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Evaluation of the spline reconstruction technique for PET

Purpose: The spline reconstruction technique (SRT), based on the analytic formula for the inverse Radon transform, has been presented earlier in the literature. In this study, the authors present an improved formulation and numerical implementation of this algorithm and evaluate it in comparison to filtered backprojection (FBP). Methods: The SRT is based on the numerical evaluation of the Hilbert transform of the sinogram via an approximation in terms of “custom made” cubic splines. By restricting reconstruction only within object pixels and by utilizing certain mathematical symmetries, the authors achieve a reconstruction time comparable to that of FBP. The authors have implemented SRT in STIR and have evaluated this technique using simulated data from a clinical positron emission tomography (PET) system, as well as real data obtained from clinical and preclinical PET scanners. For the simulation studies, the authors have simulated sinograms of a point-source and three digital phantoms. Using these sinograms, the authors have created realizations of Poisson noise at five noise levels. In addition to visual comparisons of the reconstructed images, the authors have determined contrast and bias for different regions of the phantoms as a function of noise level. For the real-data studies, sinograms of an{sup 18}F-FDG injected mouse, a NEMA NU 4-2008 image quality phantom, and a Derenzo phantom have been acquired from a commercial PET system. The authors have determined: (a) coefficient of variations (COV) and contrast from the NEMA phantom, (b) contrast for the various sections of the Derenzo phantom, and (c) line profiles for the Derenzo phantom. Furthermore, the authors have acquired sinograms from a whole-body PET scan of an {sup 18}F-FDG injected cancer patient, using the GE Discovery ST PET/CT system. SRT and FBP reconstructions of the thorax have been visually evaluated. Results: The results indicate an improvement in FWHM and FWTM in both simulated and real point-source studies. In all simulated phantoms, the SRT exhibits higher contrast and lower bias than FBP at all noise levels, by increasing the COV in the reconstructed images. Finally, in real studies, whereas the contrast of the cold chambers are similar for both algorithms, the SRT reconstructed images of the NEMA phantom exhibit slightly higher COV values than those of FBP. In the Derenzo phantom, SRT resolves the 2-mm separated holes slightly better than FBP. The small-animal and human reconstructions via SRT exhibit slightly higher resolution and contrast than the FBP reconstructions. Conclusions: The SRT provides images of higher resolution, higher contrast, and lower bias than FBP, by increasing slightly the noise in the reconstructed images. Furthermore, it eliminates streak artifacts outside the object boundary. Unlike other analytic algorithms, the reconstruction time of SRT is comparable with that of FBP. The source code for SRT will become available in a future release of STIR.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Effect of time-of-flight and point spread function modeling on detectability of myocardial defects in PET

Purpose: A study was designed to investigate the impact of time-of-flight (TOF) and point spread function (PSF) modeling on the detectability of myocardial defects. Methods: Clinical FDG-PET data were used to generate populations of defect-present and defect-absent images. Defects were incorporated at three contrast levels, and images were reconstructed by ordered subset expectation maximization (OSEM) iterative methods including ordinary Poisson, alone and with PSF, TOF, and PSF+TOF. Channelized Hotelling observer signal-to-noise ratio (SNR) was the surrogate for human observer performance. Results: For three iterations, 12 subsets, and no postreconstruction smoothing, TOF improved overall defect detection SNR by 8.6% as compared to its non-TOF counterpart for all the defect contrasts. Due to the slow convergence of PSF reconstruction, PSF yielded 4.4% less SNR than non-PSF. For reconstruction parameters (iteration number and postreconstruction smoothing kernel size) optimizing observer SNR, PSF showed larger improvement for faint defects. The combination of TOF and PSF improved mean detection SNR as compared to non-TOF and non-PSF counterparts by 3.0% and 3.2%, respectively. Conclusions: For typical reconstruction protocol used in clinical practice, i.e., less than five iterations, TOF improved defect detectability. In contrast, PSF generally yielded less detectability. For large number of iterations, TOF+PSF yields the best observer performance.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Geant4 simulation for a study of a possible use of carbon ions pencil beam for the treatment of ocular melanomas with the active scanning system at CNAO Centre

The aim of this work is to validate the Geant4 application reproducing the CNAO (National Centre for Oncological Hadrontherapy) beamline and to study of a possible use of carbon ion pencil beams for the treatment of ocular melanomas at the CNAO Centre. The promising aspect of carbon ions radiotherapy for the treatment of this disease lies in its superior relative radiobiological effectiveness (RBE). The Monte Carlo Geant4 toolkit is used to simulate the complete CNAO extraction beamline, with the active and passive components along it. A human eye modeled detector, including a realistic target tumor volume, is used as target. Cross check with previous studies at CNAO using protons allows comparisons on possible benefits on using such a technique with respect to proton beams. Before the eye-detector irradiation a validation of the Geant4 simulation with CNAO experimental data is carried out with both carbon ions and protons. Important beam parameters such as the transverse FWHM and scanned radiation field 's uniformity are tested within the simulation and compared with experimental measurements at CNAO Centre. The physical processes involved in secondary particles generation by carbon ions and protons in the eye-detector are reproduced to take into account the additional dose to the primary beam given to irradiated eye's tissues. A study of beam shaping is carried out to produce a uniform 3D dose distribution (shaped on the tumor) by the use of a spread out Bragg peak. The eye-detector is then irradiated through a two dimensional transverse beam scan at different depths. In the use case the eye-detector is rotated of an angle of 40 deg. in the vertical direction, in order to mis-align the tumor from healthy tissues in front of it. The treatment uniformity on the tumor in the eye-detector is tested. For a more quantitative description of the deposited dose in the eye-detector and for the evaluation of the ratio between the dose deposited in the tumor and the other eye components, proton and carbon DVHs (Dose Volume Histograms) are compared. A high statistics simulated sample is used to minimize statistical errors. In the simulation a new particle generation method is developed in order to reproduce the experimental treatment plan by importing the DICOM RT-PLAN file, which contains all the information on the irradiation geometries and sequences (treatment plan parameters). Conclusions Even further validations must be done, the good results so far obtained by this work point out and confirm the possibility of using carbon ions delivered with active scanning beams to treat the ocular melanoma.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Gantry and isocenter displacements of a linear accelerator caused by an add-on micromultileaf collimator

Purpose: The delivery of high quality stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT) treatments to the patient requires knowledge of the position of the isocenter to submillimeter accuracy. To meet the requirements the deviation between the radiation and mechanical isocenters must be less than 1 mm. The use of add-on micromultileaf collimators ({mu}MLCs) in SRS and SRT is an additional challenge to the anticipated high-level geometric and dosimetric accuracy of the treatment. The aim of this work was to quantify the gantry excursions during rotation with and without an add-on {mu}MLC attached to the gantry head. In addition, the shift in the position of the isocenter and its correlation to the kV beam center of the cone-beam CT system was included in the study. Methods: The quantification of the gantry rotational performance was done using a pointer supported by an in-house made rigid holder attached to the gantry head of the accelerator. The pointer positions were measured using a digital theodolite. To quantify the effect of an {mu}MLC of 50 kg, the measurements were repeated with the {mu}MLC attached to the gantry head. The displacement of the isocenter due to an add-on {mu}MLC of 50 kg was also investigated. In case of the pointer measurement the {mu}MLC was simulated by weights attached to the gantry head. A method of least squares was applied to determine the position and displacement of the mechanical isocenter. Additionally, the displacement of the radiation isocenter was measured using a ball-bearing phantom and the electronic portal image device system. These measurements were based on 8 MV photon beams irradiated onto the ball from the four cardinal angles and two opposed collimator angles. The measurements and analysis of the data were carried out automatically using software delivered by the manufacturer. Results: The displacement of the mechanical isocenter caused by a 50 kg heavy {mu}MLC was found to be (-0.01 {+-} 0.05, -0.10 {+-} 0.03, -0.26 {+-} 0.05) mm in lateral, longitudinal, and vertical direction, respectively. Similarly, the displacement of the radiation isocenter was found to be (0.00 {+-} 0.03, -0.08 {+-} 0.06, -0.32 {+-} 0.02) mm. Good agreement was found between the displacement of the two isocenters. A displacement of the kV cone-beam CT beam center due to the attached weight of 50 kg could not be detected. Conclusions: General characteristics of the gantry arm excursions and displacements caused by an add-on {mu}MLC have been reported. A 50 kg heavy add-on {mu}MLC results in a isocenter displacement downward of 0.26-0.32 mm. The authors recommend that the beam center of the kV cone-beam CT image system should be matched to the isocenter related to the weight of the {mu}MLC. Consequently, the imperfections in isocenter localizations are transferred to the conventional radiotherapy where the clinical consequences of uncertainties in the submillimeter regime are negligible.

60 APPLIED LIFE SCIENCES↗

Online Magnetic Resonance Image Guided Adaptive Radiation Therapy: First Clinical Applications

Purpose: To demonstrate the feasibility of online adaptive magnetic resonance (MR) image guided radiation therapy (MR-IGRT) through reporting of our initial clinical experience and workflow considerations. Methods and Materials: The first clinically deployed online adaptive MR-IGRT system consisted of a split 0.35T MR scanner straddling a ring gantry with 3 multileaf collimator-equipped {sup 60}Co heads. The unit is supported by a Monte Carlo–based treatment planning system that allows real-time adaptive planning with the patient on the table. All patients undergo computed tomography and MR imaging (MRI) simulation for initial treatment planning. A volumetric MRI scan is acquired for each patient at the daily treatment setup. Deformable registration is performed using the planning computed tomography data set, which allows for the transfer of the initial contours and the electron density map to the daily MRI scan. The deformed electron density map is then used to recalculate the original plan on the daily MRI scan for physician evaluation. Recontouring and plan reoptimization are performed when required, and patient-specific quality assurance (QA) is performed using an independent in-house software system. Results: The first online adaptive MR-IGRT treatments consisted of 5 patients with abdominopelvic malignancies. The clinical setting included neoadjuvant colorectal (n=3), unresectable gastric (n=1), and unresectable pheochromocytoma (n=1). Recontouring and reoptimization were deemed necessary for 3 of 5 patients, and the initial plan was deemed sufficient for 2 of the 5 patients. The reasons for plan adaptation included tumor progression or regression and a change in small bowel anatomy. In a subsequently expanded cohort of 170 fractions (20 patients), 52 fractions (30.6%) were reoptimized online, and 92 fractions (54.1%) were treated with an online-adapted or previously adapted plan. The median time for recontouring, reoptimization, and QA was 26 minutes. Conclusion: Online adaptive MR-IGRT has been successfully implemented with planning and QA workflow suitable for routine clinical application. Clinical trials are in development to formally evaluate adaptive treatments for a variety of disease sites.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Monte Carlo implementation, validation, and characterization of a 120 leaf MLC

Purpose: Recently, the new high definition multileaf collimator (HD120 MLC) was commercialized by Varian Medical Systems providing high resolution in the center section of the treatment field. The aim of this work is to investigate the characteristics of the HD120 MLC using Monte Carlo (MC) methods. Methods: Based on the information of the manufacturer, the HD120 MLC was implemented into the already existing Swiss MC Plan (SMCP). The implementation has been configured by adjusting the physical density and the air gap between adjacent leaves in order to match transmission profile measurements for 6 and 15 MV beams of a Novalis TX. These measurements have been performed in water using gafchromic films and an ionization chamber at an SSD of 95 cm and a depth of 5 cm. The implementation was validated by comparing diamond measured and calculated penumbra values (80%-20%) for different field sizes and water depths. Additionally, measured and calculated dose distributions for a head and neck IMRT case using the DELTA{sup 4} phantom have been compared. The validated HD120 MLC implementation has been used for its physical characterization. For this purpose, phase space (PS) files have been generated below the fully closed multileaf collimator (MLC) of a 40 x 22 cm{sup 2} field size for 6 and 15 MV. The PS files have been analyzed in terms of energy spectra, mean energy, fluence, and energy fluence in the direction perpendicular to the MLC leaves and have been compared with the corresponding data using the well established Varian 80 leaf (MLC80) and Millennium M120 (M120 MLC) MLCs. Additionally, the impact of the tongue and groove design of the MLCs on dose has been characterized. Results: Calculated transmission values for the HD120 MLC are 1.25% and 1.34% in the central part of the field for the 6 and 15 MV beam, respectively. The corresponding ionization chamber measurements result in a transmission of 1.20% and 1.35%. Good agreement has been found for the comparison between transmission profiles resulting from MC simulations and film measurements. The simulated and measured values for the penumbra agreed within <0.5 mm for all field sizes, depths, and beam energies, and a good agreement has been found between the measured and the calculated dose distributions for the IMRT case. The total energy spectra are almost identical for the three MLCs. However, the mean energy, fluence and energy fluence are significantly different. Due to the different leaf widths of the MLCs, the shape of these distributions is different, each representing its leave structure. Due to the increase in width from the inner to the outer HD120 MLC leaves, the fluence and energy fluence clearly decrease below the outer leaves. The MLC80 and the M120 MLC resulted in an increase of the fluence and energy fluence compared with those resulted for the HD120 MLC. The dose reduction can exceed 20% compared with the dose of the open field due to the tongue and groove design of the HD120 MLC. Conclusions: The HD120 MLC has been successfully implemented into the SMCP. Comparisons between MC calculations and measurements show very good agreement. The SMCP is now able to calculate accurate dose distributions for treatment plans using the HD120 MLC.

61 RADIATION PROTECTION AND DOSIMETRY↗

Modeling of Lead-210 Data Documents Benefits in Proactively Understanding TENORM Deposition - 18515

Radioactive decay of naturally occurring Radon-222 present in just-produced natural gas can lead to deposition of its radiogenic daughter, Lead-210, and subsequent radiogenic progeny within natural gas handling, treatment, and distribution facilities. Worker safety issues and disposal challenges arise when these accumulate to radiologically problematic activity levels. This is due to the 22.3-year half-life of Lead-210, allowing for multi-decade period of accumulation to occur and to persist, even after facility operations have ceased. Due to the far shorter half-lives of Lead-210 radiogenic progeny, especially that of Polonium-210, secular equilibrium within the Lead-210-Bismuth-210-Polonium-210 decay chain is quickly approached during facility operations and achieved after facility operations end. Lead-210 that accumulates in pipe scale can complicate any subsequent intrusive facility modifications, such as disassembly and dismantlement, potentially exposing workers to adverse radioactivity and impeding recycling and/or disposal of radiologically impacted equipment or other material. Experience has shown it is not strictly the presence of Lead-210 that is problematic but rather its 'unexpected' presence when this Technologically Enhanced Naturally Occurring Radioactive Material (TENORM) is discovered during intrusive work not incorporating radiological health and safety and material handling plans. Conversely, when implementing a program that proactively considers the potential for Lead-210, this form of TENORM simply becomes another 'special waste' that can be safely, efficiently, and effectively addressed during a decommissioning effort, without associated adverse worker exposures, project cost over-runs, and schedule delays. This paper will discuss how proactive radioactive scanning quickly and safely identified Lead-210 and its radiogenic progeny within a natural gas sweetening and compressor station located in northern Montana, a portion of which was undergoing decommissioning, aiding in safe and compliant material handling and recycling. The location of this operation necessitated that the decommissioning program be completed on schedule to prevent weather-related impacts due to the onset of adverse winter conditions. Further, the radioactive data acquired during this project will be shown to provide important insight into historic behavior of Lead-210 in terms of its disposition and its more recent decay. From these data, it became possible to back-model the average activity of Radon-222 within the natural gas being processed during the life of the operation, how the estimated Radon-222 activity within the processed natural gas conformed to measured Radon-222 at various other natural gas fields, and how this information can be leveraged in developing safe and successful plans for future intrusive work at this and companion site operations. This presentation will also note the apparent preferential accumulation of Lead-210 within both rubber-based materials, such as gaskets and seals, and grease-based products found within natural gas flow lines. Thoughts regarding processes that may lead to this finding will be explored. (authors)

12 MANAGEMENT OF RADIOACTIVE AND NON-RADIOACTIVE W↗

Statistical variability and confidence intervals for planar dose QA pass rates

Purpose: The most common metric for comparing measured to calculated dose, such as for pretreatment quality assurance of intensity-modulated photon fields, is a pass rate (%) generated using percent difference (%Diff), distance-to-agreement (DTA), or some combination of the two (e.g., gamma evaluation). For many dosimeters, the grid of analyzed points corresponds to an array with a low areal density of point detectors. In these cases, the pass rates for any given comparison criteria are not absolute but exhibit statistical variability that is a function, in part, on the detector sampling geometry. In this work, the authors analyze the statistics of various methods commonly used to calculate pass rates and propose methods for establishing confidence intervals for pass rates obtained with low-density arrays. Methods: Dose planes were acquired for 25 prostate and 79 head and neck intensity-modulated fields via diode array and electronic portal imaging device (EPID), and matching calculated dose planes were created via a commercial treatment planning system. Pass rates for each dose plane pair (both centered to the beam central axis) were calculated with several common comparison methods: %Diff/DTA composite analysis and gamma evaluation, using absolute dose comparison with both local and global normalization. Specialized software was designed to selectively sample the measured EPID response (very high data density) down to discrete points to simulate low-density measurements. The software was used to realign the simulated detector grid at many simulated positions with respect to the beam central axis, thereby altering the low-density sampled grid. Simulations were repeated with 100 positional iterations using a 1 detector/cm{sup 2} uniform grid, a 2 detector/cm{sup 2} uniform grid, and similar random detector grids. For each simulation, %/DTA composite pass rates were calculated with various %Diff/DTA criteria and for both local and global %Diff normalization techniques. Results: For the prostate and head/neck cases studied, the pass rates obtained with gamma analysis of high density dose planes were 2%-5% higher than respective %/DTA composite analysis on average (ranging as high as 11%), depending on tolerances and normalization. Meanwhile, the pass rates obtained via local normalization were 2%-12% lower than with global maximum normalization on average (ranging as high as 27%), depending on tolerances and calculation method. Repositioning of simulated low-density sampled grids leads to a distribution of possible pass rates for each measured/calculated dose plane pair. These distributions can be predicted using a binomial distribution in order to establish confidence intervals that depend largely on the sampling density and the observed pass rate (i.e., the degree of difference between measured and calculated dose). These results can be extended to apply to 3D arrays of detectors, as well. Conclusions: Dose plane QA analysis can be greatly affected by choice of calculation metric and user-defined parameters, and so all pass rates should be reported with a complete description of calculation method. Pass rates for low-density arrays are subject to statistical uncertainty (vs. the high-density pass rate), but these sampling errors can be modeled using statistical confidence intervals derived from the sampled pass rate and detector density. Thus, pass rates for low-density array measurements should be accompanied by a confidence interval indicating the uncertainty of each pass rate.

61 RADIATION PROTECTION AND DOSIMETRY↗

TH-A-BRF-02: BEST IN PHYSICS (JOINT IMAGING-THERAPY) - Modeling Tumor Evolution for Adaptive Radiation Therapy

Purpose: To develop mathematical models of tumor geometry changes under radiotherapy that may support future adaptive paradigms. Methods: A total of 29 cervical patients were scanned using MRI, once for planning and weekly thereafter for treatment monitoring. Using the tumor volumes contoured by a radiologist, three mathematical models were investigated based on the assumption of a stochastic process of tumor evolution. The “weekly MRI” model predicts tumor geometry for the following week from the last two consecutive MRI scans, based on the voxel transition probability. The other two models use only the first pair of consecutive MRI scans, and the transition probabilities were estimated via tumor type classified from the entire data set. The classification is based on either measuring the tumor volume (the “weekly volume” model), or implementing an auxiliary “Markov chain” model. These models were compared to a constant volume approach that represents the current clinical practice, using various model parameters; e.g., the threshold probability β converts the probability map into a tumor shape (larger threshold implies smaller tumor). Model performance was measured using volume conformity index (VCI), i.e., the union of the actual target and modeled target volume squared divided by product of these two volumes. Results: The “weekly MRI” model outperforms the constant volume model by 26% on average, and by 103% for the worst 10% of cases in terms of VCI under a wide range of β. The “weekly volume” and “Markov chain” models outperform the constant volume model by 20% and 16% on average, respectively. They also perform better than the “weekly MRI” model when β is large. Conclusion: It has been demonstrated that mathematical models can be developed to predict tumor geometry changes for cervical cancer undergoing radiotherapy. The models can potentially support adaptive radiotherapy paradigm by reducing normal tissue dose. This research was supported in part by the Ontario Consortium for Adaptive Interventions in Radiation Oncology (OCAIRO) funded by the Ontario Research Fund (ORF) and the MITACS Accelerate Internship Program.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Clinical Evaluation of a Robotic 6-Degree of Freedom Treatment Couch for Frameless Radiosurgery

Purpose: To evaluate the added value of 6-degree of freedom (DOF) patient positioning with a robotic couch compared with 4DOF positioning for intracranial lesions and to estimate the immobilization characteristics of the BrainLAB frameless mask (BrainLAB AG, Feldkirchen, Germany), more specifically, the setup errors and intrafraction motion. Methods and Materials: We enrolled 40 patients with 66 brain metastases treated with frameless stereotactic radiosurgery and a 6DOF robotic couch. Patient positioning was performed with the BrainLAB ExacTrac stereoscopic X-ray system. Positioning results were collected before and after treatment to assess patient setup error and intrafraction motion. Existing treatment planning data were loaded and simulated for 4DOF positioning and compared with the 6DOF positioning. The clinical relevance was analyzed by means of the Paddick conformity index and the ratio of prescribed isodose volume covered with 4DOF to that obtained with the 6DOF positioning. Results: The mean three-dimensional setup error before 6DOF correction was 1.91 mm (SD, 1.25 mm). The rotational errors were larger in the longitudinal (mean, 0.23 Degree-Sign ; SD, 0.82 Degree-Sign ) direction compared with the lateral (mean, -0.09 Degree-Sign ; SD, 0.72 Degree-Sign ) and vertical (mean, -0.10 Degree-Sign ; SD, 1.03 Degree-Sign ) directions (p < 0.05). The mean three-dimensional intrafraction shift was 0.58 mm (SD, 0.42 mm). The mean intrafractional rotational errors were comparable for the vertical, longitudinal, and lateral directions: 0.01 Degree-Sign (SD, 0.35 Degree-Sign ), 0.03 Degree-Sign (SD, 0.31 Degree-Sign ), and -0.03 Degree-Sign (SD, 0.33 Degree-Sign ), respectively. The mean conformity index decreased from 0.68 (SD, 0.08) (6DOF) to 0.59 (SD, 0.12) (4DOF) (p < 0.05). A loss of prescribed isodose coverage of 5% (SD, 0.08) was found with the 4DOF positioning (p < 0.05). Half a degree for longitudinal and lateral rotations can be identified as a threshold for coverage loss. Conclusions: With a mask immobilization, patient setup error and intrafraction motions need to be evaluated and corrected for. The 6DOF patient positioning with a 6DOF robotic couch to correct translational and rotational setup errors improves target positioning with respect to treatment isocenter, which is in direct relation with the clinical outcome, compared with the 4DOF positioning.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Characterization of a spectroscopic detector for application in x-ray computed tomography

Recent advances in cadmium telluride (CdTe) energy-discriminating pixelated detectors have enabled the possibility of Multi-Spectral X-ray Computed Tomography (MSXCT) to incorporate spectroscopic information into CT. MultiX ME 100 V2 is a CdTe-based spectroscopic x-ray detector array capable of recording energies from 20 to 160 keV in 1.1 keV energy bin increments. Hardware and software have been designed to perform radiographic and computed tomography tasks with this spectroscopic detector. Energy calibration is examined using the end-point energy of a bremsstrahlung spectrum and radioisotope spectral lines. When measuring the spectrum from Am-241 across 500 detector elements, the standard deviation of the peak-location and FWHM measurements are ±0.4 and ±0.6 keV, respectively. As these values are within the energy bin size (1.1 keV), detector elements are consistent with each other. The count rate is characterized, using a nonparalyzable model with a dead time of 64 ± 5 ns. This is consistent with the manufacturer’s quoted per detector-element linear-deviation at 2 Mpps (million photons per sec) of 8.9% (typical) and 12% (max). When comparing measured and simulated spectra, a low-energy tail is visible in the measured data due to the spectral response of the detector. If no valid photon detections are expected in the low-energy tail, then a background subtraction may be applied to allow for a possible first-order correction. If photons are expected in the low-energy tail, a detailed model must be implemented. A radiograph of an aluminum step wedge with a maximum height of about 20 mm shows an underestimation of attenuation by about 10% at 60 keV. This error is due to partial energy deposition from higher-energy (> 60 keV) photons into a lower-energy (~60 keV) bin, reducing the apparent attenuation. A radiograph of a PTFE cylinder taken using a bremsstrahlung spectrum from an x-ray voltage of 100 kV filtered by 1.3 mm Cu is reconstructed using Abel inversion. As no counts are expected in the low energy tail, a first order background correction is applied to the spectrum. The measured linear attenuation coefficient (LAC) is within 10% of the expected value in the 60 to 100 keV range. Below 60 keV, low counts in the corrected spectrum and partial energy deposition from incident photons of energy greater than 60 keV into energy bins below 60 keV impact the LAC measurements. This report ends with a demonstration of the tomographic capability of the system. The quantitative understanding of the detector developed in this report will enable further study in evaluating the system for characterization of an object’s chemical make-up for industrial and security purposes.

36 MATERIALS SCIENCE↗

SU-F-R-18: Updates to the Computational Environment for Radiological Research for Image Analysis

Purpose: To present new tools in CERR for Texture Analysis and Visualization. Method: (1) Quantitative Image Analysis: We added the ability to compute Haralick texture features based on local neighbourhood. The Texture features depend on many parameters used in their derivation. For example: (a) directionality, (b) quantization of image, (c) patch-size for the neighborhood, (d) handling of the edge voxels within the region of interest, (e) Averaging co-occurance matrix vs texture features for different directions etc. A graphical user interface was built to set these parameters and then visualize their impact on the resulting texture maps. The entire functionality was written in Matlab. Array indexing was used to speed up the texture calculation. The computation speed is very competitive with the ITK library. Moreover, our implementation works with multiple CPUs and the computation time can be further reduced by using multiple processor threads. In order to reduce the Haralick texture maps into scalar features, we propose the use of Texture Volume Histograms. This lets users make use of the entire distribution of texture values within the region of interest rather than using just the mean and the standard deviations. (2) Qualitative/Visualization tools: The derived texture maps are stored as a new scan (derived) within CERR’s planC data structure. A display that compares various scans was built to show the raw image and the derived texture maps side-by-side. These images are positionally linked and can be navigated together. CERR’s graphics handling was updated and sped-up to be compatible with the newer Matlab versions. As a result, the users can use (a) different window levels and colormaps for different viewports, (b) click-and-drag or use mouse scroll-wheel to navigate slices. Results: The new features and updates are available via https://www.github.com/adityaapte/cerr . Conclusion: Features added to CERR increase its utility in Radiomics and Outcomes modeling.

60 APPLIED LIFE SCIENCES↗

Low Cerebral Blood Volume Identifies Poor Outcome in Stent Retriever Thrombectomy

BackgroundMechanical thrombectomy (MT) is an efficient treatment of acute stroke caused by large-vessel occlusion. We evaluated the factors predicting poor clinical outcome (3-month modified Rankin Scale, mRS >2) although MT performed with modern stent retrievers.MethodsWe prospectively collected the clinical and imaging data of 105 consecutive anterior circulation stroke patients who underwent MT after multimodal CT imaging. Patients with occlusion of the internal carotid artery and/or middle cerebral artery up to the M2 segment were included. We recorded baseline clinical, procedural and imaging variables, technical outcome, 24-h imaging outcome and the clinical outcome. Differences between the groups were studied with appropriate statistical tests and binary logistic regression analysis.ResultsLow cerebral blood volume Alberta stroke program early CT score (CBV-ASPECTS) was associated with poor clinical outcome (median 7 vs. 9, p = 0.01). Lower collateral score (CS) significantly predicted poor outcome in regression modelling with CS = 0 increasing the odds of poor outcome 4.4-fold compared to CS = 3 (95% CI 1.27–15.5, p = 0.02). Lower CBV-ASPECTS significantly predicted poor clinical outcome among those with moderate or severe stroke (OR 0.82, 95% CI 0.68–1, p = 0.05) or poor collateral circulation (CS 0–1, OR 0.66, 95% CI 0.48–0.90, p = 0.009) but not among those with mild strokes or good collaterals.ConclusionsCBV-ASPECTS estimating infarct core is a significant predictor of poor clinical outcome among anterior circulation stroke patients treated with MT, especially in the setting of poor collateral circulation and/or moderate or severe stroke.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Synthetic CT: Simulating low dose single and dual energy protocols from a dual energy scan

Purpose: The choice of CT protocol can greatly impact patient dose and image quality. Since acquiring multiple scans at different techniques on a given patient is undesirable, the ability to predict image quality changes starting from a high quality exam can be quite useful. While existing methods allow one to generate simulated images of lower exposure (mAs) from an acquired CT exam, the authors present and validate a new method called synthetic CT that can generate realistic images of a patient at arbitrary low dose protocols (kVp, mAs, and filtration) for both single and dual energy scans. Methods: The synthetic CT algorithm is derived by carefully ensuring that the expected signal and noise are accurate for the simulated protocol. The method relies on the observation that the material decomposition from a dual energy CT scan allows the transmission of an arbitrary spectrum to be predicted. It requires an initial dual energy scan of the patient to either synthesize raw projections of a single energy scan or synthesize the material decompositions of a dual energy scan. The initial dual energy scan contributes inherent noise to the synthesized projections that must be accounted for before adding more noise to simulate low dose protocols. Therefore, synthetic CT is subject to the constraint that the synthesized data have noise greater than the inherent noise. The authors experimentally validated the synthetic CT algorithm across a range of protocols using a dual energy scan of an acrylic phantom with solutions of different iodine concentrations. An initial 80/140 kVp dual energy scan of the phantom provided the material decomposition necessary to synthesize images at 100 kVp and at 120 kVp, across a range of mAs values. They compared these synthesized single energy scans of the phantom to actual scans at the same protocols. Furthermore, material decompositions of a 100/120 kVp dual energy scan are synthesized by adding correlated noise to the initial material decompositions. The aforementioned noise constraint also allows us to compute feasible mAs values that can be synthesized for each kVp. Results: The single energy synthesized and actual reconstructed images exhibit identical signal and noise properties at 100 kVp and at 120 kVp, and across a range of mAs values. For example, the noise in both the synthesized and actual images at 100 kVp increases by {radical}(2) when the mAs is halved. The synthesized and actual material decompositions of a dual energy protocol show excellent agreement when the decomposition images are linearly weighted to form monoenergetic images at energies from 40 to 100 keV. For simulated single energy protocols with kVp between 80 and 140, the highest feasible mAs exceeds that of either initial scan. Conclusions: This work describes and validates the synthetic CT theory and algorithm by comparing its results to actual scans. Synthetic CT is a powerful new tool that allows users to realistically see how protocol selection affects CT images and enables radiologists to retrospectively identify the lowest dose protocol achievable that provides diagnostic quality images on real patients.

61 RADIATION PROTECTION AND DOSIMETRY↗

Photon energy-modulated radiotherapy: Monte Carlo simulation and treatment planning study

Purpose: To demonstrate the feasibility of photon energy-modulated radiotherapy during beam-on time. Methods: A cylindrical device made of aluminum was conceptually proposed as an energy modulator. The frame of the device was connected with 20 tubes through which mercury could be injected or drained to adjust the thickness of mercury along the beam axis. In Monte Carlo (MC) simulations, a flattening filter of 6 or 10 MV linac was replaced with the device. The thickness of mercury inside the device varied from 0 to 40 mm at the field sizes of 5 x 5 cm{sup 2} (FS5), 10 x 10 cm{sup 2} (FS10), and 20 x 20 cm{sup 2} (FS20). At least 5 billion histories were followed for each simulation to create phase space files at 100 cm source to surface distance (SSD). In-water beam data were acquired by additional MC simulations using the above phase space files. A treatment planning system (TPS) was commissioned to generate a virtual machine using the MC-generated beam data. Intensity modulated radiation therapy (IMRT) plans for six clinical cases were generated using conventional 6 MV, 6 MV flattening filter free, and energy-modulated photon beams of the virtual machine. Results: As increasing the thickness of mercury, Percentage depth doses (PDD) of modulated 6 and 10 MV after the depth of dose maximum were continuously increased. The amount of PDD increase at the depth of 10 and 20 cm for modulated 6 MV was 4.8% and 5.2% at FS5, 3.9% and 5.0% at FS10 and 3.2%-4.9% at FS20 as increasing the thickness of mercury from 0 to 20 mm. The same for modulated 10 MV was 4.5% and 5.0% at FS5, 3.8% and 4.7% at FS10 and 4.1% and 4.8% at FS20 as increasing the thickness of mercury from 0 to 25 mm. The outputs of modulated 6 MV with 20 mm mercury and of modulated 10 MV with 25 mm mercury were reduced into 30%, and 56% of conventional linac, respectively. The energy-modulated IMRT plans had less integral doses than 6 MV IMRT or 6 MV flattening filter free plans for tumors located in the periphery while maintaining the similar quality of target coverage, homogeneity, and conformity. Conclusions: The MC study for the designed energy modulator demonstrated the feasibility of energy-modulated photon beams available during beam-on time. The planning study showed an advantage of energy-and intensity modulated radiotherapy in terms of integral dose without sacrificing any quality of IMRT plan.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

A limited-angle intrafraction verification (LIVE) system for radiation therapy

Purpose: Currently, no 3D or 4D volumetric x-ray imaging techniques are available for intrafraction verification of target position during actual treatment delivery or in-between treatment beams, which is critical for stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) treatments. This study aims to develop a limited-angle intrafraction verification (LIVE) system to use prior information, deformation models, and limited angle kV-MV projections to verify target position intrafractionally. Methods: The LIVE system acquires limited-angle kV projections simultaneously during arc treatment delivery or in-between static 3D/IMRT treatment beams as the gantry moves from one beam to the next. Orthogonal limited-angle MV projections are acquired from the beam's eye view (BEV) exit fluence of arc treatment beam or in-between static beams to provide additional anatomical information. MV projections are converted to kV projections using a linear conversion function. Patient prior planning CT at one phase is used as the prior information, and the on-board patient volume is considered as a deformation of the prior images. The deformation field is solved using the data fidelity constraint, a breathing motion model extracted from the planning 4D-CT based on principal component analysis (PCA) and a free-form deformation (FD) model. LIVE was evaluated using a 4D digital extended cardiac torso phantom (XCAT) and a CIRS 008A dynamic thoracic phantom. In the XCAT study, patient breathing pattern and tumor size changes were simulated from CT to treatment position. In the CIRS phantom study, the artificial target in the lung region experienced both size change and position shift from CT to treatment position. Varian Truebeam research mode was used to acquire kV and MV projections simultaneously during the delivery of a dynamic conformal arc plan. The reconstruction accuracy was evaluated by calculating the 3D volume percentage difference (VPD) and the center of mass (COM) difference of the tumor in the true on-board images and reconstructed images. Results: In both simulation and phantom studies, LIVE achieved substantially better reconstruction accuracy than reconstruction using PCA or FD deformation model alone. In the XCAT study, the average VPD and COM differences among different patient scenarios for LIVE system using orthogonal 30° scan angles were 4.3% and 0.3 mm when using kV+BEV MV. Reducing scan angle to 15° increased the average VPD and COM differences to 15.1% and 1.7 mm. In the CIRS phantom study, the VPD and COM differences for the LIVE system using orthogonal 30° scan angles were 6.4% and 1.4 mm. Reducing scan angle to 15° increased the VPD and COM differences to 51.9% and 3.8 mm. Conclusions: The LIVE system has the potential to substantially improve intrafraction target localization accuracy by providing volumetric verification of tumor position simultaneously during arc treatment delivery or in-between static treatment beams. With this improvement, LIVE opens up a new avenue for margin reduction and dose escalation in both fractionated treatments and SRS and SBRT treatments.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

WE-A-BRF-01: Dual-Energy CT Imaging in Diagnostic Imaging and Radiation Therapy

The quantification accuracy of dual-energy imaging is influenced by the fundamentals of x-ray physics, system geometry, data acquisition hardware/protocol, system calibration, and image processing technique. This symposium will provide updates on the following advanced application areas: Mammography. Volumetric breast density techniques based on standard mammograms require estimation of breast thickness, which is difficult to accurately measure. By comparison, calculation of breast density using dual energy mammography does not require measurement of breast thickness. Dual energy mammography has been implemented using both energy integrating flat panel detectors in conjunction with beam energy switching and energy resolved photon counting detectors. These techniques have been optimized using simulation studies and validated using physical phantoms and postmortem breasts. Chemical decomposition was used as the gold standard for volumetric breast density measurement in postmortem breasts. Breast density measurements have also been compared with results from four-category BI-RADS density rankings, standard image thresholding and Fuzzy k-mean clustering techniques. These studies indicate that dual energy mammography can be used to accurately measure volumetric breast density. Cardiovascular CT. The predicative accuracy of risk models for recurrent stroke and cardiac arrest depends heavily on accurate differentiation of thrombus or calcium from iodine in left atrial appendage or coronary arteries. The amount of energy separation is constrained by image noise; therefore, optimal kVp, beam filtration, and balanced flux are essential for the quantification accuracy of iodine and calcium. The basis materials are combined linearly to generate monochromatic energy images, where CT# accuracy and CNR are energy dependent. With optimal monochromatic energy, the mean iodine concentration for the thrombus, circulatory stasis, and control groups are significantly different. Risk classification based on calcium scores shows excellent agreement with classification on the basis of conventional coronary artery calcium scoring. These studies demonstrate dual-energy cardiovascular CT can potentially be a noninvasive and sensitive modality in high risk patients. On-board KV/MV Imaging. To enhance soft tissue contrast and reduce metal artifacts, we have developed a dual-energy CBCT technique and a novel on-board kV/MV imaging technique based on hardware available on modern linear accelerators. We have also evaluated the feasibility of these two techniques in various phantom studies. Optimal techniques (energy, beam filtration, # of overlapping projections, etc) have been investigated with unique calibration procedures, which leads to successful decomposition of imaged material into acrylic-aluminum basis material pair. This enables the synthesis of virtual monochromatic (VM) CBCT images that demonstrate much less beam hardening, significantly reduced metal artifacts, and/or higher soft tissue CNR compared to single-energy CBCT. Adaptive Radiation Therapy. DECT could actually contribute to the area of Dose-Guided Radiation Therapy (or Adaptive Therapy). The application of DECT imaging using 80kV and 140 kV combinations could potentially increase the image quality by reducing the bone or high density material artifacts and also increase the soft tissue contrast by a light contrast agent. The result of this higher contrast / quality images is beneficial for deformable image registration / segmentation algorithm to improve its accuracy hence to make adaptive therapy less time consuming in its recontouring process. The real time re-planning prior to per treatment fraction could become more realistic with this improvement especially in hypofractional SBRT cases. Learning Objectives: Learn recent developments of dual-energy imaging in diagnosis and radiation therapy; Understand the unique clinical problem and required quantification accuracy in each application; Understand the different approaches to optimize dual-energy imaging techniques for different applications.

60 APPLIED LIFE SCIENCES↗

A Biodistribution and Toxicity Study of Cobalt Dichloride-N-Acetyl Cysteine in an Implantable MRI Marker for Prostate Cancer Treatment

Purpose: C4, a cobalt dichloride-N-acetyl cysteine complex, is being developed as a positive-signal magnetic resonance imaging (MRI) marker to localize implanted radioactive seeds in prostate brachytherapy. We evaluated the toxicity and biodistribution of C4 in rats with the goal of simulating the systemic effects of potential leakage from C4 MRI markers within the prostate. Methods and Materials: 9-μL doses (equivalent to leakage from 120 markers in a human) of control solution (0.9% sodium chloride), 1% (proposed for clinical use), and 10% C4 solution were injected into the prostates of male Sprague-Dawley rats via laparotomy. Organ toxicity and cobalt disposition in plasma, tissues, feces, and urine were evaluated. Results: No C4-related morbidity or mortality was observed in the biodistribution arm (60 rats). Biodistribution was measurable after 10% C4 injection: cobalt was cleared rapidly from periprostatic tissue; mean concentrations in prostate were 163 μg/g and 268 μg/g at 5 and 30 minutes but were undetectable by 60 minutes. Expected dual renal-hepatic elimination was observed, with percentages of injected dose recovered in tissues of 39.0 ± 5.6% (liver), >11.8 ± 6.5% (prostate), and >5.3 ± 0.9% (kidney), with low plasma concentrations detected up to 1 hour (1.40 μg/mL at 5-60 minutes). Excretion in urine was 13.1 ± 4.6%, with 3.1 ± 0.54% recovered in feces by 24 hours. In the toxicity arm, 3 animals died in the control group and 1 each in the 1% and 10% groups from surgical or anesthesia-related complications; all others survived to scheduled termination at 14 days. No C4-related adverse clinical signs or organ toxicity were observed. Conclusion: C4-related toxicity was not observed at exposures at least 10-fold the exposure proposed for use in humans. These data demonstrating lack of systemic toxicity with dual routes of elimination in the event of in situ rupture suggest that C4 warrants further investigation as an MRI marker for prostate brachytherapy.

62 RADIOLOGY AND NUCLEAR MEDICINE↗