A model to simulate day-to-day variations in rectum shape

Probabilistic evaluation of plan quality for time-dependent anatomical deformations in head and neck cancer patients

PURPOSE

In addition to patient set-up uncertainties, anatomical deformations, e.g., weight loss, lead to time-dependent differences between the planned and delivered dose in a radiotherapy course that currently cannot easily be predicted. The aim of this study was to create time-varying prediction models to describe both the average and residual anatomical deformations.

METHODS

Weekly population-based principal component analysis models were generated from on-treatment cone-beam CT scans (CBCTs) of 30 head and neck cancer patients, with additional data of 35 patients used as a validation cohort. We simulated treatment courses accounting for a) anatomical deformations, b) set-up uncertainties and c) a combination of both. The dosimetric effects of the simulated deformations were compared to a direct dose accumulation based on deformable registration of the CBCT data.

RESULTS

Set-up uncertainties were seen to have a larger effect on the organ at risk (OAR) doses than anatomical deformations for all OARs except the larynx and the primary CTV. Distributions from simulation results were in good agreement with those of the accumulated dose.

CONCLUSIONS

We present a novel method of modelling time-varying organ deformations in head and neck cancer. The effect on the OAR doses from these deformations are smaller than the effect of set-up uncertainties for most OARs. These models can, for instance, be used to predict which patients could benefit from adaptive radiotherapy, prior to commencing treatment.

Reducing systematic errors due to deformation of organs at risk in radiotherapy

PURPOSE

In radiotherapy (RT), the planning CT (pCT) is commonly used to plan the full RT-course. Due to organ deformation and motion, the organ shapes seen at the pCT will not be identical to their shapes during RT. Any difference between the pCT organ shape and the organ's mean shape during RT will cause systematic errors. We propose to use statistical shrinkage estimation to reduce this error using only the pCT and the population mean shape computed from training data.

METHODS

The method was evaluated for the rectum in a cohort of 37 prostate cancer patients that had a pCT and 7-10 treatment CTs with rectum delineations. Deformable registration was performed both within-patient and between patients, resulting in point-to-point correspondence between all rectum shapes, which enabled us to compute a population mean rectum. Shrinkage estimates were found by combining the pCTs linearly with the population mean. The method was trained and evaluated using leave-one-out cross validation. The shrinkage estimates and the patient mean shapes were compared geometrically using the Dice similarity index (DSI), Hausdorff distance (HD), and bidirectional local distance. Clinical dose/volume histograms, equivalent uniform dose (EUD) and minimum dose to the hottest 5% volume (D5%) were compared for the shrinkage estimate and the pCT.

RESULTS

The method resulted in moderate but statistically significant increase in similarity to the patient mean shape over the pCT. On average, the HD was reduced from 15.6 to 13.4 mm, while the DSI was increased from 0.74 to 0.78. Significant reduction in the bias of volume estimates was found in the DVH-range of 52.5-65 Gy, where the bias was reduced from -1.3 to -0.2 percentage points, but no significant improvement was found in EUD or D5%, CONCLUSIONS: The results suggest that shrinkage estimation can reduce systematic errors due to organ deformations in RT. The method has potential to increase the accuracy in RT of deformable organs and can improve motion modeling.

FEMOSSA: Patient-specific finite element simulation of the prostate-rectum spacer placement, a predictive model for prostate cancer radiotherapy

PURPOSE

Major advances in delivery systems in recent years have turned radiotherapy (RT) into a more effective way to manage prostate cancer. Still, adjacency of organs at risk (OARs) can severely limit RT benefits. Rectal spacer implant in recto-prostatic space provides sufficient separation between prostate and rectum, and therefore, the opportunity for potential dose escalation to the target and reduction of OAR dose. Pretreatment simulation of spacer placement can potentially provide decision support to reduce the risks and increase the efficacy of the spacer placement procedure.

METHODS

A novel finite element method-oriented spacer simulation algorithm, FEMOSSA, was developed in this study. We used the finite element (FE) method to model and predict the deformation of rectum and prostate wall, stemming from hydrogel injection. Ten cases of prostate cancer, which undergone hydrogel placement before the RT treatment, were included in this study. We used the pre-injection organ contours to create the FE model and post-injection spacer location to estimate the distribution of the virtual spacer. Material properties and boundary conditions specific to each patient's anatomy were assigned. The FE analysis was then performed to determine the displacement vectors of regions of interest (ROIs), and the results were validated by comparing the virtually simulated contours with the real post-injection contours. To evaluate the different aspects of our method's performance, we used three different figures of merit: dice similarity coefficient (DSC), nearest neighbor distance (NND), and overlapped volume histogram (OVH). Finally, to demonstrate a potential dosimetric application of FEMOSSA, the predicted rectal dose after virtual spacer placement was compared against the predicted post-injection rectal dose.

RESULTS

Our simulation showed a realistic deformation of ROIs. The post-simulation (virtual spacer) created the same separation between prostate and rectal wall, as post-injection spacer. The average DSCs for prostate and rectum were 0.87 and 0.74, respectively. Moreover, there was a statistically significant increase in rectal contour similarity coefficient (P < 0.01). Histogram of NNDs showed the same overall shape and a noticeable shift from lower to higher values for both post-simulation and post-injection, indicative of the increase in distance between prostate and rectum. There was less than 2.2- and 2.1-mm averaged difference between the mean and fifth percentile NNDs. The difference between the OVH distances and the corresponding predicted rectal dose was, on average, less than 1 mm and 1.5 Gy, respectively.

CONCLUSIONS

FEMOSSA provides a realistic simulation of the hydrogel injection process that can facilitate spacer placement planning and reduce the associated uncertainties. Consequently, it increases the robustness and success rate of spacer placement procedure that in turn improves prostate cancer RT quality.

Inter- and intra-fractional stability of rectal gas in pelvic cancer patients during MRIgRT

PURPOSE

Due to the electron return effect (ERE) during magnetic resonance imaging guided radiotherapy (MRIgRT), rectal gas during pelvic treatments can result in hot spots of over-dosage in the rectal wall. Determining the clinical impact of this effect on rectal toxicity requires estimation of the amount and mobility (and stability) of rectal gas during treatment. We therefore investigated the amount of rectal gas and local inter- and intra-fractional changes of rectal gas in pelvic cancer patients.

METHODS

To estimate the volume of gas present at treatment planning, the rectal gas contents in the planning computed tomography (CT) scans of 124 bladder, 70 cervical and 2180 prostate cancer patients were calculated. To estimate inter- and intra-fractional variations in rectal gas, 174 and 131 T2-w MRIs for six cervical and eleven bladder cancer patients were used. These scans were acquired during four scan-sessions (~20-25 min each) at various time-points. Additionally, 258 T2-w MRIs of the first five prostate cancer patients treated using MRIgRT at our center, acquired during each fraction, were analyzed. Rectums were delineated on all scans. The area of gas within the rectum delineations was identified on each MRI slice using thresholding techniques. The area of gas on each slice of the rectum was used to calculate the inter- and intra-fractional group mean, systematic and random variations along the length of the rectum. The cumulative dose perturbation as a result of the gas was estimated. Two approaches were explored: accounting or not accounting for the gas at the start of the scan-session.

RESULTS

Intra-fractional variations in rectal gas are small compared to the absolute volume of rectal gas detected for all patient groups. That is, rectal gas is likely to remain stable for periods of 20-25 min. Larger volumes of gas and larger variations in gas volume were observed in bladder cancer patients compared with cervical and prostate cancer patients. For all patients, local cumulative dose perturbations per beam over an entire treatment in the order of 60 % were estimated when gas had not been accounted for in the daily adaption. The calculated dose perturbation over the whole treatment was dramatically reduced in all patients when accounting for the gas in the daily set-up image.

CONCLUSION

Rectal gas in pelvic cancer patients is likely to remain stable over the course of an MRIgRT fraction, and also likely to reappear in the same location in multiple fractions, and can therefore result in clinically relevant over-dosage in the rectal wall. The over-dosage is reduced when accounting for gas in the daily adaption.

Generating amorphous target margins in radiation therapy to promote maximal target coverage with minimal target size

BACKGROUND AND SIGNIFICANCE

This work provides proof-of-principle for two versions of a heuristic approach that automatically creates amorphous radiation therapy planning target volume (PTV) margins considering local effects of tumor shape and motion to ensure adequate voxel coverage with while striving to minimize PTV size. The resulting target thereby promotes disease control while minimizing the risk of normal tissue toxicity.

METHODS

This work describes the mixed-PDF algorithm and the independent-PDF algorithm which generate amorphous margins around a radiation therapy target by incorporating user-defined models of target motion. Both algorithms were applied to example targets - one circular and one "cashew-shaped." Target motion was modeled by four probability density functions applied to the target quadrants. The spatially variant motion model illustrates the application of the algorithms even with tissue deformation. Performance of the margins was evaluated in silico with respect to voxelized target coverage and PTV size, and was compared to conventional techniques: a threshold-based probabilistic technique and an (an)isotropic expansion technique. To demonstrate the algorithm's clinical utility, a lung cancer patient was analyzed retrospectively. For this case, 4D CT measurements were combined with setup uncertainty to compare the PTV from the mixed-PDF algorithm with a PTV equivalent to the one used clinically.

RESULTS

For both targets, the mixed-PDF algorithm performed best, followed by the independent-PDF algorithm, the threshold algorithm, and lastly, the (an)isotropic algorithm. Superior coverage was always achieved by the amorphous margin algorithms for a given PTV size. Alternatively, the margin required for a particular level of coverage was always smaller (8-15%) when created with the amorphous algorithms. For the lung cancer patient, the mixed-PDF algorithm resulted in a PTV that was 13% smaller than the clinical PTV while still achieving ≥99.9% coverage.

CONCLUSIONS

The amorphous margin algorithms are better suited for the local effects of target shape and positional uncertainties than conventional margins. As a result, they provide superior target coverage with smaller PTVs, ensuring dose delivered to the target while decreasing the risk of normal tissue toxicity.

Developing and Evaluating Multimedia Patient Education Tools to Better Prepare Prostate-Cancer Patients for Radiotherapy Treatment (Randomized Study)

The purpose of this study is to determine the effectiveness of multimedia educational tools to improve CT planning preparation for intensity modulated radiotherapy (IMRT) for prostate cancer. Many patients are not prepared when given verbal preparation instructions to have a full bladder and empty rectum for their IMRT and require being rescanned, which results in additional costs for the patient and the hospital. A pamphlet and video outlining the proper preparation for prostate IMRT was created to decrease additional scans and the associated costs, while increasing patient satisfaction. A controlled, randomized experimental group study was conducted to examine the effectiveness of the multimedia tools (the video and the pamphlet), as compared to the pamphlet only, in preparing patients for their planning CT appointment. We found no statistical difference between the multimedia group and the pamphlet group in patients' preparedness for their appointments and the rescanning rate. However, patients in the multimedia group indicated that they felt more prepared about their treatment after watching the video and stated that they would recommend the video to other patients with prostate cancer. Furthermore, patients who had to wait longer for their planning CT appointment felt less prepared by the materials than those with a shorter wait time. We recommend reducing wait times between appointments as much as possible to increase patients' preparedness for the planning CT. We conclude that providing multimedia treatment information and minimizing wait times increases patients' feelings of preparedness leading to a more positive treatment experience and reducing costly rescans.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02410291.

Computational analysis of interfractional anisotropic shape variations of the rectum in prostate cancer radiation therapy

PURPOSE

To analyze the uncertainties of the rectum due to anisotropic shape variations by using a statistical point distribution model (PDM).

MATERIALS AND METHODS

The PDM was applied to the rectum contours that were delineated on planning computed tomography (CT) and cone-beam CT (CBCT) at 80 fractions of 11 patients. The standard deviations (SDs) of systematic and random errors of the shape variations of the whole rectum and the region in which the rectum overlapped with the PTV (ROP regions) were derived from the PDMs at all fractions of each patient. The systematic error was derived by using the PDMs of planning and average rectum surface determined from rectum surfaces at all fractions, while the random error was derived by using a PDM-based covariance matrix at all fractions of each patient.

RESULTS

Regarding whole rectum, the population SDs were larger than 1.0 mm along all directions for random error, and along the anterior, superior, and inferior directions for systematic error. The deviation is largest along the superior and inferior directions for systematic and random errors, respectively. For ROP regions, the population SDs of systematic error were larger than 1.0 mm along the superior and inferior directions. The population SDs of random error for the ROP regions were larger than 1.0 mm except along the right and posterior directions.

CONCLUSIONS

The anisotropic shape variations of the rectum, especially in the ROP regions, should be considered when determining a planning risk volume (PRV) margins for the rectum associated with the acute toxicities.

Use of regularized principal component analysis to model anatomical changes during head and neck radiation therapy for treatment adaptation and response assessment

PURPOSE

To develop standard (SPCA) and regularized (RPCA) principal component analysis models of anatomical changes from daily cone beam CTs (CBCTs) of head and neck (H&N) patients and assess their potential use in adaptive radiation therapy, and for extracting quantitative information for treatment response assessment.

METHODS

Planning CT images of ten H&N patients were artificially deformed to create "digital phantom" images, which modeled systematic anatomical changes during radiation therapy. Artificial deformations closely mirrored patients' actual deformations and were interpolated to generate 35 synthetic CBCTs, representing evolving anatomy over 35 fractions. Deformation vector fields (DVFs) were acquired between pCT and synthetic CBCTs (i.e., digital phantoms) and between pCT and clinical CBCTs. Patient-specific SPCA and RPCA models were built from these synthetic and clinical DVF sets. EigenDVFs (EDVFs) having the largest eigenvalues were hypothesized to capture the major anatomical deformations during treatment.

RESULTS

Principal component analysis (PCA) models achieve variable results, depending on the size and location of anatomical change. Random changes prevent or degrade PCA's ability to detect underlying systematic change. RPCA is able to detect smaller systematic changes against the background of random fraction-to-fraction changes and is therefore more successful than SPCA at capturing systematic changes early in treatment. SPCA models were less successful at modeling systematic changes in clinical patient images, which contain a wider range of random motion than synthetic CBCTs, while the regularized approach was able to extract major modes of motion.

CONCLUSIONS

Leading EDVFs from the both PCA approaches have the potential to capture systematic anatomical change during H&N radiotherapy when systematic changes are large enough with respect to random fraction-to-fraction changes. In all cases the RPCA approach appears to be more reliable at capturing systematic changes, enabling dosimetric consequences to be projected once trends are established early in a treatment course, or based on population models.

Population model of bladder motion and deformation based on dominant eigenmodes and mixed-effects models in prostate cancer radiotherapy

In radiotherapy for prostate cancer irradiation of neighboring organs at risk may lead to undesirable side-effects. Given this setting, the bladder presents the largest inter-fraction shape variations hampering the computation of the actual delivered dose vs. planned dose. This paper proposes a population model, based on longitudinal data, able to estimate the probability of bladder presence during treatment, using only the planning computed tomography (CT) scan as input information. As in previously-proposed principal component analysis (PCA) population-based models, we have used the data to obtain the dominant eigenmodes that describe bladder geometric variations between fractions. However, we have used a longitudinal analysis along each mode in order to properly characterize patient's variance from the total population variance. We have proposed is a mixed-effects (ME) model in order to separate intra- and inter-patient variability, in an effort to control confounding cohort effects. Other than using PCA, bladder shapes are represented by using spherical harmonics (SPHARM) that additionally enables data compression without information lost. Based on training data from repeated CT scans, the ME model was thus implemented following dimensionality reduction by means of SPHARM and PCA. We have evaluated the model in a leave-one-out cross validation framework on the training data but also using independent data. Probability maps (PMs) were thus generated with several draws from the learnt model as predicted regions where the bladder will likely move and deform. These PMs were compared with the actual regions using metrics based on mutual information distance and misestimated voxels. The prediction was also compared with two previous population PCA-based models. The proposed model was able to reduce the uncertainties in the estimation of the probable region of bladder motion and deformation. This model can thus be used for tailoring radiotherapy treatments.

Coverage-based treatment planning to accommodate deformable organ variations in prostate cancer treatment

PURPOSE

To compare two coverage-based planning (CP) techniques with standard fixed margin-based planning (FM), considering the dosimetric impact of interfraction deformable organ motion exclusively for high-risk prostate treatments.

METHODS

Nineteen prostate cancer patients with 8-13 prostate CT images of each patient were used to model patient-specific interfraction deformable organ changes. The model was based on the principal component analysis (PCA) method and was used to predict the patient geometries for virtual treatment course simulation. For each patient, an IMRT plan using zero margin on target structures, prostate (CTVprostate) and seminal vesicles (CTVSV), were created, then evaluated by simulating 1000 30-fraction virtual treatment courses. Each fraction was prostate centroid aligned. Patients whose D98 failed to achieve 95% coverage probability objective D98,95 ≥ 78 Gy (CTVprostate) or D98,95 ≥ 66 Gy (CTVSV) were replanned using planning techniques: (1) FM (PTVprostate = CTVprostate + 5 mm, PTVSV = CTVSV + 8 mm), (2) CPOM which optimized uniform PTV margins for CTVprostate and CTVSV to meet the coverage probability objective, and (3) CPCOP which directly optimized coverage probability objectives for all structures of interest. These plans were intercompared by computing probabilistic metrics, including 5% and 95% percentile DVHs (pDVH) and TCP/NTCP distributions.

RESULTS

All patients were replanned using FM and two CP techniques. The selected margins used in FM failed to ensure target coverage for 8/19 patients. Twelve CPOM plans and seven CPCOP plans were favored over the other plans by achieving desirable D98,95 while sparing more normal tissues.

CONCLUSIONS

Coverage-based treatment planning techniques can produce better plans than FM, while relative advantages of CPOM and CPCOP are patient-specific.

Prediction of gastrointestinal toxicity after external beam radiotherapy for localized prostate cancer

Background

Gastrointestinal (GI) toxicity is a common effect following radiation therapy (RT) for prostate cancer. Purpose of the present work is to compare two Normal Tissue Complication Probability (NTCP) modelling approaches for prediction of late radio-induced GI toxicity after prostate external beam radiotherapy.

Methods

The study includes 84 prostate cancer patients evaluated for late rectal toxicity after 3D conformal radiotherapy. Median age was 72 years (range 53-85). All patients received a total dose of 76 Gy to the prostate gland with daily fractions of 2 Gy. The acute and late radio-induced GI complications were classified according to the RTOG/EORTC scoring system. Rectum dose-volume histograms were extracted for Lyman-Kutcher-Burman (LKB) NTCP model fitting using Maximum Likelihood Estimation. The bootstrap method was employed to test the fit robustness. The area under the receiver operating characteristic curve (AUC) was used to evaluate the predictive power of the LKB and to compare it with a multivariate logistic NTCP model previously determined.

Results

At a median follow-up of 36 months, 42% (35/84) of patients experienced grade 1-2 (G1-2) acute GI events while 25% (21/84) of patients developed G1-2 late GI events. The best-estimate of fitting parameters for LKB NTCP model for mild\moderate GI toxicity resulted to be: D₅₀ = 87.3 Gy, m = 0.37 and n = 0.10. Bootstrap result showed that the parameter fit was robust. The AUC values for the LKB and for the multivariate logistic models were 0.60 and 0.75, respectively.

Conclusions

We derived the parameters of the LKB model for mild\moderate GI toxicity prediction and we compared its performance with that of a data-driven multivariate model. Compared to LKB, the multivariate model confirmed a higher predictive power as showed by the AUC values.

Forecasting longitudinal changes in oropharyngeal tumor morphology throughout the course of head and neck radiation therapy

PURPOSE

To create models that forecast longitudinal trends in changing tumor morphology and to evaluate and compare their predictive potential throughout the course of radiation therapy.

METHODS

Two morphology feature vectors were used to describe 35 gross tumor volumes (GTVs) throughout the course of intensity-modulated radiation therapy for oropharyngeal tumors. The feature vectors comprised the coordinates of the GTV centroids and a description of GTV shape using either interlandmark distances or a spherical harmonic decomposition of these distances. The change in the morphology feature vector observed at 33 time points throughout the course of treatment was described using static, linear, and mean models. Models were adjusted at 0, 1, 2, 3, or 5 different time points (adjustment points) to improve prediction accuracy. The potential of these models to forecast GTV morphology was evaluated using leave-one-out cross-validation, and the accuracy of the models was compared using Wilcoxon signed-rank tests.

RESULTS

Adding a single adjustment point to the static model without any adjustment points decreased the median error in forecasting the position of GTV surface landmarks by the largest amount (1.2 mm). Additional adjustment points further decreased the forecast error by about 0.4 mm each. Selection of the linear model decreased the forecast error for both the distance-based and spherical harmonic morphology descriptors (0.2 mm), while the mean model decreased the forecast error for the distance-based descriptor only (0.2 mm). The magnitude and statistical significance of these improvements decreased with each additional adjustment point, and the effect from model selection was not as large as that from adding the initial points.

CONCLUSIONS

The authors present models that anticipate longitudinal changes in tumor morphology using various models and model adjustment schemes. The accuracy of these models depended on their form, and the utility of these models includes the characterization of patient-specific response with implications for treatment management and research study design.

Statistical simulations to estimate motion-inclusive dose-volume histograms for prediction of rectal morbidity following radiotherapy

BACKGROUND AND PURPOSE

Internal organ motion over a course of radiotherapy (RT) leads to uncertainties in the actual delivered dose distributions. In studies predicting RT morbidity, the single estimate of the delivered dose provided by the treatment planning computed tomography (pCT) is typically assumed to be representative of the dose distribution throughout the course of RT. In this paper, a simple model for describing organ motion is introduced, and is associated to late rectal morbidity data, with the aim of improving morbidity prediction.

MATERIAL AND METHODS

Organ motion was described by normally distributed translational motion, with its magnitude characterised by the standard deviation (SD) of this distribution. Simulations of both isotropic and anisotropic (anterior-posterior only) motion patterns were performed, as were random, systematic or combined random and systematic motion. The associations between late rectal morbidity and motion-inclusive delivered dose-volume histograms (dDVHs) were quantified using Spearman's rank correlation coefficient (Rs) in a series of 232 prostate cancer patients, and were compared to the associations obtained with the static/planned DVH (pDVH).

RESULTS

For both isotropic and anisotropic motion, different associations with rectal morbidity were seen with the dDVHs relative to the pDVHs. The differences were most pronounced in the mid-dose region (40-60 Gy). The associations were dependent on the applied motion patterns, with the strongest association with morbidity obtained by applying random motion with an SD in the range 0.2-0.8 cm.

CONCLUSION

In this study we have introduced a simple model for describing organ motion occurring during RT. Differing and, for some cases, stronger dose-volume dependencies were found between the motion-inclusive dose distributions and rectal morbidity as compared to the associations with the planned dose distributions. This indicates that rectal organ motion during RT influences the efforts to model the risk of morbidity using planning distributions alone.

Evaluation of a new method for calculation of cumulative doses in the rectum wall using repeat CT scans

The rectum wall is an important organ at risk during irradiation of the prostate, the bladder and other organs in the pelvis. It is therefore of great interest to be able reliably to predict normal tissue complication probabilities (NTCPs) for this organ. Because the rectum wall is a hollow organ capable of large deformations between fractions, dose estimates from a single CT are unreliable, and thereby also NTCP estimates. In this study two methods for calculations of cumulative dose distributions from repetitive CT scans are compared. The first is a method presented in this article that uses tracking of volume elements for a direct summation of the doses delivered in the treatment fractions. The other, presented earlier (1), is based on information from dose-volume histograms. The comparisons were made in terms of equivalent uniform doses (EUDs) and NTCPs. The methods were also compared with mean values of EUD and NTCP values from individual CT scans. The study showed that with the relatively symmetric beam arrangements normally used for treatment of prostate and bladder cancer, it is not necessary to use the more laborious method of element tracking. However, an introduction of artificial lateral rectum movements revealed that element tracking is necessary in less symmetric situations.

Influence of daily setup measurements and corrections on the estimated delivered dose during IMRT treatment of prostate cancer patients

PURPOSE

To evaluate the impact of marker-based position verification, using daily imaging and an off-line correction protocol, by calculating the delivered dose to prostate, rectum and bladder.

METHODS

Prostate cancer patients (n=217) were treated with IMRT, receiving 35 daily fractions. Plans with five beams were optimized taking target coverage (CTV, boost) and organs-at-risk (rectum and bladder) into account. PTV margins were 8mm. Prostate position was verified daily using implanted fiducial gold markers by imaging the first segment of all the five beams on an EPID. Setup deviations were corrected off-line using an adapted shrinking-action-level protocol. The estimated delivered dose, including daily organ movements, was calculated using a version of PLATO's dose engine, enabling batch processing of large numbers of patients. The dose was calculated +/- inclusion of setup corrections, and was evaluated relative to the original static plan. The marker-based measurements were considered representative for all organs.

RESULTS

Daily organ movements would result in an underdosage of 2-3Gy to CTV and boost volume relative to the original plan, which was prevented by daily setup corrections. The dose to rectum and bladder was on average unchanged, but a large spread was introduced by organ movements, which was reduced by including setup corrections.

CONCLUSIONS

Without position verification and setup corrections, margins of 8mm would be insufficient to account for position uncertainties during IMRT of prostate cancer. With the daily off-line correction protocol, the remaining variations are accommodated adequately.

Performance evaluation of automatic anatomy segmentation algorithm on repeat or four-dimensional computed tomography images using deformable image registration method

PURPOSE

Auto-propagation of anatomic regions of interest from the planning computed tomography (CT) scan to the daily CT is an essential step in image-guided adaptive radiotherapy. The goal of this study was to quantitatively evaluate the performance of the algorithm in typical clinical applications.

METHODS AND MATERIALS

We had previously adopted an image intensity-based deformable registration algorithm to find the correspondence between two images. In the present study, the regions of interest delineated on the planning CT image were mapped onto daily CT or four-dimensional CT images using the same transformation. Postprocessing methods, such as boundary smoothing and modification, were used to enhance the robustness of the algorithm. Auto-propagated contours for 8 head-and-neck cancer patients with a total of 100 repeat CT scans, 1 prostate patient with 24 repeat CT scans, and 9 lung cancer patients with a total of 90 four-dimensional CT images were evaluated against physician-drawn contours and physician-modified deformed contours using the volume overlap index and mean absolute surface-to-surface distance.

RESULTS

The deformed contours were reasonably well matched with the daily anatomy on the repeat CT images. The volume overlap index and mean absolute surface-to-surface distance was 83% and 1.3 mm, respectively, compared with the independently drawn contours. Better agreement (>97% and <0.4 mm) was achieved if the physician was only asked to correct the deformed contours. The algorithm was also robust in the presence of random noise in the image.

CONCLUSION

The deformable algorithm might be an effective method to propagate the planning regions of interest to subsequent CT images of changed anatomy, although a final review by physicians is highly recommended.

Quantitative evaluation of a cone-beam computed tomography-planning computed tomography deformable image registration method for adaptive radiation therapy

Deformable (non‐rigid) registration is an essential tool in both adaptive radiation therapy and image‐guided radiation therapy to account for soft‐tissue changes during the course of treatment. The evaluation method most commonly used to assess the accuracy of deformable image registration is qualitative human evaluation. Here, we propose a method for systematically measuring the accuracy of an algorithm in recovering artificially introduced deformations in cases of rigid geometry, and we use that method to quantify the ability of a modified basis spline (B‐Spline) registration algorithm to recover artificially introduced deformations. The evaluation method is entirely computer‐driven and eliminates biased interpretation associated with human evaluation; it can be applied to any chosen method of image registration.

Our method involves using planning computed tomography (PCT) images acquired with a conventional CT simulator and cone‐beam computed tomography (CBCT) images acquired daily by a linear accelerator–mounted kilovoltage image system in the treatment delivery room. The deformation that occurs between the PCT and daily CBCT images is obtained using a modified version of the B‐Spline deformable model designed to overcome the low soft‐tissue contrast and the artifacts and distortions observed in CBCT images. Clinical CBCT images and contours of phantom and central nervous system cases were deformed (warped) with known random deformations. In registering the deformed with the non‐deformed image sets, we tracked the algorithm's ability to recover the original, non‐deformed set. Registration error was measured as the mean and maximum difference between the original and the registered surface contours from outlined structures. Using this approach, two sets of tests can be devised. To measure the residual error related to the optimizer's convergence performance, the warped CBCT image is registered to the unwarped version of itself, eliminating unknown factors such as noise and positioning errors. To study additional errors introduced by artifacts and noise in the CBCT image, the warped CBCT image is registered to the original PCT image.

Using a B‐Spline deformable image registration algorithm, mean residual error introduced by the algorithm's performance on noise‐free images was less than 1 mm, with a maximum of 2 mm. The chosen deformable image registration model was capable of accommodating significant variability in structures over time, because the artificially introduced deformation magnitude did not significantly influence the residual error. On the second type of test, noise and artifacts reduced registration accuracy to a mean of 1.33 mm and a maximum of 4.86 mm.

The accuracy of deformable image registration can be easily and consistently measured by evaluating the algorithm's ability to recover artificially introduced deformations in rigid cases in which the true solution is known a priori. The method is completely automated, applicable to any chosen registration algorithm, and does not require user interaction of any kind.

PACS numbers: 87.57.Gg, 87.57.Ce, 87.62.+n

Direct aperture optimization for online adaptive radiation therapy

This paper is the first investigation of using direct aperture optimization (DAO) for online adaptive radiation therapy (ART). A geometrical model representing the anatomy of a typical prostate case was created. To simulate interfractional deformations, four different anatomical deformations were created by systematically deforming the original anatomy by various amounts (0.25, 0.50, 0.75, and 1.00 cm). We describe a series of techniques where the original treatment plan was adapted in order to correct for the deterioration of dose distribution quality caused by the anatomical deformations. We found that the average time needed to adapt the original plan to arrive at a clinically acceptable plan is roughly half of the time needed for a complete plan regeneration, for all four anatomical deformations. Furthermore, through modification of the DAO algorithm the optimization search space was reduced and the plan adaptation was significantly accelerated. For the first anatomical deformation (0.25 cm), the plan adaptation was six times more efficient than the complete plan regeneration. For the 0.50 and 0.75 cm deformations, the optimization efficiency was increased by a factor of roughly 3 compared to the complete plan regeneration. However, for the anatomical deformation of 1.00 cm, the reduction of the optimization search space during plan adaptation did not result in any efficiency improvement over the original (nonmodified) plan adaptation. The anatomical deformation of 1.00 cm demonstrates the limit of this approach. We propose an innovative approach to online ART in which the plan adaptation and radiation delivery are merged together and performed concurrently-adaptive radiation delivery (ARD). A fundamental advantage of ARD is the fact that radiation delivery can start almost immediately after image acquisition and evaluation. Most of the original plan adaptation is done during the radiation delivery, so the time spent adapting the original plan does not increase the overall time the patient has to spend on the treatment couch. As a consequence, the effective time allotted for plan adaptation is drastically reduced. For the 0.25, 0.5, and 0.75 cm anatomical deformations, the treatment time was increased by only 2, 4, and 6 s, respectively, as compared to no plan adaptation. For the anatomical deformation of 1.0 cm the time increase was substantially larger. The anatomical deformation of 1.0 cm represents an extreme case, which is rarely observed for the prostate, and again demonstrates the limit of this approach. ARD shows great potential for an online adaptive method with minimal extension of treatment time.

A method to calculate coverage probability from uncertainties in radiotherapy via a statistical shape model

In this paper we describe a technique that may be used to model the geometric uncertainties that accrue during the radiotherapy process. Using data from in-treatment cone beam CT scans, we simultaneously analyse non-uniform observer delineation variability and organ motion together with patient set-up errors via the creation of a point distribution model (PDM). We introduce a novel method of generating a coverage probability matrix, that may be used to determine treatment margins and calculate uncertainties in dose, from this statistical shape model. The technique does not assume rigid body motion and can extrapolate shape variability in a statistically meaningful manner. In order to construct the PDM, we generate corresponding surface points over a set of delineations. Correspondences are established at a set of points in parameter space on spherically parameterized and canonical aligned outlines. The method is demonstrated using rectal delineations from serially acquired in-treatment cone beam CT image volumes of a prostate patient (44 image volumes total), each delineated by a minimum of two observers (maximum six). Two PDMs are constructed, one with set-up errors included and one without. We test the normality assumptions of the PDMs and find the distributions to be Gaussian in nature. The rectal PDM variability is in general agreement with data in the literature. The two resultant coverage probability matrices show differences as expected.

Emptying the rectum before treatment delivery limits the variations of rectal dose - volume parameters during 3DCRT of prostate cancer

PURPOSE

To investigate the impact of rectum motion on dose - volume histograms of the rectum including filling and of the wall (DVH and DWH, respectively), during 3D-conformal radiotherapy (3DCRT) for localized prostate cancer.

MATERIALS AND METHODS

Ten patients received a planning CT scan (CT(0)) and 11-14 CT during 3DCRT for prostate cancer (total CT scans=126). CT images were 3D matched using bony anatomy. A single observer drew the external contours of rectum and rectum wall and the CTV (prostate + seminal vesicles) on CT(0). Patients were asked to empty their rectum before every CT, as generally performed at the Institute for Cancer Research and Treatment (IRCC) before treatment delivery. Bladder was kept full by drinking 500 cm(3) of water 60 min before the scan, according to our protocol. A 4-field box 3DCRT technique was planned and dose statistics/dose - volume histograms of the rectum were calculated for each contour referred to CT(0),CT(1),...,CT(n) for each patient. Average DVHs during treatment were calculated along with their standard deviation (SD(rand)) and compared to the planned DVH. The analyses on the patient population included the assessment of systematic deviation (average difference and SD, named SD(sys)) as well as the average SD(rand) value expressing the random component of organ motion. Rectum shifts were also assessed by anterior and lateral BEV projections.

RESULTS

As to the rectum, 8/10 patients showed a "better" average DVH than DVH on CT(0). Wilcoxon test showed a statistically significant reduction when correlating the difference Delta between the average DVH during therapy and planning DVH at CT(0): for instance V(70)Delta = -3.6% and p = 0.022, V(50)Delta = -5.5% and p = 0.022, D(med)Delta = -3.2 Gy and p = 0.007. Average values of DVH systematic difference (average difference between planning scan and treatment), standard deviations (SD(sys)) and average standard deviations of the random fluctuation (SD(random)) were -4.0%, 4.7% and 6.6%, respectively. Whilst the fluctuation results were slightly smaller for DWH. Volume analysis showed a slight systematic variation of the rectal volume between planning and treatment BEV. The average rectal volume during therapy was larger than at the planning CT in 8/10 patients. The systematic shifts of the rectal wall between the planning phase and the treatment were rather small, both below and above the flexure. The larger random fluctuation of the rectum shape was found to be in the cranial half (1 SD=4.4 mm).

CONCLUSIONS

The practice of carefully emptying the rectum during simulation and therapy for prostate cancer, which is a safe and simple procedure, reduces the impact of organ motion on dose - volume parameters of the rectum.

A study of the effect of setup errors and organ motion on prostate cancer treatment with IMRT

PURPOSE

To assess the influence of setup errors and organ motion in terms of the probability of tumor control and normal-tissue complications by tumor control probability and normal-tissue complication probability.

METHODS AND MATERIALS

Twelve patients were treated for prostate cancer with intensity-modulated radiation therapy. Two orthogonal portal images were taken daily. All patients underwent three computed tomography scans during the 8-week treatment time (i.e., baseline, intermediate, and final). The original treatment plans were re-evaluated, taking into account setup errors and organ motion.

RESULTS

The mean shifts +/- standard deviation of the whole patient population in the lateral, anterior-posterior, and craniocaudal direction were 1.0 +/- 1.5 mm, 0.9 +/- 2.1 mm, and 1.9 +/- 2.1 mm, respectively. In most of the recalculated dose-volume histograms, the coverage of clinical target volume was granted despite organ motion, whereas the rectal wall histograms were often very different from the planned ones.

CONCLUSION

We have studied the impact of prostate and rectum motion, as well as setup errors, on dose-volume histograms. The estimate of these effects may have implications for predictive indications when planning intensity-modulated radiation therapy treatments on prostate.

3D interfractional patient position verification using 2D-3D registration of orthogonal images

Reproducible positioning of the patient during fractionated external beam radiation therapy is imperative to ensure that the delivered dose distribution matches the planned one. In this paper, we expand on a 2D-3D image registration method to verify a patient's setup in three dimensions (rotations and translations) using orthogonal portal images and megavoltage digitally reconstructed radiographs (MDRRs) derived from CT data. The accuracy of 2D-3D registration was improved by employing additional image preprocessing steps and a parabolic fit to interpolate the parameter space of the cost function utilized for registration. Using a humanoid phantom, precision for registration of three-dimensional translations was found to be better than 0.5 mm (1 s.d.) for any axis when no rotations were present. Three-dimensional rotations about any axis were registered with a precision of better than 0.2 degrees (1 s.d.) when no translations were present. Combined rotations and translations of up to 4 degrees and 15 mm were registered with 0.4 degrees and 0.7 mm accuracy for each axis. The influence of setup translations on registration of rotations and vice versa was also investigated and mostly agrees with a simple geometric model. Additionally, the dependence of registration accuracy on three cost functions, angular spacing between MDRRs, pixel size, and field-of-view, was examined. Best results were achieved by mutual information using 0.5 degrees angular spacing and a 10 x 10 cm2 field-of-view with 140 x 140 pixels. Approximating patient motion as rigid transformation, the registration method is applied to two treatment plans and the patients' setup errors are determined. Their magnitude was found to be < or = 6.1 mm and < or = 2.7 degrees for any axis in all of the six fractions measured for each treatment plan.

A direct voxel tracking method for four-dimensional Monte Carlo dose calculations in deforming anatomy

In this work we present a method of calculating dose in deforming anatomy where the position and shape of each dose voxel is tracked as the anatomy changes. The EGSnrc/DOSXYZnrc Monte Carlo code was modified to calculate dose in voxels that are deformed according to deformation vectors obtained from a nonlinear image registration algorithm. The defDOSXYZ code was validated by consistency checks and by comparing calculations against DOSXYZnrc calculations. Calculations in deforming phantoms were compared with a dose remapping method employing trilinear interpolation. Dose calculations with the deforming voxels agree with DOSXYZnrc calculations within 1%. In simple deforming rectangular phantoms the trilinear dose remapping method was found to underestimate the dose by up to 29% for a 1.0 cm voxel size within the field, with larger discrepancies in regions of steep dose gradients. The agreement between the two calculation methods improved with smaller voxel size and deformation magnitude. A comparison of dose remapping from Inhale to Exhale in an anatomical breathing phantom demonstrated that dose deformations are underestimated by up to 16% in the penumbra and 8% near the surface with trilinear interpolation.

Dosimetrische Auswirkungen der Verwendung eines Rektumhüllen-Volumens für die Bestrahlungsplanung fluenzmodulierter Strahlentherapie von Prostatakrebs

The present study evaluated a hull-volume definition strategy for the planning organ at risk volume (PRV) for the rectum in the planning of radiotherapy of prostate cancer. The bounding volumes of rectum contours of 1 to 5 CT scans were compared on the basis of the rectum coverage probabilities for 5 patients. In addition, IMRT treatment plans were optimized using the rectum hull PRV5 of 5 CTs and each of the conventional rectum contours PRV1. The plans were compared on the basis of the organ doses caused by the individual organ motion. PRV5 allowed to cover the rectum with a probability of nearly 90% (PRV1 67%). Rectal wall dose showed a great variability for PRV1, while planned and treatment dose agreed well for PRV5 due to the improved geometric information which resulted in a better rectal sparing. In conclusion, the rectum hull-volume PRV5 is a well suited PRV for planning of IMRT dose distributions allowing dose escalation as well as rectal sparing.

Robust treatment planning for intensity modulated radiotherapy of prostate cancer based on coverage probabilities

BACKGROUND AND PURPOSE

To evaluate an optimization approach where coverage probabilities are incorporated into the optimization of intensity modulated radiotherapy (IMRT) to overcome the problem of margin definition in the case of overlapping planning target volume and organs at risk.

PATIENTS AND METHODS

IMRT plans were generated for three optimization approaches: based on a planning CT plus margin (A), on prostate and rectum contours from five pre-treatment CT plus margin (B), and on coverage probabilities (C). For approach (C), the probability of organ occupation was computed for each voxel from five pre-treatment CTs and the population distribution of systematic setup error and it was used as local weight in the costfunctions. Monte Carlo simulations of treatment courses were used to compute the probability distribution of prostate and rectal wall equivalent uniform dose (EUD).

RESULTS

Treatment simulations showed best and most robust results for prostate and rectal wall EUD within the population for (C). For (A) the rectal wall EUD was on average about 1.5 Gy greater than in (C), while the prostate EUD was lower than those from (C) for most of the patients for (B) (especially for those with great organ motion).

CONCLUSIONS

The incorporation of coverage probabilities as local weights allows for dose escalation as well as improved rectal sparing and results in a safer and more robust IMRT treatment.

Modelling individual geometric variation based on dominant eigenmodes of organ deformation: implementation and evaluation

We present a method of modelling inter-fractional organ deformation and correlated motion of adjacent organ structures in terms of so-called eigenmodes. The method is based on a principal component analysis (PCA) of organ shapes and allows for reducing the large dimensionality of geometry information from multiple CT studies to a few-parametric statistical model of organ motion and deformation. Eigenmodes are 3D vectorfields of correlated displacements of the organ surface points and can be seen as fundamental 'modes' of the patient's geometric variability. The amount of variability represented by the eigenmodes is quantified in terms of corresponding eigenvalues. Weighted sums of eigenmodes describe organ displacements/deformations and can be used to generate new organ geometries. We applied the method to four patient datasets of prostate/rectum/bladder with N = 15-18 CTs to assess interfractional geometric variation. The spectrum of eigenvalues was found to be dominated by only few values, indicating that the geometric variability of prostate/bladder/rectum is governed by only few patient specific eigenmodes. We evaluated the capability of this approach to represent the measured organ samples by calculating the residual errors for the organ surface points, using a varying number of eigenmodes. The distribution of residual errors shows fast convergence with the number of eigenmodes. Using 4 dominating modes, the range of residual errors for the four patients was 1.3-2.0 mm (prostate), 1.4-1.9 mm (rectum) and 1.5-1.9 mm (bladder). Thus, individual geometric variation taken from multiple imaging data can be described accurately by few dominating eigenmodes, thereby providing the most important factors to characterize deformable organ motion, which can assist adaptive radiotherapy planning.

Modelling the variation in rectal dose due to inter-fraction rectal wall deformation in external beam prostate treatments

Prostate radiotherapy inevitably deposits radiation dose in the rectal wall, and the dose delivered to prostate is limited by the expected rectal complications. Accurate evaluation of the rectal dose is non-trivial due to a number of factors. One of these is variation of the shape and position of the rectal wall (with respect to the clinical target volume (CTV)), which may differ daily from that taken during planning CT acquisition. This study uses data currently available in the literature on rectal wall motion to provide estimates of mean population rectal wall dose. The rectal wall geometry is characterized by a population mean radius of the rectum as well as inter-patient and inter-fraction standard deviations in rectum radius. The model is used to evaluate the range of inter-fraction and inter-patient rectal dose variations. The simulation of individual patients with full and empty rectum in the planning CT scan showed that large variations in rectal dose (>15 Gy) are possible. Mean calculated dose accounting for treatment and planning uncertainties in the rectal wall surface was calculated as well as the map of planning dose over/underpredictions. It was found that accuracy of planning dose is dependent on the CTV-PTV margin size with larger margins producing more accurate estimates. Over a patient population, the variation in rectal dose is reduced by increasing the number of pre-treatment CT scans.

Computed Tomography Guided Management of Interfractional Patient Variation

Interfractional patient variation occurs regularly and considerably during the radiotherapy course. Consequently, a generic but large planning target margin has to be applied when patient treatment plan design based on a single pre-treatment computed tomography scan is used to guide multifraction radiation treatment, which creates a major limiting factor for radiotherapy improvement. Planning target margins can be significantly reduced using multiple (or 4-dimensional) image feedback management in the routine treatment process. The most effective method in multiple-image feedback management of radiotherapy is the adaptive control methodology. The adaptive radiotherapy technique aims to customize each patient's treatment plan to patient-specific variation by evaluating and characterizing the systematic and random variations through image feedback and including them in adaptive planning. Adaptive radiotherapy will become a new treatment standard, in which a predesigned adaptive treatment strategy, including the schedules of imaging and replanning, will eventually replace the predesigned treatment plan in the routine clinical practice.

Dosimetric consequences of the application of off-line setup error correction protocols and a hull-volume definition strategy for intensity modulated radiotherapy of prostate cancer

PURPOSE

To evaluate the consequences of a planning volume definition based on multiple CTs and the application of off-line setup error correction for the treatment of prostate cancer with intensity-modulated radiotherapy (IMRT). Further, to compare various setup correction protocols (SCP) by their influence on the average dose distributions.

MATERIALS AND METHODS

A planning target volume (PTV) consisting of the bounding volume of prostate contours of five CTs (CTV_hull) plus an additional margin of 5mm and a virtual Rectum_hull volume (the solid bounding volume of the five corresponding rectum contours) are used for treatment planning. Simulations of treatment courses with the non-parametric bootstrap method allow to estimate the distribution of the expected equivalent uniform dose (EUD). The impact of off-line setup error correction protocols is evaluated based on estimated EUD distributions.

RESULTS

Off-line SCP allow to achieve the intended prostate and rectum EUD and a reliable coverage of the CTV despite the reduced margins. The EUD of the virtual hull volumes is a good estimate for the EUD of prostate and rectal wall.

CONCLUSION

Treatment planning based on Rectum_hull and CTV_hull plus setup margin as PTV in combination with SCP results in a robust and safe IMRT planning concept.

Testing the new ICRU 62 ‘Planning Organ at Risk Volume’ concept for the rectum

BACKGROUND AND PURPOSE

To study the impact of the new ICRU 62 'Planning organ at Risk Volume' (PRV) concept on the relationship between rectum dose-volume histogram (DVH) data and toxicity.

PATIENTS AND METHODS

The acute gastro-intestinal (GI) RTOG toxicity in 127 prostate cancer patients prescribed a total dose of 70 Gy with conformal irradiation to either the prostate, the prostate and seminal vesicles or the whole pelvis (initial 50 Gy only) were analysed. DVHs were derived for the rectum only and for rectum extended with six PRV margin sets (narrow/intermediate/wide; anterior/anterior and posterior). The data was analysed using permutation tests, logistic regression and effective uniform dose (EUD) calculations.

RESULTS

Acute Grade 2 GI toxicity was seen in 22 of 127 cases (17%). Permutation tests showed that the difference between DVHs for patients with and without Grade 2 effects was significant, both for rectum only and rectum PRVs (P-value range: 0.02-0.04), with generally lower P-values for the PRVs. In the logistic regression, the fractional DVH variables (i.e. volumes) were significantly related to toxicity, with approximately 2-3 times as many significant dose levels for the PRVs as for rectum only. E.g. with wide anterior and posterior margins (16 and 11 mm, respectively) the relation was significant at 26 different dose levels (6-7, 13-14, 35-43, 60-71 and 73 Gy), compared to nine levels (38-40, 43-44 and 71-74 Gy) for rectum only. EUDs were significantly different for patients with and without Grade 2 effects both for rectum only and the PRVs (95% confidence interval for EUD increase with Grade 2 effects: 0.1-3.1 Gy).

CONCLUSIONS

All statistical methods applied indicated a small, but definite difference in DVH parameters between patients with versus those without Grade 2 effects. The difference was most pronounced when margins of 16 mm anterior and 11 mm posterior were applied.

Impact of geometric uncertainties on evaluation of treatment techniques for prostate cancer

PURPOSE

To assess the impact of patient repositioning and internal organ motion on prostate treatment plans using three-dimensional conformal and intensity-modulated radiotherapy.

METHODS AND MATERIALS

Four-field, six-field, and simplified intensity-modulated arc therapy plans were generated for 5 prostate cancer patients. The planning target volume was created by adding a 1-cm margin to the clinical target volume. A convolution model was used to estimate the effect of random geometric uncertainties during treatment. Dose statistics, tumor control probabilities, and normal tissue complication probabilities were compared with and without the presence of uncertainty. The impact of systematic uncertainties was also investigated.

RESULTS

Compared with the planned treatments, the delivered dose distribution with random geometric uncertainties displayed an increase in the apparent minimal dose to the prostate and seminal vesicles and a decrease in the rectal volume receiving a high dose. This increased the tumor control probabilities and decreased the normal tissue complication probabilities. Changes were seen in the percentage of prostate volume receiving 100% and 95% of the prescribed dose, and the minimal dose and tumor control probabilities for the target volume. In addition, the volume receiving at least 65 Gy, the minimal dose, and normal tissue complication probabilities changed considerably for the rectum. The simplified intensity-modulated arc therapy technique was the most sensitive to systematic errors, especially in the anterior-posterior and superior-inferior directions.

CONCLUSION

Geometric uncertainties should be considered when evaluating treatment plans. Contrary to the widely held belief, increased conformation of the dose distribution is not always associated with increased sensitivity to random geometric uncertainties if a sufficient planning target volume margin is used. Systematic errors may have a variable effect, depending on the treatment technique used.

Use of deformed intensity distributions for on-line modification of image-guided IMRT to account for interfractional anatomic changes

PURPOSE

Recent imaging studies have demonstrated that there can be significant changes in anatomy from day to day and over the course of radiotherapy as a result of daily positioning uncertainties and physiologic and clinical factors. There are a number of strategies to minimize such changes, reduce their impact, or correct for them. Measures to date have included improved immobilization of external and internal anatomy or adjustment of positions based on portal or ultrasound images. Perhaps the most accurate way is to use CT image-guided radiotherapy, for which the possibilities range from simple correction of setup based on daily CT images to on-line near real-time intensity modulated radiotherapy (IMRT) replanning. In addition, there are numerous intermediate possibilities. In this paper, we report the development of one such intermediate method that takes into account anatomic changes by deforming the intensity distributions of each beam based on deformations of anatomy as seen in the beam's-eye-view.

METHODS AND MATERIALS

The intensity distribution deformations are computed based on anatomy deformations discerned from the changes in the current image relative to a reference image (e.g., the pretreatment CT scan). First, a reference IMRT plan is generated based on the reference CT image. A new CT image is acquired using an in-room CT for every fraction. The anatomic structure contours are obtained for the new image. (For this article, these contours were manually drawn. When image guided IMRT methods are implemented, anatomic structure contours on subsequent images will likely be obtained with automatic or semiautomatic means. This could be achieved by, for example, first deforming the original CT image to match today's image, and then using the same deformation transformation to map original contours to today's image.) The reference intensity distributions for each beam are then deformed so that the projected geometric relationship within the beam's-eye-view between the anatomy (both target and normal tissues) extracted from the reference image and the reference intensity distribution is the same as (or as close as possible to) the corresponding relationship between anatomy derived from today's image and the newly deformed intensity distributions. To verify whether the dose distributions calculated using the deformed intensity distributions are acceptable for treatment as compared to the original intensity distributions, the deformed intensities are transformed into leaf sequences, which are then used to compute intensity and dose distributions expected to be delivered. The corresponding dose-volume histograms and dose-volume and dose-response indices are also computed. These data are compared with the corresponding data derived (a) from the original treatment plan applied to the original image, (b) from the original treatment plan applied to today's image, and (c) from a new full-fledged IMRT plan designed based on today's image.

RESULTS

Depending on the degree of anatomic changes, the use of an IMRT plan designed based on the original planning CT for the treatment of the current fraction could lead to significant differences compared to the intended dose distributions. CT-guided setup compared to the setup based on skin marks or bony landmarks may improve dose distributions somewhat. Replanning IMRT based on the current fraction's image yields the best physically deliverable plan (the "gold standard"). For the prostate and head-and-neck examples studied as proof of principle, the results of deforming intensities within each beam based on the anatomy seen in the beam's-eye-view are a good approximation of full-fledged replanning compared with other alternatives.

CONCLUSIONS

Our preliminary results encourage us to believe that deforming intensities taking into account deformation in the anatomy may be a rapid way to produce new treatment plans on-line in near real-time based on daily CT images. The methods we have developed need to be applied to a group of patients for both prostate and head-and-neck cases to confirm the validity of our approach.

Comparison of rectal dose-wall histogram versus dose-volume histogram for modeling the incidence of late rectal bleeding after radiotherapy

PURPOSE

To compare the fits of normal-tissue complication probability (NTCP) models based on rectal dose-wall histograms (DWHs) vs. dose-volume histograms (DVHs) when the two are used to analyze a common set of late rectal toxicity data.

METHODS AND MATERIALS

Data were analyzed from 128 prostate cancer patients treated with 3-dimensional conformal radiotherapy (3D-CRT) at The University of Texas M.D. Anderson Cancer Center (UTMDACC). The DVH for total rectal volume, including contents, was obtained for each patient from the treatment-planning system. A DWH was also computed, using the outer rectal contour plus an autogenerated inner contour that corresponds to an assumed 3-mm rectal wall thickness. The endpoint for analysis was Grade 2 or higher late rectal bleeding within 2 years of treatment; all patients had at least 2 years of follow-up. Four different NTCP models were fitted to the response data by using either the DVH or the DWH to describe the dose distribution to rectum or rectal wall, respectively. The 4 models considered were the Lyman model, the mean dose model, the parallel-architecture model, and a model based on the volume of a organ receiving more than a specified dose (the "cutoff-dose" model).

RESULTS

For each of the models, the fit to the late rectal bleeding data was slightly improved when the analysis was based on the rectal DWH instead of on the DVH. In addition, the results of the cutoff dose and parallel architecture models were consistent with one another for the DWH data but not for the DVH data. For the DWH data, both models predict a 50% or higher incidence of Grade 2 or worse late rectal bleeding within 2 years if 80% or more of the rectal wall is exposed to doses greater than 32 Gy. A 50% or higher incidence of rectal bleeding is also predicted if the mean dose to rectal wall exceeds 53.2 Gy.

CONCLUSIONS

A consistent, although modest, improvement occurs in the fits of NTCP models to the UTMDACC 2-year late rectal bleeding data when the fit is based on the rectal dose-wall histogram instead of on the dose-volume histogram for entire rectum, including contents.

Conformal radiotherapy of urinary bladder cancer

Recent advances in radiotherapy (RT) are founded on the enhanced tumour visualisation capabilities of new imaging modalities and the precise deposition of individualised radiation dose distributions made possible with the new systems for RT planning and delivery. These techniques have a large potential to also improve the results of RT of urinary bladder cancer. Major challenges to take full advantage of these advances in the management of bladder cancer are to control, and, as far as possible, reduce bladder motion, and to reliably account for the related intestine and rectum motion. If these obstacles are overcome, it should be possible in the near future to offer selected patients with muscle invading bladder cancer an organ-sparing, yet effective combined-modality treatment as an alternative to radical surgery.

Rectal and bladder motion during conformal radiotherapy after radical prostatectomy

BACKGROUND AND PURPOSE

To investigate the extent and the impact of rectum and bladder motion during adjuvant conformal radiotherapy (3DCRT) after radical prostatectomy (RP).

MATERIALS AND METHODS

Nine patients previously operated with RP and treated with early adjuvant 3DCRT were considered for this investigation. Weekly CT scans were collected during treatment (CT1-CTn, n=4-6) and were 3D matched using bony anatomy with the planning CT (CT0). A single observer drew the contours of rectum and bladder on all CTs. The CTV (prostate+/-seminal vesicles surgical bed) was contoured on CT0 by a single observer and a 4-field 3DCRT technique was planned: dose statistics/dose-volume histograms (DVH) of the rectum and bladder were calculated for each contour referred to CT0, CT1...CTn. Average DVHs during the treatment were then calculated and compared with the planned DVH. Cranial, caudal, anterior and posterior shifts of rectum and bladder were also assessed by lateral BEV projections. NTCP values for the rectum were also calculated using the Lyman-Kutcher model.

RESULTS

Random variations of volume and DVHs due to variable filling content were found for the bladder; a trend of the bladder to be more empty during therapy with respect to CT0 was also found (median values: 45 cm3 vs. 79 cm3, P=0.02). Regarding the rectum, 6/9 patients showed an average DVH 'worse' than the planned one (up to 10-20%). BEV and volume analyses showed that the rectal volume decreased in 3/9 patients after the first week. In 6/9 patients a systematic anterior shift of the cranial half of the rectum was detected and found to be correlated with a corresponding shift of the posterior border of CTV contoured by five different observers. The average rectal NTCP during therapy was systematically higher than the NTCP referred to CT0 (average increase 1.2%; range 0.0-3.7%, for a 70 Gy ICRU dose, P=0.01).

CONCLUSIONS

The impact of systematic uncertainty due to rectal wall motion seems to be relatively high for patients treated with adjuvant 3DCRT after RP. The detected trend of the rectum in migrating anteriorly during therapy is consistent with post-surgery settlement effects and/or some modification of rectum mobility due to irradiation. Rectal motion (and consequent shifts of CTV) was large at the half cranial portion of the rectum while it was very small below the flexure.

A Monte Carlo study of the impact of the choice of rectum volume definition on estimates of equivalent uniform doses and the volume parameter

Calculations of normal tissue complication probability (NTCP) values for the rectum are difficult because it is a hollow, non-rigid, organ. Finding the true cumulative dose distribution for a number of treatment fractions requires a CT scan before each treatment fraction. This is labour intensive, and several surrogate distributions have therefore been suggested, such as dose wall histograms, dose surface histograms and histograms for the solid rectum, with and without margins. In this study, a Monte Carlo method is used to investigate the relationships between the cumulative dose distributions based on all treatment fractions and the above-mentioned histograms that are based on one CT scan only, in terms of equivalent uniform dose. Furthermore, the effect of a specific choice of histogram on estimates of the volume parameter of the probit NTCP model was investigated. It was found that the solid rectum and the rectum wall histograms (without margins) gave equivalent uniform doses with an expected value close to the values calculated from the cumulative dose distributions in the rectum wall. With the number of patients available in this study the standard deviations of the estimates of the volume parameter were large, and it was not possible to decide which volume gave the best estimates of the volume parameter, but there were distinct differences in the mean values of the values obtained.

Characterization of rectal normal tissue complication probability after high-dose external beam radiotherapy for prostate cancer

PURPOSE

Conformal radiotherapy (RT) has allowed radiation dose escalation to improve the outcome of prostate cancer. With higher doses, concern exists that rectal injury may increase. This study analyzed the utility and limitations of the widely used Lyman-Kutcher- Burman (LKB) normal tissue complication probability model in projecting the hazards of rectal complication with high-dose RT.

METHODS AND MATERIALS

A total of 128 patients were included in this study. These patients were treated with three-dimensional conformal RT alone at the University of Texas M.D. Anderson Cancer Center between 1992 and 1999. Patients were treated to 46 Gy with a four-field box technique followed by a six-field arrangement to boost the total dose to 78 Gy. All doses were delivered at 2 Gy/fraction to the isocenter. The minimal follow-up was 2 years. The end point for analysis was Grade 2 or worse rectal bleeding by 2 years. The LKB model was fitted to the data using the maximal likelihood method.

RESULTS

Of the 128 patients, 29 experienced Grade 2 or worse rectal bleeding by 2 years. For the entire cohort, the parameters obtained from the fit of the LKB model were as follows: the volume factor was n = 3.91 (95% confidence interval [CI] 0.031 to infinity ), dose associated with 50% chance of complication for uniform whole rectal irradiation [TD50(1)] was 53.6 Gy (95% CI 50.0-75.1), and a determinant of the steepness of the dose-response curve, (m), was 0.156 (95% CI 0.036-0.271). A statistically significant difference was found in the rate of postradiation rectal bleeding in patients with hemorrhoids vs. those without hemorrhoids. The parameters obtained for the patients without hemorrhoids were as follows: n = 0.746 (95% CI 0.026 to infinity ), TD50(1) 56.7 Gy (95% CI 49.9-75.2), and m 0.092 (95% CI 0.019-0.189).

CONCLUSION

Our analysis suggests a dose response for rectal bleeding probability along with a volume effect. We found that the LKB model might have limited utility in determining a large volume effect. We further suggest that LKB model should be used with caution in clinical practice.

Acute morbidity related to treatment volume during 3D-conformal radiation therapy for prostate cancer

PURPOSE

To investigate the relation between acute toxicity and irradiated volume in the organs at risk during three-dimensional conformal radiation therapy for prostate cancer.

METHODS AND MATERIALS

From January to December 2001, we treated 132 prostate cancer patients to a prescribed target dose of 70 Gy. Twenty-six patients (20%) received irradiation to the prostate only (Group P), 86 patients (65%) had field arrangements encompassing the prostate and seminal vesicles (Group PSV) while 20 (15%) received modified pelvic fields (Group MPF). A four-field conformal box technique was used. Acute toxicity according to the RTOG scoring system was prospectively recorded throughout the course of treatment.

RESULTS

Overall, radiation was well tolerated with 11%, 16% and 35% Grade 2 gastro-intestinal (GI) toxicity and 19%, 34% and 35% Grade 2 or higher genito-urinary (GU) toxicity in Groups P, PSV and MPF, respectively. In univariate and multivariate analyses treatment group was a significant predictor for Grade 2 or higher acute morbidity. In multivariate logistic regression, the rectum dose-volume histogram parameters were correlated to the incidence of acute Grade 2 GI toxicity, with the fractional volumes receiving more than 37-40 Gy and above 70 Gy showing the statistically strongest correlation. The fractional bladder volume receiving more than 14-27 Gy showed the statistically strongest correlation with acute GU toxicity.

CONCLUSIONS

3D-CRT radiation therapy to 70 Gy for prostate cancer was well tolerated. Only two of the 132 patients in the cohort experienced acute bladder toxicity Grade 3, none had Grade 3 rectal toxicity. Uni- and multivariate analyses indicated that the volume treated was a significant factor for the incidence of Grade 2 or higher acute morbidity.

Tracking the dose distribution in radiation therapy by accounting for variable anatomy

The goal of this research is to calculate the daily and cumulative dose distribution received by the radiotherapy patient while accounting for variable anatomy, by tracking the dose distribution delivered to tissue elements (voxels) that move within the patient. Non-linear image registration techniques (i.e., thin-plate splines) are used along with a conventional treatment planning system to combine the dose distributions computed for each 3D computed tomography (CT) study taken during treatment. For a clinical prostate case, we demonstrate that there are significant localized dose differences due to systematic voxel motion in a single fraction as well as in 15 cumulative fractions. The largest positive dose differences in rectum, bladder and seminal vesicles were 29%, 2% and 24%, respectively, after the first fraction of radiation treatment compared to the planned dose. After 15 cumulative fractions, the largest positive dose differences in rectum, bladder and seminal vesicles were 23%, 32% and 18%, respectively, compared to the planned dose. A sensitivity analysis of control point placement is also presented. This method provides an important understanding of actual delivered doses and has the potential to provide quantitative information to use as a guide for adaptive radiation treatments.

On the use of margins for geometrical uncertainties around the rectum in radiotherapy planning

BACKGROUND AND PURPOSE

To derive planning organ at risk volume (PRV) margins for the rectum and to analyse the impact of such margins on rectum dose volume histograms (DVHs).

PATIENTS AND METHODS

Weekly repeat computer tomography (CT) scans of 19 bladder cancer patients acquired during a conformal radiotherapy course were registered with the corresponding planning CT scans. From these scans, the internal rectal motion was quantified, and the margins that had to be added to the rectum contour in the planning scan to encompass the observed span of rectum motion were determined. These margins were compared to the margins derived using a recent PRV margin recipe. To illustrate the impact of margins on rectum DVHs, the margins were applied in treatment plans of six prostate cancer patients.

RESULTS

Altogether 141 CT scans were analysed. On average 24% of the repeat scan rectum volume was displaced outside the planning scan contours, and wall movements of up to 30 mm were observed. Margins of 16 mm anterior and 11 mm posterior encompassed all rectal motion except for the two most displaced rectum walls in each of these directions, in 89% of the patients. Using a recently published statistics-based recipe, margins of 6 mm anterior and 5 mm posterior accounted for the systematic rectum variation, i.e. the average wall position, in 90% of the patients. Adding anterior margin only caused consistent increases (up to 20%) in the fraction of the volume inside the high-dose region (40-70 Gy) compared to the DVH of rectum only. When using both anterior and posterior margins only small shifts (<5%) in the volume fractions were observed.

CONCLUSIONS

Rectum PRV margins of 5-6 mm will encompass the systematic component of rectum motion, while margins up to 16 mm are required to also account for most of the random variation. Use of anterior margins only caused large shifts in the DVHs in the clinically significant dose range, while only minor shifts were seen when using both anterior and posterior margins.

Quantification of local rectal wall displacements by virtual rectum unfolding

BACKGROUND AND PURPOSE

To develop a method to project surface elements of a bent tubular organ, e.g. the rectum, in order to create a two-dimensional (2D) map and to use this method to quantify on a local scale shape and position variations of the rectum.

PATIENTS AND METHODS

For this study we used data of 19 patients, who each received a planning CT scan and 9-13 repeat CT scans that were considered representative for the radiotherapy course. We combined maps from multiple CT scans of the same patient to quantify local rectal wall displacements. To make a map we first computed a central axis through the rectum and divided it into segments of equal length assuming that the length of these segments was invariant under rectum shape and position changes. Next, we constructed for each segment a planar cross section through the rectum, which was oriented orthogonally to that segment. The amount of rectal wall tissue was assumed to be constant in all orthogonal cross sections throughout the entire rectum. We unfolded the cross-sected rectal wall at the dorsal side and projected either the associated dose or the coordinates onto the map.

RESULTS

The largest variation in the position of the rectal wall during the treatment course occurred at the upper anterior, left and right side (1 SD=5-7 mm). Near the anus the variation was <3 mm (1 SD) and at the posterior side of the rectum <4 mm (1 SD). The anterior-posterior (AP) and left-right displacements between the rectum in the planning CT scan and the mean rectum shape during the treatment were localized between 40 and 80% of the central axis. At the upper anterior, left, and right side the displacements were 5-8 mm (1 SD). These rectal wall displacements correlated with the rectum volume in the planning CT scan. At the upper anterior side the correlation coefficient between the AP displacements and the planning rectum volume was 0.85.

CONCLUSIONS

We quantified variations in rectum shape and in dose in the rectal wall. The systematic error in rectal wall position was found to be larger than the random shape and position variations. We successfully developed a method to virtually unfold a rectum and to project the dose onto a 2D map. The spatial information of the dose distribution can be used in the analysis of rectum complications.

A cylindrical model of the rectum: comparing dose-volume, dose-surface and dose-wall histograms in the radiotherapy of prostate cancer

The calculation of the percentage cumulative histogram of the rectal wall (DWH) in prostate cancer radiotherapy may be subject to large uncertainties due to the difficulty of assessing the wall thickness on CT images. For this reason often only the external contour is used to define the rectum and then the percentage cumulative dose-volume histogram (DVH) of the rectum including any filling is calculated as a 'surrogate' for the DWH. More recently, other approaches using only the external contour have been proposed to estimate the DWH such as the percentage normalized dose-surface histograms (NDSH). A similar concept can be used when considering the solid rectum (the percentage normalized DVH, NDVH). The purpose of this investigation was to assess the relationships between rectal DVH, NDVH, DSH, NDSH and DWH in the common case of three- and four-field techniques in prostate cancer irradiation. Analytical relationships between the above parameters have been derived for a cylindrical rectum model in the case of three- and four-field techniques. The model is applied to the case of an empty rectum, a full rectum and to the more realistic mixed full/empty rectum situation for a four-field technique delivering 76 Gy (ICRU dose) with 18 MV x-rays. Different positions of the lateral beam with respect to the rectum axis were simulated. In the case of no lumen variation along the z-axis, the DWH is found to be very close to the DVH and to the DSH for empty and full rectum, respectively. The largest differences (up to 15%) between DVH and DSH were seen in the high-dose region (>70 Gy). In the more realistic case of lumen variation along the z-axis, the DWH always lies between NDVH and NDSH and, excluding the full-rectum situation, the DWH differs from the DVH by less than 7% in the 50-75 Gy range. In the case of significant portions of rectum being completely shielded, the DVH may differ from the NDVH/NDSH/DWH by up to 10-15%. In most clinical situations NDVH is within a few per cent of DWH, whilst NDSH may differ from DWH by up to 15-20%, especially in the high-dose region (V70). In conclusion, for most situations, the DVH is highly correlated with NDVH and DWH. A high degree of consistency between NDVH and DWH was found in most clinical cases whilst largest deviations between NDSH and DWH were evident in the high-dose region (70-75 Gy). In the less common case of a very full rectum a poorer correlation between DVH/NDVH and DWH was found whilst NDSH mimicked the DWH very well. In summary, except for the case of a 'very full' rectum, NDVH may be used as a robust surrogate for DWH. The DVH seems to be sufficiently robust if the rectum is prevalently empty.