Evaluation of Radiation Dose Effect on Lung Function Using Iodine Maps Derived From Dual-Energy Computed Tomography.

PURPOSE: There is interest in using dual-energy computed tomography (DECT) to evaluate organ function before and after radiation therapy (RT). The purpose of this study (trial identifier: NCT04863027) is to assess longitudinal changes in lung perfusion using iodine maps derived from DECT in patients with lung cancer treated with conventional or stereotactic RT. METHODS AND MATERIALS: For 48 prospectively enrolled patients with lung cancer, a contrast-enhanced DECT using a dual-source CT simulator was acquired pretreatment and at 6 and 12 months posttreatment. Pulmonary functions tests (PFT) were obtained at baseline and at 6 and 12 months posttreatment. Iodine maps were extracted from the DECT images using a previously described 2-material decomposition framework. Longitudinal iodine maps were normalized using a reference region defined as all voxels with perfusion in the top 10% outside of the 5 Gy isodose volume. Normalized functional responses (NFR) were calculated for 3 dose ranges: <5, 5 to 20, and >20 Gy. Mixed model analysis was used to assess the correlation between dose metrics and NFR. Pearson correlation was used to assess if NFRs were correlated with PFT changes. RESULTS: Out of the 48 patients, 21 (44%) were treated with stereotactic body RT and 27 (56%) were treated with conventionally fractionated intensity-modulated RT. Thirty-one out of these 48 patients were ultimately included in data analysis. It was found that NFR is linearly correlated with dose (P < .001) for both groups. The number of months elapsed post-RT was also found to correlate with NFR (P = .029), although this correlation was not observed for the stereotactic body RT subgroup. The NFR was not found to correlate with PFT changes. CONCLUSIONS: DECT-derived iodine maps are a promising method for detailed anatomic evaluation of radiation effect on lung function, including potentially subclinical changes.

The Montreal split ring applicator: Towards highly adaptive gynecological brachytherapy using 3D-printed biocompatible patient-specific interstitial caps.

Purpose: The addition of interstitial (IS) needles to intra-cavitary (IC) brachytherapy applicators is associated with improved outcomes in locally advanced cervical cancers involving parametrial tumor extensions. The purpose of this work was to validate a clinical workflow involving 3D-printed caps for a commercial IC split ring applicator that enable using IS needle trajectories tailored to each treatment. Material and methods: A dedicated software module was developed in this work allowing users to design patient-specific IS caps without knowledge of computer-aided design (CAD) software. This software module was integrated to 3D Brachy, a commercial software developed by Adaptiiv Medical Technologies Inc. For validation of the workflow, CAD models of ground truth caps with five IS needle trajectories were designed with Fusion 360™, 3D-printed, assembled with a split ring applicator, and CT-scanned with radio-opaque markers. 3D Brachy was then applied to generate a replica based on trajectories reconstructed from the radio-opaque markers. A comparison between ground truth and replicated IS needle trajectories was done using intersection points with planes at the level of the cervix (z = 0 cm) and a representative needle depth (z = 3 cm). Results: Prototypes of interstitial caps 3D-printed in both BioMed Amber and BioMed Clear SLA resins were tested to be functional both pre- and post-sterilization for IS needles with obliquity angles ≤ 45°. Distance-to-agreement at z = 0 cm and 3 cm as well as deviations in pitch and yaw angles of the five IS needle trajectories were found to have mean values of 3.3 ±2.1 mm, 7.3 ±2.0 mm, 2.9° ±2.3°, and 7.0° ±7.0°, respectively. Conclusions: The clinical workflow for image-guided adaptive cervical cancer brachytherapy using the Montreal split ring applicator was validated.

Clinical Evaluation of In-House-Produced 3D-Printed Nasopharyngeal Swabs for COVID-19 Testing.

3D-printed alternatives to standard flocked swabs were rapidly developed to provide a response to the unprecedented and sudden need for an exponentially growing amount of diagnostic tools to fight the COVID-19 pandemic. In light of the anticipated shortage, a hospital-based 3D-printing platform was implemented in our institution for the production of swabs for nasopharyngeal and oropharyngeal sampling based on the freely available, open-source design provided to the community by University of South Florida's Health Radiology and Northwell Health System teams as a replacement for locally used commercial swabs. Validation of our 3D-printed swabs was performed with a head-to-head diagnostic accuracy study of the 3D-printed "Northwell model" with the cobas PCR Media® swab sample kit. We observed an excellent concordance (total agreement 96.8%, Kappa 0.936) in results obtained with the 3D-printed and flocked swabs, indicating that the in-house 3D-printed swab could be used reliably in the context of a shortage of flocked swabs. To our knowledge, this is the first study to report on autonomous hospital-based production and clinical validation of 3D-printed swabs.

Eliminating computed tomography imaging artifacts through 3D printed radiotherapy head supports.

PURPOSE: The geometry of an immobilization device such as a headrest can cause undesired computed tomography (CT) artifacts that may affect both volume definition and dosimetry in radiotherapy of the brain. The purpose of this work was to reduce CT artifacts caused by a standard hard plastic hollow radiotherapy headrest. This was to be achieved through design and prototyping of a custom-made head support. METHODS: A series of CT scans were acquired of both a water phantom and an anthropomorphic head phantom which were resting on custom-made three-dimensional (3D) printed supports. All custom-made supports were made of polylactic acid (PLA) plastic filament and printed by fused deposition modeling (FDM) 3D printing technology. Initial designs were studied with a water phantom using a simplified support with straight and curved shapes both at the edges and as infill patterns. Imaging of a 3D printed clinical prototype was then compared to our standard headrest using an anthropomorphic head phantom. RESULTS: The presence of dark streaks inside both phantoms was seen on the CT images for headrests involving supports with straight shapes at the edges or as infill patterns. Such artifacts were ascribed to the exponential edge-gradient effect (EEGE). No such artifact was observed when the support was designed with a combination of curved edges and infill patterns. CONCLUSION: When developing immobilization accessories for use in CT scanners, more attention could be paid to artifact attenuating design elements. This work illustrates the usefulness of 3D printing in prototyping radiotherapy accessories and solving concrete clinical problems.

Cardiac Sparing with Personalized Treatment Planning for Early-stage Left Breast Cancer.

Purpose To compare cardiac doses of different whole-breast optimization schemes including free-breathing (FB) tangential radiotherapy (TRT), deep-inspiration breath-hold (DIBH) TRT, and FB helical tomotherapy (HT). Methods Early-stage left-sided breast cancer patients who underwent breast-conserving surgery followed by adjuvant radiotherapy were included in the study. Planning images included FB and DIBH CT scans acquired in the same supine treatment position with both arms abducted. A hypofractionated regimen of 42.5 Gy in 16 fractions was used. Clinical target volume delineation was aided through the use of a radio-opaque wire. A 7-mm margin was used in generating the planning target volumes. TRT plans were generated both in FB and DIBH. For the FB tomotherapy technique, a first plan (Tomo 1) was optimized limiting the maximum contralateral breast dose to 3.1 Gy. A second tomotherapy plan (Tomo 2) focused on the reduction of the mean heart dose without controlling the contralateral breast dose. All plans were optimized to obtain an equivalent planning target volume (PTV) coverage of ≥95% of the prescribed dose while minimizing the dose to organs at risk. Results Twenty-three patients treated between October 2012 and March 2016 were included in this retrospective study. Eleven patients (48%) had at least one major cardiovascular risk factors including one patient (4%) with a history of myocardial infarction. Six patients (26%) had been exposed to cardiotoxic chemotherapy agents. The average mean dose to the heart was 3.1 Gy with FB TRT, 1.1 with DIBH TRT, 2.4 Gy for Tomo 1, and 1.5 Gy for Tomo 2. The mean dose to the left anterior descending artery was 27.0 Gy, 8.0 Gy, 13.7 Gy and 6.6 Gy for FB TRT, DIBH TRT, Tomo 1 and Tomo 2 plans respectively. Conclusion Different cardiac-sparing optimization schemes are possible when treating left breast cancer. Although DIBH offers clear mean heart dose reductions, tomotherapy can be an interesting alternative treatment modality to spare the heart and coronary vessels, notably in patients who cannot comply with DIBH.

Iterative reconstruction for image enhancement and dose reduction in diagnostic cone beam CT imaging.

BACKGROUND: Iterative reconstruction is well-established in diagnostic multidetector computed tomography (MDCT) for dose reduction and image quality enhancement. Its application to diagnostic cone beam computed tomography (CBCT) is only emerging and warrants a quantitative evaluation. METHODS: Several phantoms and a canine head specimen were imaged using a commercially available small-field CBCT scanner. Raw projection data were reconstructed using the Feldkamp-Davis-Kress (FDK) method with different filters, including denoising via total variation (TV) minimization (FDK-TV). Iterative reconstruction was carried out using the TV-regularized ordered subsets convex technique (OSC-TV). Signal-to-noise ratio (SNR), noise power spectrum (NPS) and spatial resolution of images were estimated. Dose levels were measured via the weighted computed tomography dose index, while low-dose image quality degradation was estimated via structural similarity (SSIM). RESULTS: OSC-TV and FDK-TV were shown to significantly improve image signal-to-noise ratio (SNR) compared to FDK with a standard filter, 5.8 and 4.0 times, respectively. Spatial resolution attained with different algorithms varied moderately across different experiments. For low-dose acquisitions, image quality decreased dramatically for FDK but not for FDK-TV nor OSC-TV. For low-dose canine head images acquired using about 1/5 of the dose compared to a reference image, SSIM dropped to about 0.3 for FDK, while remaining at 0.92 for FDK-TV and 0.96 for OSC-TV. CONCLUSION: OSC-TV was shown to improve image quality compared to FDK and FDK-TV. Moreover, this iterative approach allowed for significant dose reduction while maintaining image quality.

Dual-energy computed tomography for prediction of loco-regional recurrence after radiotherapy in larynx and hypopharynx squamous cell carcinoma.

PURPOSE: To investigate the role of quantitative pre-treatment dual-energy computed tomography (DECT) for prediction of loco-regional recurrence (LRR) in patients with larynx/hypopharynx squamous cell cancer (L/H SCC). METHODS: Patients with L/H SCC treated with curative intent loco-regional radiotherapy and that underwent treatment planning with contrast-enhanced DECT of the neck were included. Primary and nodal gross tumor volumes (GTVp and GTVn) were contoured and transferred into a Matlab® workspace. Using a two-material decomposition, GTV iodine concentration (IC) maps were obtained. Quantitative histogram statistics (maximum, mean, standard deviation, kurtosis and skewness) were retrieved from the IC maps. Cox regression analysis was conducted to determine potential predictive factors of LRR. RESULTS: Twenty-five patients, including 20 supraglottic and 5 pyriform sinus tumors were analysed. Stage I, II, III, IVa and IVb constituted 4% (1 patient), 24%, 36%, 28% and 8% of patients, respectively; 44% had concurrent chemo-radiotherapy and 28% had neodjuvant chemotherapy. Median follow-up was 21 months. Locoregional control at 1 and 2 years were 75% and 69%, respectively. For the entire cohort, GTVn volume (HR 1.177 [1.001-1.392], p = 0.05), voxel-based maximum IC of GTVp (HR 1.099 [95% CI: 1.001-1.209], p = 0.05) and IC standard deviation of GTVn (HR 9.300 [95% CI: 1.113-77.725] p = 0.04) were predictive of LRR. On subgroup analysis of patients treated with upfront radiotherapy +/- chemotherapy, both voxel-based maximum IC of GTVp (HR 1.127 [95% CI: 1.010-1.258], p = 0.05) and IC kurtosis of GTVp (HR 1.088 [95% CI: 1.014-1.166], p = 0.02) were predictive of LRR. CONCLUSION: This exploratory study suggests that pre-radiotherapy DECT-derived IC quantitative analysis of tumoral volume may help predict LRR in L/H SCC.

Central3D: A Computer Tool to Help Clinicians Differentiate Central and Peripheral Lung Tumors.

PURPOSE: We present a concise description of an in-house decision aid software called "Central3D" that allows a quick and robust lung tumor classification between central and peripheral as defined by the Radiation Therapy Oncology Group (RTOG) 0813. METHODS AND MATERIALS: Twenty cases of lung tumors were selected for this study and four radiation oncologists blindly classified them as peripheral versus central without assistance of our software. All discordant cases were reviewed using Central3D and prompt consensus was obtained. RESULTS: Many authors have stressed the importance of adopting risk adaptive fractionation schedule with lower biological equivalent dose when treating centrally-located high risks lesions. Central3D addresses the limitation of current treatment planning systems to represent image data in fixed planes and can help radiation oncologists to fully characterize these pulmonary lesions.

Robust quantitative contrast-enhanced dual-energy CT for radiotherapy applications.

PURPOSE: The purpose of this study was to develop and validate accurate methods for determining iodine content and virtual noncontrast maps of physical parameters, such as electron density, in the context of radiotherapy. METHODS: A simulation environment is developed to compare three methods allowing extracting iodine content and virtual noncontrast composition: (a) two-material decomposition, (b) three-material decomposition with the conservation of volume constraint, and (c) eigentissue decomposition. The simulation allows comparing the performance of the methods using iodine-based contrast agent contents in tissues from a reference dataset with variable density and elemental composition. The comparison is performed in two ways: (a) with a priori knowledge on the composition of the targeted tissue, and (b) without a priori knowledge on the base tissue. The three methods are tested with patient images scanned with dual-energy CT and iodine-based contrast agent. An experimental calibration adapted to the presence of iodine is performed by imaging tissue equivalent materials and diluted contrast agent solutions with known atomic composition. RESULTS: Results show that in the case of known a priori on the composition of the targeted tissue, the two-material decomposition is robust to variable densities and atomic compositions without biasing the results. In the absence of a priori knowledge on the target tissue composition, the eigentissue decomposition method yields minimal bias and higher robustness to variations. Results from the experimental calibration and the images of two patients show that the extracted quantities are accurate and the bias is negligible for both methods with respect to clinical applications in their respective scope of use. For the patient imaged with a contrast agent, virtual noncontrast electron densities are found in good agreement with values extracted from the scan without contrast agent. CONCLUSION: This study identifies two accurate methods to quantify iodine-based contrast agents and virtual noncontrast composition images with dual-energy CT. One is the two-material decomposition with a priori knowledge of the constituent components focused on organ-specific applications, such as kidney or lung function assessment. The other method is the eigentissue decomposition and is useful for general radiotherapy applications, such as treatment planning where accurate dose calculations are needed in the absence of contrast agent.

In a Heartbeat: An Assessment of Dynamic Dose Variation to Cardiac Structures Using Dual Source Computed Tomography.

PURPOSE: To assess radiation dose variation to the left anterior descending artery (LAD), left main coronary artery (LMCA), left ventricle (LV), and whole heart (WH) during the cardiac cycle using dual source computed tomography (DSCT). METHODS AND MATERIALS: The present prospective study included patients with left-side breast cancer planned to undergo tangential radiation therapy. An electrocardiogram-synchronized contrast-injected DSCT scan was obtained with the patient in the treatment position, in deep-inspiration breath-hold, using retrospective sequential acquisition. The WH, LV, LMCA, and proximal, middle, and distal LAD segments were contoured on each phase of the cardiac cycle. The maximum, minimum, and mean Hausdorff distance between each structure and the tangential fields was assessed in ventricular systole and diastole. Four-dimensional dose-volume histograms were used to compare the systolic and diastolic dosimetric data. RESULTS: Ten patients were enrolled. The average maximum, minimum, and mean Hausdorff distance variation from systole to diastole was ≤4 mm for the LV and LMCA and ≤3 mm for the WH and LAD segments. WH maximum dose and volume receiving 5 Gy were decreased in systole compared with diastole (42.9 Gy versus 44.5 Gy, P = .03, and 21.7 cm3 versus 27.7 cm3, P = .01), but the mean dose remained similar throughout the cycle. The maximum and mean dose to the distal LAD was 21.2 Gy versus 26.6 Gy (P = .005) and 8.6 Gy versus 13.2 Gy (P = .006) in systole versus diastole, respectively. The maximum and mean dose to the middle LAD was 18.4 Gy versus 25.1 Gy (P = .005) and 8.5 Gy versus 10.2 Gy in systole versus diastole (P = .005). The maximum dose to the LV was lower in systole than in diastole (21.5 Gy vs 26.7 Gy; P = .005). CONCLUSIONS: In addition to deep-inspiration breath-hold, systolic irradiation is associated with a reduction in dose to the LAD, LV, and WH. In addition to its potential use in radiation planning for cardiac gating, DSCT imaging can be used to help define a planning organ at risk volume for clinically important cardiac substructures.

A comparison of early prostate-specific antigen decline between prostate brachytherapy and different fractionation of external beam radiation-Impact on biochemical failure.

PURPOSE: The aim of this study was to compare early prostate-specific antigen (PSA) decline patterns and PSA nadirs between low-dose-rate seed prostate brachytherapy (LDR-PB) and different fractionations of external beam radiotherapy (EBRT) and their predictive importance for biochemical failure (bF). METHODS AND MATERIALS: Patients with D'Amico low- or intermediate-risk prostate cancer who underwent a single-modality treatment without androgen deprivation were included in this study. Three different treatment groups were compared: (1) normofractionation EBRT up to 70.2-79.2 Gy/1.8-2.0 Gy, (2) LDR-PB, and (3) EBRT with hypofractionation 60 Gy/3 Gy daily or 5-7.25 Gy once a week over 9-5 weeks, to a total dose of 45-36.25 Gy, respectively. The log-rank test, Cox regression analysis, and nonparametric tests were used. RESULTS: We analyzed 892 patients: the median followup for patients without bF was 84 months (interquartile range 60-102 months), with 12% of patients experiencing bF. The PSA decline within the first 15 months was generally exponential. LDR-PB showed a faster early exponential decline compared with EBRT treatments, but whether decline was fast or slow had no influence on recurrence. The only factors that were positive predictive factors in univariate and multivariate analyses were the time to nadir >48 months (median), PSA nadir <0.5 ng/mL, and <0.2 ng/mL (all p < 0.001). CONCLUSIONS: Although there are significant differences in early exponential PSA decline between different treatments, only the PSA nadir and longer time to nadir were predictive factors for bF.

Particle Filter-Based Target Tracking Algorithm for Magnetic Resonance-Guided Respiratory Compensation: Robustness and Accuracy Assessment.

PURPOSE: To assess overall robustness and accuracy of a modified particle filter-based tracking algorithm for magnetic resonance (MR)-guided radiation therapy treatments. METHODS AND MATERIALS: An improved particle filter-based tracking algorithm was implemented, which used a normalized cross-correlation function as the likelihood calculation. With a total of 5 healthy volunteers and 8 patients, the robustness of the algorithm was tested on 24 dynamic magnetic resonance imaging (MRI) time series with varying resolution, contrast, and signal-to-noise ratio. The complete data set included data acquired with different scan parameters on a number of MRI scanners with varying field strengths, including the 1.5T MR linear accelerator. Tracking errors were computed by comparing the results obtained by the particle filter algorithm with experts' delineations. RESULTS: The ameliorated tracking algorithm was able to accurately track abdominal as well as thoracic tumors, whereas the previous Bhattacharyya distance-based implementation failed in more than 50% of the cases. The tracking error, combined over all MRI acquisitions, is 1.1 ± 0.4 mm, which demonstrated high robustness against variations in contrast, noise, and image resolution. Finally, the effect of the input/control parameters of the model was very similar across all cases, suggesting a class-based optimization is possible. CONCLUSIONS: The modified particle filter tracking algorithm is highly accurate and robust against varying image quality. This makes the algorithm a promising candidate for automated tracking on the MR linear accelerator.

Phase 1-2 Study of Dual-Energy Computed Tomography for Assessment of Pulmonary Function in Radiation Therapy Planning.

PURPOSE: To quantify lung function according to a dual-energy computed tomography (DECT)-derived iodine map in patients treated with radiation therapy for lung cancer, and to assess the dosimetric impact of its integration in radiation therapy planning. METHODS AND MATERIALS: Patients treated with stereotactic ablative radiation therapy for early-stage or intensity modulated radiation therapy for locally advanced lung cancer were prospectively enrolled in this study. A DECT in treatment position was obtained at time of treatment planning. The relative contribution of each voxel to the total lung function was based on iodine distribution. The composition of each voxel was determined on the basis of a 2-material decomposition. The DECT-derived lobar function was compared with single photon emission computed tomography/computed tomography (SPECT/CT). A functional map was integrated in the treatment planning system using 6 subvolumes of increasing iodine distribution levels. Percent lung volume receiving 5 Gy (V5), V20, and mean dose (MLD) to whole lungs (anatomic) versus functional lungs were compared. RESULTS: Twenty-five patients with lung cancer, including 18 patients treated with stereotactic ablative radiation therapy and 7 patients with intensity modulated radiation therapy (locally advanced), were included. Eighty-four percent had chronic obstructive pulmonary disease. Median (range) forced expiratory volume in 1 second was 62% of predicted (29%-113%), and median diffusing capacity of the lung for carbon monoxide was 56% (39%-91%). There was a strong linear correlation between DECT- and SPECT/CT-derived lobar function (Pearson coefficient correlation r=0.89, P<.00001). Mean (range) differences in V5, V20, and MLD between anatomic and functional lung volumes were 16% (0%-48%, P=.03), 5% (1%-15%, P=.12), and 15% (1%-43%, P=.047), respectively. CONCLUSIONS: Lobar function derived from a DECT iodine map correlates well with SPECT/CT, and its integration in lung treatment planning is associated with significant differences in V5 and MLD to functional lungs. Future work will involve integration of the weighted functional volume in the treatment planning system, along with integration of an iodine map for functional lung-sparing IMRT.

Assessing lung function using contrast-enhanced dual-energy computed tomography for potential applications in radiation therapy.

PURPOSE: There is an increasing interest in the evaluation of lung function from physiological images in radiation therapy treatment planning to reduce the extent of postradiation toxicities. The purpose of this work was to retrieve reliable functional information from contrast-enhanced dual-energy computed tomography (DECT) for new applications in radiation therapy. The functional information obtained by DECT is also compared with other methods using single-energy CT (SECT) and single-photon emission computed tomography (SPECT) with CT. The differential function between left and right lung, as well as between lobes is computed for all methods. METHODS: Five lung cancer patients were retrospectively selected for this study; each underwent a SPECT/CT scan and a contrast-injected DECT scan, using 100 and 140 Sn kVp. The DECT images are postprocessed into iodine concentration maps, which are further used to determine the perfused blood volume. These maps are calculated in two steps: (a) a DECT stoichiometric calibration adapted to the presence of iodine and followed by (b) a two-material decomposition technique. The functional information from SECT is assumed proportional to the HU numbers from a mixed CT image. The functional data from SPECT/CT are considered proportional to the number of counts. A radiation oncologist segmented the entire lung volume into five lobes on both mixed CT images and low-dose CT images from SPECT/CT to allow a regional comparison. The differential function for each subvolume is computed relative to the entire lung volume. RESULTS: The differential function per lobe derived from SPECT/CT correlates strongly with DECT (Pearson's coefficient r = 0.91) and moderately with SECT (r = 0.46). The differential function for the left lung shows a mean difference of 7% between SPECT/CT and DECT; and 17% between SPECT/CT and SECT. The presence of nonfunctional areas, such as localized emphysema or a lung tumor, is reflected by an intensity drop in the iodine concentration maps. Functional dose volume histograms (fDVH) are also generated for two patients as a proof of concept. CONCLUSION: The extraction of iodine concentration maps from a contrast-enhanced DECT scan is achieved to compute the differential function for each lung subvolume and good agreement is found in respect to SPECT/CT. One promising avenue in radiation therapy is to include such functional information during treatment planning dose optimization to spare functional lung tissues.

The impacts of mid-treatment CBCT-guided patient repositioning on target coverage during lung VMAT.

INTRODUCTION: The purpose of this study is quantify intrafraction motion (IFM) during lung volumetric-modulated arc therapy (VMAT) and evaluate the impact of mid-treatment cone beam computed tomography (CBCT)-guided patient repositioning on target coverage. METHOD: This analysis included lung tumours treated with VMAT to 50-60 Gy in 3-5 fractions. Treatment planning was based on four-dimensional CT scans from which internal tumour volumes (ITV) were derived. An isotropic 5 mm margin was added to obtain the final planning target volume (PTV). Patients were treated supine with a customized dual vacuum immobilization device (BodyFIX, Elekta, Sweden). All patients underwent pre and mid-treatment CBCTs. Following each CBCT, a rigid registration was performed by a radiation oncologist. IFM was defined as the target displacement from pre to mid-treatment CBCT. For patients with an IFM vector ≥5 mm, a post hoc dose calculation analysis was performed to assess the dosimetric impact of CBCT-guided repositioning. RESULTS: Ninety-seven patients (367 fractions) were included. Mean (±SD) overall treatment time was 53:02 ± 13:08 min. Mean time for mid-treatment CBCT scan acquisition and patient repositioning was 15:49 ± 4:14 min. Mean IFM vector was 1.5 ± 1.4 mm (max = 8.1 mm) and was <5 mm in 354/367 (96%) of fractions. For all 13 fractions with an IFM vector ≥5 mm, dose calculation analysis of worst-case scenario indicates that ITV coverage would have remained ≥95% without mid-treatment repositioning. CONCLUSION: For 96% of fractions, the IFM vector was within the 5 mm PTV margin. Mid-treatment CBCT-guided couch repositioning did not significantly impact ITV coverage and prolonged treatment duration.

A particle filter based autocontouring algorithm for lung tumor tracking using dynamic magnetic resonance imaging.

PURPOSE: This study introduces a novel autocontouring algorithm based on particle filter for lung tumors. It is validated on dynamic magnetic resonance (MR) images and is developed in the context of MR-linac treatments. METHODS: A sequential Monte Carlo method called particle filter is used as the main structure of the algorithm and is combined with Otsu's thresholding technique to contour lung tumors on dynamic MR images. Four non-small cell lung cancer (NSCLC) patients were imaged with a 1.5 T MR for 60 s at a rate of 4 images/s and were asked to breathe normally. Prior to treatment, some image processing is required by the proposed algorithm, which includes a manual contour of the tumor, the tumor's displacement, and its descriptive statistics. During treatment, the contours are automatically generated by thresholding around the center of mass of the particles. A comparison with the expert's contours is obtained by calculating the Dice similarity coefficient (DSC), the precision, the recall, the Hausdorff distance, and the difference in centroid positions (Δd). RESULTS: This autocontouring algorithm is independent of pretreatment training and presents continuous adaptability as provided by the nature of particle filters. The number of particles is proportional to the area of the tumor and increases the computational time at a rate of 2 ms for every 500 particles, whereas the contouring step adds a constant 14 ms. The contours' comparison is obtained with a mean DSC of 0.89-0.91, mean precision of 0.88-0.91, mean recall of 0.89-0.95, and mean Δd of 0.6-2.0 mm. CONCLUSIONS: This work presents a proof of concept of a new autocontouring algorithm for NSCLC patients on dynamic MR images. The contours were generated in good agreement with the expert's contours.

Improved tissue assignment using dual-energy computed tomography in low-dose rate prostate brachytherapy for Monte Carlo dose calculation.

PURPOSE: An improvement in tissue assignment for low-dose rate brachytherapy (LDRB) patients using more accurate Monte Carlo (MC) dose calculation was accomplished with a metallic artifact reduction (MAR) method specific to dual-energy computed tomography (DECT). METHODS: The proposed MAR algorithm followed a four-step procedure. The first step involved applying a weighted blend of both DECT scans (I H/L) to generate a new image (I Mix). This action minimized Hounsfield unit (HU) variations surrounding the brachytherapy seeds. In the second step, the mean HU of the prostate in I Mix was calculated and shifted toward the mean HU of the two original DECT images (I H/L). The third step involved smoothing the newly shifted I Mix and the two original I H/L, followed by a subtraction of both, generating an image that represented the metallic artifact (I A,(H/L)) of reduced noise levels. The final step consisted of subtracting the original I H/L from the newly generated I A,(H/L) and obtaining a final image corrected for metallic artifacts. Following the completion of the algorithm, a DECT stoichiometric method was used to extract the relative electronic density (ρe) and effective atomic number (Z eff) at each voxel of the corrected scans. Tissue assignment could then be determined with these two newly acquired physical parameters. Each voxel was assigned the tissue bearing the closest resemblance in terms of ρe and Z eff, comparing with values from the ICRU 42 database. A MC study was then performed to compare the dosimetric impacts of alternative MAR algorithms. RESULTS: An improvement in tissue assignment was observed with the DECT MAR algorithm, compared to the single-energy computed tomography (SECT) approach. In a phantom study, tissue misassignment was found to reach 0.05% of voxels using the DECT approach, compared with 0.40% using the SECT method. Comparison of the DECT and SECT D 90 dose parameter (volume receiving 90% of the dose) indicated that D 90 could be underestimated by up to 2.3% using the SECT method. CONCLUSIONS: The DECT MAR approach is a simple alternative to reduce metallic artifacts found in LDRB patient scans. Images can be processed quickly and do not require the determination of x-ray spectra. Substantial information on density and atomic number can also be obtained. Furthermore, calcifications within the prostate are detected by the tissue assignment algorithm. This enables more accurate, patient-specific MC dose calculations.

A theoretical comparison of tissue parameter extraction methods for dual energy computed tomography.

PURPOSE: To evaluate the reliability of common sinogram-based DECT reconstruction methods for radiotherapy tissue characterization and to evaluate the advantage of combining them with a stoichiometric calibration. METHODS: The sinogram-based DECT method defined byAlvarez and Macovski ["Energy-selective reconstructions in x-ray computerized tomography," Phys. Med. Biol. 21, 733-744 (1976)] is adapted to the XCOM photon cross sections database and also generalized to a two-material decomposition method. A theoretical framework is developed using a test phantom containing human tissue compositions for comparing the sinogram-based methods and the calibration-based method, being defined as the application of the stoichiometric calibration technique of Bourque et al. ["A stoichiometric calibration method for dual energy computed tomography," Phys. Med. Biol. 59, 2059-2088 (2014)] on monoenergetic images being generated with a sinogram-based method. Applying a bias correction to the sinogram-based method, its performance in extracting human tissue parameters in the presence of noise as well as by altering the photon energy spectrum is compared to the calibration-based method. RESULTS: In the absence of noise and without spectrum alteration, the calibration-based method is found to have no benefit on the sinogram-based method. However, the calibration-based method is shown to be potentially more reliable than bias-corrected sinogram-based methods in situations comparable to the clinical environment, where noise is present and the photon energy spectra can differ from what is used during image reconstruction. In determining electron density, the performance of all methods is comparable in the presence of noise only. Moreover, combined with heavy spectrum alteration, the mean errors on electron density are found higher in sinogram-based methods in comparison with the calibration-based method, with 1.2% versus 0.2%. In the presence of significant noise, bias-corrected sinogram-based methods yield mean errors on effective atomic number of about 2.5%, as compared to 0.5% for the calibration-based method. When combined with heavy spectrum alteration, bias-corrected sinogram-based methods can lead to error of up to 4% on the effective atomic number versus 1.8% for the calibration-based method. CONCLUSIONS: While sinogram-based methods have the advantage of eliminating beam hardening effects, results of this study suggest improvements in the accuracy and reliability of extracting tissue parameters by applying the DECT stoichiometric calibration of Bourqueet al. to monoenergetic images being generated with such DECT reconstruction methods.

A single molecule Kondo switch: multistability of tetracyanoethylene on Cu(111).

Single tetracyanoethyelene (TCNE) molecules on Cu(111) are reversibly switched among five states by applying voltage pulses with the tip of a scanning tunneling microscope. A pronounced Kondo resonance in tunneling spectroscopy indicates that one of the states is magnetic. Side bands of the Kondo resonance appear at energies which correspond to inter- and intramolecular vibrational modes. Density functional theory suggests that molecular deformation changes the occupancy in TCNE's molecular orbitals, thus producing the magnetic state.

Strongly reshaped organic-metal interfaces: tetracyanoethylene on Cu(100).

The interaction of the strong electron-acceptor tetracyanoethylene with the Cu(100) surface is studied with scanning tunneling microscopy experiments and first-principles density functional theory calculations. We compare two different adsorption models with the experimental results and show that the molecular self-assembly is caused by a strong structural modification of the Cu(100) surface rather than the formation of a coordination network by diffusing Cu adatoms. Surface atoms become highly buckled, and the chemisorption of tetracyanoethylene is accompanied by a partial charge transfer.