Addressing challenges in diagnostic X-ray dosimetry: uncertainties and corrections for Al2O3:C-based optically stimulated luminescent dosimeters

The use of Al2O3:C-based optically stimulated luminescent dosimeters (OSLDs) in diagnostic X-ray is a challenge because of their energy dependence (ED) and variability of element sensitivity factors (ESFs). This study aims to develop a method to determine ED and ESFs of Landauer nanoDot™ OSLDs for clinical X-ray and investigate the uncertainties associated with ESF and ED correction factors. An area of 2 × 2 cm2 at the central axis of the X-ray field was used to establish the ESFs. A total of 80 OSLDs were categorized into "controlled" (n = 40) and "less-controlled" groups (n = 40). The ESFs of the OSLDs were determined using an 80 kVp X-ray beam quality in free-air geometry. The OSLDs were cross-calibrated with an ion chamber to establish the average calibration coefficient and ESFs. The OSLDs were then irradiated at tube potentials ranging from 50 to 150 kVp to determine their ED. The uniformity of the X-ray field was ± 1.5% at 100 cm source-to-surface distance. The batch homogeneities of user-defined ESFs were 2.4% and 8.7% for controlled and less-controlled OSLDs, respectively. The ED of OSLDs ranged from 1.125 to 0.812 as tube potential increased from 50 kVp to 150 kVp. The total uncertainty of OSLDs, without ED correction, could be as high as 16%. After applying ESF and ED correction, the total uncertainties were reduced to 6.3% in controlled OLSDs and 11.6% in less-controlled ones. OSLDs corrected with user-defined ESF and ED can reduce the uncertainty of dose measurements in diagnostic X-rays, particularly in managing less-controlled OSLDs.

Radioport: a radiomics-reporting network for interpretable deep learning in BI-RADS classification of mammographic calcification

Objective.Generally, due to a lack of explainability, radiomics based on deep learning has been perceived as a black-box solution for radiologists. Automatic generation of diagnostic reports is a semantic approach to enhance the explanation of deep learning radiomics (DLR).Approach.In this paper, we propose a novel model called radiomics-reporting network (Radioport), which incorporates text attention. This model aims to improve the interpretability of DLR in mammographic calcification diagnosis. Firstly, it employs convolutional neural networks to extract visual features as radiomics for multi-category classification based on breast imaging reporting and data system. Then, it builds a mapping between these visual features and textual features to generate diagnostic reports, incorporating an attention module for improved clarity.Main results.To demonstrate the effectiveness of our proposed model, we conducted experiments on a breast calcification dataset comprising mammograms and diagnostic reports. The results demonstrate that our model can: (i) semantically enhance the interpretability of DLR; and, (ii) improve the readability of generated medical reports.Significance.Our interpretable textual model can explicitly simulate the mammographic calcification diagnosis process.

2D shear wave elastography for the assessment of quadriceps entheses-a methodological study

OBJECTIVE

To establish the scanning protocol for 2-dimensional shear wave elastography (SWE) on normal entheses by investigating the possible confounding factors that may increase the variability of measured elasticity.

MATERIAL AND METHODS

30 normal quadriceps entheses were scanned using SWE to compare the stiffness and coefficient variation by changing the ultrasonic coupling gel thickness, knee position, region of interest size, and scanning plane.

RESULTS

No significant difference in median shear wave velocity (SWV) was observed in different coupling gel thicknesses. The median SWV was higher in the knee flexion position than in the extended position (p < 0.001). Increased knee flexion led to stiffer quadriceps enthesis and higher SWV (ρ = 0.8, p < 0.001). The median SWV was higher when the diameter region of interest was 4.0 mm than 2.0 mm (p = 0.001). The median SWV was higher in the transverse plane than in the longitudinal plane (p < 0.001). Strong correlation was found between SWV and the degree of the shear wave to muscle fiber direction (ρ = 0.8, p < 0.001). The coefficient variation was lower in a gel thickness of 2.5 cm, with an extended knee, a region of interest of 2.0 mm, and a longitudinal plane (p > 0.05). For interobserver reliability for the proposed protocol, the intraclass correlation coefficients was 0.763.

CONCLUSION

In this study, we determined supine position with the knee extended; using 2.0 mm diameter region of interest and image acquisition at the longitudinal plane with thicker layer coupling gel seems most appropriate to reliably image healthy quadriceps entheses with SWE.

Shear wave elastography in chronic kidney disease - the physics and clinical application

Chronic kidney disease is a leading public health problem worldwide. The global prevalence of chronic kidney disease is nearly five hundred million people, with almost one million deaths worldwide. Estimated glomerular filtration rate, imaging such as conventional ultrasound, and histopathological findings are necessary as each technique provides specific information which, when taken together, may help to detect and arrest the development of chronic kidney disease, besides managing its adverse outcomes. However, estimated glomerular filtration rate measurements are hampered by substantial error margins while conventional ultrasound involves subjective assessment. Although histopathological assessment is the best tool for evaluating the severity of the renal pathology, it may lead to renal insufficiency and haemorrhage if complications occurred. Ultrasound shear wave elastography, an emerging imaging that quantifies tissue stiffness non-invasively has gained interest recently. This method applies acoustic force pulses to generate shear wave within the tissue that propagate perpendicular to the main ultrasound beam. By measuring the speed of shear wave propagation, the tissue stiffness is estimated. This paper reviews the literature and presents our combined experience and knowledge in renal shear wave elastography research. It discusses and highlights the confounding factors on shear wave elastography, current and future possibilities in ultrasound renal imaging and is not limited to new sophisticated techniques.

Customised weight-based volume contrast media protocol for multiphase abdominal computed tomography

INTRODUCTION

Multiphase computed tomography (CT) using fixed volume contrast media may lead to high radiation exposure and toxicity in patients with low body weight. We evaluated a customised weight-based protocol for multiphase CT in terms of radiation exposure, image quality and cost savings.

METHODS

A total of 224 patients were recruited. An optimised CT protocol was applied using 100 kV and 1 mL/kg of contrast media dosing. The image quality and radiation dose exposure of this CT protocol were compared to those of a standard 120 kV, 80 mL fixed volume protocol. The radiation dose information and CT Hounsfield units were recorded. The signal-to-noise ratio, contrast-to-noise ratio (CNR) and figure of merit (FOM) were used as comparison metrics. The images were assessed for contrast opacification and visual quality by two radiologists. The renal function, contrast media volume and cost were also evaluated.

RESULTS

The median effective dose was lowered by 16% in the optimised protocol, while the arterial phase images achieved significantly higher CNR and FOM. The radiologists' evaluation showed more than 97% absolute agreement with no significant differences in image quality. No significant differences were found in the pre- and post-CT estimated glomerular filtration rate. However, contrast media usage was significantly reduced by 1,680 mL, with an overall cost savings of USD 421 in the optimised protocol.

CONCLUSION

The optimised weight-based protocol is cost-efficient and lowers radiation dose while maintaining overall contrast enhancement and image quality.

A Radiomics Study: Classification of Breast Lesions by Textural Features from Mammography Images

This study investigates the feasibility of using texture radiomics features extracted from mammography images to distinguish between benign and malignant breast lesions and to classify benign lesions into different categories and determine the best machine learning (ML) model to perform the tasks. Six hundred and twenty-two breast lesions from 200 retrospective patient data were segmented and analysed. Three hundred fifty radiomics features were extracted using the Standardized Environment for Radiomics Analysis (SERA) library, one of the radiomics implementations endorsed by the Image Biomarker Standardisation Initiative (IBSI). The radiomics features and selected patient characteristics were used to train selected machine learning models to classify the breast lesions. A fivefold cross-validation was used to evaluate the performance of the ML models and the top 10 most important features were identified. The random forest (RF) ensemble gave the highest accuracy (89.3%) and positive predictive value (66%) and likelihood ratio of 13.5 in categorising benign and malignant lesions. For the classification of benign lesions, the RF model again gave the highest likelihood ratio of 3.4 compared to the other models. Morphological and textural radiomics features were identified as the top 10 most important features from the random forest models. Patient age was also identified as one of the significant features in the RF model. We concluded that machine learning models trained against texture-based radiomics features and patient features give reasonable performance in differentiating benign versus malignant breast lesions. Our study also demonstrated that the radiomics-based machine learning models were able to emulate the visual assessment of mammography lesions, typically used by radiologists, leading to a better understanding of how the machine learning model arrive at their decision.

Automatic slice thickness measurement on three types of Catphan CT phantoms

OBJECTIVE

To develop an algorithm to measure slice thickness to run on three types of Catphan phantoms with the ability to adapt to any misalignment and rotation of the phantoms.&#xD;Method: Images of Catphan 500, 504, and 604 phantoms were examined. In addition, images with various slice thicknesses ranging from 1.5 to 10.0 mm, distance to the iso-center and phantom rotations were also examined. The automatic slice thickness algorithm was carried out by processing only objects within a circle having a diameter half that of the phantom diameter. A segmentation was performed within an inner circle with dynamic thresholds to produce binary images with wire and bead objects. Region properties were used to distinguish wire ramps and bead objects. At each identified wire ramp, the angle was detected using the Hough transform. Profile lines were then placed on each ramp based on the centroid coordinates and detected angles, and the full-width at half maximum (FWHM) determined for the average pixel profile. The slice thickness was obtained by multiplying the FWHM by the tangent of the ramp angle (23o). &#xD;Results: Automatic measurements work well and have only a small difference (<0.5 mm) from manual measurements. For variations of slice thickness, automatic measurement successfully performs segmentation and correctly locates the profile line on all wire ramps. The results show values that are close (< 3mm) to the nominal thickness on thin slices, but less close for thicker slices. There is a strong correlation (R2 = 0.873) between automatic and manual measurements. Testing the algorithm at various distances from the iso-center and phantom rotation angle also produced accurate results. &#xD;Conclusion: An automated algorithm for measuring slice thickness on three types of Catphan CT phantom images has been developed. The algorithm works well on various thicknesses, distances from the iso-center, and phantom rotations.

Ultrasound shear wave elastography for the evaluation of renal pathological changes in adult patients

OBJECTIVE

Many studies have conflicting findings in using shear wave elastography (SWE) to assess renal fibrosis. This study reviews the use of SWE to evaluate pathological changes in native kidneys and renal allografts. It also tries to elucidate the confounding factors and care taken to ensure the results are consistent and reliable.

METHODS

The review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Literature search was conducted in Pubmed, Web of Science and Scopus database up to 23 October 2021. To evaluate risk and bias applicability, the Cochrane risk-of bias tool and GRADE was used. The review was registered under PROSPERO CRD42021265303.

RESULTS

A total of 2921 articles were identified. 104 full texts were examined and 26 studies included in systematic review. 11 studies performed on native kidneys and 15 studies on transplanted kidney. A wide range of impact factors was found that affect the accuracy of SWE of renal fibrosis in adult patients.

CONCLUSIONS

Compared to point SWE, two-dimensional SWE with elastogram could enable better selection of the region of interest in kidneys, leading to reproducible results. Tracking waves were attenuated as the depth from skin to region of interest increased, therefore, SWE is not recommended for overweight or obese patients. Variable transducer forces might also affect SWE reproducibility, thus, training of operators to ensure consistent operator-dependent transducer forces may be helpful.

ADVANCES IN KNOWLEDGE

This review provides a holistic insight on the efficiency of using SWE in evaluating pathological changes in native and transplanted kidneys, thereby contributing to the knowledge of its utilisation in clinical practice.

Preliminary study of longitudinal changes in the pituitary and brain of children on growth hormone therapy

BACKGROUND

In subjects with isolated growth hormone deficiency (IGHD), recombinant human growth hormone (rhGH) is an approved method to achieve potential mid-parental height. However, data reporting rhGH treatment response in terms of brain structure volumes were scarce. We report the volumetric changes of the pituitary gland, basal ganglia, corpus callosum, thalamus, hippocampus and amygdala in these subjects post rhGH treatment.

MATERIALS AND METHODS

This was a longitudinal study of eight IGHD subjects (2 males, 6 females) with a mean age of 11.1 ± 0.8 years and age-matched control groups. The pituitary gland, basal ganglia and limbic structures volumes were obtained using 3T MRI voxel-based morphology. The left-hand bone age was assessed using the Tanner-Whitehouse method. Follow-up imaging was performed after an average of 1.8 ± 0.4 years on rhGH.

RESULTS

Subjects with IGHD had a smaller mean volume of the pituitary gland, right thalamus, hippocampus, and amygdala than the controls. After rhGH therapy, these volumes normalized to the age-matched controls. Corpus callosum of IGHD subjects had a larger mean volume than the controls and did not show much volume changes in response to rhGH therapy. There were changes towards normalization of bone age deficit of IGHD in response to rhGH therapy.

CONCLUSION

The pituitary gland, hippocampus, and amygdala volumes in IGHD subjects were smaller than age-matched controls and showed the most response to rhGH therapy. Semi-automated volumetric assessment of pituitary gland, hippocampus, and amygdala using MRI may provide an objective assessment of response to rhGH therapy.

Lipid Alterations in Glioma: A Systematic Review

Gliomas are highly lethal tumours characterised by heterogeneous molecular features, producing various metabolic phenotypes leading to therapeutic resistance. Lipid metabolism reprogramming is predominant and has contributed to the metabolic plasticity in glioma. This systematic review aims to discover lipids alteration and their biological roles in glioma and the identification of potential lipids biomarker. This systematic review was conducted using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Extensive research articles search for the last 10 years, from 2011 to 2021, were conducted using four electronic databases, including PubMed, Web of Science, CINAHL and ScienceDirect. A total of 158 research articles were included in this study. All studies reported significant lipid alteration between glioma and control groups, impacting glioma cell growth, proliferation, drug resistance, patients' survival and metastasis. Different lipids demonstrated different biological roles, either beneficial or detrimental effects on glioma. Notably, prostaglandin (PGE2), triacylglycerol (TG), phosphatidylcholine (PC), and sphingosine-1-phosphate play significant roles in glioma development. Conversely, the most prominent anti-carcinogenic lipids include docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), and vitamin D3 have been reported to have detrimental effects on glioma cells. Furthermore, high lipid signals were detected at 0.9 and 1.3 ppm in high-grade glioma relative to low-grade glioma. This evidence shows that lipid metabolisms were significantly dysregulated in glioma. Concurrent with this knowledge, the discovery of specific lipid classes altered in glioma will accelerate the development of potential lipid biomarkers and enhance future glioma therapeutics.

Magnetic Resonance Imaging Phenotypes of Breast Cancer Molecular Subtypes: A Systematic Review

OBJECTIVE

Magnetic resonance imaging (MRI) is the most sensitive imaging modality in detecting breast cancer. The purpose of this systematic review is to investigate the role of human extracted MRI phenotypes in classifying molecular subtypes of breast cancer.

METHODS

We performed a literature search of published articles on the application of MRI phenotypic features in invasive breast cancer molecular subtype classifications by radiologists' interpretation on Medline Complete, Pubmed, and Google scholar from 1st January 2000 to 31st March 2021. Of the 1453 literature identified, 42 fulfilled the inclusion criteria.

RESULTS

All studies were case-controlled, retrospective study and research-based. The majority of the studies assessed the MRI features using American College of Radiology- Breast Imaging Reporting and Data System (ACR-BIRADS) classification and using dynamic contrast-enhanced (DCE) kinetic features, Apparent Diffusion Coefficient (ADC) values, and T2 sequence. Most studies divided invasive breast cancer into 4 main subtypes, luminal A, luminal B, HER2, and triple-negative (TN) cancers, and used 2 readers. We present a summary of the radiologists' extracted breast MRI phenotypical features and their correlating breast cancer subtypes classifications. The characteristic features are morphology, enhancement kinetics, and T2 signal intensity. We found that the TN subtype has the most distinctive MRI features compared to the other subtypes and luminal A and B have many similar features.

CONCLUSION

The MRI features which are predictive of each subtype are the morphology, internal enhancement features, and T2 signal intensity, predominantly between TN and the rest. Radiologists' visual interpretation of some of MRI features may offer insight into the respective invasive breast cancer molecular subtype. However, current evidence are still limited to "suggestive" features instead of a diagnostic standard.  Further research is recommended to explore this potential application, for example, by augmentation of radiologists' visual interpretation by artificial intelligence.

Neural Fiber Integrity in High- Versus Low-Grade Glioma using Probabilistic Fiber Tracking

RATIONALE AND OBJECTIVES

Gliomatous tumors are known to affect neural fiber integrity, either by displacement or destruction. The aim of this study is to investigate the integrity and distribution of the white matter tracts within and around the glioma regions using probabilistic fiber tracking.

MATERIAL AND METHODS

Forty-two glioma patients were subjected to MRI using a standard tumor protocol with diffusion tensor imaging (DTI). The tumor and peritumor regions were delineated using snake model with reference to structural and diffusion MRI. A preprocessing pipeline of the structural MRI image, DTI data, and tumor regions was implemented. Tractography was performed to delineate the white matter (WM) tracts in the selected tumor regions via probabilistic fiber tracking. DTI indices were investigated through comparative mapping of WM tracts and tumor regions in low-grade gliomas (LGG) and high-grade gliomas (HGG).

RESULTS

Significant differences were seen in the planar tensor (C_p) in peritumor regions; mean diffusivity, axial diffusivity and pure isotropic diffusion in solid-enhancing tumor regions; and fractional anisotropy, axial diffusivity, pure anisotropic diffusion (q), total magnitude of diffusion tensor (L), relative anisotropy, C_p and spherical tensor (C_s) in solid nonenhancing tumor regions for affected WM tracts. In most cases of HGG, the WM tracts were not completely destroyed, but found intact inside the tumor.

DISCUSSION

Probabilistic fiber tracking revealed the existence and distribution of WM tracts inside tumor core for both LGG and HGG groups. There were more DTI indices in the solid nonenhancing tumor region, which showed significant differences between LGG and HGG.

Evaluation of skin dose and skin toxicity in patients undergoing intraoperative radiotherapy for early breast cancer

PURPOSE

This study aims to evaluate in vivo skin dose delivered by intraoperative radiotherapy (IORT) and determine the factors associated with an increased risk of radiation-induced skin toxicity.

METHODOLOGY

A total of 21 breast cancer patients who underwent breast-conserving surgery and IORT, either as IORT alone or IORT boost plus external beam radiotherapy (EBRT), were recruited in this prospective study. EBT3 film was calibrated in water and used to measure skin dose during IORT at concentric circles of 5 mm and 40 mm away from the applicator. For patients who also had EBRT, the maximum skin dose was estimated using the radiotherapy treatment planning system. Mid-term skin toxicities were evaluated at 3 and 6 months post-IORT.

RESULTS

The average skin dose at 5 mm and 40 mm away from the applicator was 3.07 ± 0.82 Gy and 0.99 ± 0.28 Gy, respectively. Patients treated with IORT boost plus EBRT received an additional skin dose of 41.07 ± 1.57 Gy from the EBRT component. At 3 months post-IORT, 86% of patients showed no evidence of skin toxicity. However, the number of patients suffering from skin toxicity increased from 15% to 38% at 6 months post-IORT. We found no association between the IORT alone or with the IORT boost plus EBRT and skin toxicity. Older age was associated with increased risk of skin toxicities. A mathematical model was derived to predict skin dose.

CONCLUSION

EBT3 film is a suitable dosimeter for in vivo skin dosimetry in IORT, providing patient-specific skin doses. Both IORT alone and IORT boost techniques resulted in similar skin toxicity rates.

The perceptions of medical physicists towards relevance and impact of artificial intelligence

Artificial intelligence (AI) is an innovative tool with the potential to impact medical physicists' clinical practices, research, and the profession. The relevance of AI and its impact on the clinical practice and routine of professionals in medical physics were evaluated by medical physicists and researchers in this field. An online survey questionnaire was designed for distribution to professionals and students in medical physics around the world. In addition to demographics questions, we surveyed opinions on the role of AI in medical physicists' practices, the possibility of AI threatening/disrupting the medical physicists' practices and career, the need for medical physicists to acquire knowledge on AI, and the need for teaching AI in postgraduate medical physics programmes. The level of knowledge of medical physicists on AI was also consulted. A total of 1019 respondents from 94 countries participated. More than 85% of the respondents agreed that AI would play an essential role in medical physicists' practices. AI should be taught in the postgraduate medical physics programmes, and that more applications such as quality control (QC), treatment planning would be performed by AI. Half of the respondents thought AI would not threaten/disrupt the medical physicists' practices. AI knowledge was mainly acquired through self-taught and work-related activities. Nonetheless, many (40%) reported that they have no skill in AI. The general perception of medical physicists was that AI is here to stay, influencing our practices. Medical physicists should be prepared with education and training for this new reality.

Semi-supervised GAN-based Radiomics Model for Data Augmentation in Breast Ultrasound Mass Classification

BACKGROUND AND OBJECTIVE

The capability of deep learning radiomics (DLR) to extract high-level medical imaging features has promoted the use of computer-aided diagnosis of breast mass detected on ultrasound. Recently, generative adversarial network (GAN) has aided in tackling a general issue in DLR, i.e., obtaining a sufficient number of medical images. However, GAN methods require a pair of input and labeled images, which require an exhaustive human annotation process that is very time-consuming. The aim of this paper is to develop a radiomics model based on a semi-supervised GAN method to perform data augmentation in breast ultrasound images.

METHODS

A total of 1447 ultrasound images, including 767 benign masses and 680 malignant masses were acquired from a tertiary hospital. A semi-supervised GAN model was developed to augment the breast ultrasound images. The synthesized images were subsequently used to classify breast masses using a convolutional neural network (CNN). The model was validated using a 5-fold cross-validation method.

RESULTS

The proposed GAN architecture generated high-quality breast ultrasound images, verified by two experienced radiologists. The improved performance of semi-supervised learning increased the quality of the synthetic data produced in comparison to the baseline method. We achieved more accurate breast mass classification results (accuracy 90.41%, sensitivity 87.94%, specificity 85.86%) with our synthetic data augmentation compared to other state-of-the-art methods.

CONCLUSION

The proposed radiomics model has demonstrated a promising potential to synthesize and classify breast masses on ultrasound in a semi-supervised manner.

Monte Carlo-based patient internal dosimetry in fluoroscopy-guided interventional procedures: A review

PURPOSE

This systematic review aims to understand the dose estimation approaches and their major challenges. Specifically, we focused on state-of-the-art Monte Carlo (MC) methods in fluoroscopy-guided interventional procedures.

METHODS

All relevant studies were identified through keyword searches in electronic databases from inception until September 2020. The searched publications were reviewed, categorised and analysed based on their respective methodology.

RESULTS

Hundred and one publications were identified which utilised existing MC-based applications/programs or customised MC simulations. Two outstanding challenges were identified that contribute to uncertainties in the virtual simulation reconstruction. The first challenge involves the use of anatomical models to represent individuals. Currently, phantom libraries best balance the needs of clinical practicality with those of specificity. However, mismatches of anatomical variations including body size and organ shape can create significant discrepancies in dose estimations. The second challenge is that the exact positioning of the patient relative to the beam is generally unknown. Most dose prediction models assume the patient is located centrally on the examination couch, which can lead to significant errors.

CONCLUSION

The continuing rise of computing power suggests a near future where MC methods become practical for routine clinical dosimetry. Dynamic, deformable phantoms help to improve patient specificity, but at present are only limited to adjustment of gross body volume. Dynamic internal organ displacement or reshaping is likely the next logical frontier. Image-based alignment is probably the most promising solution to enable this, but it must be automated to be clinically practical.

Customised weight-based volume contrast media protocol in CT of chest, abdomen and pelvis examination

INTRODUCTION

Fixed volume (FV) contrast media administration during CT examination is the standard practice in most healthcare institutions. We aim to validate a customised weight-based volume (WBV) method and compare it to the conventional FV methods, introduced in a regional setting.

METHODS

220 patients underwent CT of the chest, abdomen and pelvis (CAP) using a standard FV protocol, and subsequently, a customised 1.0 mL/kg WBV protocol within one year. Both image sets were assessed for contrast enhancement using CT attenuation at selected regions-of-interest (ROIs). The visual image quality was evaluated by three radiologists using a 4-point Likert scale. Quantitative CT attenuation was correlated with the visual quality assessment to determine the HU's enhancement indicative of the image quality grades. Contrast media usage was calculated to estimate cost-savings from both protocols.

RESULTS

Mean patient age was 61 ± 14 years, and weight was 56.1 ± 8.7 kg. FV protocol produced higher contrast enhancement than WBV, p < 0.001. CT images' overall contrast enhancement was negatively correlated with body weight for FV protocol while the WBV protocol produced more consistent enhancement across different body weight. More than 90% of the images from both protocols were graded "Excellent". WBV protocol also enabled a 28% cost reduction with cost savings of US$1238.

CONCLUSION

The customised WBV protocol produced CT images which were comparable to FV protocol for CT CAP examinations. A median CT value of 100 HU can be an indicator of good image quality for the WBV protocol.

Shear wave elastography accurately detects chronic changes in renal histopathology

AIM

Renal biopsy is the gold standard for the histological characterization of chronic kidney disease (CKD), of which renal fibrosis is a dominant component, affecting its stiffness. The aim of this study was to investigate the correlation between kidney stiffness obtained by shear wave elastography (SWE) and renal histological fibrosis.

METHODS

Shear wave elastography assessments were performed in 75 CKD patients who underwent renal biopsy. The SWE-derived estimates of the tissue Young's modulus (YM), given as kilopascals (kPa), were measured. YM was correlated to patients' renal histological scores, broadly categorized into glomerular, tubulointerstitial and vascular scores.

RESULTS

Young's modulus correlates significantly with tubulointerstitial score (ρ = 0.442, P < .001) and glomerular score (ρ = 0.375, P = .001). Patients with no glomerular sclerosis showed lower mean YM measurements compared to those with glomerular sclerosis. The mean YM increased as the percentage of interstitial fibrosis and tubular atrophy increased. The area under the receiver operating characteristic curve (ROC) for SWE in differentiating between mildly and moderately impaired kidneys was 0.702.

CONCLUSION

Shear wave elastography accurately detects chronic renal damage resulting from glomerular sclerosis, interstitial fibrosis and tubular atrophy, using the optimal cut-off YM value of ≥5.81 kPa.

Teaching and learning of postgraduate medical physics using Internet-based e-learning during the COVID-19 pandemic - A case study from Malaysia

PURPOSE

We present the implementation of e-learning in the Master of Medical Physics programme at the University of Malaya during a partial lockdown from March to June 2020 due to the COVID-19 pandemic.

METHODS

Teaching and Learning (T&L) activities were conducted virtually on e-learning platforms. The students' experience and feedback were evaluated after 15 weeks.

RESULTS

We found that while students preferred face-to-face, physical teaching, they were able to adapt to the new norm of e-learning. More than 60% of the students agreed that pre-recorded lectures and viewing videos of practical sessions, plus answering short questions, were beneficial. Certain aspects, such as hands-on practical and clinical experience, could never be replaced. The e-learning and study-from-home environment accorded a lot of flexibility. However, students also found it challenging to focus because of distractions, lack of engagement and mental stress. Technical problems, such as poor Internet connectivity and limited data plans, also compounded the problem.

CONCLUSION

We expect e-learning to prevail in future. Hybrid learning strategies, which includes face-to-face classes and e-learning, will become common, at least in the medical physics programme of the University of Malaya even after the pandemic.

Diagnostic Reference Level of Radiation Dose and Image Quality among Paediatric CT Examinations in A Tertiary Hospital in Malaysia

Pediatrics are more vulnerable to radiation and are prone to dose compared to adults, requiring more attention to computed tomography (CT) optimization. Hence, diagnostic reference levels (DRLs) have been implemented as part of optimization process in order to monitor CT dose and diagnostic quality. The noise index has recently been endorsed to be included as a part of CT optimization in the DRLs report. In this study, we have therefore set local DRLs for pediatric CT examination with a noise index as an indicator of image quality. One thousand one hundred and ninety-two (1192) paediatric patients undergoing CT brain, CT thorax and CT chest-abdomen-pelvis (CAP) examinations were analyzed retrospectively and categorized into four age groups; group 1 (0-1 year), group 2 (1-5 years), group 3 (5-10 years) and group 4 (10-15 years). For each group, data such as the volume-weighted CT dose index (CTDIvol), dose-length product (DLP) and the effective dose (E) were calculated and DRLs for each age group set at 50th percentile were determined. Both CT dose and image noise values between age groups have differed significantly with p-value < 0.05. The highest CTDIvol and DLP values in all age groups with the lowest noise index value reported in the 10-15 age group were found in CT brain examination. In conclusion, there was a significant variation in doses and noise intensity among children of different ages, and the need to change specific parameters to fit the clinical requirement.

The clinical utility of fluoroscopic versus CT guided percutaneous transpedicular core needle biopsy for spinal infections and tumours: a randomized trial

BACKGROUND CONTEXT

Biopsy is important to obtain microbiological and histopathological diagnosis in spine infections and tumors. To date, there have been no prospective randomized trials comparing fluoroscopic guided and computed tomography (CT) transpedicular biopsy techniques. The goal of this study was to evaluate the accuracy, safety, and diagnostic outcome of these two diagnostic techniques.

PURPOSE

To evaluate the accuracy, safety, and diagnostic outcome of fluoroscopic guided and CT transpedicular biopsy techniques.

STUDY DESIGN

Prospective randomized trial.

PATIENT SAMPLE

Sixty consecutive patients with clinical symptoms and radiological features suggestive of spinal infection or malignancy were recruited and randomized into fluoroscopic or CT guided spinal biopsy groups. Both groups were similar in terms of patient demographics, distribution of spinal infections and malignancy cases, and the level of biopsies.

OUTCOME MEASURES

The primary outcome measure was diagnostic accuracy of both methods, determined based on true positive, true negative, false positive, and false negative biopsy findings. Secondary outcome measures included radiation exposure to patients and doctors, complications, and postbiopsy pain score.

METHODS

A transpedicular approach was performed with an 8G core biopsy needle. Specimens were sent for histopathological and microbiological examinations. Diagnosis was made based on biopsy results, clinical criteria and monitoring of disease progression during a 6-month follow up duration. Clinical criteria included presence of risk factors, level of inflammatory markers and magnetic resonance imaging findings. Radiation exposure to patients and doctors was measured with dosimeters.

RESULTS

There was no significant difference between the diagnostic accuracy of fluoroscopic and CT guided spinal biopsy (p=0.67) or between the diagnostic accuracy of spinal infection and spinal tumor in both groups (p=0.402 for fluoroscopy group and p=0.223 for CT group). Radiation exposure to patients was approximately 26 times higher in the CT group. Radiation exposure to doctors in the CT group was approximately 2 times higher compared to the fluoroscopic group if a lead shield was not used. Lead shields significantly reduced radiation exposure to doctors anywhere from 2 to 8 times. No complications were observed for either group and the differences in postbiopsy pain scores were not significant.

CONCLUSIONS

The accuracy, procedure time, complication rate and pain score for both groups were similar. However, radiation exposure to patients and doctors were significantly higher in the CT group without lead protection. With lead protection, radiation to doctors reduced significantly.

Lipid Fraction Derived From MRI In- and Opposed-Phase Sequence as a Novel Biomarker for Predicting Survival Outcome of Glioma

RATIONALE AND PURPOSE

Our study evaluated the capability of magnetic resonance imaging in- and opposed-phase (IOP) derived lipid fraction as a novel prognostic biomarker of survival outcome in glioma.

MATERIALS AND METHODS

We analyzed 46 histologically proven glioma (WHO grades II-IV) patients using standard 3T magnetic resonance imaging brain tumor protocol and IOP sequence. Lipid fraction was derived from the IOP sequence signal-loss ratio. The lipid fraction of solid nonenhancing region of glioma was analyzed, using a three-group analysis approach based on volume under surface of receiver-operating characteristics to stratify the prognostic factors into three groups of low, medium, and high lipid fraction. The survival outcome was evaluated, using Kaplan-Meier survival analysis and Cox regression model.

RESULTS

Significant differences were seen between the three groups (low, medium, and high lipid fraction groups) stratified by the optimal cut-off point for overall survival (OS) (p ≤ 0.01) and time to progression (p ≤ 0.01) for solid nonenhancing region. The group with high lipid fraction had five times higher risk of poor survival and earlier time to progression compared to the low lipid fraction group. The OS plot stratified by lipid fraction also had a strong correlation with OS plot stratified by WHO grade (R = 0.61, p < 0.01), implying association to underlying histopathological changes.

CONCLUSION

The lipid fraction of solid nonenhancing region showed potential for prognostication of glioma. This method will be a useful adjunct in imaging protocol for treatment stratification and as a prognostic tool in glioma patients.

Stiffness and Anisotropy Effect on Shear Wave Elastography: A Phantom and in Vivo Renal Study

Tissue elasticity is related to the pathologic state of kidneys and can be measured using shear wave elastography (SWE). However, SWE quantification has not been rigorously validated. The aim of this study was to evaluate the accuracy of SWE-measured stiffness and the effect of tissue anisotropy on SWE measurements. Point SWE (pSWE), 2-D SWE and dynamic mechanical analysis (DMA) were used to measure stiffness and evaluate the effect of tissue anisotropy on the measurements. SWE and DMA were performed on phantoms of different gelatin concentrations. In the tissue anisotropy study, SWE and DMA were performed on the outer cortex of sheep kidneys. In the in vivo study, 15 patients with different levels of interstitial fibrosis were recruited for pSWE measurements. Another 10 healthy volunteers were recruited for tissue anisotropy studies. SWE imaging revealed a non-linear increase with gelatin concentration. There was a significant correlation between pSWE and 2-D SWE, leading to the establishment of a linear regression equation between the two SWE ultrasound measurements. In the anisotropy study, the median difference in stiffness between shear waves oriented at 0° and 90° towards the pyramid axis was significant. In the in vivo study, there was a strong positive linear correlation between pSWE and the percentage of interstitial fibrosis. There was a significant difference in the Young's modulus (YM) between severities of fibrosis. The mean YM values were lower in control patients than in patients with mild, moderate and severe fibrosis. YM values were also significantly higher when shear waves were oriented at 0° toward the pyramid axis. Tissue stiffness and anisotropy affects SWE measurements. These factors should be recognized before applying SWE for the interpretation of measured values.

CHARACTERISATION AND EVALUATION OF AL2O3:C-BASED OPTICALLY STIMULATED LUMINESCENT DOSEMETER SYSTEM FOR DIAGNOSTIC X-RAYS: PERSONAL AND IN VIVO DOSIMETRY

This study characterises and evaluates an Al2O3:C-based optically stimulated luminescent dosemeter (OSLD) system, commercially known as the nanoDot™ dosemeter and the InLight® microStar reader, for personal and in vivo dose measurements in diagnostic radiology. The system characteristics, such as dose linearity, reader accuracy, reproducibility, batch homogeneity, energy dependence and signal stability, were explored. The suitability of the nanoDot™ dosemeters was evaluated by measuring the depth dose curve, in vivo dose measurement and image perturbation. The nanoDot™ dosemeters were observed to produce a linear dose with ±2.8% coefficient variation. Significant batch inhomogeneity (8.3%) was observed. A slight energy dependence (±6.1%) was observed between 60 and 140 kVp. The InLight® microStar reader demonstrated good accuracy and a reproducibility of ±2%. The depth dose curve measured using nanoDot™ dosemeters showed slightly lower responses than Monte Carlo simulation results. The total uncertainty for a single dose measurement using this system was 11%, but it could be reduced to 9.2% when energy dependence correction was applied.

Survey of postgraduate medical physics programmes in the Asia-Oceania region

The increased use of medical imaging and radiation therapies has resulted in a high demand for medical physicists. Although medical physics programmes are well established in advanced countries, the same cannot be said for many low- and medium-income countries. In some countries, there may be huge variations in the graduates' skill and quality, which pose a problem in ensuring patient safety, providing quality assurance in treatments, optimisation of protocols and standardisation of quality. It also makes any yet-to-be-established regional peer recognition efforts problematic. In order to understand the depth of this problem, a survey was carried out as part of the home-based assignment under the RAS 6088 IAEA programme. A large diversity in terms of course content, duration, clinical training and student profile could be observed across the Asia-Oceania universities surveyed. Out of 25 programmes, only six received recognition from professional bodies, and they were mostly in Australia and New Zealand. Hence, to ensure quality education, a regional curriculum model needs to be developed to harmonise standards. And there is still a long way to go towards standardizing medical physics education and clinical training in the region.

Comparison of Shear Wave Elastography and Conventional Ultrasound in Assessing Kidney Function as Measured Using 51Cr-ethylenediaminetetraacetic Acid and 99Tc-Dimercaptosuccinic Acid

The purpose of this study was to assess the potential of shear wave elastography (SWE) as an indicator of abnormal kidney function defined by radiolabeled glomerular filtration rate (GFR). Fifty-seven patients referred for ⁵¹Cr-ethylenediaminetetraacetic acid GFR and ^99mTc-dimercaptosuccinic acid renal scintigraphy were included. Young's modulus (YM) measured with SWE and kidney length, volume, cortical thickness and parenchymal echogenicity measured with conventional ultrasound were correlated with patients' GFR and renal scintigraphy results. Spearman correlation coefficients between SWE and GFR were negative for the right (r = -0.635, p < 0.0001) and left (r = -0.817, p < 0.0001) kidneys. Positive correlations between left renal cortical thickness (r = 0.381, p = 0.04) and left kidney volume (r = 0.356, p = 0.019) with GFR were reported. SWE correctly predicted the dominant functioning kidney in 94.7% of cases. The area under the receiver operating characteristic curve for SWE (0.800) was superior to that for conventional ultrasound (0.252-0.415). The cutoff value of ≥5.52 kPa suggested a kidney function ≤60 mL/min/1.73 m² (82.4% sensitivity and 76.2% specificity). SWE has advantages over conventional ultrasound in assessing kidney function and distinguishing the dominant functioning kidney.

Quantitative magnetic resonance imaging and radiogenomic biomarkers for glioma characterisation: a systematic review

OBJECTIVE:

The diversity of tumour characteristics among glioma patients, even within same tumour grade, is a big challenge for disease outcome prediction. A possible approach for improved radiological imaging could come from combining information obtained at the molecular level. This review assembles recent evidence highlighting the value of using radiogenomic biomarkers to infer the underlying biology of gliomas and its correlation with imaging features.

METHODS:

A literature search was done for articles published between 2002 and 2017 on Medline electronic databases. Of 249 titles identified, 38 fulfilled the inclusion criteria, with 14 articles related to quantifiable imaging parameters (heterogeneity, vascularity, diffusion, cell density, infiltrations, perfusion, and metabolite changes) and 24 articles relevant to molecular biomarkers linked to imaging.

RESULTS:

Genes found to correlate with various imaging phenotypes were EGFR, MGMT, IDH1, VEGF, PDGF, TP53, and Ki-67. EGFR is the most studied gene related to imaging characteristics in the studies reviewed (41.7%), followed by MGMT (20.8%) and IDH1 (16.7%). A summary of the relationship amongst glioma morphology, gene expressions, imaging characteristics, prognosis and therapeutic response are presented.

CONCLUSION:

The use of radiogenomics can provide insights to understanding tumour biology and the underlying molecular pathways. Certain MRI characteristics that show strong correlations with EGFR, MGMT and IDH1 could be used as imaging biomarkers. Knowing the pathways involved in tumour progression and their associated imaging patterns may assist in diagnosis, prognosis and treatment management, while facilitating personalised medicine.

ADVANCES IN KNOWLEDGE:

Radiogenomics can offer clinicians better insight into diagnosis, prognosis, and prediction of therapeutic responses of glioma.

Neurometabolites Alteration in the Acute Phase of Mild Traumatic Brain Injury (mTBI): An In Vivo Proton Magnetic Resonance Spectroscopy (1H-MRS) Study

RATIONALE AND OBJECTIVES

Magnetic resonance spectroscopy is a noninvasive imaging technique that allows for reliable assessment of microscopic changes in brain cytoarchitecture, neuronal injuries, and neurochemical changes resultant from traumatic insults. We aimed to evaluate the acute alteration of neurometabolites in complicated and uncomplicated mild traumatic brain injury (mTBI) patients in comparison to control subjects using proton magnetic resonance spectroscopy (1H magnetic resonance spectroscopy).

MATERIAL AND METHODS

Forty-eight subjects (23 complicated mTBI [cmTBI] patients, 12 uncomplicated mTBI [umTBI] patients, and 13 controls) underwent magnetic resonance imaging scan with additional single voxel spectroscopy sequence. Magnetic resonance imaging scans for patients were done at an average of 10 hours (standard deviation 4.26) post injury. The single voxel spectroscopy adjacent to side of injury and noninjury regions were analysed to obtain absolute concentrations and ratio relative to creatine of the neurometabolites. One-way analysis of variance was performed to compare neurometabolite concentrations of the three groups, and a correlation study was done between the neurometabolite concentration and Glasgow Coma Scale.

RESULTS

Significant difference was found in ratio of N-acetylaspartate to creatine (NAA/Cr + PCr) (χ²(2) = 0.22, P < .05) between the groups. The sum of NAA and N-acetylaspartylglutamate (NAAG) also shows significant differences in both the absolute concentration (NAA + NAAG) and ratio to creatine (NAA + NAAG/Cr + PCr) between groups (χ²(2) = 4.03, P < .05and (χ²(2) = 0.79, P < .05)). NAA values were lower in cmTBI and umTBI compared to control group. A moderate weak positive correlation were found between Glasgow Coma Scale with NAA/Cr + PCr (ρ = 0.36, P < .05 and NAA + NAAG/Cr + PCr (ρ = 0.45, P < .05)), whereas a moderate correlation was seen with NAA + NAAG (ρ = 0.38, P < .05).

CONCLUSION

Neurometabolite alterations were already apparent at onset of both complicated and uncomplicated traumatic brain injury. The ratio of NAA and NAAG has potential to serve as a biomarker reflecting injury severity in a quantifiable manner as it discriminates between the complicated and uncomplicated cases of mTBI.

Quantification and visualization of lipid landscape in glioma using in -and opposed-phase imaging

Objectives

This study maps the lipid distributions based on magnetic resonance imaging (MRI) in-and opposed-phase (IOP) sequence and correlates the findings generated from lipid map to histological grading of glioma.

Methods

Forty histologically proven glioma patients underwent a standard MRI tumour protocol with the addition of IOP sequence. The regions of tumour (solid enhancing, solid non-enhancing, and cystic regions) were delineated using snake model (ITK-SNAP) with reference to structural and diffusion MRI images. The lipid distribution map was constructed based on signal loss ratio (SLR) obtained from the IOP imaging. The mean SLR values of the regions were computed and compared across the different glioma grades.

Results

The solid enhancing region of glioma had the highest SLR for both Grade II and III. The mean SLR of solid non-enhancing region of tumour demonstrated statistically significant difference between the WHO grades (grades II, III & IV) (mean SLR_II = 0.04, mean SLR_III = 0.06, mean SLR_IV = 0.08, & p < .01). A strong positive correlation was seen between WHO grades with mean SLR on lipid map of solid non-enhancing (ρ=0.68, p < .01).

Conclusion

Lipid quantification via lipid map provides useful information on lipid landscape in tumour heterogeneity characterisation of glioma. This technique adds to the surgical diagnostic yield by identifying biopsy targets. It can also be used as an adjunct grading tool for glioma as well as to provide information about lipidomics landscape in glioma development.

•

In- and opposed-phase imaging is useful in gliomas characterisation and grading.

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Signal loss ratio in the solid non-enhancing region is a potential imaging marker for discriminating between the WHO grades.

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Lipid quantification via lipid distribution mapping provides useful information on lipid landscape in tumour heterogeneity.

Shear wave elastography in the evaluation of renal parenchymal stiffness in patients with chronic kidney disease

OBJECTIVE

To investigate the use of shear wave elastography (SWE)-derived estimates of Young's modulus (YM) as an indicator to detect abnormal renal tissue diagnosed by estimated glomerular filtration rate (eGFR).

METHODS

The study comprised 106 chronic kidney disease (CKD) patients and 203 control subjects. Conventional ultrasound was performed to measure the kidney length and cortical thickness. SWE imaging was performed to measure renal parenchymal stiffness. Diagnostic performance of SWE and conventional ultrasound were correlated with serum creatinine, urea levels and eGFR.

RESULTS

Pearson's correlation coefficient revealed a negative correlation between YM measurements and eGFR (r = -0.576, p < 0.0001). Positive correlations between YM measurements and age (r = 0.321, p < 0.05), serum creatinine (r = 0.375, p < 0.0001) and urea (r = 0.287, p < 0.0001) were also observed. The area under the receiver operating characteristic curve for SWE (0.87) was superior to conventional ultrasound alone (0.35-0.37). The cut-off value of less or equal to 4.31 kPa suggested a non-diseased kidney (80.3% sensitivity, 79.5% specificity).

CONCLUSION

SWE was superior to renal length and cortical thickness in detecting CKD. A value of 4.31 kPa or less showed good accuracy in determining whether a kidney was diseased or not. Advances in knowledge: On SWE, CKD patients show greater renal parenchymal stiffness than non-CKD patients. Determining a cut-off value between normal and diseased renal parenchyma may help in early non-invasive detection and management of CKD.

Dosimetric characterisation of the optically-stimulated luminescence dosimeter in cobalt-60 high dose rate brachytherapy system

This study investigates the characteristics and application of the optically-stimulated luminescence dosimeter (OSLD) in cobalt-60 high dose rate (HDR) brachytherapy, and compares the results with the dosage produced by the treatment planning system (TPS). The OSLD characteristics comprised linearity, reproducibility, angular dependence, depth dependence, signal depletion, bleaching rate and cumulative dose measurement. A phantom verification exercise was also conducted using the Farmer ionisation chamber and in vivo diodes. The OSLD signal indicated a supralinear response (R² = 0.9998). It exhibited a depth-independent trend after a steep dose gradient region. The signal depletion per readout was negligible (0.02%), with expected deviation for angular dependence due to off-axis sensitive volume, ranging from 1 to 16%. The residual signal of the OSLDs after 1 day bleached was within 1.5%. The accumulated and bleached OSLD signals had a standard deviation of ± 0.78 and ± 0.18 Gy, respectively. The TPS was found to underestimate the measured doses with deviations of 5% in OSLD, 17% in the Farmer ionisation chamber, and 7 and 8% for bladder and rectal diode probes. Discrepancies can be due to the positional uncertainty in the high-dose gradient. This demonstrates a slight displacement of the organ at risk near the steep dose gradient region will result in a large dose uncertainty. This justifies the importance of in vivo measurements in cobalt-60 HDR brachytherapy.

Evaluation of Imaging Dose From Different Image Guided Systems During Head and Neck Radiotherapy: A Phantom Study

This work evaluated and compared the absorbed doses to selected organs in the head and neck region from the three image guided radiotherapy systems: cone-beam computed tomography (CBCT) and kilovoltage (kV) planar imaging using the On-board Imager® (OBI) as well as the ExacTrac® X-ray system, all available on the Varian Novalis TX linear accelerator. The head and neck region of an anthropomorphic phantom was used to simulate patients' head within the imaging field. Nanodots optically stimulated luminescent dosemeters were positioned at selected sites to measure the absorbed doses. CBCT was found to be delivering the highest dose to internal organs while OBI-2D gave the highest doses to the eye lenses. The setting of half-rotation in CBCT effectively reduces the dose to the eye lenses. Daily high-quality CBCT verification was found to increase the secondary cancer risk by 0.79%.

Characterization of a MOSkin detector for in vivo skin dose measurements during interventional radiology procedures

PURPOSE

The MOSkin is a MOSFET detector designed especially for skin dose measurements. This detector has been characterized for various factors affecting its response for megavoltage photon beams and has been used for patient dose measurements during radiotherapy procedures. However, the characteristics of this detector in kilovoltage photon beams and low dose ranges have not been studied. The purpose of this study was to characterize the MOSkin detector to determine its suitability for in vivo entrance skin dose measurements during interventional radiology procedures.

METHODS

The calibration and reproducibility of the MOSkin detector and its dependency on different radiation beam qualities were carried out using RQR standard radiation qualities in free-in-air geometry. Studies of the other characterization parameters, such as the dose linearity and dependency on exposure angle, field size, frame rate, depth-dose, and source-to-surface distance (SSD), were carried out using a solid water phantom under a clinical x-ray unit.

RESULTS

The MOSkin detector showed good reproducibility (94%) and dose linearity (99%) for the dose range of 2 to 213 cGy. The sensitivity did not significantly change with the variation of SSD (± 1%), field size (± 1%), frame rate (± 3%), or beam energy (± 5%). The detector angular dependence was within ± 5% over 360° and the dose recorded by the MOSkin detector in different depths of a solid water phantom was in good agreement with the Markus parallel plate ionization chamber to within ± 3%.

CONCLUSIONS

The MOSkin detector proved to be reliable when exposed to different field sizes, SSDs, depths in solid water, dose rates, frame rates, and radiation incident angles within a clinical x-ray beam. The MOSkin detector with water equivalent depth equal to 0.07 mm is a suitable detector for in vivo skin dosimetry during interventional radiology procedures.

On the Use of Optically Stimulated Luminescent Dosimeter for Surface Dose Measurement during Radiotherapy

This study was carried out to investigate the suitability of using the optically stimulated luminescence dosimeter (OSLD) in measuring surface dose during radiotherapy. The water equivalent depth (WED) of the OSLD was first determined by comparing the surface dose measured using the OSLD with the percentage depth dose at the buildup region measured using a Markus ionization chamber. Surface doses were measured on a solid water phantom using the OSLD and compared against the Markus ionization chamber and Gafchromic EBT3 film measurements. The effect of incident beam angles on surface dose was also studied. The OSLD was subsequently used to measure surface dose during tangential breast radiotherapy treatments in a phantom study and in the clinical measurement of 10 patients. Surface dose to the treated breast or chest wall, and on the contralateral breast were measured. The WED of the OSLD was found to be at 0.4 mm. For surface dose measurement on a solid water phantom, the Markus ionization chamber measured 15.95% for 6 MV photon beam and 12.64% for 10 MV photon beam followed by EBT3 film (23.79% and 17.14%) and OSLD (37.77% and 25.38%). Surface dose increased with the increase of the incident beam angle. For phantom and patient breast surface dose measurement, the response of the OSLD was higher than EBT3 film. The in-vivo measurements were also compared with the treatment planning system predicted dose. The OSLD measured higher dose values compared to dose at the surface (Hp(0.0)) by a factor of 2.37 for 6 MV and 2.01 for 10 MV photon beams, respectively. The measurement of absorbed dose at the skin depth of 0.4 mm by the OSLD can still be a useful tool to assess radiation effects on the skin dermis layer. This knowledge can be used to prevent and manage potential acute skin reaction and late skin toxicity from radiotherapy treatments.

Characterization of MOSkin detector for in vivo skin dose measurement during megavoltage radiotherapy

In vivo dosimetry is important during radiotherapy to ensure the accuracy of the dose delivered to the treatment volume. A dosimeter should be characterized based on its application before it is used for in vivo dosimetry. In this study, we characterize a new MOSFET‐based detector, the MOSkin detector, on surface for in vivo skin dosimetry. The advantages of the MOSkin detector are its water equivalent depth of measurement of 0.07 mm, small physical size with submicron dosimetric volume, and the ability to provide real‐time readout. A MOSkin detector was calibrated and the reproducibility, linearity, and response over a large dose range to different threshold voltages were determined. Surface dose on solid water phantom was measured using MOSkin detector and compared with Markus ionization chamber and GAFCHROMIC EBT2 film measurements. Dependence in the response of the MOSkin detector on the surface of solid water phantom was also tested for different (i) source to surface distances (SSDs); (ii) field sizes; (iii) surface dose; (iv) radiation incident angles; and (v) wedges. The MOSkin detector showed excellent reproducibility and linearity for dose range of 50 cGy to 300 cGy. The MOSkin detector showed reliable response to different SSDs, field sizes, surface, radiation incident angles, and wedges. The MOSkin detector is suitable for in vivo skin dosimetry.

PACS number: 87.55.Qr

The use of radiochromic EBT2 film for the quality assurance and dosimetric verification of 3D conformal radiotherapy using Microtek ScanMaker 9800XL flatbed scanner

Radiochromic and radiographic films are widely used for radiation dosimetry due to the advantage of high spatial resolution and two‐dimensional dose measurement. Different types of scanners, including various models of flatbed scanners, have been used as part of the dosimetry readout procedure. This paper focuses on the characterization of the EBT2 film response in combination with a Microtek ScanMaker 9800XL scanner and the subsequent use in the dosimetric verification of a 3D conformal radiotherapy treatment. The film reproducibility and scanner uniformity of the Microtek ScanMaker 9800XL was studied. A three‐field 3D conformal radiotherapy treatment was planned on an anthropomorphic phantom and EBT2 film measurements were carried out to verify the treatment. The interfilm reproducibility was found to be 0.25%. Over a period of three months, the films darkened by 1%. The scanner reproducibility was ± 2% and a nonuniformity was ±1.9% along the direction perpendicular to the scan direction. EBT2 measurements showed an underdose of 6.2% at high‐dose region compared to TPS predicted dose. This may be due to the inability of the treatment planning system to predict the correct dose distribution in the presence of tissue inhomogeneities and the uncertainty of the scanner reproducibility and uniformity. The use of EBT2 film in conjunction with the axial CT image of the anthropomorphic phantom allows the evaluation of the anatomical location of dose discrepancies between the EBT2 measured dose distribution and TPS predicted dose distribution.

PACS number: 87.55.Qr

Improvements in dose calculation accuracy for small off-axis targets in high dose per fraction tomotherapy

PURPOSE

A recent field safety notice from TomoTherapy detailed the underdosing of small, off-axis targets when receiving high doses per fraction. This is due to angular undersampling in the dose calculation gantry angles. This study evaluates a correction method to reduce the underdosing, to be implemented in the current version (v4.1) of the TomoTherapy treatment planning software.

METHODS

The correction method, termed "Super Sampling" involved the tripling of the number of gantry angles from which the dose is calculated during optimization and dose calculation. Radiochromic film was used to measure the dose to small targets at various off-axis distances receiving a minimum of 21 Gy in one fraction. Measurements were also performed for single small targets at the center of the Lucy phantom, using radiochromic film and the dose magnifying glass (DMG).

RESULTS

Without super sampling, the peak dose deficit increased from 0% to 18% for a 10 mm target and 0% to 30% for a 5 mm target as off-axis target distances increased from 0 to 16.5 cm. When super sampling was turned on, the dose deficit trend was removed and all peak doses were within 5% of the planned dose. For measurements in the Lucy phantom at 9.7 cm off-axis, the positional and dose magnitude accuracy using super sampling was verified using radiochromic film and the DMG.

CONCLUSIONS

A correction method implemented in the TomoTherapy treatment planning system which triples the angular sampling of the gantry angles used during optimization and dose calculation removes the underdosing for targets as small as 5 mm diameter, up to 16.5 cm off-axis receiving up to 21 Gy.

Independent quality assurance of a helical tomotherapy machine using the dose magnifying glass

PURPOSE

Helical tomotherapy is a complex delivery technique, integrating CT image guidance and intensity modulated radiotherapy in a single system. The integration of the CT detector ring on the gantry not only allows patient position verification but is also often used to perform various QA procedures. This convenience lacks the rigor of a machine-independent QA process.

METHODS

In this article, a Si strip detector, known as the Dose Magnifying Glass (DMG), was used to perform machine-independent QA measurements of the multileaf collimator alignment, leaf open time threshold, and leaf fluence output factor (LFOF).

RESULTS

The DMG measurements showed good agreements with EDR2 film for the MLC alignment test while the CT detector agrees well with DMG measurements for leaf open time threshold and LFOF measurements. The leaf open time threshold was found to be approximately 20 ms. The LFOF measured with the DMG agreed within error with the CT detector measured LFOF.

CONCLUSIONS

The DMG with its 0.2 mm spatial resolution coupled to TERA ASIC allowed real-time high temporal resolution measurements of the tomotherapy leaf movement. In conclusion, DMG was shown to be a suitable tool for machine-independent QA of a tomotherapy unit.

A silicon strip detector dose magnifying glass for IMRT dosimetry

PURPOSE

Intensity modulated radiation therapy (IMRT) allows the delivery of escalated radiation dose to tumor while sparing adjacent critical organs. In doing so, IMRT plans tend to incorporate steep dose gradients at interfaces between the target and the organs at risk. Current quality assurance (QA) verification tools such as 2D diode arrays, are limited by their spatial resolution and conventional films are nonreal time. In this article, the authors describe a novel silicon strip detector (CMRP DMG) of high spatial resolution (200 microm) suitable for measuring the high dose gradients in an IMRT delivery.

METHODS

A full characterization of the detector was performed, including dose per pulse effect, percent depth dose comparison with Farmer ion chamber measurements, stem effect, dose linearity, uniformity, energy response, angular response, and penumbra measurements. They also present the application of the CMRP DMG in the dosimetric verification of a clinical IMRT plan.

RESULTS

The detector response changed by 23% for a 390-fold change in the dose per pulse. A correction function is derived to correct for this effect. The strip detector depth dose curve agrees with the Farmer ion chamber within 0.8%. The stem effect was negligible (0.2%). The dose linearity was excellent for the dose range of 3-300 cGy. A uniformity correction method is described to correct for variations in the individual detector pixel responses. The detector showed an over-response relative to tissue dose at lower photon energies with the maximum dose response at 75 kVp nominal photon energy. Penumbra studies using a Varian Clinac 21EX at 1.5 and 10.0 cm depths were measured to be 2.77 and 3.94 mm for the secondary collimators, 3.52 and 5.60 mm for the multileaf collimator rounded leaf ends, respectively. Point doses measured with the strip detector were compared to doses measured with EBT film and doses predicted by the Philips Pinnacle treatment planning system. The differences were 1.1% +/- 1.8% and 1.0% +/- 1.6%, respectively. They demonstrated the high temporal resolution capability of the detector readout system, which will allow one to investigate the temporal dose pattern of IMRT and volumetric modulated are therapy (VMAT) deliveries.

CONCLUSIONS

The CMRP silicon strip detector dose magnifying glass interfaced to a TERA ASIC DAQ system has high spatial and temporal resolution. It is a novel and valuable tool for QA in IMRT dose delivery and for VMAT dose delivery.

Quality assurance in mammography: College of Radiology Survey in Malaysia

Malaysia's mammography QA practice was surveyed based on the Malaysian Ministry of Health and the American College of Radiology (ACR) requirements. Data on mammography unit, processor, image receptor, exposure factors, mean glandular dose (MGD), sensitometry, image quality and viewbox luminance were obtained. Mean developer temperature and cycle time were 34.1 +/- 1.8degreesC and 107.7 +/- 33.2 seconds. Mean base+fog level, speed index and contrast index were 0.20+/-0.01, 1.20+/-0.01 and 1.33+/-0.26 respectively. Eighty-six percent of the fifty centres passed the image quality test while 12.5% complied with ACR recommended viewbox luminance. Average MGD was 1.0+/-0.4 mGy. Malaysia is on the right track for QA but with room for total quality improvement.

A low-cost, high-quality method for remote recording of presentations

OBJECTIVE

The purpose of this article was to develop a low-cost method for high-quality remote capturing and recording of multimedia presentations.

CONCLUSION

The method for making high-quality digital recordings of presentations by using the mix of freely available software presented in this article offers great potential for institutions on a budget as well as others seeking viable alternatives to current methods of presentation recording.