Automated review of patient position in DIBH breast hybrid IMRT with EPID images.

Deep Inspiration Breath Hold (DIBH) is a respiratory-gating technique adopted in radiation therapy to lower cardiac irradiation. When performing DIBH treatments, it is important to have a monitoring system to ensure the patient's breath hold level is stable and reproducible at each fraction. In this retrospective study, we developed a system capable of monitoring DIBH breast treatments by utilizing cine EPID images taken during treatment. Setup error and intrafraction motion were measured for all fractions of 20 left-sided breast patients. All patients were treated with a hybrid static-IMRT technique, with EPID images from the static fields analyzed. Ten patients had open static fields and the other ten patients had static fields partially blocked with the multileaf collimator (MLC). Three image-processing algorithms were evaluated on their ability to accurately measure the chest wall position (CWP) in EPID images. CWP measurements were recorded along a 61-pixel region of interest centered along the midline of the image. The median and standard deviation of the CWP were recorded for each image. The algorithm showing the highest agreement with manual measurements was then used to calculate intrafraction motion and setup error. To measure intrafraction motion, the median CWP of the first EPID frame was compared with that of the subsequent EPID images of the treatment. The maximum difference was recorded as the intrafraction motion. The setup error was calculated as the difference in median CWP between the MV DRR and the first EPID image of the lateral tangential field. The results showed that the most accurate image-processing algorithm can identify the chest wall within 1.2 mm on both EPID and MV DRR images, and measures intrafraction motion and setup errors within 1.4 mm.

The use of 0.5rcav as an effective point of measurement for cylindrical chambers may result in a systematic shift of electron percentage depth doses.

Electron dosimetry can be performed using cylindrical chambers, plane-parallel chambers, and diode detectors. The finite volume of these detectors results in a displacement effect which is taken into account using an effective point of measurement (EPOM). Dosimetry protocols have recommended a shift of 0.5 rcav for cylindrical chambers; however, various studies have shown that the optimal shift may deviate from this recommended value. This study investigated the effect that the selection of EPOM shift for cylindrical chamber has on percentage depth dose (PDD) curves. Depth dose curves were measured in a water phantom for electron beams with energies ranging from 6 to 18 MeV. The detectors investigated were of three different types: diodes (Diode-E PTW 60017 and SFD IBA), cylindrical (Semiflex PTW 31010, PinPoint PTW 31015, and A12 Exradin), and parallel plate ionization chambers (Advanced Markus PTW 34045 and Markus PTW 23343). Depth dose curves measured with Diode-E and Advanced Markus agreed within 0.2 mm at R50 except for 18 MeV and extremely large field size. The PDDs measured with the Semiflex chamber and Exradin A12 were about 1.1 mm (with respect to the Advanced Markus chamber) shallower than those measured with the other detectors using a 0.5 rcav shift. The difference between the PDDs decreased when a Pinpoint chamber, with a smaller cavity radius, was used. Agreement improved at lower energies, with the use of previously published EPOM corrections (0.3 rcav ). Therefore, the use of 0.5 rcav as an EPOM may result in a systematic shift of the therapeutic portion of the PDD (distances < R90 ). Our results suggest that a 0.1 rcav shift is more appropriate for one chamber model (Semiflex PTW 31010).

A modern mold room: Meshing 3D surface scanning, digital design, and 3D printing with bolus fabrication.

PURPOSE: This case series represents an initial experience with implementing 3-dimensional (3D) surface scanning, digital design, and 3D printing for bolus fabrication for patients with complex surface anatomy where traditional approaches are challenging. METHODS AND MATERIALS: For 10 patients requiring bolus in regions with complex contours, bolus was designed digitally from 3D surface scanning data or computed tomography (CT) images using either a treatment planning system or mesh editing software. Boluses were printed using a fused deposition modeling printer with polylactic acid. Quality assurance tests were performed for each printed bolus to verify density and shape. RESULTS: For 9 of 10 patients, digitally designed boluses were used for treatment with no issues. In 1 case, the bolus was not used because dosimetric requirements were met without the bolus. QA tests revealed that the bulk density was within 3% of the reference value for 9 of 12 prints, and with more judicious selection of print settings this could be increased. For these 9 prints, density uniformity was as good as or better than our traditional sheet bolus material. The average shape error of the pieces was less than 0.5 mm, and no issues with fit or comfort were encountered during use. CONCLUSIONS: This study demonstrates that new technologies such as 3D surface scanning, digital design and 3D printing can be safely and effectively used to modernize bolus fabrication.

Low-cost optical scanner and 3-dimensional printing technology to create lead shielding for radiation therapy of facial skin cancer: First clinical case series.

PURPOSE: Three-dimensional printing has been implemented at our institution to create customized treatment accessories, including lead shields used during radiation therapy for facial skin cancer. To effectively use 3-dimensional printing, the topography of the patient must first be acquired. We evaluated a low-cost, structured-light, 3-dimensional, optical scanner to assess the clinical viability of this technology. METHODS AND MATERIALS: For ease of use, the scanner was mounted to a simple gantry that guided its motion and maintained an optimum distance between the scanner and the object. To characterize the spatial accuracy of the scanner, we used a geometric phantom and an anthropomorphic head phantom. The geometric phantom was machined from plastic and included hemispherical and tetrahedral protrusions that were roughly the dimensions of an average forehead and nose, respectively. Polygon meshes acquired by the optical scanner were compared with meshes generated from high-resolution computed tomography images. Most optical scans contained minor artifacts. Using an algorithm that calculated the distances between the 2 meshes, we found that most of the optical scanner measurements agreed with those from the computed tomography scanner within approximately 1 mm for the geometric phantom and approximately 2 mm for the head phantom. We used this optical scanner along with 3-dimensional printer technology to create custom lead shields for 10 patients receiving orthovoltage treatments of nonmelanoma skin cancers of the face. Patient, tumor, and treatment data were documented. RESULTS: Lead shields created using this approach were accurate, fitting the contours of each patient's face. This process added to patient convenience and addressed potential claustrophobia and medical inability to lie supine. CONCLUSIONS: The scanner was found to be clinically acceptable, and we suggest that the use of an optical scanner and 3-dimensional printer technology become the new standard of care to generate lead shielding for orthovoltage radiation therapy of nonmelanoma facial skin cancer.

A novel hybrid reconstruction algorithm for first generation incoherent scatter CT (ISCT) of large objects with potential medical imaging applications.

This work presents a first generation incoherent scatter CT (ISCT) hybrid (analytic-iterative) reconstruction algorithm for accurate ρ{e}imaging of objects with clinically relevant sizes. The algorithm reconstructs quantitative images of ρ{e} within a few iterations, avoiding the challenges of optimization based reconstruction algorithms while addressing the limitations of current analytical algorithms. A 4π detector is conceptualized in order to address the issue of directional dependency and is then replaced with a ring of detectors which detect a constant fraction of the scattered photons. The ISCT algorithm corrects for the attenuation of photons using a limited number of iterations and filtered back projection (FBP) for image reconstruction. This results in a hybrid reconstruction algorithm that was tested with sinograms generated by Monte Carlo (MC) and analytical (AN) simulations. Results show that the ISCT algorithm is weakly dependent on the ρ{e} initial estimate. Simulation results show that the proposed algorithm reconstruct ρ{e} images with a mean error of -1% ± 3% for the AN model and from -6% to -8% for the MC model. Finally, the algorithm is capable of reconstructing qualitatively good images even in the presence of multiple scatter. The proposed algorithm would be suitable for in-vivo medical imaging as long as practical limitations can be addressed.

A 1st generation scatter CT algorithm for electron density breast imaging which accounts for bound incoherent, coherent and multiple scatter: A Monte Carlo study.

Breast CT is an emerging modality that reconstructs 3D linear attenuation coefficient (µ) images of the breast. Its tomographic nature reduces the overlap of structures and may improve tissue visualization. Current prototype systems produce large levels of scatter that could be used to reconstruct electron density (ρ _{e}) images. This could potentially enhance diagnosis. We are developing a first generation bench top CT system to investigate the benefits of simultaneous imaging µ and ρ _{e} of the intact breast. The system uses an algorithm capable of reconstructing ρ _{e} images from single Klein-Nishina scatter. It has been suggested that this algorithm may be impractical since measurements include coherent, bound incoherent and multiple scatter. To investigate this, the EGSnrc Monte Carlo (MC) code was used to simulate scans using a first generation system. These simulations were used to quantify the dose per scan, to provide raw data for the ρ _{e} reconstructions and to investigate corrections for multiple and coherent scatter since these can not be directly related to ρ _{e}. MC simulations show that the dose coefficients are similar to those of cone beam breast CT. Coherent scatter is only ∼9% concentrated in scattering angles < 8°. Electron binding reduces the number of incoherently scattered photons but this reduction can be included in the quantification of scatter measured by the system. Multiple scatter was found to be the major source of errors and, if not corrected for, can result in an overestimation of ρ _{e} by more than a factor of two. Empirical corrections, based on breast thickness or radiological path, can be used to reconstruct images where the variance in ρ _{e} error is half of that found in images derived from primary photons only. Although some practical challenges remain in creating a laboratory system, this work has shown that it is possible to reconstruct scatter images of the breast with a 4 mGy dose and further experimental evaluation of this technique is warranted.