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DOE OSTI2014

SU-E-J-100: Reconstruction of Prompt Gamma Ray Three Dimensional SPECT Image From Boron Neutron Capture Therapy(BNCT)

Purpose: Purpose of paper is to confirm the feasibility of acquisition of three dimensional single photon emission computed tomography (SPECT) image from boron neutron capture therapy (BNCT) using Monte Carlo simulation. Methods: In case of simulation, the pixelated SPECT detector, collimator and phantom were simulated using Monte Carlo n particle extended (MCNPX) simulation tool. A thermal neutron source (<1 eV) was used to react with the boron uptake region (BUR) in the phantom. Each geometry had a spherical pattern, and three different BURs (A, B and C region, density: 2.08 g/cm3) were located in the middle of the brain phantom. The data from 128 projections for each sorting process were used to achieve image reconstruction. The ordered subset expectation maximization (OSEM) reconstruction algorithm was used to obtain a tomographic image with eight subsets and five iterations. The receiver operating characteristic (ROC) curve analysis was used to evaluate the geometric accuracy of reconstructed image. Results: The OSEM image was compared with the original phantom pattern image. The area under the curve (AUC) was calculated as the gross area under each ROC curve. The three calculated AUC values were 0.738 (A region), 0.623 (B region), and 0.817 (C region). The differences between length of centers of two boron regions and distance of maximum count points were 0.3 cm, 1.6 cm and 1.4 cm. Conclusion: The possibility of extracting a 3D BNCT SPECT image was confirmed using the Monte Carlo simulation and OSEM algorithm. The prospects for obtaining an actual BNCT SPECT image were estimated from the quality of the simulated image and the simulation conditions. When multiple tumor region should be treated using the BNCT, a reasonable model to determine how many useful images can be obtained from the SPECT could be provided to the BNCT facilities. This research was supported by the Leading Foreign Research Institute Recruitment Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, Information and Communication Technologies (ICT) and Future Planning (MSIP)(Grant No.200900420) and the Radiation Technology Research and Development program (Grant No.2013043498), Republic of Korea.

07 ISOTOPE AND RADIATION SOURCES↗

DOE OSTI2014

SU-E-J-141: Comparison of Dose Calculation On Automatically Generated MRBased ED Maps and Corresponding Patient CT for Clinical Prostate EBRT Plans

Purpose: To analyze the effect of computing radiation dose on automatically generated MR-based simulated CT images compared to true patient CTs. Methods: Six prostate cancer patients received a regular planning CT for RT planning as well as a conventional 3D fast-field dual-echo scan on a Philips 3.0T Achieva, adding approximately 2 min of scan time to the clinical protocol. Simulated CTs (simCT) where synthesized by assigning known average CT values to the tissue classes air, water, fat, cortical and cancellous bone. For this, Dixon reconstruction of the nearly out-of-phase (echo 1) and in-phase images (echo 2) allowed for water and fat classification. Model based bone segmentation was performed on a combination of the DIXON images. A subsequent automatic threshold divides into cortical and cancellous bone. For validation, the simCT was registered to the true CT and clinical treatment plans were re-computed on the simCT in pinnacle{sup 3}. To differentiate effects related to the 5 tissue classes and changes in the patient anatomy not compensated by rigid registration, we also calculate the dose on a stratified CT, where HU values are sorted in to the same 5 tissue classes as the simCT. Results: Dose and volume parameters on PTV and risk organs as used for the clinical approval were compared. All deviations are below 1.1%, except the anal sphincter mean dose, which is at most 2.2%, but well below clinical acceptance threshold. Average deviations are below 0.4% for PTV and risk organs and 1.3% for the anal sphincter. The deviations of the stratifiedCT are in the same range as for the simCT. All plans would have passed clinical acceptance thresholds on the simulated CT images. Conclusion: This study demonstrated the clinical usability of MR based dose calculation with the presented Dixon acquisition and subsequent fully automatic image processing. N. Schadewaldt, H. Schulz, M. Helle and S. Renisch are employed by Phlips Technologie Innovative Techonologies, a subsidiary of Royal Philips NV.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2014

SU-E-J-226: Propagation of Pancreas Target Contours On Respiratory Correlated CT Images Using Deformable Image Registration

Purpose: Respiratory Correlated CT (RCCT) scans to assess intra-fraction motion among pancreatic cancer patients undergoing radiotherapy allow for dose sparing of normal tissues, in particular for the duodenum. Contour propagation of the gross tumor volume (GTV) from one reference respiratory phase to 9 other phases is time consuming. Deformable image registration (DIR) has been successfully used for high contrast disease sites but lower contrast for pancreatic tumors may compromise accuracy. This study evaluates the accuracy of Fast Free Form (FFF) registration-based contour propagation of the GTV on RCCT scans of pancreas cancer patients. Methods: Twenty-four pancreatic cancer patients were retrospectively studied; 20 had tumors in the pancreatic head/neck, 4 in the body/tail. Patients were simulated with RCCT and images were sorted into 10 respiratory phases. A radiation oncologist manually delineated the GTV for 5 phases (0%, 30%, 50%, 70% and 90%). The FFF algorithm was used to map deformations between the EE (50%) phase and each of the other 4 phases. The resultant deformation fields served to propagate GTV contours from EE to the other phases. The Dice Similarity Coefficient (DSC), which measures agreement between the DIR-propagated and manually-delineated GTVs, was used to quantitatively examine DIR accuracy. Results: Average DSC over all scans and patients is 0.82 and standard deviation is 0.09 (DSC range 0.97–0.57). For GTV volumes above and below the median volume of 20.2 cc, a Wilcoxon rank-sum test shows significantly different DSC (p=0.0000002). For the GTVs above the median volume, average +/− SD is 0.85 +/− 0.07; and for the GTVs below, the average +/− SD is 0.75 +/−0.08. Conclusion: For pancreatic tumors, the FFF DIR algorithm accurately propagated the GTV between the images in different phases of RCCT, with improved performance for larger tumors.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2014

SU-E-J-241: Creation of Ventilation CT From Daily 4D CTs Or 4D Conebeam CTs Acquired During IGRT for Thoracic Cancers

Purpose: To develop a method to create ventilation CTs from daily 4D CTs or 4D KV conebeam CTs (4DCBCT) acquired during image-guided radiation therapy (IGRT) for thoracic tumors, and to explore the potential for using the ventilation CTs as a means for early detection of lung injury during radiation treatment. Methods: 4DCT acquired using an in-room CT (CTVision, Siemens) and 4DCBCT acquired using the X-ray Volume Imaging (XVI) system (Infinity, Elekta) for representative lung cancer patients were analyzed. These 4D data sets were sorted into 10 phase images. A newly-available deformable image registration tool (ADMIRE, Elekta) is used to deform the phase images at the end of exhale (EE) to the phase images at the end of inhale (EI). The lung volumes at EI and EE were carefully contoured using an intensity-based auto-contour tool and then manually edited. The ventilation images were calculated from the variations of CT numbers of those voxels masked by the lung contour at EI between the registered phase images. The deformable image registration is also performed between the daily 4D images and planning 4DCT, and the resulting deformable field vector (DFV) is used to deform the planning doses to the daily images by an in-house Matlab program. Results: The ventilation images were successfully created. The tide volumes calculated using the ventilation images agree with those measured through volume difference of contours at EE and EI, indicating the accuracy of ventilation images. The association between the delivered doses and the change of lung ventilation from the daily ventilation CTs is identified. Conclusions: A method to create the ventilation CT using daily 4DCTs or 4D KV conebeam CTs was developed and demonstrated.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2014

SU-E-T-217: Intrinsic Respiratory Gating in Small Animal CT

Purpose: Preclinical animal models of lung cancer can provide a controlled test-bed for testing dose escalation or function-based-treatment-planning studies. However, to extract lung function, i.e. ventilation, one needs to be able to image the lung at different phases of ventilation (in-hale / ex-hale). Most respiratory-gated imaging using micro-CT involves using an external ventilator and surgical intervention limiting the utility in longitudinal studies. A new intrinsic respiratory retrospective gating method was developed and tested in mice. Methods: A fixed region of interest (ROI) that covers the diaphragm was selected on all projection images to estimate the mean intensity (M). The mean intensity depends on the projection angle and diaphragm position. A 3-point moving average (A) of consecutive M values: Mpre, Mcurrent and Mpost, was calculated to be subtracted from Mcurrent. A fixed threshold was used to enable amplitude based sorting into 4 different phases of respiration. Images at full-inhale and end-exhale phases of respiration were reconstructed using the open source OSCaR. Lung volumes estimated at the 2 phases of respiration were validated against literature values. Results: Intrinsic retrospective gating was accomplished without the use of any external breathing waveform. While projection images were acquired at 360 different angles. Only 138 and 104 projections were used to reconstruct images at full-inhale and end-exhale. This often results in non-uniform under-sampled angular projections leading to some minor streaking artifacts. The calculated expiratory, inspiratory and tidal lung volumes correlated well with the values known from the literature. Conclusion: Our initial result demonstrates an intrinsic gating method that is suitable for flat panel cone beam small animal CT systems. Reduction in streaking artifacts can be accomplished by oversampling the data or using iterative reconstruction methods. This initial experience will enable freebreathing small animal micro-CT imaging to fuel longitudinal studies of lung function.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2014

SU-E-T-330: To Analyze the Calculation Error of Live Dose-Volume Indices Applying 4D-CT in Radiotherapy for PTVs Within the Liver Completely

Purpose: To study the variation rule of normal liver dose-volume indices calculation for the liver malignancy patients whose plan target volumes were in the liver completely in all breath phases. Methods: Ten patients who accepted radiotherapy for malignant tumor were selected in our study. All patients underwent 4D-CT simulation and 3D-CT simulation in free breathing(FB). 4D-CT was sorted into 10 series CT images according to breath phase, named CT0, CT10 to CT90, respectively. And GTVs were contoured on different CT series, and the individual target volume(ITV) was obtained by merging 10 GTVs from 4D-CT. The PTVs were obtained from ITV applying margins. The PTVs were not beyond the boundary of liver in all breath phase observed by dynamic 4D-CT. The radiotherapy plans were designed and irradiation dose was calculated on 3D-CT images, and the livers were contoured on different series CT images and mapped to 3D-CT images applying rigid registration. To compare the dose-volume difference of livers based on distinct CT images. Results: (1)The liver volumes were similar on 4D-CT and 3D-CT images(CTFB 1485±500cm{sup 3}, CT0 1413±377cm{sup 3}, CT10 1409±396cm{sup 3}, CT20 1419±418cm{sup 3},CT30 1485±500cm{sup 3}, CT40 1438±392cm{sup 3}, CT50 1437±404cm{sup 3}, CT60 1439±409cm{sup 3}, CT70 1408±393cm{sup 3}, CT80 1384±397cm{sup 3}, CT90 1398±397cm{sup 3}; F=0.064,p=1.00) (2) The PTVs volume were 30.17±14.62cm{sup 3};(3) The mean dose and V5 to V10 of liver were similar among 4D-CT different series CT images(p>0.05), and the indices varied less than ±4% refer to liver on CT50. Conclusion: The calculation affection of liver dose-volume indices induced by breath motion were not significant for the PTV within liver completely as estimation before. And more objective prediction indices for radiation induced l.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2014

SU-E-T-473: A Patient-Specific QC Paradigm Based On Trajectory Log Files and DICOM Plan Files

Purpose: To evaluate a remote QC tool for monitoring treatment machine parameters and treatment workflow. Methods: The Varian TrueBeamTM linear accelerator is a digital machine that records machine axis parameters and MLC leaf positions as a function of delivered monitor unit or control point. This information is saved to a binary trajectory log file for every treatment or imaging field in the patient treatment session. A MATLAB analysis routine was developed to parse the trajectory log files for a given patient, compare the expected versus actual machine and MLC positions as well as perform a cross-comparison with the DICOM-RT plan file exported from the treatment planning system. The parsing routine sorts the trajectory log files based on the time and date stamp and generates a sequential report file listing treatment parameters and provides a match relative to the DICOM-RT plan file. Results: The trajectory log parsing-routine was compared against a standard record and verify listing for patients undergoing initial IMRT dosimetry verification and weekly and final chart QC. The complete treatment course was independently verified for 10 patients of varying treatment site and a total of 1267 treatment fields were evaluated including pre-treatment imaging fields where applicable. In the context of IMRT plan verification, eight prostate SBRT plans with 4-arcs per plan were evaluated based on expected versus actual machine axis parameters. The average value for the maximum RMS MLC error was 0.067±0.001mm and 0.066±0.002mm for leaf bank A and B respectively. Conclusion: A real-time QC analysis program was tested using trajectory log files and DICOM-RT plan files. The parsing routine is efficient and able to evaluate all relevant machine axis parameters during a patient treatment course including MLC leaf positions and table positions at time of image acquisition and during treatment.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2014

MO-E-17A-09: Has Cancer Risk for Pediatric CT Increased Or Decreased? An Analysis of Cohort Data From 2004-2013

Purpose: To analyze CT radiation dosimetry trends in a pediatric population imaged with modern (2004-2013) CT technology Methods: The institutional review board approved this retrospective review. Two cohorts of pediatric patients that received CT scans for treatment or surveillance for Wilms tumor (n=73) or Neuroblastoma (n=74) from 2004–2013 were included in this study. Patients were scanned during this time period on a GE Ultra (8 slice; 2004–2007), a GE VCT (2008–2011), or a GE VCT-XTe (2011–2013). Each patient's individual or combined chest, abdomen, and pelvic CT exams (n=4138) were loaded onto a PACS workstation (Intelerad, Canada) and measured to calculate their effective diameter and SSDE. Patient SSDE was used to estimate patient organ dosimetry based on previously published data. Patient's organ dosimetry were sorted by gender, weight, age, scan protocol (i.e., chest, abdomen, or pelvis), and CT scanner technology and averaged accordingly to calculate population averaged absolute and effective dose values. Results: Patient radiation dose burden calculated for all genders, weights, and ages decreased at a rate of 0.2 mSv/year (4.2 mGy/year; average organ dose) from 2004–2013; overall levels decreased by 50% from 3.0 mSv (60.0 mGy) to 1.5 mSv (25.9 mGy). Patient dose decreased at equal rates for both male and female, and for individual scan protocols. The greatest dose savings was found for patients between 0–4 years old (65%) followed by 5-9 years old (45%), 10–14 years old (30%), and > 14 years old (21%). Conclusion: Assuming a linear-nothreshold model, there always will be potential risk of cancer induction from CT. However, as demonstrated among these patient populations, effective and organ dose has decreased over the last decade; thus, potential risk of long-term side effects from pediatric CT examinations has also been reduced.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2014

MO-G-BRE-05: Clinical Process Improvement and Billing in Radiation Oncology: A Case Study of Applying FMEA for CPT Code 77336 (continuing Medical Physics Consultation)

Purpose: The improvement of quality in healthcare can be assessed by Failure Mode and Effects Analysis (FMEA). In radiation oncology, FMEA, as applied to the billing CPT code 77336, can improve both charge capture and, most importantly, quality of the performed services. Methods: We created an FMEA table for the process performed under CPT code 77336. For a given process step, each member of the assembled team (physicist, dosimetrist, and therapist) independently assigned numerical values for: probability of occurrence (O, 1–10), severity (S, 1–10), and probability of detection (D, 1–10) for every failure mode cause and effect combination. The risk priority number, RPN, was then calculated as a product of O, S and D from which an average RPN was calculated for each combination mentioned above. A fault tree diagram, with each process sorted into 6 categories, was created with linked RPN. For processes with high RPN recommended actions were assigned. 2 separate R and V systems (Lantis and EMR-based ARIA) were considered. Results: We identified 9 potential failure modes and corresponding 19 potential causes of these failure modes all resulting in unjustified 77336 charge and compromised quality of care. In Lantis, the range of RPN was 24.5–110.8, and of S values – 2–10. The highest ranking RPN of 110.8 came from the failure mode described as “end-of-treatment check not done before the completion of treatment”, and the highest S value of 10 (RPN=105) from “overrides not checked”. For the same failure modes, within ARIA electronic environment with its additional controls, RPN values were significantly lower (44.3 for end-of-treatment missing check and 20.0 for overrides not checked). Conclusion: Our work has shown that when charge capture was missed that also resulted in some services not being performed. Absence of such necessary services may result in sub-optimal quality of care rendered to patients.

29 ENERGY PLANNING, POLICY, AND ECONOMY↗

DOE OSTI2014

TU-F-17A-04: Respiratory Phase-Resolved 3D MRI with Isotropic High Spatial Resolution: Determination of the Average Breathing Motion Pattern for Abdominal Radiotherapy Planning

Purpose: To develop a retrospective 4D-MRI technique (respiratory phase-resolved 3D-MRI) for providing an accurate assessment of tumor motion secondary to respiration. Methods: A 3D projection reconstruction (PR) sequence with self-gating (SG) was developed for 4D-MRI on a 3.0T MRI scanner. The respiration-induced shift of the imaging target was recorded by SG signals acquired in the superior-inferior direction every 15 radial projections (i.e. temporal resolution 98 ms). A total of 73000 radial projections obtained in 8-min were retrospectively sorted into 10 time-domain evenly distributed respiratory phases based on the SG information. Ten 3D image sets were then reconstructed offline. The technique was validated on a motion phantom (gadolinium-doped water-filled box, frequency of 10 and 18 cycles/min) and humans (4 healthy and 2 patients with liver tumors). Imaging protocol included 8-min 4D-MRI followed by 1-min 2D-realtime (498 ms/frame) MRI as a reference. Results: The multiphase 3D image sets with isotropic high spatial resolution (1.56 mm) permits flexible image reformatting and visualization. No intra-phase motion-induced blurring was observed. Comparing to 2D-realtime, 4D-MRI yielded similar motion range (phantom: 10.46 vs. 11.27 mm; healthy subject: 25.20 vs. 17.9 mm; patient: 11.38 vs. 9.30 mm), reasonable displacement difference averaged over the 10 phases (0.74mm; 3.63mm; 1.65mm), and excellent cross-correlation (0.98; 0.96; 0.94) between the two displacement series. Conclusion: Our preliminary study has demonstrated that the 4D-MRI technique can provide high-quality respiratory phase-resolved 3D images that feature: a) isotropic high spatial resolution, b) a fixed scan time of 8 minutes, c) an accurate estimate of average motion pattern, and d) minimal intra-phase motion artifact. This approach has the potential to become a viable alternative solution to assess the impact of breathing on tumor motion and determine appropriate treatment margins. Comparison with 4D-CT in a clinical setting is warranted to assess the value of 4D-MRI in radiotherapy planning. This work supported in part by grant 1R03CA173273-01.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2014

TU-F-18C-01: Breast Tissue Decomposition Using Spectral CT After Distortion Correction

Purpose: To investigate the feasibility of accurate breast tissue compositional characterization by using spectral-distortion-corrected dual energy images from a photon-counting spectral CT. Methods: Thirty eight postmortem breasts were imaged with a Cadmium-Zinc-Telluride (CZT)-based photon-counting spectral CT system at beam energy of 100 kVp. The energy-resolved detector sorted photons into low and high energy bins with a splitting energy of 42 keV. The estimated mean glandular dose (MGD) for each breast was approximately 2.0 mGy. Dual energy technique was used to decompose breast tissue into water, lipid, and protein contents. Two image-based methods were investigated to improve the accuracy of tissue compositional characterization. The first method simply limited the recorded spectra up to 90 keV. This reduced the pulse pile-up artifacts but it has some dose penalty. The second method corrected the spectral information of all measured photons by using a spectral distortion correction technique. Breasts were then chemically decomposed into their respective water, lipid, and protein contents, which was used as the reference standard. The accuracy of the tissue compositional measurement with spectral CT was evaluated by the root-mean-square (RMS) errors in percentage composition. Results: The errors in quantitative material decomposition were significantly reduced after the appropriate image processing methods. As compared to the chemical analysis as the reference standard, the averages of the RMS errors were estimated to be 15.5%, 3.3%, and 2.8% for the raw, energy-limited, and spectral-corrected images, respectively. Conclusion: Spectral CT can be used to accurately quantify the water, lipid, and protein contents in breast tissues by implementing a spectral distortion correction algorithm. The tissue compositional information can potentially improve the sensitivity and specificity for breast cancer diagnosis.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2014

WE-E-18A-11: Fluoro-Tomographic Images From Projections of On-Board Imager (OBI) While Gantry Is Moving

Purpose: A method to generate a series of fluoro-tomographic images (FTI) of the slice of interest (SOI) from the projection images of the On-board imager (OBI) while gantry is moving is developed and tested. Methods: Tomographic image via background subtraction, TIBS has been published by our group. TIBS uses a priori anatomical information from a previous CT scan to isolate a SOI from a planar kV image by factoring out the attenuations by tissues outside the SOI (background). We extended the idea to 4D TIBS, which enables to generate from the projection of different gantry angles. A set of background images for different angles are prepared. A background image at a given gantry angle is subtracted from the projection image at the same angle to generate a TIBS image. Then the TIBS image is converted to a reference angle. The 4D TIBS is the set of TIBS that originated from gantry angles other than the reference angle. Projection images of lung patients for CBCT acquisition are used to test the 4D TIBS. Results: Fluoroscopic images of a coronal plane of lung patients are acquired from the CBCT projections at different gantry angles and times. Change of morphology of hilar vessels due to breathing and heart beating are visible in the coronal plane, which are generated from the set of the projection images at gantry angles other than antero-posterior. Breathing surrogate or sorting process is not needed. Unlike tomosynthesis, FTI from 4D TIBS maintains the independence of each of the projections thereby reveals temporal variations within the SOI. Conclusion: FTI, fluoroscopic imaging of a SOI with x-ray projections, directly generated from the x-ray projection images at different gantry angles is tested with a lung case and proven feasible. This technique can be used for on-line imaging of moving targets. NIH Grant R01CA133539.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2014

WE-G-18C-08: Real Time Tumor Imaging Using a Novel Dynamic Keyhole MRI Reconstruction Technique

Purpose: To test the hypothesis that the novel Dynamic Keyhole MRI reconstruction technique can accelerate image acquisition whilst maintaining high image quality for lung cancer patients. Methods: 18 MRI datasets from 5 lung cancer patients were acquired using a 3T MRI scanner. These datasets were retrospectively reconstructed using (A) The novel Dynamic Keyhole technique, (B) The conventional keyhole technique and (C) the conventional zero filling technique. The dynamic keyhole technique in MRI refers to techniques in which previously acquired k-space data is used to supplement under sampled data obtained in real time. The novel Dynamic Keyhole technique utilizes a previously acquired a library of kspace datasets in conjunction with central k-space datasets acquired in realtime. A simultaneously acquired respiratory signal is utilized to sort, match and combine the two k-space streams with respect to respiratory displacement. Reconstruction performance was quantified by (1) comparing the keyhole size (which corresponds to imaging speed) required to achieve the same image quality, and (2) maintaining a constant keyhole size across the three reconstruction methods to compare the resulting image quality to the ground truth image. Results: (1) The dynamic keyhole method required a mean keyhole size which was 48% smaller than the conventional keyhole technique and 60% smaller than the zero filling technique to achieve the same image quality. This directly corresponds to faster imaging. (2) When a constant keyhole size was utilized, the Dynamic Keyhole technique resulted in the smallest difference of the tumor region compared to the ground truth. Conclusion: The dynamic keyhole is a simple and adaptable technique for clinical applications requiring real-time imaging and tumor monitoring such as MRI guided radiotherapy. Based on the results from this study, the dynamic keyhole method could increase the imaging frequency by a factor of five compared with full k-space methods.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2014

TH-C-18A-11: Investigating the Minimum Scan Parameters Required to Generate Free-Breathing Fast-Helical CT Scans Without Motion-Artifacts

Purpose: A recently proposed 4D-CT protocol uses deformable registration of free-breathing fast-helical CT scans to generate a breathing motion model. In order to allow accurate registration, free-breathing images are required to be free of doubling-artifacts, which arise when tissue motion is greater than scan speed. This work identifies the minimum scanner parameters required to successfully generate free-breathing fast-helical scans without doubling-artifacts. Methods: 10 patients were imaged under free breathing conditions 25 times in alternating directions with a 64-slice CT scanner using a low dose fast helical protocol. A high temporal resolution (0.1s) 4D-CT was generated using a patient specific motion model and patient breathing waveforms, and used as the input for a scanner simulation. Forward projections were calculated using helical cone-beam geometry (800 projections per rotation) and a GPU accelerated reconstruction algorithm was implemented. Various CT scanner detector widths and rotation times were simulated, and verified using a motion phantom. Doubling-artifacts were quantified in patient images using structural similarity maps to determine the similarity between axial slices. Results: Increasing amounts of doubling-artifacts were observed with increasing rotation times > 0.2s for 16×1mm slice scan geometry. No significant increase in doubling artifacts was observed for 64×1mm slice scan geometry up to 1.0s rotation time although blurring artifacts were observed >0.6s. Using a 16×1mm slice scan geometry, a rotation time of less than 0.3s (53mm/s scan speed) would be required to produce images of similar quality to a 64×1mm slice scan geometry. Conclusion: The current generation of 16 slice CT scanners, which are present in most Radiation Oncology departments, are not capable of generating free-breathing sorting-artifact-free images in the majority of patients. The next generation of CT scanners should be capable of at least 53mm/s scan speed in order to use a fast-helical 4D-CT protocol to generate a motion-artifact free 4D-CT. NIH R01CA096679.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2014

TH-E-17A-09: High Quality and Artifact-Free 4D Cone Beam CT and Its Application in Adaptive Treatment Planning

Purpose: To develop a high quality 4D cone beam CT (4DCBCT) method that is immune to patient/couch truncations and to investigate its application in adaptive replanning of lung XRT. Methods: In this study, IRB-approved human subject CBCT data was acquired using a Varian on-board imager with 1 minute rotation time. The acquired projection data was retrospectively sorted into 20 respiratory phase bins, from which 4DCBCT images with high SNR and high temporal resolution were generated using Prior Image Constrained Compressed Sensing (PICCS). Couch and patient truncations generate strong data inconsistency in the projection data and artifacts in the 4DCBCT image. They were addressed using an adaptive PICCS method. The artifact-free PICCS-4DCBCT images were used to generate adaptive treatment plans for the same patient at the 10th (day 21) and 30th (day 47) fractions. Dosimetric impacts with and without PICCS- 4DCBCT were evaluated by isodose distributions, DVHs, and other dosimetric factors. Results: The adaptive PICCS-4DCBCT method improves image quality by removing residue truncation artifacts; measured universal image quality increased 37%. The isodose lines and DVHs with PICCS-4DCBCT-based adaptive replanning were significantly more conformal to PTV than without replanning due to changes in patient anatomy caused by progress of the treatment. The mean dose to PTV at the 10th fraction was 63.1Gy with replanning and 64.2Gy without replanning, where the prescribed dose was 60Gy, in 2Gy × 30 fractions. The mean dose to PTV at the 30th fraction was 61.6Gy with replanning and 64.9Gy without replanning. Lung V20 was 37.1%, 41.9% and 43.3% for original plan, 10th fraction plan and 30th fraction plan; with re-planning, Lung V20 was 37.1%, 32%, 27.8%. Conclusion: 4DCBCT imaging using adaptive PICCS is able to generate high quality, artifact-free images that potentially can be used to create replanning for improving radiotherapy of the lung. K Niu, K Li, J Smilowitz: Nothing to Disclose. G Chen: General Electric Company Research funded, Siemens AG Research funded, Varian Medical Systems Research funded, Hologic Research funded.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2014

Toward optimizing patient-specific IMRT QA techniques in the accurate detection of dosimetrically acceptable and unacceptable patient plans

Purpose: The authors investigated the performance of several patient-specific intensity-modulated radiation therapy (IMRT) quality assurance (QA) dosimeters in terms of their ability to correctly identify dosimetrically acceptable and unacceptable IMRT patient plans, as determined by an in-house-designed multiple ion chamber phantom used as the gold standard. A further goal was to examine optimal threshold criteria that were consistent and based on the same criteria among the various dosimeters. Methods: The authors used receiver operating characteristic (ROC) curves to determine the sensitivity and specificity of (1) a 2D diode array undergoing anterior irradiation with field-by-field evaluation, (2) a 2D diode array undergoing anterior irradiation with composite evaluation, (3) a 2D diode array using planned irradiation angles with composite evaluation, (4) a helical diode array, (5) radiographic film, and (6) an ion chamber. This was done with a variety of evaluation criteria for a set of 15 dosimetrically unacceptable and 9 acceptable clinical IMRT patient plans, where acceptability was defined on the basis of multiple ion chamber measurements using independent ion chambers and a phantom. The area under the curve (AUC) on the ROC curves was used to compare dosimeter performance across all thresholds. Optimal threshold values were obtained from the ROC curves while incorporating considerations for cost and prevalence of unacceptable plans. Results: Using common clinical acceptance thresholds, most devices performed very poorly in terms of identifying unacceptable plans. Grouping the detector performance based on AUC showed two significantly different groups. The ion chamber, radiographic film, helical diode array, and anterior-delivered composite 2D diode array were in the better-performing group, whereas the anterior-delivered field-by-field and planned gantry angle delivery using the 2D diode array performed less well. Additionally, based on the AUCs, there was no significant difference in the performance of any device between gamma criteria of 2%/2 mm, 3%/3 mm, and 5%/3 mm. Finally, optimal cutoffs (e.g., percent of pixels passing gamma) were determined for each device and while clinical practice commonly uses a threshold of 90% of pixels passing for most cases, these results showed variability in the optimal cutoff among devices. Conclusions: IMRT QA devices have differences in their ability to accurately detect dosimetrically acceptable and unacceptable plans. Field-by-field analysis with a MapCheck device and use of the MapCheck with a MapPhan phantom while delivering at planned rotational gantry angles resulted in a significantly poorer ability to accurately sort acceptable and unacceptable plans compared with the other techniques examined. Patient-specific IMRT QA techniques in general should be thoroughly evaluated for their ability to correctly differentiate acceptable and unacceptable plans. Additionally, optimal agreement thresholds should be identified and used as common clinical thresholds typically worked very poorly to identify unacceptable plans.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2015

Evaluation of intrinsic respiratory signal determination methods for 4D CBCT adapted for mice

Purpose: 4D CT imaging in mice is important in a variety of areas including studies of lung function and tumor motion. A necessary step in 4D imaging is obtaining a respiratory signal, which can be done through an external system or intrinsically through the projection images. A number of methods have been developed that can successfully determine the respiratory signal from cone-beam projection images of humans, however only a few have been utilized in a preclinical setting and most of these rely on step-and-shoot style imaging. The purpose of this work is to assess and make adaptions of several successful methods developed for humans for an image-guided preclinical radiation therapy system. Methods: Respiratory signals were determined from the projection images of free-breathing mice scanned on the X-RAD system using four methods: the so-called Amsterdam shroud method, a method based on the phase of the Fourier transform, a pixel intensity method, and a center of mass method. The Amsterdam shroud method was modified so the sharp inspiration peaks associated with anesthetized mouse breathing could be detected. Respiratory signals were used to sort projections into phase bins and 4D images were reconstructed. Error and standard deviation in the assignment of phase bins for the four methods compared to a manual method considered to be ground truth were calculated for a range of region of interest (ROI) sizes. Qualitative comparisons were additionally made between the 4D images obtained using each of the methods and the manual method. Results: 4D images were successfully created for all mice with each of the respiratory signal extraction methods. Only minimal qualitative differences were noted between each of the methods and the manual method. The average error (and standard deviation) in phase bin assignment was 0.24 ± 0.08 (0.49 ± 0.11) phase bins for the Fourier transform method, 0.09 ± 0.03 (0.31 ± 0.08) phase bins for the modified Amsterdam shroud method, 0.09 ± 0.02 (0.33 ± 0.07) phase bins for the intensity method, and 0.37 ± 0.10 (0.57 ± 0.08) phase bins for the center of mass method. Little dependence on ROI size was noted for the modified Amsterdam shroud and intensity methods while the Fourier transform and center of mass methods showed a noticeable dependence on the ROI size. Conclusions: The modified Amsterdam shroud, Fourier transform, and intensity respiratory signal methods are sufficiently accurate to be used for 4D imaging on the X-RAD system and show improvement over the existing center of mass method. The intensity and modified Amsterdam shroud methods are recommended due to their high accuracy and low dependence on ROI size.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2015

Impact of CT attenuation correction method on quantitative respiratory-correlated (4D) PET/CT imaging

Purpose: Respiratory-correlated positron emission tomography (PET/CT) 4D PET/CT is used to mitigate errors from respiratory motion; however, the optimal CT attenuation correction (CTAC) method for 4D PET/CT is unknown. The authors performed a phantom study to evaluate the quantitative performance of CTAC methods for 4D PET/CT in the ground truth setting. Methods: A programmable respiratory motion phantom with a custom movable insert designed to emulate a lung lesion and lung tissue was used for this study. The insert was driven by one of five waveforms: two sinusoidal waveforms or three patient-specific respiratory waveforms. 3DPET and 4DPET images of the phantom under motion were acquired and reconstructed with six CTAC methods: helical breath-hold (3DHEL), helical free-breathing (3DMOT), 4D phase-averaged (4DAVG), 4D maximum intensity projection (4DMIP), 4D phase-matched (4DMATCH), and 4D end-exhale (4DEXH) CTAC. Recovery of SUV{sub max}, SUV{sub mean}, SUV{sub peak}, and segmented tumor volume was evaluated as RC{sub max}, RC{sub mean}, RC{sub peak}, and RC{sub vol}, representing percent difference relative to the static ground truth case. Paired Wilcoxon tests and Kruskal–Wallis ANOVA were used to test for significant differences. Results: For 4DPET imaging, the maximum intensity projection CTAC produced significantly more accurate recovery coefficients than all other CTAC methods (p < 0.0001 over all metrics). Over all motion waveforms, ratios of 4DMIP CTAC recovery were 0.2 ± 5.4, −1.8 ± 6.5, −3.2 ± 5.0, and 3.0 ± 5.9 for RC{sub max}, RC{sub peak}, RC{sub mean}, and RC{sub vol}. In comparison, recovery coefficients for phase-matched CTAC were −8.4 ± 5.3, −10.5 ± 6.2, −7.6 ± 5.0, and −13.0 ± 7.7 for RC{sub max}, RC{sub peak}, RC{sub mean}, and RC{sub vol}. When testing differences between phases over all CTAC methods and waveforms, end-exhale phases were significantly more accurate (p = 0.005). However, these differences were driven by the patient-specific respiratory waveforms; when testing patient and sinusoidal waveforms separately, patient waveforms were significantly different between phases (p < 0.0001) while the sinusoidal waveforms were not significantly different (p = 0.98). When considering only the subset of 4DMATCH images that corresponded to the end-exhale image phase, 4DEXH, mean and interquartile range were similar to 4DMATCH but variability was considerably reduced. Conclusions: Comparative advantages in accuracy and precision of SUV metrics and segmented volumes were demonstrated with the use of the maximum intensity projection and end-exhale CT attenuation correction. While respiratory phase-matched CTAC should in theory provide optimal corrections, image artifacts and differences in implementation of 4DCT and 4DPET sorting can degrade the benefit of this approach. These results may be useful to guide the implementation, analysis, and development of respiratory-correlated thoracic PET/CT in the radiation oncology and diagnostic settings.

60 APPLIED LIFE SCIENCES↗