United States. doi:10.1118/1.4955737.
Atkinson, P, and Chen, Q. 2016. "SU-F-P-30: Clinical Assessment of Auto Beam-Hold Triggered by Fiducial Localization During Prostate RapidArc Delivery". United States. doi:10.1118/1.4955737.
@article{osti_22624469,
title = {SU-F-P-30: Clinical Assessment of Auto Beam-Hold Triggered by Fiducial Localization During Prostate RapidArc Delivery},
author = {Atkinson, P and Chen, Q},
abstractNote = {Purpose: To assess the clinical efficacy of auto beam hold during prostate RapidArc delivery, triggered by fiducial localization on kV imaging with a Varian True Beam. Methods: Prostate patients with four gold fiducials were candidates in this study. Daily setup was accomplished by aligning to fiducials using orthogonal kV imaging. During RapidArc delivery, a kV image was automatically acquired with a momentary beam hold every 60 degrees of gantry rotation. The position of each fiducial was identified by a search algorithm and compared to a predetermined 1.4 cm diameter target area. Treatment continued if all the fiducials were within the target area. If any fiducial was outside the target area the beam hold was not released, and the operators determined if the patient needed re-alignment using the daily setup method. Results: Four patients were initially selected. For three patients, the auto beam hold performed seamlessly. In one instance, the system correctly identified misaligned fiducials, stopped treatment, and the patient was re-positioned. The fourth patient had a prosthetic hip which sometimes blocked the fiducials and caused the fiducial search algorithm to fail. The auto beam hold was disabled for this patient and the therapists manually monitored the fiducial positions during treatment. Average delivery time for a 2-arc fraction was increased by 59 seconds. Phantom studies indicated the dose discrepancy related to multiple beam holds is <0.1%. For a plan with 43 fractions, the additional imaging increased dose by an estimated 68 cGy. Conclusion: Automated intrafraction kV imaging can effectively perform auto beam holds due to patient movement, with the exception of prosthetic hip patients. The additional imaging dose and delivery time are clinically acceptable. It may be a cost-effective alternative to Calypso in RapidArc prostate patient delivery. Further study is warranted to explore its feasibility under various clinical conditions.},
doi = {10.1118/1.4955737},
journal = {Medical Physics},
number = 6,
volume = 43,
place = {United States},
year = 2016,
month = 6
}
  • Three-dimensional ultrasound localization has been performed for external beam prostate treatments at our institution since September 2001. This article presents data from the daily shifts for 221 patients and 5005 fractions, and the results of tests performed to assess the system's performance under clinical conditions. Three tests are presented: (1) To measure the accuracy of the shifts, eight patients treated on a helical tomotherapy machine were localized daily using both ultrasound (US) and a megavoltage computed tomography (MVCT) scan. Comparison of the shifts showed that US localization improved alignment for six of the eight patients when compared to alignment usingmore » skin marks alone. The mean US-MVCT vector for these six patients was 3.1{+-}1.3 mm, compared to 5.1{+-}2.1 mm between the MVCT and the skin marks. The other two patients were identified as poor candidates for US prior to their first treatment fraction. (2) To assess the extent of intrafraction motion, US localization was repeated after treatment for six patients and a total of 29 fractions. The mean intrafraction prostate shift was 1.9{+-}1.0 mm, and the shift was within the 3 mm localization uncertainty [Tome et al., Med. Phys. 29, 1781-1788 (2002); in New Technologies in Radiotion Oncology, edited by W. Schlegel, T. Bortfelde, and A. Grosu (Springer, Berlin, 2005)] of the system for 25 of 29 fractions. (3) To assess the interuser variation in shifts, four experienced operators independently localized five patients for five consecutive fractions. The standard deviation of the users' shifts was found to be approximately the same as the system's localization uncertainty. For shifts larger than the system localization uncertainty, the standard deviation of the users' shifts was nearly always much smaller than the mean shift. Taken together with the results of the US-MVCT comparison, this indicates that the shifts improved patient localization despite differences between users.« less
  • Purpose: The aim of this work was to assess the accuracy of kilovoltage (kV) cone-beam computed tomography (CBCT)-based setup corrections as compared with orthogonal megavoltage (MV) portal image-based corrections for patients undergoing external-beam radiotherapy of the prostate. Methods and Materials: Daily cone-beam CT volumetric images were acquired after setup for patients with three intraprostatic fiducial markers. The estimated couch shifts were compared retrospectively to patient adjustments based on two orthogonal MV portal images (the current clinical standard of care in our institution). The CBCT soft-tissue based shifts were also estimated by digitally removing the gold markers in each projection tomore » suppress the artifacts in the reconstructed volumes. A total of 256 volumetric images for 15 patients were analyzed. Results: The Pearson coefficient of correlation for the patient position shifts using fiducial markers in MV vs. kV was (R{sup 2} = 0.95, 0.84, 0.81) in the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) directions, respectively. The correlation using soft-tissue matching was as follows: R{sup 2} = 0.90, 0.49, 0.51 in the LR, AP and SI directions. A Bland-Altman analysis showed no significant trends in the data. The percentage of shifts within a {+-}3-mm tolerance (the clinical action level) was 99.7%, 95.5%, 91.3% for fiducial marker matching and 99.5%, 70.3%, 78.4% for soft-tissue matching. Conclusions: Cone-beam CT is an accurate and precise tool for image guidance. It provides an equivalent means of patient setup correction for prostate patients with implanted gold fiducial markers. Use of the additional information provided by the visualization of soft-tissue structures is an active area of research.« less
  • The online image-guided localization data from 696 ultrasound (United States), 598 mega-voltage cone-beam computed tomography (MV-CBCT), and 393 seed markers (SMs) couch alignments for patients undergoing intensity modulation radiotherapy of the prostate were analyzed. Daily US, MV-CBCT and SM images were acquired for 19, 17 and 12 patients, respectively, after each patient was immobilized in a vacuum cradle and setup to skin markers as the center of mass. The couch shifts applied in the lateral (left-right/LR), vertical (anterior-posterior/AP), and longitudinal (superior-inferior/SI) directions, along with the magnitude of the three-dimensional (3D) shift vector, were analyzed and compared for all three methods.more » The percentage of shifts larger than 5 mm in all directions was also compared. Clinical target volume-planning target volume (CTV-to-PTV) expansion margins were estimated based on the localization data with US, CB, and SM image guidance. Results show the US data have greater variability. Systematic and random shifts were -1.2{+-}6.8 mm (LR), -2.8{+-}5.1 mm (SI) and -1.0{+-}5.9 mm (AP) for US, 1.0{+-}3.9 mm (LR), -1.3{+-}2.5 mm (SI) and -0.3{+-}3.9 mm (AP) for CB, and -1.0{+-}3.4 mm (LR), 0.0{+-}3.4 mm (SI) and 0.5{+-}4.1 mm (AP) for SM. The mean 3D shift distance was larger using US (8.8{+-}6.2 mm) compared to CB and SM (5.3{+-}3.4 mm and 5.2{+-}3.7 mm, respectively). The percentage of US shifts larger than 5 mm were 34%, 31%, and 38% in the LR, SI, and AP directions, respectively, compared to 18%, 6%, and 16% for CB and 14%, 10%, and 20% for SM. MV-CBCT and SM localization data suggest a different distribution of prostate center-of-mass shifts with smaller variability, compared to US. The online MV-CBCT and SM image-guidance data show that for treatments that do not include daily prostate localization, one can use a CTV-to-PTV margin that is 4 mm smaller than the one suggested by US data, hence allowing more rectum and bladder sparing and potentially improving the therapeutic ratio.« less
  • Purpose: To assess the accuracy of ultrasound-based repositioning (BAT) before prostate radiation with fiducial-based three-dimensional matching with cone-beam computed tomography (CBCT). Patients and Methods: Fifty-four positionings in 8 patients with {sup 125}I seeds/intraprostatic calcifications as fiducials were evaluated. Patients were initially positioned according to skin marks and after this according to bony structures based on CBCT. Prostate position correction was then performed with BAT. Residual error after repositioning based on skin marks, bony anatomy, and BAT was estimated by a second CBCT based on user-independent automatic fiducial registration. Results: Overall mean value (MV {+-} SD) residual error after BAT basedmore » on fiducial registration by CBCT was 0.7 {+-} 1.7 mm in x (group systematic error [M] = 0.5 mm; SD of systematic error [{sigma}] = 0.8 mm; SD of random error [{sigma}] = 1.4 mm), 0.9 {+-} 3.3 mm in y (M = 0.5 mm, {sigma} = 2.2 mm, {sigma} = 2.8 mm), and -1.7 {+-} 3.4 mm in z (M = -1.7 mm, {sigma} = 2.3 mm, {sigma} = 3.0 mm) directions, whereas residual error relative to positioning based on skin marks was 2.1 {+-} 4.6 mm in x (M = 2.6 mm, {sigma} = 3.3 mm, {sigma} = 3.9 mm), -4.8 {+-} 8.5 mm in y (M = -4.4 mm, {sigma} = 3.7 mm, {sigma} = 6.7 mm), and -5.2 {+-} 3.6 mm in z (M = -4.8 mm, {sigma} = 1.7 mm, {sigma} = 3.5mm) directions and relative to positioning based on bony anatomy was 0 {+-} 1.8 mm in x (M = 0.2 mm, {sigma} = 0.9 mm, {sigma} = 1.1 mm), -3.5 {+-} 6.8 mm in y (M = -3.0 mm, {sigma} = 1.8 mm, {sigma} = 3.7 mm), and -1.9 {+-} 5.2 mm in z (M = -2.0 mm, {sigma} = 1.3 mm, {sigma} = 4.0 mm) directions. Conclusions: BAT improved the daily repositioning accuracy over skin marks or even bony anatomy. The results obtained with BAT are within the precision of extracranial stereotactic procedures and represent values that can be achieved with several users with different education levels. If sonographic visibility is insufficient, CBCT or kV/MV portal imaging with implanted fiducials are recommended.« less
  • Purpose: To analyze the intrafraction motion of the prostate during external-beam radiation therapy of patients with prostate cancer. Methods and Materials: Between August 2001-December 2005, 427 patients with Stage T3Nx/0Mx/0 prostate carcinoma received intensity-modulated radiation therapy treatment combined with position verification with fiducial gold markers. For a total of 11,426 treatment fractions (average, 27 per patient), portal images were taken of the first segment of all five beams. The irradiation time of the technique varied between 5-7 min. From these data, the location of gold markers could be established within every treatment beam under the assumption of minimal marker movement.more » Results: In 66% of treatment fractions, a motion outside a range of 2 mm was observed, with 28% outside a range of 3 mm. The intrafraction marker movements showed that motion directions were often reversed. However, the effect was small. Even with perfect online position-correction at the start of irradiation, intrafraction motion caused position uncertainty, but systematic errors ({sigma}) were limited to <0.6 mm, and random errors ({sigma}) to <0.9 mm. This would result in a lower limit of 2 mm for margins, in the absence of any other uncertainties. Conclusions: Intrafraction motion of the prostate occurs frequently during external-beam irradiation on a time scale of 5-7 min. Margins of 2 mm account for these intrafraction motions. However, larger margins are required in practice to accommodate other uncertainties in the treatment.« less