Quantitative evaluation of cone-beam computed tomography in target volume definition for offline image-guided radiation therapy of prostate cancer

Dose-volume relationships of planned versus estimated delivered radiation doses to pelvic organs at risk and side effects in patients treated with salvage radiotherapy for recurrent prostate cancer

Purpose

To investigate estimated delivered dose distributions using weekly cone-beam computed tomography (CBCT) scans for pelvic organs at risk (OARs) in salvage radiotherapy (SRT) after radical prostatectomy. Furthermore, to compare them with the originally planned dose distributions and analyse associations with gastrointestinal (GI) and genitourinary (GU) side effects.

Methods

This study is part of a phase II trial involving SRT for recurrent prostate cancer. Treatment was personalised based on PSA response during SRT, classifying patients as PSA responders or non-responders. Estimated radiation dose distributions were obtained using deformable image registration from weekly CBCT scans. GI and GU toxicities were assessed using the RTOG toxicity scale, while patient-reported symptoms were monitored through self-assessment questionnaires.

Results

The study included 100 patients, with similar treatment-related side effects observed in both responders and non-responders. Differences in dose-volume metrics between the planned and estimated delivered doses for the examined OARs were mostly modest, although generally statistically significant. We identified statistically significant associations between QUANTEC-recommended dose-volume constraints and acute bowel toxicity, as well as late urinary patient-reported symptoms, for both the estimated delivered and planned dose distributions.

Conclusion

We found small but statistically significant differences between estimated delivered and planned doses to OARs. These differences showed trends toward improved associations for estimated delivered dose distributions with side effects. Enhanced registration methods and imaging techniques could potentially further enhance the assessment of truly delivered doses and yield more reliable dose-volume constraints for future therapies.

Dosimetric and volumetric effects in clinical target volume and organs at risk during postprostatectomy radiotherapy

PURPOSE

To assess the reproducibility of the dose-volume distribution of the initial simulation CT, generated using volumetric modulated arc therapy (VMAT) planning, during the radiotherapy of the prostatic bed based on weekly cone beam CTs (CBCT).

METHODS

Twenty-three patients, after radical prostatectomy were treated with adjuvant or salvage radiotherapy between July and December 2016 and considered for this evaluation. Weekly CBCT scans (n = 138) were imported into the treatment planning system, and the clinical tumor volume (CTV), the rectum and the bladder were contoured. The initially calculated dose distribution and the dose-volume histograms generated from weekly CBCTs were compared. The prostatic fossa dose coverage was assessed by the proportion of the CTV fully encompassed by the 95% and 98% isodose lines. Rectal and bladder volumes receiving 50, 60 and 65 Gy during the treatment were compared to the initial plan, with statistical significance determined using the one-sample t‑test.

RESULTS

Marked variations in the total organ volume of the rectum and the bladder were observed. The correlation between rectum volume and V₅₀ was not significant (p = 0.487), while the bladder volume and V₅₀ demonstrated a significant correlation. There was no correlation between urinary bladder volume and CTV. The change in rectal volume correlated significantly with CTV. The dose coverage (D_98% and D_95%) to the prostatic bed could be achieved for all patients due to the ventral shift in the volume differences of the rectum.

CONCLUSION

Weekly CBCTs can be considered as adequate verification tools to assess the interfractional variability of the CTV and organs at risk. The proven volume changes in the urinary bladder and the rectum do not compromise the final delivered dose in the CTV.

The dosimetric impact of manual adjustments following automated registration in prostate image-guided radiotherapy

Aim

Although manual adjustment of automatic cone beam computed tomography (CBCT) matching may improve the target coverage in certain points of interest, concerns exist that this may lead to dosimetric uncertainties which would negate the theoretical benefit of this approach. The objective of this study is to evaluate the dosimetric impact of manual adjustments made after automatic bony registration on CBCT in prostate patients.

Methods

A total of 50 CBCT datasets of ten high-risk prostate cancer patients were randomly chosen. Each CBCT dataset was registered three times. Method (A): Automatic registration, Method (M1): Manual adjustment carried out by two experienced radiation therapists, Method (M2): Manual adjustment carried out by different radiation therapists with varying levels of experience. The clinical target volume (CTV), planning target volume (PTV), the bladder and the rectum were subsequently contoured on each CBCT dataset by a radiation oncologist blinded to the registration methods. The absolute difference of various dosimetric parameters were then analysed and compared with the original planning doses. A comparison of the three matching methods employed was also carried out.

Results

There was a statistically significant difference in the magnitude of move taken in the inferior superior direction between M1 and M2 method. There were no significant differences observed in any of the dosimetric parameters examined in relation to the rectum, bladder or CTV. The only significant difference observed was the volume of PTV covered by the prescription isodose (95%) which was statistically significant lower in method A compared with both M1 and M2. There was no difference observed between M1 and M2 methods. The mean duration of the automated registration and subsequent analysis was 64 seconds compared with 91 seconds for automated registrations which included the additional manual adjustment.

Findings

CBCT-based manual adjustments of automated bony-based registrations during the image-guided radiotherapy verification of prostate cancer patients can improve PTV coverage without impacting negatively on the doses received by the organs at risk. This strategy is associated with a small increase in overall treatment time.

A study on image quality provided by a kilovoltage cone-beam computed tomography

The image‐guided radiotherapy technique (IGRT) makes use of imaging devices to verify the positions of the target volume and organs at risk during the treatment sessions. In this work we evaluate the image quality provided by an imaging system based on a kilovoltage cone‐beam CT, and explore its ability to perform IGRT and adaptive radiotherapy. We analyze the accuracy of the image slice width, the spatial resolution using the MTF function, the image uniformity, the signal‐to‐noise ratio, the contrast‐to‐noise ratio, the low‐contrast sensitivity, and the HU linearity with density. The studied parameters are evaluated in an objective and quantitative way, allowing for a direct comparison with other imaging devices. We conclude that the analyzed cone‐beam imaging system is adequate to accurately perform IGRT within its clinical use, despite the high level of noise present in a cone beam caused by scatter. We also point out the presence of a bowtie wobble artifact in the reconstructed images. Nevertheless, we conclude that these features do not limit the capability of the system to perform adaptive radiotherapy in most cases.

PACS number: 87.57.‐s

Utilization of cone-beam CT for offline evaluation of target volume coverage during prostate image-guided radiotherapy based on bony anatomy alignment

AIM

To assess target volume coverage during prostate image-guided radiotherapy based on bony anatomy alignment and to assess possibility of safety margin reduction.

BACKGROUND

Implementation of IGRT should influence safety margins. Utilization of cone-beam CT provides current 3D anatomic information directly in irradiation position. Such information enables reconstruction of the actual dose distribution.

MATERIALS AND METHODS

Seventeen prostate patients were treated with daily bony anatomy image-guidance. Cone-beam CT (CBCT) scans were acquired once a week immediately after bony anatomy alignment. After the prostate, seminal vesicles, rectum and bladder were contoured, the delivered dose distribution was reconstructed. Target dose coverage was evaluated by the proportion of the CTV encompassed by the 95% isodose. Original plans employed a 1 cm safety margin. Alternative plans assuming a smaller 7 mm margin between CTV and PTV were evaluated in the same way. Rectal and bladder volumes were compared with the initial ones. Rectal and bladder volumes irradiated with doses higher than 75 Gy, 70 Gy, 60 Gy, 50 Gy and 40 Gy were analyzed.

RESULTS

In 12% of reconstructed plans the prostate coverage was not sufficient. The prostate underdosage was observed in 5 patients. Coverage of seminal vesicles was not satisfactory in 3% of plans. Most of the target underdosage corresponded to excessive rectal or bladder filling. Evaluation of alternative plans assuming a smaller 7 mm margin revealed 22% and 11% of plans where prostate and seminal vesicles coverage, respectively, was compromised. These were distributed over 8 and 7 patients, respectively.

CONCLUSION

Sufficient dose coverage of target volumes was not achieved for all patients. Reducing of safety margin is not acceptable. Initial rectal and bladder volumes cannot be considered representative for subsequent treatment.

Deformable registration using edge-preserving scale space for adaptive image-guided radiation therapy

Incorporating of daily cone-beam computer tomography (CBCT) image into online radiation therapy process can achieve adaptive image-guided radiation therapy (AIGRT). Registration of planning CT (PCT) and daily CBCT are the key issues in this process. In our work, a new multiscale deformable registration method is proposed by combining edge-preserving scale space with the multilevel free-form deformation (FFD) grids for CBCT-based AIGRT system. The edge-preserving scale space, which is able to select edges and contours of images according to their geometric size, is derived from the total variation model with the L1 norm (TV-L1). At each scale, despite the noise and contrast resolution differences between the PCT and CBCT, the selected edges and contours are sufficiently strong to drive the deformation using the FFD grid, and the edge-preserving property ensures more meaningful spatial information for mutual information (MI)-based registration. At last, the deformation fields are gained by a coarse to fine manner. Furthermore, in consideration of clinical application we designed an optimal estimation of the TV-L1 parameters by minimizing the defined offset function for automated registration. Six types of patients are studied in our work, including rectum, prostate, lung, H&N (head and neck), breast, and chest cancer patients. The experiment results demonstrate the significance of the proposed method both quantitatively with ground truth known and qualitatively with ground truth unknown. The applications for AIGRT, including adaptive deformable recontouring and redosing, and DVH (dose volume histogram) analysis in the course of radiation therapy are also studied.

Evaluation of image quality for different kV cone-beam CT acquisition and reconstruction methods in the head and neck region

PURPOSE

To evaluate the image quality obtained in a standard QA phantom with both clinical and non-clinical cone-beam computed tomography (CBCT) acquisition modes for the head and neck (HN) region as a step towards CBCT-based treatment planning. The impact of deteriorated Hounsfield unit (HU) accuracy was investigated by comparing results from clinical CBCT image reconstructions to those obtained from a pre-clinical scatter correction algorithm.

METHODS

Five different CBCT acquisition modes on a clinical system for kV CBCT-guided radiotherapy were investigated. Image reconstruction was performed in both standard clinical software and with an experimental reconstruction algorithm with improved beam hardening and scatter correction. Using the Catphan 504 phantom, quantitative measures of HU uniformity, HU verification and linearity, contrast-to-noise ratio (CNR), and spatial resolution using modulation transfer function (MTF) estimation were assessed. To benchmark the CBCT image properties, comparison to standard HN protocols on conventional CT scanners was performed by similar measures.

RESULTS

The HU uniformity within a water-equivalent homogeneous region was considerably improved using experimental vs. standard reconstruction, by factors of two for partial scans and four for full scans. Similarly, the amount of capping/cupping artifact was reduced by more than 1.5%. With mode and reconstruction specific HU calibration using seven inhomogeneity inserts comparable HU linearity was observed. CNR was on average 5% higher for experimental reconstruction (scaled with the square-root of dose between modes for both reconstruction methods).

CONCLUSIONS

Judged on parameters affecting the common diagnostic image properties, improved beam hardening and scatter correction diminishes the difference between CBCT and CT image quality considerably. In the pursuit of CBCT-based treatment adaptation, dedicated imaging protocols may be required.

Dosimetric and geometric evaluation of a hybrid strategy of offline adaptive planning and online image guidance for prostate cancer radiotherapy

For prostate cancer patients, online image-guided (IG) radiotherapy has been widely used in clinic to correct the translational inter-fractional motion at each treatment fraction. For uncertainties that cannot be corrected online, such as rotation and deformation of the target volume, margins are still required to be added to the clinical target volume (CTV) for the treatment planning. Offline adaptive radiotherapy has been implemented to optimize the treatment for each individual patient based on the measurements at early stages of treatment process. It has been shown that offline adaptive radiotherapy can effectively reduce the required margin. Recently a hybrid strategy of offline adaptive replanning and online IG was proposed and the geometric evaluation was performed. It was found that the planning margins can further be reduced by 1-2 mm compared to online IG only strategy. The purpose of this study was to investigate the dosimetric benefits of such a hybrid strategy on the target and organs at risk. A total of 420 repeated helical computed tomography scans from 28 patients were included in the study. Both low-risk patients (LRP, CTV = prostate) and intermediate-risk patients (IRP, CTV = prostate + seminal vesicles, SV) were included in the simulation. Two registration methods, based on center-of-mass shift of prostate only and prostate plus SV, were performed for IRP. The intensity-modulated radiotherapy was used in the simulation. Criteria on both cumulative and fractional doses were evaluated. Furthermore, the geometric evaluation was extended to investigate the optimal number of fractions necessary to construct the internal target volume (ITV) for the hybrid strategy. The dosimetric margin improvement was smaller than its geometric counterpart and was in the range of 0-1 mm. The optimal number of fractions necessary for the ITV construction is 2 for LRPs and 3-4 for IRPs in a hypofractionation protocol. A new cumulative index of target volume was proposed for the evaluation of adaptive radiotherapy strategies, and it was found that it had the advantages over other indices in evaluating different adaptive radiotherapy strategies.

A hybrid strategy of offline adaptive planning and online image guidance for prostate cancer radiotherapy

Offline adaptive radiotherapy (ART) has been used to effectively correct and compensate for prostate motion and reduce the required margin. The efficacy depends on the characteristics of the patient setup error and interfraction motion through the whole treatment; specifically, systematic errors are corrected and random errors are compensated for through the margins. In online image-guided radiation therapy (IGRT) of prostate cancer, the translational setup error and inter-fractional prostate motion are corrected through pre-treatment imaging and couch correction at each fraction. However, the rotation and deformation of the target are not corrected and only accounted for with margins in treatment planning. The purpose of this study was to investigate whether the offline ART strategy is necessary for an online IGRT protocol and to evaluate the benefit of the hybrid strategy. First, to investigate the rationale of the hybrid strategy, 592 cone-beam-computed tomography (CBCT) images taken before and after each fraction for an online IGRT protocol from 16 patients were analyzed. Specifically, the characteristics of prostate rotation were analyzed. It was found that there exist systematic inter-fractional prostate rotations, and they are patient specific. These rotations, if not corrected, are persistent through the treatment fraction, and rotations detected in early fractions are representative of those in later fractions. These findings suggest that the offline adaptive replanning strategy is beneficial to the online IGRT protocol with further margin reductions. Second, to quantitatively evaluate the benefit of the hybrid strategy, 412 repeated helical CT scans from 25 patients during the course of treatment were included in the replanning study. Both low-risk patients (LRP, clinical target volume, CTV = prostate) and intermediate-risk patients (IRP, CTV = prostate + seminal vesicles) were included in the simulation. The contours of prostate and seminal vesicles were delineated on each CT. The benefit of margin reduction to compensate for both rotation and deformation in the hybrid strategy was evaluated geometrically. With the hybrid strategy, the planning margins can be reduced by 1.4 mm for LRP, and 2.0 mm for IRP, compared with the standard online IGRT only, to maintain the same 99% target volume coverage. The average relative reduction in planning target volume (PTV) based on the internal target volume (ITV) from PTV based on CTV is 19% for LRP, and 27% for IRP.

Schedule for CT image guidance in treating prostate cancer with helical tomotherapy

The aim of this study was to determine the effect of reducing the number of image guidance sessions and patient-specific target margins on the dose distribution in the treatment of prostate cancer with helical tomotherapy. 20 patients with prostate cancer who were treated with helical tomotherapy using daily megavoltage CT (MVCT) imaging before treatment served as the study population. The average geometric shifts applied for set-up corrections, as a result of co-registration of MVCT and planning kilovoltage CT studies over an increasing number of image guidance sessions, were determined. Simulation of the consequences of various imaging scenarios on the dose distribution was performed for two patients with different patterns of interfraction changes in anatomy. Our analysis of the daily set-up correction shifts for 20 prostate cancer patients suggests that the use of four fractions would result in a population average shift that was within 1 mm of the average obtained from the data accumulated over all daily MVCT sessions. Simulation of a scenario in which imaging sessions are performed at a reduced frequency and the planning target volume margin is adapted provided significantly better sparing of organs at risk, with acceptable reproducibility of dose delivery to the clinical target volume. Our results indicate that four MVCT sessions on helical tomotherapy are sufficient to provide information for the creation of personalised target margins and the establishment of the new reference position that accounts for the systematic error. This simplified approach reduces overall treatment session time and decreases the imaging dose to the patient.