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Abstract

Dosimetric errors in a magnetic resonance imaging (MRI) only radiotherapy workflow may be caused by system specific geometric distortion from MRI. The aim of this study was to evaluate the impact on planned dose distribution and delineated structures for prostate patients, originating from this distortion. A method was developed, in which computer tomography (CT) images were distorted using the MRI distortion field. The displacement map for an optimized MRI treatment planning sequence was measured using a dedicated phantom in a 3 T MRI system. To simulate the distortion aspects of a synthetic CT (electron density derived from MR images), the displacement map was applied to CT images, referred to as distorted CT images. A volumetric modulated arc prostate treatment plan was applied to the original CT and the distorted CT, creating a reference and a distorted CT dose distribution. By applying the inverse of the displacement map to the distorted CT dose distribution, a dose distribution in the same geometry as the original CT images was created. For 10 prostate cancer patients, the dose difference between the reference dose distribution and inverse distorted CT dose distribution was analyzed in isodose level bins. The mean magnitude of the geometric distortion was 1.97 mm for the radial distance of 200–250 mm from isocenter. The mean percentage dose differences for all isodose level bins, were ≤0.02% and the radiotherapy structure mean volume deviations were <0.2%. The method developed can quantify the dosimetric effects of MRI system specific distortion in a prostate MRI only radiotherapy workflow, separated from dosimetric effects originating from synthetic CT generation. No clinically relevant dose difference or structure deformation was found when 3D distortion correction and high acquisition bandwidth was used. The method could be used for any MRI sequence together with any anatomy of interest.

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... The systematic review identified 13 studies investigating MR distortion quantification methods or phantom development. 18,19,[22][23][24][25][26][27][28][29][30][31][32] A key summary of study results can be found in Table 3. 18,19,[27][28][29] investigated the effects of MR scanner distortions on patient treatments by applying measured or simulated distortions to patient treatment plans. Kemppainen et al 19 and Gustafsson et al 27 measured system-induced geometric distortions using large FoV phantoms for 15 and 10 patients, respectively. ...
... The systematic review identified 13 studies investigating MR distortion quantification methods or phantom development. 18,19,[22][23][24][25][26][27][28][29][30][31][32] A key summary of study results can be found in Table 3. 18,19,[27][28][29] investigated the effects of MR scanner distortions on patient treatments by applying measured or simulated distortions to patient treatment plans. Kemppainen et al 19 and Gustafsson et al 27 measured system-induced geometric distortions using large FoV phantoms for 15 and 10 patients, respectively. ...
... To be sufficiently confident of this for clinical implementation requires robust quality assurance techniques, phantoms, and the characterization of the MRI distortions. The reported studies focused on designing suitable phantoms for measuring geometric distortions or end-to-end testing the MR-only pathway, [22][23][24][25][26] the quantification of distortions on patient data, 18,19,[27][28][29] or the reproducibility of distortion measurements 30 and provide information to aid distortion commissioning for an MR-only pathway. ...
Article
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The use of magnetic resonance imaging (MRI) scans alone for radiotherapy treatment planning (MR-only planning) has been highlighted as one method of improving patient outcomes. Recent technological advances have meant that introducing MR-only planning to the clinic is now becoming a reality, with several specialist radiotherapy clinics treating patients with this technique. As such, substantial efforts are being made to introduce this technique into wide-spread clinical implementation. A systematic review of publications investigating the clinical implementation of pelvic MR-only radiotherapy treatment planning was undertaken following the PRISMA guidelines. The Medline, Embase, Scopus, Science Direct, CINAHL and Web of Science databases were searched (timespan: all years to 2nd January 2019). Twenty six articles met the inclusion criteria. The studies were grouped into the following categories: 1. MR acquisition and synthetic-CT generation verification, 2. MR distortion quantification and phantom development, 3. Clinical validation of patient treatment positioning in an MR-only workflow and 4. MR-only commissioning processes. Key conclusions from this review are: i) MR-only planning has been clinically implemented for prostate cancer treatments; ii) A substantial amount of work remains to translate MR-only planning into wide spread clinical implementation for all pelvic sites; iii) MR scanner distortions are no longer a barrier to MR-only planning; however they must be managed appropriately; iv) MR-only based patient positioning verification shows promise, however limited evidence is reported in the literature and further investigation is required; and v) a number of MR-only commissioning processes have been reported which can aid centres as they undertake local commissioning, however this needs to be formalised in guidance from national bodies.
... Several studies have isolated the effect of MRI's spatial inaccuracies on prostate cancer RTP, 14,16,[24][25][26] showing dose differences of less than 2.0% between MRI-and CT-based treatment plans. These studies were done in a region where the anatomic volume of interest is situated at the center of the FOV, 27 where system distortions are negligible. ...
... The system automatically estimated the marker displacements by using a nonrigid image registration between the uploaded images and a digital reference model of the phantom. 24 The result of this analysis was a displacement vector field map showing the difference in marker positions calculated by inverse mapping. 32 We used patient CT images from the prospective Swedish phase 3 multicenter randomized control study, ARTSCAN, 30 to estimate patient-induced susceptibility effects. ...
... Our findings are consistent with the results of previous investigations on the effect of distortions on dose distributions at different anatomic sites, where a dose difference of less than 2% has been found between MRI and CT RTP. 14,16,24,25,27,39,40 We also showed that user-defined ROI shimming elevates the magnitude of distortion shifts in nearby regions not included in the shimmed volume. ...
Article
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Purpose: To evaluate the effect of magnetic resonance (MR) imaging (MRI) geometric distortions on head and neck radiation therapy treatment planning (RTP) for an MRI-only RTP. We also assessed the potential benefits of patient-specific shimming to reduce the magnitude of MR distortions for a 3-T scanner. Methods and Materials: Using an in-house Matlab algorithm, shimming within entire imaging volumes and user-defined regions of interest were simulated. We deformed 21 patient computed tomography (CT) images with MR distortion fields (gradient nonlinearity and patient-induced susceptibility effects) to create distorted CT (dCT) images using bandwidths of 122 and 488 Hz/mm at 3 T. Field parameters from volumetric modulated arc therapy plans initially optimized on dCT data sets were transferred to CT data to compute a new plan. Both plans were compared to determine the impact of distortions on dose distributions. Results: Shimming across entire patient volumes decreased the percentage of voxels with distortions of more than 2 mm from 15.4% to 2.0%. Using the user-defined region of interest (ROI) shimming strategy, (here the Planning target volume (PTV) was the chosen ROI volume) led to increased geometric for volumes outside the PTV, as such voxels within the spinal cord with geometric shifts above 2 mm increased from 11.5% to 32.3%. The worst phantom-measured residual system distortions after 3-dimensional gradient nonlinearity correction within a radial distance of 200 mm from the isocenter was 2.17 mm. For all patients, voxels with distortion shifts of more than 2 mm resulting from patient-induced susceptibility effects were 15.4% and 0.0% using bandwidths of 122 Hz/mm and 488 Hz/mm at 3 T. Dose differences between dCT and CT treatment plans in D 50 at the planning target volume were 0.4% ± 0.6% and 0.3% ± 0.5% at 122 and 488 Hz/mm, respectively. Conclusions: The overall effect of MRI geometric distortions on data used for RTP was minimal. Shimming over entire imaging volumes decreased distortions, but user-defined subvolume shimming introduced significant errors in nearby organs and should probably be avoided.
... Hardware-related distortions occur due to magnetic field inhomogeneity and gradient-nonlinearity [15]. Gradient-nonlinearity is the main cause of geometric distortion in MRI systems [16][17][18]. MRI scanner gradient performance can be specified both in terms of the maximum spatial gradient strengths that can be achieved and the rate at which the gradients can be switched (the slew rate). Achieving high gradient strengths and slew rates can lead to compromises in gradient linearity [18,19], which may compromise the scanner performance in terms of geometric accuracy. ...
... Gustafsson et al. [17] studied the effects of geometric distortion on RT planning for prostate patients on a 3 T MRI scanner using the same a large FOV MRI distortion phantom used in this study. The repeatability of measurements with such a phantom have also been demonstrated by Wyatt et al. [24]. ...
... Gustafsson et al. [17] used a GRADE phantom with a GE Discovery MR750w 3 T MR Scanner (General Electric Healthcare, Milwaukee, WI), and found mean and maximum distortions at all distances to isocentre similar to the mean values over all scanners that we have shown in Table 2. ...
Article
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Background and purpose Magnetic Resonance Imaging (MRI) is increasingly being used in radiotherapy (RT). However, geometric distortions are a known challenge of using MRI in RT. The aim of this study was to demonstrate feasibility of a national audit of MRI geometric distortions. This was achieved by assessing large field of view (FOV) MRI distortions on a number of scanners used clinically for RT. Materials and methods MRI scans of a large FOV MRI geometric distortion phantom were acquired on 11 MRI scanners that are used clinically for RT in the UK. The mean and maximum distortions and variance between scanners were reported at different distances from the isocentre. Results For a small FOV representing a brain (100–150 mm from isocentre) all distortions were < 2 mm except for the maximum distortion of one scanner. For a large FOV representing a head and neck/pelvis (200–250 mm from isocentre) mean distortions were < 2 mm except for one scanner, maximum distortions were > 10 mm in some cases. The variance between scanners was low and was found to increase with distance from isocentre. Conclusions This study demonstrated feasibility of the technique to be repeated in a country wide geometric distortion audit of all MRI scanners used clinically for RT. Recommendations were made for performing such an audit and how to derive acceptable limits of distortion in such an audit.
... Multiple studies have also investigated the MRI geometric accuracy from RTP point-of-view as a part of MRI-only protocol commissioning or feasibility study [10,[13][14][15][16]. The dose uncertainty of the whole radiotherapy process should be less than 5% [17] as inaccurate dose in PTV or OAR or both can lead to an undesired clinical response. ...
... Kemppainen et al. [21] reported distortions less than 2 mm in the body-outline of pelvis area and less than 1 mm in PTVs (prostate, rectum, and gynecological) and OARs (rectum and bladder). Adjeiwaah et al. [15] measured maximum distortions of 2.17 mm in 200 mm radial distance from isocenter, and Gustafsson et al. [13] mean distortions <2 mm in 200-250 mm radial distance from isocenter in phantom studies. These studies were performed with clinical sequences for MRI-only commissioning, and the dose differences between distorted and planning-CTs were <1%, when a dose difference of <2% is generally accepted [23]. ...
... Either due to the limited acquisition FOV or severe distortions, the analyses were limited to markers within <200 mm distance from isocenter in zdirection. Gustafsson et al. [13] have evaluated the intrinsic susceptibility of the GRADE-phantom, and deemed it insignificant (<0.5 mm in radian distances <250 mm measured with receiver bandwidth of 554 Hz/mm). Wyatt et al. [24] have evaluated the repeatability and set-up sensitivity of measurements with the GRADE-phantom and corresponding MriPlanner-sofware, and deemed the measurements repeatable but relatively sensitive to small (<1 mm or <1 • ) set-up errors. ...
Article
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Background and Purpose Magnetic resonance imaging is increasingly used in radiotherapy planning; yet, the performance of the utilized scanners is rarely regulated by any authority. The aim of this study was to determine the geometric accuracy of several magnetic resonance imaging scanners used for radiotherapy planning, and to establish acceptance criteria for such scanners. Materials and Methods The geometric accuracy of five different scanners was measured with three sequences using a commercial large-field-of-view phantom. The distortion magnitudes were determined in spherical volumes around the scanner isocenter and in cylindrical volumes along scanner z-axis. The repeatability of the measurements was determined on a single scanner with two quality assurance sequences with three single-setup and seven repeated-setup measurements. Results For all scanners and sequences except one, the mean and median distortion magnitude was <1 mm and <2 mm in spherical volumes with diameters of 400 mm and 500 mm, respectively. For all sequences maximum distortion was <2 mm in spherical volume with diameter of 300 mm. The mean standard deviation of marker-by-marker distortion magnitudes over repeated acquisitions was ≤0.6 mm with both tested sequences. Conclusions All tested scanners were geometrically accurate for their current use in radiotherapy planning. The acceptance criteria of geometric accuracy for regulatory inspections of a supervising authority could be set according to these results.
... There are several studies that have looked at the potential effects of MR geometric distortions on either MR-CT or MR-only RT treatment planning on anatomic sites such as the breast, brain, and prostate (5,(14)(15)(16)(17)(18)(19)(20). Particularly, the study on the breast concluded that even at high BWs the dosimetric impact of system-and patient-induced distortion could be clinically unacceptable. ...
... We used a commercially manufactured phantom (Spectronic Medical, Helsingborg, Sweden) with a signalproducing volume of 350.7 Â 470 Â 450.7 mm 3 to measure residual system distortions. Susceptibility-induced distortions from the phantom have been reported to be negligible (20). Axial MR images of the phantom were acquired using our clinical sequence for prostate cancer examinations. ...
... Each vector in the displacement field represented the distance between a geometric point in the CT image space and its corresponding point in the dCT data. Contrary to previous studies that did not take patient-induced susceptibility effects into account, the delineated RT structures were also distorted instead of directly copied from the CT to the dCT images (20,22). Thus, for each of the 17 patient CTs, 6 distorted CT datasets were obtained on the basis of the different BW and gradient readout directions, as follows: (1) dCT datasets at BW of 122 Hz per pixel in the R/L gradient direction; (2) dCT datasets at BW of 122 Hz per pixel in the A/P gradient direction; (3) dCT datasets at BW of 244 Hz per pixel in the R/L gradient direction; (4) dCT datasets at BW of 244 Hz per pixel in the A/P gradient direction; (5) dCT datasets at BW of 488 Hz per pixel in the R/L gradient direction; and (6) dCT datasets at BW of 488 Hz per pixel in the A/P gradient direction. ...
Article
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Purpose To investigate the effect of magnetic resonance system- and patient-induced susceptibility distortions from a 3T scanner on dose distributions for prostate cancers. Methods and Materials Combined displacement fields from the residual system and patient-induced susceptibility distortions were used to distort 17 prostate patient CT images. VMAT dose plans were initially optimized on distorted CT images and the plan parameters transferred to the original patient CT images to calculate a new dose distribution. Results Maximum residual mean distortions of 3.19 mm at a radial distance of 25 cm and maximum mean patient-induced susceptibility shifts of 5.8 mm were found using the lowest bandwidth of 122 Hz per pixel. There was a dose difference of <0.5% between distorted and undistorted treatment plans. The 90% confidence intervals of the mean difference between the dCT and CT treatment plans were all within an equivalence interval of (−0.5, 0.5) for all investigated plan quality measures. Conclusions Patient-induced susceptibility distortions at high field strengths in closed bore magnetic resonance scanners are larger than residual system distortions after using vendor-supplied 3-dimensional correction for the delineated regions studied. However, errors in dose due to disturbed patient outline and shifts caused by patient-induced susceptibility effects are below 0.5%.
... There are several studies that have looked at the potential effects of MR geometric distortions on either MR-CT or MR-only RT treatment planning on anatomic sites such as the breast, brain, and prostate (5,(14)(15)(16)(17)(18)(19)(20). Particularly, the study on the breast concluded that even at high BWs the dosimetric impact of system-and patient-induced distortion could be clinically unacceptable. ...
... We used a commercially manufactured phantom (Spectronic Medical, Helsingborg, Sweden) with a signalproducing volume of 350.7 Â 470 Â 450.7 mm 3 to measure residual system distortions. Susceptibility-induced distortions from the phantom have been reported to be negligible (20). Axial MR images of the phantom were acquired using our clinical sequence for prostate cancer examinations. ...
... Each vector in the displacement field represented the distance between a geometric point in the CT image space and its corresponding point in the dCT data. Contrary to previous studies that did not take patient-induced susceptibility effects into account, the delineated RT structures were also distorted instead of directly copied from the CT to the dCT images (20,22). Thus, for each of the 17 patient CTs, 6 distorted CT datasets were obtained on the basis of the different BW and gradient readout directions, as follows: (1) dCT datasets at BW of 122 Hz per pixel in the R/L gradient direction; (2) dCT datasets at BW of 122 Hz per pixel in the A/P gradient direction; (3) dCT datasets at BW of 244 Hz per pixel in the R/L gradient direction; (4) dCT datasets at BW of 244 Hz per pixel in the A/P gradient direction; (5) dCT datasets at BW of 488 Hz per pixel in the R/L gradient direction; and (6) dCT datasets at BW of 488 Hz per pixel in the A/P gradient direction. ...
Article
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Despite the many advantages of using magnetic resonance imaging (MRI) in radiation therapy treatment planning, there are concerns about geometric distortions. Displacement fields from system distortions and patient-induced susceptibil-ities were used to distort 17 prostate patient CT images. Dose plans were optimized on the distorted CT and the plan parameters transferred to the CT images to calculate Purpose: To investigate the effect of magnetic resonance system-and patient-induced susceptibility distortions from a 3T scanner on dose distributions for prostate cancers. Methods and Materials: Combined displacement fields from the residual system and patient-induced susceptibility distortions were used to distort 17 prostate patient CT images. VMAT dose plans were initially optimized on distorted CT images and the plan parameters transferred to the original patient CT images to calculate a new dose distribution. Results: Maximum residual mean distortions of 3.19 mm at a radial distance of 25 cm and maximum mean patient-induced susceptibility shifts of 5.8 mm were found using the lowest bandwidth of 122 Hz per pixel. There was a dose difference of <0.5% between distorted and undistorted treatment plans. The 90% confidence intervals of the mean difference between the dCT and CT treatment plans were all within an equivalence interval of (À0.5, 0.5) for all investigated plan quality measures. Conclusions: Patient-induced susceptibility distortions at high field strengths in closed bore magnetic resonance scanners are larger than residual system distortions after using vendor-supplied 3-dimensional correction for the delineated regions studied.
... Studying the geometric accuracy of MRI has been a subject of great interest in recent decades, especially from the aspect of quality assurance (QA) [3][4][5][6], radiotherapy treatment planning (RTP) [7][8][9][10][11][12][13][14][15][16], and stereotactic operations [17][18][19]. Most MRI QA protocols include at least a limited investigation of the geometric accuracy, often reporting deviations from known phantom structure lengths. ...
... Whereas most previous studies have used interpolation methods to determine the displacement fields, Baldwin et al. [8], Sun et al. [10] and Walker et al. [11] implemented nonrigid image registration. In addition, Gustafsson et al. [14] and Adjeiwaah et al. [15] used a commercially available phantom and software GRADE (Spectronic Medical AB, Helsingborg, Sweden) that utilizes nonrigid registration. However, to our knowledge, only Walker et al. applied the nonrigid registration to the plain image data and not to the already localized CP pairs of the MR and ground truth images. ...
Article
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Objective We aimed to develop a vendor-neutral and interaction-free quality assurance protocol for measuring geometric accuracy of head and brain magnetic resonance (MR) images. We investigated the usability of nonrigid image registration in the analysis and looked for the optimal registration parameters. Materials and methods We constructed a 3D-printed phantom and imaged it with 12 MR scanners using clinical sequences. We registered a geometric-ground-truth computed tomography (CT) acquisition to the MR images using an open-source nonrigid-registration-toolbox with varying parameters. We applied the transforms to a set of control points in the CT image and compared their locations to the corresponding visually verified reference points in the MR images. Results With optimized registration parameters, the mean difference (and standard deviation) of control point locations when compared to the reference method was (0.17 ± 0.02) mm for the 12 studied scanners. The maximum displacements varied from 0.50 to 1.35 mm or 0.89 to 2.30 mm, with vendors’ distortion correction on or off, respectively. Discussion Using nonrigid CT–MR registration can provide a robust and relatively test-object-agnostic method for estimating the intra- and inter-scanner variations of the geometric distortions.
... p-Values of the scanner-to-scanner comparison as gradient non-linearity or B 0 field inhomogeneities should be evaluated before introducing a clinical MRI-only workflow [37]. Additional artifacts can derive from patient induced distortions, such as susceptibility and chemical shift. ...
... Previous studies have shown that with geometric accuracy better than 2 mm within the entire FOV it is possible to achieve clinically feasible dose calculation accuracy for MRI-only RTP [21,23,[38][39][40][41]. The geometric accuracy of the applied MR platforms was sufficient for MRI-only RT [10,11,21,23,37]. An MRI-only approach is feasible and utilized internationally in few clinics for radiotherapy of the prostate employing either commercial or in-house sCT techniques. ...
Article
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Background and purpose: Recent studies have shown that it is possible to conduct entire radiotherapy treatment planning (RTP) workflow using only MR images. This study aims to develop a generalized intensity-based method to generate synthetic CT (sCT) images from standard T2-weighted (T2w) MR images of the pelvis. Materials and methods: This study developed a generalized dual model HU conversion method to convert standard T2w MR image intensity values to synthetic HU values, separately inside and outside of atlas-segmented bone volume contour. The method was developed and evaluated with 20 and 35 prostate cancer patients, respectively. MR images with scanning sequences in clinical use were acquired with four different MR scanners of three vendors. Results: For the generated synthetic CT (sCT) images of the 35 prostate patients, the mean (and maximal) HU differences in soft and bony tissue volumes were 16 ± 6 HUs (34 HUs) and -46 ± 56 HUs (181 HUs), respectively, against the true CT images. The average of the PTV mean dose difference in sCTs compared to those in true CTs was -0.6 ± 0.4% (-1.3%). Conclusions: The study provides a generalized method for sCT creation from standard T2w images of the pelvis. The method produced clinically acceptable dose calculation results for all the included scanners and MR sequences.
... More recently, MR imaging-only planning is gaining acceptance through techniques that model electron density from MR imaging data, enabling dose calculation (Fig. 4). 27 When devising an MR imaging acquisition protocol dedicated to treatment planning, it is important to explicitly state imaging goals, because they are often distinct from diagnostics. Goals typically include a clear definition of the prostate gland boundary, depiction of implanted fiducial markers to assist in image-registration (Fig. 5) and/or online guidance, and mapping of disease. ...
Article
The use of prostate MR imaging in radiotherapy continues to evolve. This article describes its current application in the selection of treatment regimens, integration in treatment planning or simulation, and assessment of response. An expert consensus statement from the annual MR in RT symposium is presented, as a list of 21 key quality indicators for the practice of MR imaging simulation in prostate cancer. Although imaging requirements generally follow PIRADSv2 guidelines, additional requirements specific to radiotherapy planning are described. MR imaging-only workflows and MR imaging-guided treatment systems are expected to replace conventional computed tomography-based practice, further adding specific requirements for MR imaging in radiotherapy.
... The system-related distortion has been reduced significantly by recent development on MRI hardware and software and the patient-induced distortion can be minimized by appropriate sequence parameters. The geometric accuracy achieved by recently installed MR platforms is acceptable for RT planning [5][6][7][8][9][10][11]. ...
Article
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Background: Magnetic resonance imaging (MRI) is the most comprehensive imaging modality for radiation therapy (RT) target delineation of most soft tissue tumors including prostate cancer. We have earlier presented step by step the MRI-only based workflow for RT planning and image guidance for localized prostate cancer. In this study we present early clinical experiences of MRI-only based planning. Material and methods: We have analyzed the technical planning workflow of the first 200 patients having received MRI-only planned radiation therapy for localized prostate cancer in Helsinki University Hospital Cancer center. Early prostate specific antigen (PSA) results were analyzed from n = 125 MRI-only patients (n = 25 RT only, n = 100 hormone treatment + RT) and were compared with the corresponding computed tomography (CT) planned patient group. Results: Technically the MRI-only planning procedure was suitable for 92% of the patients, only 8% of the patients required supplemental CT imaging. Early PSA response in the MRI-only planned group showed similar treatment results compared with the CT planned group and with an equal toxicity level. Conclusion: Based on this retrospective study, MRI-only planning procedure is an effective and safe way to perform RT for localized prostate cancer. It is suitable for the majority of the patients.
... MR images suffer from inherent distortions. Sources of distortion relate to either the MRI system , Baldwin et al 2007, Moutsatsos et al 2013, Tadic et al 2014, Pappas et al 2016, Gustafsson et al 2017, Damyanovich et al 2018 or the subject being scanned (Baldwin et al 2009, Stanescu et al 2012, Wang et al 2013, Adjeiwaah et al 2018. In the former case, geometric distortions arise from gradient field non-linearity and static magnetic field (B 0 ) inhomogeneity. ...
Article
This work focuses on MR-related sequence dependent geometric distortions, which are associated with B 0 inhomogeneity and patient-induced distortion (susceptibility differences and chemical shift effects), in MR images used in stereotactic radiosurgery (SRS) applications. Emphasis is put on characterizing distortion at target brain areas identified by gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA) paramagnetic contrast agent uptake. A custom-made phantom for distortion detection was modified to accommodate two small cylindrical inserts, simulating small brain targets. The inserts were filled with Gd-DTPA solutions of various concentrations (0-20 mM). The phantom was scanned at 1.5 T unit using both the reversed read gradient polarity (to determine the overall distortion as reflected by the inserts centroid offset) and the field mapping (to determine B 0 inhomogeneity related distortion in the vicinity of the inserts) techniques. Post-Gd patient images involving a total of 10 brain metastases/targets were also studied using a similar methodology. For the specific imaging conditions, contrast agent presence was found to evidently affect phantom insert position, with centroid offset extending up to 0.068 mm mM-1 (0.208 ppm mM-1). The Gd-DTPA induced distortion in patient images was of the order of 0.5 mm for the MRI protocol used, in agreement with the phantom results. Total localization uncertainty of metastases-targets in patient images ranged from 0.35 mm to 0.87 mm, depending on target location, with an average value of 0.54 mm (2.24 ppm). This relative wide range of target localization uncertainty results from the fact that the B 0 inhomogeneity distortion vector in a specific location may add to or partly counterbalance Gd-DTPA induced distortion, thus increasing or decreasing, respectively, the total sequence dependent distortion. Although relatively small, the sequence dependent distortion in Gd-DTPA enhanced brain images can be easily taken into account for SRS treatment planning and target definition purposes by carefully inspecting both the forward and reversed polarity series.
... MRI provides the gold standard for defining soft tissue structures during RT planning, and the use of MRI-guided treatment delivery is providing a further argument for an MRI-only workflow, which will eliminate setup and registration error while also reducing workload and strain on the patient, especially additional radiation in the RT workflow. But the dosimetric errors in an MRI-only RT workflow need to be considered due to the specific geometric distortion from MRI. 98 ...
Article
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Modern radiotherapy (RT) is being enriched by big digital data and intensive technology. Multimodality image registration, intelligence-guided planning, real-time tracking, image-guided RT (IGRT), and automatic follow-up surveys are the products of the digital era. Enormous digital data are created in the process of treatment, including benefits and risks. Generally, decision making in RT tries to balance these two aspects, which is based on the archival and retrieving of data from various platforms. However, modern risk-based analysis shows that many errors that occur in radiation oncology are due to failures in workflow. These errors can lead to imbalance between benefits and risks. In addition, the exact mechanism and dose–response relationship for radiation-induced malignancy are not well understood. The cancer risk in modern RT workflow continues to be a problem. Therefore, in this review, we develop risk assessments based on our current knowledge of IGRT and provide strategies for cancer risk reduction. Artificial intelligence (AI) such as machine learning is also discussed because big data are transforming RT via AI.
... The sequence used for the sCT generation has previously been described. 14,17 The sCT conversion software required a T2-weighted MRI data set with a FOV enclosing the complete patient contour. The cranio-caudal extent of the MRI was set to include the target area (i.e., the prostate) and the OARs, including rectum and bladder. ...
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Purpose: Magnetic resonance imaging (MRI)-only radiotherapy is performed without computed tomography (CT). A synthetic CT (sCT) is used for treatment planning. The aim of this study was to develop a clinically feasible quality assurance (QA) procedure for sCT using the kV-cone beam CT (CBCT), in an MRI-only workflow for prostate cancer patients. Material and method: Three criteria were addressed; stability in Hounsfield Units (HUs), deviations in HUs between the CT and CBCT, and validation of the QA procedure. For the two first criteria, weekly phantom measurements were performed. For the third criteria, sCT, CT, and CBCT for ten patients were used. Treatment plans were created based on the sCT (MriPlannerTM ). CT and CBCT images were registered to the sCT. The treatment plan was copied to the CT and CBCT and recalculated. Dose-volume histogram (DVH) metrics were used to evaluate dosimetric differences between the sCT plan and the recalculated CT and CBCT plans. HU distributions in sCT, CT, and CBCT were compared. Well-defined errors were introduced in the sCT for one patient to evaluate efficacy of the QA procedure. Results: The kV-CBCT system was stable in HU over time (standard deviation <40 HU). Variation in HUs between CT and CBCT was <60 HU. The differences between sCT-CT and sCT-CBCT dose distributions were below or equal to 1.0%. The highest mean dose difference for the CT and CBCT dose distribution was 0.6%. No statistically significant difference was found between total mean dose deviations from recalculated CT and CBCT plans, except for femoral head. Comparing HU distributions, the CBCT appeared to be similar to the CT. All introduced errors were identified by the proposed QA procedure, except all tissue compartments assigned as water. Conclusion: The results in this study shows that CBCT can be used as a clinically feasible QA procedure for MRI-only radiotherapy of prostate cancer patients.
... The software and the MRI imaging protocol were recently validated against CT. 22,23 In the MR-PROTECT study, the center of mass (CoM), for each GFM in each patient, was manually identified in the sCT geometry using Eclipse Treatment Planning system version 13.6 (Varian Medical Systems, Palo Alto, CA, USA). The identification of GFM in the T2w MRI-images, i.e., sCT geometry, was aided by multi- echo gradient echo MRI-images. ...
Article
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Prostate cancer radiotherapy workflows, solely based on magnetic resonance imaging (MRI), are now in clinical use. In these workflows, intraprostatic gold fiducial markers (GFM) show similar signal behavior as calcifications and bleeding in T2-weighted MRI-images. Accurate GFM identification in MRI-only radiotherapy work-flows is therefore a major challenge. C-arm X-ray images (CkV-images), acquired at GFM implantation, could provide GFM position information and be used to confirm correct identification in T2-weighted MRI-images. This would require negligible GFM migration between implantation and MRI-imaging. Marker migration was therefore investigated. The aim of this study was to show the feasibility of using CkV-images to confirm GFM identification in an MRI-only prostate radiotherapy workflow. An anterior-posterior digitally reconstructed radiograph (DRR)-image and a mirrored posterior-anterior CkV-image were acquired two weeks apart for 16 patients in an MRI-only radiotherapy workflow. The DRR-image originated from synthetic CT-images (created from MRI-images). A common image geometry was defined between the DRR-and CkV-image for each patient. A rigid registration between the GFM center of mass (CoM) coordinates was performed and the distance between each of the GFM in the DRR-and registered CkV-image was calculated. The same methodology was used to assess GFM migration for 31 patients in a CT-based radiotherapy workflow. The distance calculated was considered a measure of GFM migration. A statistical test was performed to assess any difference between the cohorts. The mean absolute distance difference for the GFM CoM between the DRR-and CkV-image in the MRI-only cohort was 1.7 ± 1.4 mm. The mean GFM migration was 1.2 ± 0.7 mm. No significant difference between the measured total distances of the two cohorts could be detected (P = 0.37). This demonstrated that, a C-Arm X-ray image acquired from the GFM implantation procedure could be used to confirm GFM identification from MRI-images. GFM migration was present but did not constitute a problem.
... MR-only radiotherapy is an emerging technique, which has gained interest especially in the male pelvis, i.e. prostate cancer, for which synthetic CT generation methods are available. The geometric distortions in the MR images, which previously created concerns, are no longer considered an issue [17,18]. In addition, techniques have been developed to identify the fiducial markers in MR-images [16,19]. ...
Article
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In magnetic resonance (MR) only radiotherapy, the target delineation needs to be performed without computed tomography (CT). We investigated in thirteen patients with prostate cancer, how the clinical target volume (CTV) was affected, when the target delineation procedure was changed from using both CT and MR images to using MR images only. The mean volume of the CTVCT/MR was 61.0 cm3 as compared to 49.9 cm3 from MR-only based target delineation, corresponding to an average decrease of 18%. Our results show that CTVMR-only was consistently smaller than CTVCT/MR, which has to be taken into consideration before clinical commissioning of MR-only radiotherapy.
... This requirement can be justified by evaluating previous feasibility research of MRI-only dose calculation accuracy. A mean body outline error of ≤2 mm around the planning area resulted in mean dose differences of < 1% on the planning target volume (PTV) and organs-at-risk (OAR) areas compared to the CT-based RTP [5,[24][25][26]. ...
Article
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Background: Using magnetic resonance imaging (MRI) as the only imaging method for radiotherapy treatment planning (RTP) is becoming more common as MRI-only RTP solutions have evolved. The geometric accuracy of MR images is an essential factor of image quality when determining the suitability of MRI for RTP. The need is therefore clear for clinically feasible quality assurance (QA) methods for the geometric accuracy measurement. Materials and methods: This work evaluates long-term stability of geometric accuracy and the validity of a 2D geometric accuracy QA method compared to a prototype 3D method and analysis software in routine QA. The long-term follow-up measurements were conducted on one of the 1.5 T scanners over a period of 19 months using both methods. Inter-scanner variability of geometric distortions was also evaluated in three 1.5 T and three 3 T MRI scanners from a single vendor by using the prototype 3D QA method. Results: The geometric accuracy of the magnetic resonance for radiotherapy (MR-RT) platform remained stable within 2 mm at distances of <250 mm from isocenter. All scanners achieved good geometric accuracy with mean geometric distortions of <1 mm at <150 mm and <2 mm at <250 mm from the isocenter. Both measurement methods provided relevant information about geometric distortions. Conclusions: Geometric distortions are often considered a limitation of MRI-only RTP. Results indicate that geometric accuracy of modern scanners remain within acceptable limits by default even after many years of clinical use based on the 3D QA evaluation.
... [10][11][12][13][14][15][16][17][18][19][20][21] The dosimetric impact of this distortion has also been analyzed and reported. [22][23][24][25] Measurements carried out in these studies are based on phantoms with fixed configurations. Some of these phantoms were constructed in-house 11,14,16 while others were commercialized. ...
Article
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One of the main challenges to using magnetic resonance imaging (MRI) in radiotherapy is the existence of system‐related geometric inaccuracies caused mainly by the inhomogeneity in the main magnetic field and the nonlinearities of the gradient coils. Several physical phantoms, with fixed configuration, have been developed and commercialized for the assessment of the MRI geometric distortion. In this study, we propose a new design of a customizable phantom that can fit any type of radio frequency (RF) coil. It is composed of 3D printed plastic blocks containing holes that can hold glass tubes which can be filled with any liquid. The blocks can be assembled to construct phantoms with any dimension. The feasibility of this design has been demonstrated by assembling four phantoms with high robustness allowing the assessment of the geometric distortion for the GE split head coil, the head and neck array coil, the anterior array coil, and the body coil. Phantom reproducibility was evaluated by analyzing the geometric distortion on CT acquisition of five independent assemblages of the phantom. This solution meets all expectations in terms of having a robust, lightweight, modular, and practical tool for measuring distortion in three dimensions. Mean error in the position of the tubes was less than 0.2 mm. For the geometric distortion, our results showed that for all typical MRI sequences used for radiotherapy, the mean geometric distortion was less than 1 mm and less than 2.5 mm over radial distances of 150 mm and 250 mm, respectively. These tools will be part of a quality assurance program aimed at monitoring the image quality of MRI scanners used to guide radiation therapy.
... [10][11][12][13][14][15][16][17][18][19][20][21] The dosimetric impact of this distortion has also been analyzed and reported. [22][23][24][25] Measurements carried out in these studies are based on phantoms with fixed configurations. Some of these phantoms were constructed in-house 11,14,16 while others were commercialized. ...
... We consider numerical inversion of a deformation vector field (DVF). Inverse DVFs are needed, together with their respective forward DVFs, to map images, structure contours, or doses back and forth in applications such as 4D image reconstruction [1], dose accumulation calculations and multi-modality treatment planning in adaptive radiotherapy [2,3,4,5], and cardiac functional analysis [6]. DVF inversion is also a fundamental operation in simultaneous and symmetric registration methods [7,8,9,10,11]. ...
Article
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Purpose: Often, the inverse deformation vector field (DVF) is needed together with the corresponding forward DVF in 4D reconstruction and dose calculation, adaptive radiation therapy, and simultaneous deformable registration. This study aims at improving both accuracy and efficiency of iterative algorithms for DVF inversion, and advancing our understanding of divergence and latency conditions. Method: We introduce a framework of fixed-point iteration algorithms with active feedback control for DVF inversion. Based on rigorous convergence analysis, we design control mechanisms for modulating the inverse consistency (IC) residual of the current iterate, to be used as feedback into the next iterate. The control is designed adaptively to the input DVF with the objective to enlarge the convergence area and expedite convergence. Three particular settings of feedback control are introduced: constant value over the domain throughout the iteration; alternating values between iteration steps; and spatially variant values. We also introduce three spectral measures of the displacement Jacobian for characterizing a DVF. These measures reveal the critical role of what we term the non-translational displacement component (NTDC) of the DVF. We carry out inversion experiments with an analytical DVF pair, and with DVFs associated with thoracic CT images of 6 patients at end of expiration and end of inspiration. Results: NTDC-adaptive iterations are shown to attain a larger convergence region at a faster pace compared to previous non-adaptive DVF inversion iteration algorithms. By our numerical experiments, alternating control yields smaller IC residuals and inversion errors than constant control. Spatially variant control renders smaller residuals and errors by at least an order of magnitude, compared to other schemes, in no more than 10 steps. Inversion results also show remarkable quantitative agreement with analysis-based predictions. Conclusion: Our analysis captures properties of DVF data associated with clinical CT images, and provides new understanding of iterative DVF inversion algorithms with a simple residual feedback control. Adaptive control is necessary and highly effective in the presence of non-small NTDCs. The adaptive iterations or the spectral measures, or both, may potentially be incorporated into deformable image registration methods.
... General Electric Healthcare, Milwaukee, WI, USA). The MRI system was subjected to monthly QC using vendor-specific coil tests and a large volume geometry phantom to assess geometric accuracy (Spectronic Medical AB, Helsingborg, Sweden) (Gustafsson et al 2017b, Wyatt et al 2018. A GE GEM Anterior Array 16 channel receiver array coil was placed on stiff coil bridges over the pelvic area of the patient. ...
Article
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Identification of prostate gold fiducial markers in MRI images is challenging when CT images are not available, due to misclassifications from intra-prostatic calcifications. It is also a time consuming task and automated identification methods have been suggested as an improvement for both objectives. Multi-echo gradient echo (MEGRE) images have been utilized for manual fiducial identification with 100% detection accuracy. The aim is therefore to develop an automatic deep learning based method for fiducial identification in MRI images intended for MRI-only prostate radiotherapy. MEGRE images from 326 prostate cancer patients with fiducials were acquired on a 3T MRI, post-processed with N4 bias correction, and the fiducial center of mass (CoM) was identified. A 9 mm radius sphere was created around the CoM as ground truth. A deep learning HighRes3DNet model for semantic segmentation was trained using image augmentation. The model was applied to 39 MRI-only patients and 3D probability maps for fiducial location and segmentation were produced and spatially smoothed. In each of the three largest probability peaks, a 9 mm radius sphere was defined. Detection sensitivity and geometric accuracy was assessed. To raise awareness of potential false findings a 'BeAware' score was developed, calculated from the total number and quality of the probability peaks. All datasets, annotations and source code used were made publicly available. The detection sensitivity for all fiducials were 97.4%. 36/39 patients had all fiducial markers correctly identified. All three failed patients generated a user notification using the BeAware score. The mean absolute difference between the detected fiducial and ground truth CoM was 0.7±0.9 [0 3.1] mm. A deep learning method for automatic fiducial identification in MRI images was developed and evaluated with state-of-the-art results. The BeAware score has the potential to notify the user regarding patients where the proposed method is uncertain.
... Future studies are required to strengthen the clinical use of sCT, especially considering that geometric accuracy has been already extensively investigated for sCT generated with classical methods for 3 T and below. [160][161][162] DL-based sCT generation in the context of MRguided RT 20,163-167 may reduce the treatment time, facilitating for daily image guidance and plan adaptation based on sole MRI. 168,169 For this application, the accuracy of dose calculation in the magnetic field's presence must be assessed before clinical implementation. ...
Article
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Recently, deep learning (DL)‐based methods for the generation of synthetic computed tomography (sCT) have received significant research attention as an alternative to classical ones. We present here a systematic review of these methods by grouping them into three categories, according to their clinical applications: I) to replace CT in magnetic resonance (MR)‐based treatment planning, II) facilitate cone‐beam computed tomography (CBCT)‐based image‐guided adaptive radiotherapy, and III) derive attenuation maps for the correction of positron emission tomography (PET). Appropriate database searching was performed on journal articles published between January 2014 and December 2020. The DL methods' key characteristics were extracted from each eligible study, and a comprehensive comparison among network architectures and metrics was reported. A detailed review of each category was given, highlighting essential contributions, identifying specific challenges, and summarising the achievements. Lastly, the statistics of all the cited works from various aspects were analysed, revealing the popularity and future trends and the potential of DL‐based sCT generation. The current status of DL‐based sCT generation was evaluated, assessing the clinical readiness of the presented methods.
... In addition, several researchers have studied the effect of MRI spatial inaccuracies on treatment planning for prostate cancer. These can lead to dose differences of less than 2.0% between the MRI-and CT-based treatment plans (29)(30)(31). ...
Article
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Purpose A 3D printed geometric phantom was developed that can be scanned with computed tomography (CT) and magnetic resonance imaging (MRI) to measure the geometric distortion and determine the relevant dose changes. Materials and Methods A self-designed 3D printed photosensitive resin phantom was used, which adopts grid-like structures and has 822 1 cm ² squares. The scanning plan was delivered by three MRI scanners: the Elekta Unity MR-Linac 1.5T, GE Signa HDe 1.5T, and GE Discovery-sim 750 3.0T. The geometric distortion comparison was concentrated on two 1.5T MRI systems, whereas the 3.0T MRI was used as a supplemental experiment. The most central transverse images in each dataset were selected to demonstrate the plane distortion. Some mark points were selected to analyze the distortion in the 3D direction based on the plane geometric distortion. A treatment plan was created with the off-line Monaco system. Results The distortion increases gradually from the center to the outside. The distortion range is 0.79 ± 0.40 mm for the Unity, 1.31 ± 0.56 mm for the GE Signa HDe, and 2.82 ± 1.48 mm for the GE Discovery-sim 750. Additionally, the geometric distortion slightly affects the actual planning dose of the radiotherapy. Conclusion Geometric distortion increases gradually from the center to the outside. The distortion values of the Unity were smaller than those of the GE Signa HDe, and the Unity has the smallest geometric distortion. Finally, the Unity’s dose variation best matched with the standard treatment plan.
... Phantom measurements were carried out prior to patient inclusion to determine the impact of system dependent geometric distortion, due to main magnetic field inhomogeneities and gradient non-linearities. For this purpose, the GRADE phantom for geometric distortion measurements (Spectronic Medical AB, Helsingborg, Sweden) [23,24] was imaged using the Dixon sequence with the same acquisition parameters as in Table 1, except for the field of view which was set to 500 × 500 mm 2 and the scan matrix of 512 × 512 to fit the phantom size. The phantom contains approximately 1200 spherical markers which were automatically evaluated relative to a control template. ...
Article
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Background Most studies on synthetic computed tomography (sCT) generation for brain rely on in-house developed methods. They often focus on performance rather than clinical feasibility. Therefore, the aim of this work was to validate sCT images generated using a commercially available software, based on a convolutional neural network (CNN) algorithm, to enable MRI-only treatment planning for the brain in a clinical setting. Methods This prospective study included 20 patients with brain malignancies of which 14 had areas of resected skull bone due to surgery. A Dixon magnetic resonance (MR) acquisition sequence for sCT generation was added to the clinical brain MR-protocol. The corresponding sCT images were provided by the software MRI Planner (Spectronic Medical AB, Sweden). sCT images were rigidly registered and resampled to CT for each patient. Treatment plans were optimized on CT and recalculated on sCT images for evaluation of dosimetric and geometric endpoints. Further analysis was also performed for the post-surgical cases. Clinical robustness in patient setup verification was assessed by rigidly registering cone beam CT (CBCT) to sCT and CT images, respectively. Results All sCT images were successfully generated. Areas of bone resection due to surgery were accurately depicted. Mean absolute error of the sCT images within the body contour for all patients was 62.2 ± 4.1 HU. Average absorbed dose differences were below 0.2% for parameters evaluated for both targets and organs at risk. Mean pass rate of global gamma (1%/1 mm) for all patients was 100.0 ± 0.0% within PTV and 99.1 ± 0.6% for the full dose distribution. No clinically relevant deviations were found in the CBCT-sCT vs CBCT-CT image registrations. In addition, mean values of voxel-wise patient specific geometric distortion in the Dixon images for sCT generation were below 0.1 mm for soft tissue, and below 0.2 mm for air and bone. Conclusions This work successfully validated a commercially available CNN-based software for sCT generation. Results were comparable for sCT and CT images in both dosimetric and geometric evaluation, for both patients with and without anatomical anomalies. Thus, MRI Planner is feasible to use for radiotherapy treatment planning of brain tumours.
... One possibility would be to independently measure susceptibility-induced distortions and gradient nonlinearity distortions, calculating a resulting deformation field, and applying this deformation field to the PCT, creating a new dose distribution. Recent studies that investigated the dosimetric effect of distortions found a deviation < 2% [88, [119][120][121][122]. ...
Thesis
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The importance of magnetic resonance imaging (MRI) for radiotherapy has increased steadily over the last few years. In contrast to CT images, MR images offer superior soft-tissue contrast, which is a decisive advantage, for example during treatment planning of brain tumors. While CT images provide geometrically exact images of the patient’s anatomy, there are many possible error sources that can influence the geometric accuracy of MRI images. These error sources are largely based on fundamental physical processes that are also responsible for the signal generation. Therefore, these errors can never be eliminated completely. However, errors can be reduced to a minimum by careful selection of the acquisition parameters. The first part of this thesis gives a detailed overview of the requirements for MRIs to be used for radiotherapy planning. In addition, parameters are introduced whose optimization results in a significant improvement in geometric accuracy. Also, the possible advantages and methods of generating synthetic CTs from MR images are briefly presented, thus creating a workflow based only on MR images. In the second part, a common source of error is examined in more detail, which is susceptibility-induced distortions. For this purpose, an additional sequence was used to measure the distortions in treatment planning MRIs for brain irradiation. These were evaluated for different organs at risk (OARs). The influence of magnetic field strength and type of shimming on the distortions was also investigated. Based on the distortions found, recommendations for the creation of planning organ at risk volumes (PRVs) are developed. In the last part, a guide for the implementation of a dedicated radiotherapy treatment planning MRI is given. Optimized protocols for pelvis and brain measurements as well as optimized positioning and coil setups are presented.
... These artifacts are higher with an increase in field strength used in modern MRI [28]. The distortions in MRI has been shown to result in errors of dosimetric replication in prostate [29] and also in other sites [30]. The lack of electron density information in MRI necessitates fusion of MRI with a CT scan for radiotherapy planning. ...
Article
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Purpose: The standard imaging used for delineation of dominant intraprostatic lesion (DIL) is multiparametric MRI (mpMRI). The use of biologic imaging such as Ga-68 prostate-specific membrane antigen (PSMA) PET-computed tomography (PET-CT) for this purpose is being explored in view of increased sensitivity of this modality and the associated ease of delineation. Materials and methods: The primary objective of the study was to compare the autogenerated volumes of the DIL in Ga-68 PSMA PET-CT with the standard volume delineated in mpMRI. Twenty patients with biopsy-proven untreated prostatic adenocarcinoma were included. Multiple percentages of the maximum standardized uptake value (%SUVmax) were used to autogenerate DIL volumes in Ga-68 PSMA PET-CT and these volumes were numerically matched with the consensus DIL volume in mpMRI. PSMA tumor volume (PSMA-TV) and total lesion PSMA (TL-PSMA) were also calculated for each lesion. Results: Median volume of DIL in mpMRI was 4 cm (interquartile range, IQR = 2.5-7.6 cm). The IQR for interobserver variability was 0.5-2.5 cm. Median SUVmax of the DIL was 14.1 (IQR = 10.2-22.3). Median %SUVmax corresponding to mpMRI volume was 41% of SUVmax (IQR = 34-55%). There was a strong negative correlation between MRI volume and %SUVmax (r = -0.829, P < 0.001). There was a significant correlation between TL-PSMA and prostate-specific antigen (r = 0.609, P = 0.004). Conclusions: The median DIL volume was 4 cm and median %SUVmax corresponding to MR volume of DIL was 41%. A strong inverse relationship is found between mpMRI-defined DIL volume and the %SUVmax which generates similar volume in Ga-68 PSMA PET-CT. TL-PSMA could be a quantitative biomarker for tumor load and prognosis.
... The intra-patient variation is a crucial indication for whether B 0 maps should be acquired for each treatment fraction to be relevant, or if a single map at the first treatment is sufficient. To address the consequences of the distortion level for the treatment the dosimetric effect should also be evaluated [25]. ...
Article
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Magnetic resonance imaging (MRI) has exquisite soft-tissue contrast and is the foundation for image guided radiotherapy (IGRT) with integrated magnetic resonance linacs. However, MRI suffers from geometrical distortions. In this study the MRI system- and patient-induced geometric distortion at four different tumor-sites was investigated: adrenal gland (7 patients), liver (4 patients), pancreas (6 patients), prostate (20 patients). Maximum level of total distortion within the gross-tumor-volume (GTV) was 0.96 mm with no significant difference between abdominal patients (adrenal gland, liver, pancreas) and pelvic patients (prostate). Total tumor-site specific distortion depended on location in the field-of-view and increased with the distance to MRI iso-center.
... GE Healthcare, Chicago, Illinois, USA). The MR-QA was performed according to clinical practice during the study, which included a monthly geometric distortion check using a large field of view (FoV) phantom (GRADE, Spectronic Medical AB, Helsingborg, Sweden) [23,24]. ...
Article
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Background: Retrospective studies on MRI-only radiotherapy have been presented. Widespread clinical implementations of MRI-only workflows are however limited by the absence of guidelines. The MR-PROTECT trial presents an MRI-only radiotherapy workflow for prostate cancer using a new single sequence strategy. The workflow incorporated the commercial synthetic CT (sCT) generation software MriPlanner™ (Spectronic Medical, Helsingborg, Sweden). Feasibility of the workflow and limits for acceptance criteria were investigated for the suggested workflow with the aim to facilitate future clinical implementations. Methods: An MRI-only workflow including imaging, post imaging tasks, treatment plan creation, quality assurance and treatment delivery was created with questionnaires. All tasks were performed in a single MR-sequence geometry, eliminating image registrations. Prospective CT-quality assurance (QA) was performed prior treatment comparing the PTV mean dose between sCT and CT dose-distributions. Retrospective analysis of the MRI-only gold fiducial marker (GFM) identification, DVH- analysis, gamma evaluation and patient set-up verification using GFMs and cone beam CT were performed. Results: An MRI-only treatment was delivered to 39 out of 40 patients. The excluded patient was too large for the predefined imaging field-of-view. All tasks could successfully be performed for the treated patients. There was a maximum deviation of 1.2% in PTV mean dose was seen in the prospective CT-QA. Retrospective analysis showed a maximum deviation below 2% in the DVH-analysis after correction for rectal gas and gamma pass-rates above 98%. MRI-only patient set-up deviation was below 2 mm for all but one investigated case and a maximum of 2.2 mm deviation in the GFM-identification compared to CT. Conclusions: The MR-PROTECT trial shows the feasibility of an MRI-only prostate radiotherapy workflow. A major advantage with the presented workflow is the incorporation of a sCT-generation method with multi-vendor capability. The presented single sequence approach are easily adapted by other clinics and the general implementation procedure can be replicated. The dose deviation and the gamma pass-rate acceptance criteria earlier suggested was achievable, and these limits can thereby be confirmed. GFM-identification acceptance criteria are depending on the choice of identification method and slice thickness. Patient positioning strategies needs further investigations to establish acceptance criteria.
Article
The purpose of this study was to develop a method enabling synthetic computed tomography (sCT) generation of the whole abdomen using magnetic resonance imaging (MRI) scans of pediatric patients with abdominal tumors. The proposed method relies on an automatic atlas-based segmentation of bone and lungs followed by an MRI intensity to synthetic Hounsfield unit conversion. Separate conversion algorithms were used for bone, lungs and soft-tissue. Rigidly registered CT and T2-weighted MR images of 30 patients in treatment position and with the same field of view were used for the evaluation of the atlas and the conversion algorithms. The dose calculation accuracy of the generated sCTs was verified for volumetric modulated arc therapy (VMAT) and pencil beam scanning (PBS). VMAT and PBS plans were robust optimized on an internal target volume (ITV) against a patient set-up uncertainty of 5 mm. Average differences between CT and sCT dose calculations for the ITV V 95% were 0.5% (min 0.0%; max 5.0%) and 0.0% (min -0.1%; max 0.1%) for VMAT and PBS dose distributions, respectively. Average differences for the mean dose to the organs at risk were <0.2% (min -0.6%; max 1.2%) and <0.2% (min -2.0%; max 2.6%) for VMAT and PBS dose distributions, respectively. Results show that MRI-only photon and proton dose calculations are feasible for children with abdominal tumors.
Article
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Purpose MRI‐based treatment planning is a promising technique for liver stereotactic‐body radiation therapy (SBRT) treatment planning to improve target volume delineation and reduce radiation dose to normal tissues. MR geometric distortion, however, is a source of potential error in MRI‐based treatment planning. The aim of this study is to investigate dosimetric uncertainties caused by MRI geometric distortion in MRI‐based treatment planning for liver SBRT. Materials and Methods The study was conducted using computer simulations. 3D MR geometric distortion was simulated using measured data in the literature. Planning MR images with distortions were generated by integrating the simulated 3D MR geometric distortion onto planning CT images. MRI‐based treatment plans were then generated on the planning MR images with two dose calculation methods: (1) using original CT numbers; and (2) using organ‐specific assigned CT numbers. Dosimetric uncertainties of various dose‐volume‐histogram parameters were determined as their differences between the simulated MRI‐based plans and the original clinical CT‐based plans for five liver SBRT cases. Results The average simulated distortion for the five liver SBRT cases was 2.77 mm. In the case of using original CT numbers for dose calculation, the average dose uncertainties for target volumes and critical structures were <0.5 Gy, and the average target volume percentage at prescription dose uncertainties was 0.97%. In the case of using assigned CT numbers, the average dose uncertainties for target volumes and critical structures were <1.0 Gy, and the average target volume percentage at prescription dose uncertainties was 2.02%. Conclusions Dosimetric uncertainties caused by MR geometric distortion in MRI‐based liver SBRT treatment planning was generally small (<1 Gy) when the distortion is 3 mm.
Thesis
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Article
In this article we aim to introduce the main considerations in integrating magnetic resonance imaging (MRI) into the radiotherapy workflow. We will cover the use of MRI for improved delineation, considerations regarding MRI-only workflows, and the potential of functional imaging techniques. The challenges of implementing each of these will be discussed to ensure safe usage in radiotherapy.
Article
In a radiation therapy workflow based on Magnetic Resonance Imaging (MRI), dosimetric errors may arise due to geometric distortions introduced by MRI. The aim of this study was to quantify the dosimetric effect of system-dependent geometric distortions in an MRI-only workflow for proton therapy applied at extra-cranial sites. An approach was developed, in which computed tomography (CT) images were distorted using an MRI displacement map, which represented the MR distortions in a spoiled gradient-echo sequence due to gradient nonlinearities and static magnetic field inhomogeneities. A retrospective study was conducted on 4DCT/MRI digital phantoms and 18 4DCT clinical datasets of the thoraco-abdominal site. The treatment plans were designed and separately optimized for each beam in a beam specific Planning Target Volume on the distorted CT, and the final dose distribution was obtained as the average. The dose was then recalculated in undistorted CT using the same beam geometry and beam weights. The analysis was performed in terms of Dose Volume Histogram (DVH) parameters. No clinically relevant dosimetric impact was observed on organs at risk, whereas in the target structure, geometric distortions caused statistically significant variations in the planned dose DVH parameters and dose homogeneity index (DHI). The dosimetric variations in the target structure were smaller in abdominal cases (ΔD2%, ΔD98%, and ΔDmean all below 0.1% and ΔDHI below 0.003) compared to the lung cases. Indeed, lung patients with tumors isolated inside lung parenchyma exhibited higher dosimetric variations (ΔD2% ≥ 0.3%, ΔD98% ≥ 15.9%, ΔDmean ≥ 3.3% and ΔDHI ≥ 0.102) than lung patients with tumor close to soft tissue (ΔD2% ≤ 0.4%, ΔD98% ≤ 5.6%, ΔDmean ≤ 0.9% and ΔDHI ≤ 0.027) potentially due to higher density variations along the beam path. Results suggest the potential applicability of MRI-only proton therapy, provided that specific analysis is applied for isolated lung tumors.
Thesis
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A workflow based solely on MRI images for prostate radiotherapy planning eliminates the need for CT imaging and CT/MRI image registration. The density map required for the calculation of absorbed dose is generated from MRI data providing a synthetic CT image. This is referred to as an MRI-only workflow. Geometric distortion can occur in MRI images, and will thus be propagated in the synthetic CT images. This can lead to errors in target delineation and an undesirable dosimetric impact. Gold fiducial markers are implanted in the prostate for treatment target positioning. These markers have excellent visibility in CT images, but are difficult to detect using MRI. These issues must be investigated and resolved before an MRI-only workflow can be clinically implemented. A method has been developed to investigate the dosimetric implications and impact on structure delineation from MRI-system-related geometric distortion. The method was applied to an MRI acquisition sequence, designed specifically for synthetic CT generation. No clinically relevant dose difference (≤ 0.02%) or structural deformation (< 0.5 mm) was found when a 3D distortion correction was applied and a high acquisition bandwidth was used. Synthetic CT images of the male pelvis were generated using dedicated MRI acquisition sequences and commercially available software. The dosimetric accuracy and clinical robustness of the software were evaluated in a multicenter/multivendor setting. Synthetic CT generation was found to be possible with a variety of MRI systems, and radiotherapy treatment techniques, with minimal overall mean dose differences (< 0.3%) compared to CT. To resolve the problem of poor visibility and detection of gold fiducial markers in MRI images, a multi-echo gradient echo acquisition sequence was developed, optimized and validated. Gold fiducial markers could then be reliably identified, with 99% detection accuracy. An MRI-independent method was developed and evaluated to confirm the location of the identified gold fiducial markers. All the fiducial markers were confirmed to have been correctly identified. The method takes advantage of an X-ray image acquired during insertion of the gold fiducial markers, prior to radiotherapy. No additional imaging was therefore required for this independent quality control step. The methods developed and presented in this thesis can facilitate a clinically feasible and safe implementation of an MRI-only prostate radiotherapy workflow.
Article
Magnetic Resonance has become a standard imaging modality for target volume delineation and treatment planning in radiation oncology. Geometric distortions, however, have the potential to detrimentally affect both tumour definition and the dose delivered to the target volume. We report the design, fabrication and imaging of a 3D printed unibody MR distortion phantom along with quantitative image analysis. Methods: The internal cavity of the phantom is an orthogonal three-dimensional planar lattice, composed of 3mm diameter rods spaced equidistantly at a 20mm centre-centre offset repeating along the X, Y and Z axes. The phantom featured an overall length of 308.5 mm, a width of 246 mm and a height of 264 mm with lines on the external surface for phantom positioning matched to external lasers. The MR phantom was 3D printed in Nylon-12 using an advancement on traditional selective laser sintering (SLS) (HP Jet Fusion 3D - 4200 machine). The phantom was scanned on a Toshiba Aquilion CT scanner to check the integrity of the 3D print and to correct for any resultant issues. The phantom was then filled with NiSO4 solution and scanned on a 3T PET-MR Siemens scanner for selected T1 and T2 sequences, from which distortion vectors were generated and analysed using in-house software written in Python. Results: All deviations were less than 1 mm, with an average displacement of 0.228 mm. The majority of the deviations are smaller than the 0.692 mm pixel size for this dataset. Conclusion: A cost-effective, 3D printed MRI-phantom was successfully printed and tested for assessing geometric distortion on MRI scanners. The custom phantom with markings for phantom alignment may be considered for radiotherapy departments looking to add MR scanners for simulation and image guidance.
Article
Objective Inversion recovery-pointwise encoding time reduction with radial acquisition (IR-PETRA) is an effective magnetic resonance (MR) pulse sequence in generating pseudo-CTs. The hardware-related spatial-distortion (HRSD) in MR images potentially deteriorates the accuracy of pseudo-CTs. Thus, we aimed at characterizing HRSD for IR-PETRA.Materials and methodsgross-HRSDoverall (Euclidean-sum of gross-HRSDi (i = x, y, z)) for IR-PETRA was assessed using a brain-specific phantom for two MR scanners (1.5 T-Aera and 3.0 T-Prisma). Moreover, hardware imperfections were analyzed by determining gradient-nonlinearity spatial-distortion (GNSD) and B0-inhomogeneity spatial-distortion (B0ISD) for magnetization-prepared rapid acquisition gradient-echo (MP-RAGE) which has well-known distortion characteristics.ResultsIn 3.0 T, maximum of gross-GNSDoverall (Euclidean-sum of gross-GNSDi) and gross-B0ISD for MP-RAGE was 2.77 mm and 0.57 mm, respectively. For this scanner, the mean and maximum of gross-HRSDoverall for IR-PETRA were 0.63 ± 0.38 mm and 1.91 mm, respectively. In 1.5 T, maximum of gross-GNSDoverall and gross-B0ISD for MP-RAGE was 3.41 mm and 0.78 mm, respectively. The mean and maximum of gross-HRSDoverall for IR-PETRA were 1.02 ± 0.50 mm and 3.12 mm, respectively.DiscussionThe spatial accuracy of MR images, besides being impacted by hardware performance, scanner capabilities, and imaging parameters, is mainly affected by its imaging strategy and data acquisition scheme. In 3.0 T, even without applying vendor correction algorithms, spatial accuracy of IR-PETRA image is sufficient for generating pseudo-CTs. In 1.5 T, distortion-correction is required to provide this accuracy.
Article
Purpose: The importance of 4D-MRI is increasing in guiding online plan adapta-tion in thoracic and abdominal radiotherapy. Many 4D-MRI sequences are based on multi-slice 2D acquisitions which provide contrast exibility. Intrinsic to MRI, how-ever, are machine- and subject-related geometric image distortions. Full correction of slice-based 4D-MRIs acquired on the Unity MR-linac (Elekta AB, Stockholm, Sweden) is challenging, since through-plane corrections are currently not available for 2D sequences. In this study we implement a full 3D correction and quantify the geometric and dosimetric effects of machine-related (residual) geometric image distortions. Methods: A commercial 3D geometric QA phantom (Philips, Best, The Netherlands) was used to quantify the effect of gradient non-linearity (GNL) and static-field inhomogeneity (B0I) on geometric accuracy. Additionally, the effectiveness of 2D (in-plane, machine-generic), 3D (machine-generic), and in-house developed 3D+ (machine-specific) corrections was investigated. Corrections were based on deformable vector fields derived from spherical harmonics coefficients. Three patients with oligometas-tases in the liver were scanned with axial 4D-MRIs on our MR-linac (total: 10 imaging sessions). For each patient, a step-and-shoot IMRT plan (3x20 Gy) was created based on the simulation mid-position (midP)-CT. The 4D-MRIs were then warped into a daily midP-MRI and geometrically corrected. Next, the treatment plan was adapted according to the position offset of the tumour between midP-CT and the 3D-corrected midP-MRIs. The midP-CT was also deformably registered to the daily midP-MRIs (different corrections applied) to quantify the dosimetric effects of (residual) geometric image distortions. Results: Using phantom data, median GNL distortions were 0.58 mm (no correction), 0.42{48 mm (2D), 0.34 mm (3D), and 0.34 mm (3D+), measured over a diameter of spherical volume (DSV) of 200 mm. Median B0I distortions were 0.09 mm for the same DSV. For DSVs up to 500 mm, through-plane corrections are necessary to keep the median residual GNL distortion below 1 mm. 3D and 3D+ corrections agreed within 0.15 mm. 2D-corrected images featured uncorrected through-plane distortions of up to 21.11 mm at a distance of 20{25 cm from the machine's isocentre. Based on the 4D-MRI patient scans, the average external body contour distortions were 3.1 mm (uncorrected) and 1.2 mm (2D-corrected), with maximum local distortions of 9.5 mm in the uncorrected images. No (residual) distortions were visible for the metastases, which were all located within 10 cm of the machine's isocentre. The interquartile range (IQR) of dose di_erences between planned and daily dose caused by variable patient setup, patient anatomy, and online plan adaptation was 1.37 Gy/Fx for the PTV D95%. When comparing dose on 3D-corrected with uncorrected (2D-corrected) images the IQR was 0.61 (0.31) Gy/Fx. Conclusions: GNL is the main machine-related source of image distortions on the Unity MR-linac. For slice-based 4D-MRI, a full 3D correction can be applied after respiratory sorting to maximise spatial fidelity. The machine-specific 3D+ correction did not substantially reduce residual geometric distortions compared to the machine-generic 3D correction for our MR-linac. In our patients, dosimetric variations in the target not related to geometric distortions were larger than those caused by geometric distortions. This article is protected by copyright. All rights reserved.
Article
Purpose To create synthetic CTs and DRRs from MR images that allow for fiducial visualization and accurate dose calculation for MR-only radiosurgery. Methods We developed a machine learning model to create synthetic CTs from pelvic MRs for prostate treatments. This model has been previously proven to generate synthetic CTs with accuracy on par or better than alternate methods, such as atlas based registration. Our dataset consisted of 11 paired CT and conventional MR (T2) images used for previous CyberKnife (Accuray, Inc) radiotherapy treatments. The MR images were pre-processed to mimic the appearance of fiducial-enhancing images. Two models were trained for each parameter case, using a sub-set of the available image pairs, with the remaining images set aside for testing and validation of the model to identify the optimal patch size and number of image pairs used for training. Four models were then trained using the identified parameters and used to generate synthetic CTs, which in turn were used to generate DRRs at angles 45 and 315 degrees, as would be used for a CyberKnife treatment. The synthetic CTs and DRRs were compared visually and using the mean squared error and peak signal-to-noise ratio against the ground-truth images to evaluate their similarity. Results The synthetic CTs, as well as the DRRs generated from them, gave similar visualization of the fiducial markers in the prostate as the true counterparts. There was no significant difference found for the fiducial localization for the CTs and DRRs. Across the 8 DRRs analyzed, the mean MSE between the normalized true and synthetic DRRs was 0.66 ± 0.42% and the mean PSNR for this region was 22.88 ± 3.74 dB. For the full CTs, the mean MAE was 72.9 ± 88.1 HU and the mean PSNR was 31.23 ± 2.16 dB. Conclusions Our machine learning-based method provides a proof of concept of a way to generate synthetic CTs and DRRs for accurate dose calculation and fiducial localization for use in radiation treatment of the prostate.
Article
Purpose: To investigate the dosimetric accuracy of synthetic computed tomography (sCT) images generated by a clinically-ready voxel-based MRI simulation package, and to develop a simple and feasible method to improve the accuracy. Methods: 20 patients with brain tumor were selected to undergo CT and MRI simulation. sCT images were generated by a clinical MRI simulation package. The discrepancy between planning CT and sCT in CT number and body contour were evaluated. To resolve the discrepancies, an sCT specific CT-relative electron density (RED) calibration curve was used, and a layer of pseudo-skin was created on the sCT. The dosimetric impact of these discrepancies, and the improvement brought about by the modifications, were evaluated by a planning study. Volumetric modulated arc therapy (VMAT) treatment plans for each patient were created and optimized on the planning CT, which were then transferred to the original sCT and the modified-sCT for dose re-calculation. Dosimetric comparisons and gamma analysis between the calculated doses in different images were performed. Results: The average gamma passing rate with 1%/1 mm criteria was only 70.8% for the comparison of dose distribution between planning CT and original sCT. The mean dose difference between the planning CT and the original sCT were -1.2% for PTV D95 and -1.7% for PTV Dmax, while the mean dose difference was within 0.7 Gy for all relevant OARs. After applying the modifications on the sCT, the average gamma passing rate was increased to 92.2%. Mean dose difference in PTV D95 and Dmax were reduced to -0.1% and -0.3% respectively. The mean dose difference was within 0.2 Gy for all OAR structures and no statistically significant difference were found. Conclusions: The modified-sCT demonstrated improved dosimetric agreement with the planning CT. These results indicated the overall dosimetric accuracy and practicality of this improved MR-based treatment planning method.
Technical Report
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Key Findings: Clinical evidence of limited quality from one retrospective cohort study of patients with prostate cancer suggested that the use of magnetic resonance imaging simulation in conjunction with computed tomography simulation for treatment planning may reduce acute genitourinary toxicity compared with computed tomography simulation only. Magnetic resonance imaging use had no identified benefit for reduced acute gastrointestinal (rectal) toxicity. No relevant cost-effectiveness studies were identified on the use of magnetic resonance imaging simulators for simulation and treatment planning for patients requiring radiation therapy. No relevant evidence-based guidelines were identified for the use of magnetic resonance imaging simulators in the simulation and treatment of patients requiring radiation therapy. Given the limited availability and low quality of evidence, the effectiveness and use of magnetic resonance imaging simulators for simulation and treatment planning for patients requiring radiation therapy remains uncertain.
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The purpose of this research was to investigate the geometrical accuracy of magnetic resonance (MR) images used in the radiation therapy treatment planning for lung cancer. In this study, the capability of MR imaging to acquire dynamic two‐dimensional images was explored to access the motion of lung tumors. Due to a number of factors, including the use of a large field‐of‐view for the thorax, MR images are particularly subject to geometrical distortions caused by the inhomogeneity and gradient nonlinearity of the magnetic field. To quantify such distortions, we constructed a phantom, which approximated the dimensions of the upper thorax and included two air cavities. Evenly spaced vials containing contrast agent could be held in three directions with their cross‐sections in the coronal, sagittal, and axial planes, respectively, within the air cavities. MR images of the phantom were acquired using fast spin echo (FSE) and fast gradient echo (fGRE) sequences. The positions of the vials according to their centers of mass were measured from the MR images and registered to the corresponding computed tomography images for comparison. Results showed the fGRE sequence exhibited no errors >2.0 mm in the sagittal and coronal planes, whereas the FSE sequence produced images with errors between 2.0 and 4.0 mm along the phantom's perimeter in the axial plane. On the basis of these results, the fGRE sequence was considered to be clinically acceptable in acquiring images in all sagittal and coronal planes tested. However, the spatial accuracy in periphery of the axial FSE images exceeded the acceptable criteria for the acquisition parameters used in this study. PACS number(s): 87.57.–s, 87.61.–c
Article
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Background Magnetic resonance imaging (MRI) has been incorporated as an adjunct to CT to take advantage of its excellent soft tissue contrast for contouring. MR-only treatment planning approaches have been developed to avoid errors introduced during the MR-CT registration process. The purpose of this study is to evaluate calculated dose distributions after incorporating a novel synthetic CT (synCT) derived from magnetic resonance simulation images into prostate cancer treatment planning and to compare dose distributions calculated using three previously published MR-only treatment planning methodologies. Methods An IRB-approved retrospective study evaluated 15 prostate cancer patients that underwent IMRT (n = 11) or arc therapy (n = 4) to a total dose of 70.2-79.2 Gy. Original treatment plans were derived from CT simulation images (CT-SIM). T1-weighted, T2-weighted, and balanced turbo field echo images were acquired on a 1.0 T high field open MR simulator with patients immobilized in treatment position. Four MR-derived images were studied: bulk density assignment (10 HU) to water (MRW), bulk density assignments to water and bone with pelvic bone values derived either from literature (491 HU, MRW+B491) or from CT-SIM population average bone values (300 HU, MRW+B300), and synCTs. Plans were recalculated using fixed monitor units, plan dosimetry was evaluated, and local dose differences were characterized using gamma analysis (1 %/1 mm dose difference/distance to agreement). Results While synCT provided closest agreement to CT-SIM for D95, D99, and mean dose (<0.7 Gy (1 %)) compared to MRW, MRW+B491, and MRW+B300, pairwise comparisons showed differences were not significant (p < 0.05). Significant improvements were observed for synCT in the bladder, but not for rectum or penile bulb. SynCT gamma analysis pass rates (97.2 %) evaluated at 1 %/1 mm exceeded those from MRW (94.7 %), MRW+B300 (94.0 %), or MRW+B491 (90.4 %). One subject’s synCT gamma (1 %/1 mm) results (89.9 %) were lower than MRW (98.7 %) and MRW+B300 (96.7 %) due to increased rectal gas during MR-simulation that did not affect bulk density assignment-based calculations but was reflected in higher rectal doses for synCT. Conclusions SynCT values provided closest dosimetric and gamma analysis agreement to CT-SIM compared to bulk density assignment-based CT surrogates. SynCTs may provide additional clinical value in treatment sites with greater air-to-soft tissue ratio.
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The aims of this work were to evaluate the performance of several deformable image registration (DIR) algorithms implemented in our in-house software (NiftyReg) and the uncertainties inherent to using different algorithms for dose warping. The authors describe a DIR based adaptive radiotherapy workflow, using CT and cone-beam CT (CBCT) imaging. The transformations that mapped the anatomy between the two time points were obtained using four different DIR approaches available in NiftyReg. These included a standard unidirectional algorithm and more sophisticated bidirectional ones that encourage or ensure inverse consistency. The forward (CT-to-CBCT) deformation vector fields (DVFs) were used to propagate the CT Hounsfield units and structures to the daily geometry for "dose of the day" calculations, while the backward (CBCT-to-CT) DVFs were used to remap the dose of the day onto the planning CT (pCT). Data from five head and neck patients were used to evaluate the performance of each implementation based on geometrical matching, physical properties of the DVFs, and similarity between warped dose distributions. Geometrical matching was verified in terms of dice similarity coefficient (DSC), distance transform, false positives, and false negatives. The physical properties of the DVFs were assessed calculating the harmonic energy, determinant of the Jacobian, and inverse consistency error of the transformations. Dose distributions were displayed on the pCT dose space and compared using dose difference (DD), distance to dose difference, and dose volume histograms. All the DIR algorithms gave similar results in terms of geometrical matching, with an average DSC of 0.85 ± 0.08, but the underlying properties of the DVFs varied in terms of smoothness and inverse consistency. When comparing the doses warped by different algorithms, we found a root mean square DD of 1.9% ± 0.8% of the prescribed dose (pD) and that an average of 9% ± 4% of voxels within the treated volume failed a 2%pD DD-test (DD2%-pp). Larger DD2%-pp was found within the high dose gradient (21% ± 6%) and regions where the CBCT quality was poorer (28% ± 9%). The differences when estimating the mean and maximum dose delivered to organs-at-risk were up to 2.0%pD and 2.8%pD, respectively. The authors evaluated several DIR algorithms for CT-to-CBCT registrations. In spite of all methods resulting in comparable geometrical matching, the choice of DIR implementation leads to uncertainties in dose warped, particularly in regions of high gradient and/or poor imaging quality.
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Radiotherapy (RT) based on magnetic resonance imaging (MRI) as the only modality, so-called MRI-only RT, would remove the systematic registration error between MR and computed tomography (CT), and provide co-registered MRI for assessment of treatment response and adaptive RT. Electron densities, however, need to be assigned to the MRI images for dose calculation and patient setup based on digitally reconstructed radiographs (DRRs). Here, we investigate the geometric and dosimetric performance for a number of popular voxel-based methods to generate a so-called pseudo CT (pCT).
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Purpose: The lack of electron density information in magnetic resonance images (MRI) poses a major challenge for MRI-based radiotherapy treatment planning (RTP). In this study the authors convert MRI intensity values into Hounsfield units (HUs) in the male pelvis and thus enable accurate MRI-based RTP for prostate cancer patients with varying tissue anatomy and body fat contents. Methods: T1/T2*-weighted MRI intensity values and standard computed tomography (CT) image HUs in the male pelvis were analyzed using image data of 10 prostate cancer patients. The collected data were utilized to generate a dual model HU conversion technique from MRI intensity values of the single image set separately within and outside of contoured pelvic bones. Within the bone segment local MRI intensity values were converted to HUs by applying a second-order polynomial model. This model was tuned for each patient by two patient-specific adjustments: MR signal normalization to correct shifts in absolute intensity level and application of a cutoff value to accurately represent low density bony tissue HUs. For soft tissues, such as fat and muscle, located outside of the bone contours, a threshold-based segmentation method without requirements for any patient-specific adjustments was introduced to convert MRI intensity values into HUs. The dual model HU conversion technique was implemented by constructing pseudo-CT images for 10 other prostate cancer patients. The feasibility of these images for RTP was evaluated by comparing HUs in the generated pseudo-CT images with those in standard CT images, and by determining deviations in MRI-based dose distributions compared to those in CT images with 7-field intensity modulated radiation therapy (IMRT) with the anisotropic analytical algorithm and 360° volumetric-modulated arc therapy (VMAT) with the Voxel Monte Carlo algorithm. Results: The average HU differences between the constructed pseudo-CT images and standard CT images of each test patient ranged from -2 to 5 HUs and from 22 to 78 HUs in soft and bony tissues, respectively. The average local absolute value differences were 11 HUs in soft tissues and 99 HUs in bones. The planning target volume doses (volumes 95%, 50%, 5%) in the pseudo-CT images were within 0.8% compared to those in CT images in all of the 20 treatment plans. The average deviation was 0.3%. With all the test patients over 94% (IMRT) and 92% (VMAT) of dose points within body (lower than 10% of maximum dose suppressed) passed the 1 mm and 1% 2D gamma index criterion. The statistical tests (t- and F-tests) showed significantly improved (p ≤ 0.05) HU and dose calculation accuracies with the soft tissue conversion method instead of homogeneous representation of these tissues in MRI-based RTP images. Conclusions: This study indicates that it is possible to construct high quality pseudo-CT images by converting the intensity values of a single MRI series into HUs in the male pelvis, and to use these images for accurate MRI-based prostate RTP dose calculations.
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The process of creating MR images frequently gives rise to artifacts in the final display. Many artifacts may be corrected or ameliorated through an understanding of their cause. This requires familiarity with scanner design; theory of operation; and image acquisition, generation, and display. Some artifacts are obvious, totally degrading the image; others are regional, leaving much of the scan undisturbed. In some cases, the degradation is permanent; in others, the data can be reprocessed or manipulated to yield artifact-free images. Some artifacts are overt and easily identified. Others, such as those caused by phase-shift or gradient-strength effects, are subtle and require careful observation for detection.
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In the present work we compared the spatial uncertainties associated with a MR-based workflow for external radiotherapy of prostate cancer to a standard CT-based workflow. The MR-based workflow relies on target definition and patient positioning based on MR imaging. A solution for patient transport between the MR scanner and the treatment units has been developed. For the CT-based workflow, the target is defined on a MR series but then transferred to a CT study through image registration before treatment planning, and a patient positioning using portal imaging and fiducial markers. An "open bore" 1.5T MRI scanner, Siemens Espree, has been installed in the radiotherapy department in near proximity to a treatment unit to enable patient transport between the two installations, and hence use the MRI for patient positioning. The spatial uncertainty caused by the transport was added to the uncertainty originating from the target definition process, estimated through a review of the scientific literature. The uncertainty in the CT-based workflow was estimated through a literature review. The systematic uncertainties, affecting all treatment fractions, are reduced from 3-4 mm (1Sd) with a CT based workflow to 2-3 mm with a MR based workflow. The main contributing factor to this improvement is the exclusion of registration between MR and CT in the planning phase of the treatment. Treatment planning directly on MR images reduce the spatial uncertainty for prostate treatments.
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We present the detailed planning and execution of the Insight Toolkit (ITK), an application programmers interface (API) for the segmentation and registration of medical image data. This public resource has been developed through the NLM Visible Human Project, and is in beta test as an open-source software offering under cost-free licensing. The toolkit concentrates on 3D medical data segmentation and registration algorithms, multimodal and multiresolution capabilities, and portable platform independent support for Windows, Linux/Unix systems. This toolkit was built using current practices in software engineering. Specifically, we embraced the concept of generic programming during the development of these tools, working extensively with C++ templates and the freedom and flexibility they allow. Software development tools for distributed consortium-based code development have been created and are also publicly available. We discuss our assumptions, design decisions, and some lessons learned.
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The purpose of this study is to evaluate the dosimetric accuracy of MRI-based treatment planning for prostate cancer using a commercial radiotherapy treatment planning system. Three-dimensional conformal plans for 15 prostate patients were generated using the AcQPlan system. For each patient, dose distributions were calculated using patient CT data with and without heterogeneity correction, and using patient MRI data without heterogeneity correction. MR images were post-processed using the gradient distortion correction (GDC) software. The distortion corrected MR images were fused to the corresponding CT for each patient for target and structure delineation. The femoral heads were delineated based on CT. Other anatomic structures relevant to the treatment (i.e., prostate, seminal vesicles, lymph notes, rectum and bladder) were delineated based on MRI. The external contours were drawn separately on CT and MRI. The same internal contours were used in the dose calculation using CT- and MRI-based geometries by directly transferring them between MRI and CT as needed. Treatment plans were evaluated based on maximum dose, isodose distributions and dose-volume histograms. The results confirm previous investigations that there is no clinically significant dose difference between CT-based prostate plans with and without heterogeneity correction. The difference in the target dose between CT- and MRI-based plans using homogeneous geometry was within 2.5%. Our results suggest that MRI-based treatment planning is suitable for radiotherapy of prostate cancer.
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MR images are known to be distorted because of both gradient nonlinearity and imperfections in the B0 field, the latter caused either by an imperfect shim or sample-induced distortions. This paper describes in detail a method for correcting the gradient warp distortion, based on a direct field mapping using a custom-built phantom with three orthogonal grids of fluid-filled rods. The key advance of the current work over previous contributions is the large volume of the mapping phantom and the large distortions (>25 mm) corrected, making the method suitable for use with large field of view, extra-cranial images. Experimental measurements on the Siemens AS25 gradient set, as installed on a Siemens Vision scanner, are compared with a theoretical description of the gradient set, based on the manufacturer's spherical harmonic coefficients. It was found that over a volume of 320x200x340 mm3 distortions can be successfully mapped to within the voxel resolution of the raw imaging data, whilst outside this volume, correction is still good but some systematic errors are present. The phenomenon of through-plane distortion (also known as 'slice warp') is examined in detail, and the perturbation it causes to the measurements is quantified and corrected. At the very edges of the region of support provided by the phantom, through-plane distortion is extreme and only partially corrected by the present method. Solutions to this problem are discussed. Both phantom and patient data demonstrate the efficacy of the gradient warp correction.
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Radiotherapy treatment planning relies on the use of geometrically correct images. This paper presents a fully automatic tool for correcting MR images for the effects of B(0) inhomogeneities. The post-processing method is based on the gradient-reversal technique of Chang and Fitzpatrick (1992 IEEE Trans. Med. Imaging 11 319-29) which combines two identical images acquired with a forward- and a reversed read gradient. This paper demonstrates how maximization of mutual information for registration of forward and reverse read gradient images allows the elimination of user interaction for the correction. Image quality is preserved to a degree not reported previously.
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The purpose of this study was to evaluate distortion-corrected MRI as a radiotherapy planning tool for prostate cancer and the resultant implications for dose sparing of organs at risk. 11 men who were to be treated with radical conformal radiotherapy for localized prostate cancer had an MRI scan under radiotherapy planning conditions, which was corrected for geometric distortion. Radiotherapy plans were created for planning target volumes derived from the MRI- and CT-defined prostate. Dose volume histograms were produced for the rectum, bladder and penile bulb. The mean volume of the prostate as defined on CT and MRI was 41 cm3 and 36 cm3, respectively (p = 0.009). The predicted percentage of the rectum treated to dose levels of 45-65 Gy was significantly lower for plans delineating the prostate with MRI than for those with CT. The rectal-sparing effect was confined to the lowermost 4 cm of the rectum (anal canal). There were no differences between the predicted doses to bladder or penile bulb (as defined using MRI) between plans. In conclusion, prostate radiotherapy planning based on distortion-corrected MRI is feasible and results in a smaller target volume than does CT. This leads to a lower predicted proportion of the rectum, in particular the lower rectum (anal canal), treated to a given dose than with CT.
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The purpose of this research was to investigate the geometrical accuracy of magnetic resonance (MR) images used in the radiation therapy treatment planning for lung cancer. In this study, the capability of MR imaging to acquire dynamic two-dimensional images was explored to access the motion of lung tumors. Due to a number of factors, including the use of a large field-of-view for the thorax, MR images are particularly subject to geometrical distortions caused by the inhomogeneity and gradient nonlinearity of the magnetic field. To quantify such distortions, we constructed a phantom, which approximated the dimensions of the upper thorax and included two air cavities. Evenly spaced vials containing contrast agent could be held in three directions with their cross-sections in the coronal, sagittal, and axial planes, respectively, within the air cavities. MR images of the phantom were acquired using fast spin echo (FSE) and fast gradient echo (fGRE) sequences. The positions of the vials according to their centers of mass were measured from the MR images and registered to the corresponding computed tomography images for comparison. Results showed the fGRE sequence exhibited no errors >2.0 mm in the sagittal and coronal planes, whereas the FSE sequence produced images with errors between 2.0 and 4.0 mm along the phantom's perimeter in the axial plane. On the basis of these results, the fGRE sequence was considered to be clinically acceptable in acquiring images in all sagittal and coronal planes tested. However, the spatial accuracy in periphery of the axial FSE images exceeded the acceptable criteria for the acquisition parameters used in this study.
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Purpose:To quantify the effect of MR-only treatment planning on dose distributions for prostate cancer for the clinical validation of MR-only workflow. Methods:For pre-clinical validation of the MR workflow where five-value stratified synthetic CT (Magnetic Resonance for Calculating Attenuation (MRCAT) algorithm Philips Ingenia 3.0T) are used for dose calculation instead of CT we (1) converted conventional 12-bit CT scans to five-value stratified CT and (2) applied the measured geometric distortions (deformation vector field measured with a dedicated phantom) from the MR scanner to the CT scans of 10 patients to quantify the effect on dose to target and organs-at-risk (OAR) for IMAT prostate plans. For the clinical validation we calculated the gamma index of the 3D dose distribution for MR-only and conventional CT dose calculations for the same patient. Results:Five-value perturbed CT and conventional CT dose distributions were equivalent. No difference was observed for DVH-parameters for standard CT compared to five-value CT with MR distortion vector field applied. DVH-parameters were generally higher for five-density CT/CT dose calculations; PTV mean dose was 100.5% compared to 100% for CT-based plans. For rectum the effect of CT HU histogram reduction on the mean dose and D2cc was not significant (rectum Dmean_CT=31.2 Gy, rectum Dmean_5valCT=31.6 Gy). MR-only compared to CT 3D dose distribution 3D gamma analysis (1mm/2%) pass rates were >95% except for one patient (92%) in the 50% and 90% isodose volumes. Conclusion:Synthetic CT dose distributions are equivalent to CT for OARs and slightly overestimate the dose to the target. The differences due to the simplified CT composition and deformation are small. 3D gamma analysis (1mm/2%) pass rates for MR-only dose distributions compared to CT are >95% for comparable organ filling at both scans.
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Because magnetic resonance imaging-guided radiotherapy (MRIgRT) offers exquisite soft tissue contrast and the ability to image tissues in arbitrary planes, the interest in this technology has increased dramatically in recent years. However, intrinsic geometric distortion stemming from both the system hardware and the magnetic properties of the patient affects MR images and compromises the spatial integrity of MRI-based radiation treatment planning, given that for real-time MRIgRT, precision within 2 mm is desired. In this article, we discuss the causes of geometric distortion, describe some well-known distortion correction algorithms, and review geometric distortion measurements from 12 studies, while taking into account relevant imaging parameters. Eleven of the studies reported phantom measurements quantifying system-dependent geometric distortion, while two studies reported simulation data quantifying magnetic susceptibility-induced geometric distortion. Of the 11studies investigating system-dependent geometric distortion, 5 reported maximum measurements less than 2 mm. The simulation studies demonstrated that magnetic susceptibility-induced distortion is typically smaller than system-dependent distortion but still nonnegligible, with maximum distortion ranging from 2.1 to 2.6 mm at a field strength of 1.5 T. As expected, anatomic landmarks containing interfaces between air and soft tissue had the largest distortions. The evidence indicates that geometric distortion reduces the spatial integrity of MRI-based radiation treatment planning and likely diminishes the efficacy of MRIgRT. Better phantom measurement techniques and more effective distortion correction algorithms are needed to achieve the desired spatial precision.
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One of the major issues potentially limiting treatment planning with solely MR images is the possibility of geometric distortion inherent in MR images. We designed a large distortion phantom containing a 3D array of spheres and proposed a three-dimensional (3D) approach to determine the distortion of MR image volume. The approach to overcome partially filled spheres is also presented. The phantom was assembled with a 3D array of spheres filled with contrast and was scanned with a 3T MRI simulator. A 3D whole-sphere or half-sphere template is used to match the image pattern. The half-sphere template is used when the normalized cross-correlation value for the whole-sphere template is below a predetermined threshold. Procrustes method was applied to remove the shift induced by rotation and translation of the phantom. Then the distortion map was generated. Accuracy of the method was verified using CT images of a small phantom of the same design. The analysis of the small phantom showed that the method is accurate with an average offset of estimated sphere center 0.12 ± 0.04 mm. The Procrustes analysis estimated the rotation angle to be 1.95° and 0.01°, respectively, when the phantom was placed at 2° and 0° from the ceiling laser. The analysis showed that on the central plane through the magnet center, the average displacement is less than 1 mm for all radii. At distal planes, when the radius is less than 18 cm, the average displacement is less than 1 mm. However, the average displacement is over 1 mm but still less than 1.5 mm for larger radii. A large distortion phantom was assembled and analysis software was developed to characterize distortions in MRI scans. The use of two templates helps reduce the potential impact of residual air bubbles in some of the spheres.
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Purpose: In order to enable a magnetic resonance imaging (MRI) only workflow in radiotherapy treatment planning, methods are required for generating Hounsfield unit (HU) maps (i.e., synthetic computed tomography, sCT) for dose calculations, directly from MRI. The Statistical Decomposition Algorithm (SDA) is a method for automatically generating sCT images from a single MR image volume, based on automatic tissue classification in combination with a model trained using a multimodal template material. This study compares dose calculations between sCT generated by the SDA and conventional CT in the male pelvic region.
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To develop and validate a large field of view phantom and quality assurance software tool for the assessment and characterization of geometric distortion in MRI scanners commissioned for Radiation Therapy planning. A purpose built phantom was developed consisting of 357 rods (6 mm in diameter) of polymethyl-methacrylat separated by 20 mm intervals, providing a three dimensional array of control points at known spatial locations covering a large field of view up to a diameter of 420mm.An in-house software module was developed to allow automatic geometric distortion assessment. This software module was validated against a virtual dataset of the phantom that reproduced the exact geometry of the physical phantom, but with known translational and rotational displacements and warping. For validation experiments, clinical MRI sequences were acquired with and without the application of a commercial 3D distortion correction algorithm (Gradwarp(TM) ). The software module was used to characterize and assess system related geometric distortion in the sequences relative to a benchmark CT dataset, and the efficacy of the vendor Geometric Distortion Correction algorithms (GDC) was also assessed. Results issued from the validation of the software against virtual images demonstrate the algorithm's ability to accurately calculate geometric distortion with sub-pixel precision by the extraction of rods and quantization of displacements. Geometric distortion was assessed for the typical sequences used in Radiotherapy applications and over a clinically relevant 420mm Field of View (FOV). As expected and towards the edges of the Field Of View (FOV), distortion increased with increasing FOV. For all assessed sequences, the vendor GDC was able to reduce the mean distortion to below 1 mm over a field of view of 5, 10, 15 and 20 cm radius respectively. Results issued from the application of the developed phantoms and algorithms demonstrate a high level of precision. The results indicate that this platform represents an important, robust and objective tool to perform routine quality assurance of MR guided therapeutic applications, where spatial accuracy is paramount. Copyright © 2015 Elsevier Inc. All rights reserved.
Article
Purpose: Accurate geometry is required for radiotherapy treatment planning (RTP). When considering the use of magnetic resonance imaging (MRI) for RTP, geometric distortions observed in the acquired images should be considered. While scanner technology and vendor supplied correction algorithms provide some correction, large distortions are still present in images, even when considering considerably smaller scan lengths than those typically acquired with CT in conventional RTP. This study investigates MRI acquisition with a moving table compared with static scans for potential geometric benefits for RTP.
Article
To clinically implement MRI simulation or MRI-alone treatment planning requires comprehensive end-to-end testing to ensure an accurate process. The purpose of this study was to design and build a geometric phantom simulating a human male pelvis that is suitable for both CT and MRI scanning and use it to test geometric and dosimetric aspects of MRI simulation including treatment planning and digitally reconstructed radiograph (DRR) generation. A liquid filled pelvic shaped phantom with simulated pelvic organs was scanned in a 3T MRI simulator with dedicated radiotherapy couch-top, laser bridge and pelvic coil mounts. A second phantom with the same external shape but with an internal distortion grid was used to quantify the distortion of the MR image. Both phantoms were also CT scanned as the gold-standard for both geometry and dosimetry. Deformable image registration was used to quantify the MR distortion. Dose comparison was made using a seven-field IMRT plan developed on the CT scan with the fluences copied to the MR image and recalculated using bulk electron densities. Without correction the maximum distortion of the MR compared with the CT scan was 7.5 mm across the pelvis, while this was reduced to 2.6 and 1.7 mm by the vendor's 2D and 3D correction algorithms, respectively. Within the locations of the internal organs of interest, the distortion was <1.5 and <1 mm with 2D and 3D correction algorithms, respectively. The dose at the prostate isocentre calculated on CT and MRI images differed by 0.01% (1.1 cGy). Positioning shifts were within 1 mm when setup was performed using MRI generated DRRs compared to setup using CT DRRs. The MRI pelvic phantom allows end-to-end testing of the MRI simulation workflow with comparison to the gold-standard CT based process. MRI simulation was found to be geometrically accurate with organ dimensions, dose distributions and DRR based setup within acceptable limits compared to CT.
Article
Purpose: In radiotherapy (RT) based on magnetic resonance imaging (MRI) as the only modality, the information on electron density must be derived from the MRI scan by creating a so-called pseudo computed tomography (pCT). This is a nontrivial task, since the voxel-intensities in an MRI scan are not uniquely related to electron density. To solve the task, voxel-based or atlas-based models have typically been used. The voxel-based models require a specialized dual ultrashort echo time MRI sequence for bone visualization and the atlas-based models require deformable registrations of conventional MRI scans. In this study, we investigate the potential of a patch-based method for creating a pCT based on conventional T1-weighted MRI scans without using deformable registrations. We compare this method against two state-of-the-art methods within the voxel-based and atlas-based categories. Methods: The data consisted of CT and MRI scans of five cranial RT patients. To compare the performance of the different methods, a nested cross validation was done to find optimal model parameters for all the methods. Voxel-wise and geometric evaluations of the pCTs were done. Furthermore, a radiologic evaluation based on water equivalent path lengths was carried out, comparing the upper hemisphere of the head in the pCT and the real CT. Finally, the dosimetric accuracy was tested and compared for a photon treatment plan. Results: The pCTs produced with the patch-based method had the best voxel-wise, geometric, and radiologic agreement with the real CT, closely followed by the atlas-based method. In terms of the dosimetric accuracy, the patch-based method had average deviations of less than 0.5% in measures related to target coverage. Conclusions: We showed that a patch-based method could generate an accurate pCT based on conventional T1-weighted MRI sequences and without deformable registrations. In our evaluations, the method performed better than existing voxel-based and atlas-based methods and showed a promising potential for RT of the brain based only on MRI.
Article
Purpose: Magnetic resonance imaging (MRI) is gaining widespread use in radiation therapy planning, patient setup verification, and real-time guidance of radiation delivery. Successful implementation of these technologies relies on the development of simple and efficient methods to characterize and monitor the geometric distortions arising due to system imperfections and gradient nonlinearities. To this end, the authors present the theory and validation of a novel harmonic approach to the quantification of system-related distortions in MRI. Methods: The theory of spatial encoding in MRI is applied to demonstrate that the 3D distortion vector field (DVF) is given by the solution of a second-order boundary value problem (BVP). This BVP is comprised of Laplace's equation and a limited measurement of the distortion on the boundary of a specified region of interest (ROI). An analytical series expansion solving this BVP within a spherical ROI is obtained, and a statistical uncertainty analysis is performed to determine how random errors in the boundary measurements propagate to the ROI interior. This series expansion is then evaluated to obtain volumetric DVF mappings that are compared to reference data obtained on a 3 T full-body scanner. This validation is performed within two spheres of 20 cm diameter (one centered at the scanner origin and the other offset +3 cm along each of the transverse directions). Initially, a high-order mapping requiring measurements at 5810 boundary points is used. Then, after exploring the impact of the boundary sampling density and the effect of series truncation, a reduced-order mapping requiring measurements at 302 boundary points is evaluated. Results: The volumetric DVF mappings obtained from the harmonic analysis are in good agreement with the reference data. Following distortion correction using the high-order mapping, the authors estimate a reduction in the mean distortion magnitude from 0.86 to 0.42 mm and from 0.93 to 0.39 mm within the central and offset ROIs, respectively. In addition, the fraction of points with a distortion magnitude greater than 1 mm is reduced from 35.6% to 2.8% and from 40.4% to 1.5%, respectively. Similarly, following correction using the reduced-order mapping, the mean distortion magnitude reduces to 0.45-0.42 mm within the central and offset ROIs, and the fraction of points with a distortion magnitude greater than 1 mm is reduced to 2.8% and 1.5%, respectively. Conclusions: A novel harmonic approach to the characterization of system-related distortions in MRI is presented. This method permits a complete and accurate mapping of the DVF within a specified ROI using a limited measurement of the distortion on the ROI boundary. This technique eliminates the requirement to exhaustively sample the DVF at a dense 3D array of points, thereby permitting the design of simple, inexpensive phantoms that may incorporate additional modules for auxiliary quality assurance objectives.
Article
Distortion in magnetic resonance images needs to be taken into account for the purposes of radiotherapy treatment planning (RTP). A commercial MRI grid phantom was scanned on four different MRI scanners with multiple sequences to assess variations in the geometric distortion. The distortions present across the field of view were then determined. The effect of varying bandwidth on image distortion and signal to noise was also investigated. Distortion maps were created and these were compared to the location of patient anatomy within the scanner bore to estimate the magnitude and distribution of distortions located within specific clinical regions. Distortion magnitude and patterns varied between MRI sequence protocols and scanners. The magnitude of the distortions increased with increasing distance from the isocentre of the scanner within a 2D imaging plane. Average distortion across the phantom generally remained below 2.0 mm, although towards the edge of the phantom for a turbo spin echo sequence, the distortion increased to a maximum value of 4.1 mm. Application of correction algorithms supplied by each vendor reduced but did not completely remove distortions. Increasing the bandwidth of the acquisition sequence decreased the amount of distortion at the expense of a reduction in signal-to-noise ratio of 13.5 across measured bandwidths. Imaging protocol parameters including bandwidth, slice thickness and phase encoding direction, should be noted for distortion investigations in RTP since each can influence the distortion. The magnitude of distortion varies across different clinical sites.
Article
Magnetic resonance (MR) images often provide superior anatomic and functional information over computed tomography (CT) images, but generally are not used alone without CT images for radiotherapy treatment planning and image guidance. This study aims to investigate the potential of probabilistic classification of voxels from multiple MRI contrasts to generate synthetic CT ('MRCT') images. The method consists of (1) acquiring multiple MRI volumes: T1-weighted, T2-weighted, two echoes from a ultra-short echo time (UTE) sequence, and calculated fat and water image volumes using a Dixon method, (2) classifying tissues using fuzzy c-means clustering with a spatial constraint, (3) assigning attenuation properties with weights based on the probability of individual tissue classes being present in each voxel, and (4) generating a MRCT image volume from the sum of attenuation properties in each voxel. The capability of each MRI contrast to differentiate tissues of interest was investigated based on a retrospective analysis of ten patients. For one prospective patient, the correlation of skull intensities between CT and MR was investigated, the discriminatory power of MRI in separating air from bone was evaluated, and the generated MRCT image volume was qualitatively evaluated. Our analyses showed that one MRI volume was not sufficient to separate all tissue types, and T2-weighted images was more sensitive to bone density variation compared to other MRI image types. The short echo UTE image showed significant improvement in contrasting air versus bone, but could not completely separate air from bone without false labeling. Generated MRCT and CT images showed similar contrast between bone and soft/solid tissues. These results demonstrate the potential of the presented method to generate synthetic CT images to support the workflow of radiation oncology treatment planning and image guidance.
Article
In radiotherapy, target tissues are defined best on MR images due to their superior soft tissue contrast. Computed tomography imaging is geometrically accurate and it is needed for dose calculation and generation of reference images for treatment localization. Co-registration errors between MR and computed tomography images can be eliminated using magnetic resonance imaging-only based treatment planning. Use of ionizing radiation can be avoided which is especially important in adaptive treatments requiring several re-scans. We commissioned magnetic resonance imaging-only based procedure for external radiotherapy, treatment planning of the prostate cancer. Geometrical issues relevant in radiotherapy, were investigated including quality assurance testing of the scanner, evaluation of the displacement of skin contour and radiosensitive rectum wall, and detection of intraprostatic fiducial gold seed markers used for treatment localization. Quantitative analysis was carried out for 30 randomly chosen patients. Systematic geometrical errors were within 2.2 mm. The gold seed markers were correctly identified for 29 out of the 30 patients. Positions of the seed midpoints were consistent within 1.3 mm in magnetic resonance imaging and computed tomography. Positional error of rectal anterior wall due to susceptibility effect was minimal. Geometrical accuracy of the investigated equipment and procedure was sufficient for magnetic resonance imaging-only based radiotherapy, treatment planning of the prostate cancer including treatment virtual simulation. Magn Reson Med, 2012. © 2012 Wiley Periodicals, Inc.
Article
In an earlier work, we demonstrated that substitutes for CT images can be derived from MR images using ultrashort echo time (UTE) sequences, conventional T2 weighted sequences, and Gaussian mixture regression (GMR). In this study, we extend this work by analyzing the uncertainties associated with the GMR model and the information contributions from the individual imaging sequences. An analytical expression for the voxel-wise conditional expected absolute deviation (EAD) in substitute CT (s-CT) images was derived. The expression depends only on MR images and can thus be calculated along with each s-CT image. The uncertainty measure was evaluated by comparing the EAD to the true mean absolute prediction deviation (MAPD) between the s-CT and CT images for 14 patients. Further, the influence of the different MR images included in the GMR model on the generated s-CTs was investigated by removing one or more images and evaluating the MAPD for a spectrum of predicted radiological densities. The largest EAD was predicted at air-soft tissue and bone-soft tissue interfaces. The EAD agreed with the MAPD in both these regions and in regions with lower EADs, such as the brain. Two of the MR images included in the GMR model were found to be mutually redundant for the purpose of s-CT generation. The presented uncertainty estimation method accurately predicts the voxel-wise MAPD in s-CT images. Also, the non-UTE sequence previously used in the model was found to be redundant.
Article
Prostate radiation therapy dose planning directly on magnetic resonance imaging (MRI) scans would reduce costs and uncertainties due to multimodality image registration. Adaptive planning using a combined MRI-linear accelerator approach will also require dose calculations to be performed using MRI data. The aim of this work was to develop an atlas-based method to map realistic electron densities to MRI scans for dose calculations and digitally reconstructed radiograph (DRR) generation. Whole-pelvis MRI and CT scan data were collected from 39 prostate patients. Scans from 2 patients showed significantly different anatomy from that of the remaining patient population, and these patients were excluded. A whole-pelvis MRI atlas was generated based on the manually delineated MRI scans. In addition, a conjugate electron-density atlas was generated from the coregistered computed tomography (CT)-MRI scans. Pseudo-CT scans for each patient were automatically generated by global and nonrigid registration of the MRI atlas to the patient MRI scan, followed by application of the same transformations to the electron-density atlas. Comparisons were made between organ segmentations by using the Dice similarity coefficient (DSC) and point dose calculations for 26 patients on planning CT and pseudo-CT scans. The agreement between pseudo-CT and planning CT was quantified by differences in the point dose at isocenter and distance to agreement in corresponding voxels. Dose differences were found to be less than 2%. Chi-squared values indicated that the planning CT and pseudo-CT dose distributions were equivalent. No significant differences (p > 0.9) were found between CT and pseudo-CT Hounsfield units for organs of interest. Mean ± standard deviation DSC scores for the atlas-based segmentation of the pelvic bones were 0.79 ± 0.12, 0.70 ± 0.14 for the prostate, 0.64 ± 0.16 for the bladder, and 0.63 ± 0.16 for the rectum. The electron-density atlas method provides the ability to automatically define organs and map realistic electron densities to MRI scans for radiotherapy dose planning and DRR generation. This method provides the necessary tools for MRI-alone treatment planning and adaptive MRI-based prostate radiation therapy.
Conference Paper
A new technique is presented for the metamorphosis of one digital image into another. The approach gives the animator high-level control of the visual effect by providing natural feature-based specification and interaction. When used effectively, this technique can give the illusion that the photographed or computer generated subjects are transforming in a fluid, surrealistic, and often dramatic way. Comparisons with existing methods are drawn, and the advantages and disadvantages of each are examined. The new method is then extended to accommodate keyframed transformations between image sequences for motion image work. Several examples are illustrated with resulting images.
Article
Dose planning requires a CT scan which provides the electron density distribution for dose calculation. MR provides superior soft tissue contrast compared to CT and the use of MR-alone for prostate planning would provide further benefits such as lower cost to the patient. This study compares the accuracy of MR-alone based dose calculations with bulk electron density assignment to CT-based dose calculations for prostate radiotherapy. CT and whole pelvis MR images were contoured for 39 prostate patients. Plans with uniform density and plans with bulk density values assigned to bone and tissue were compared to the patient's gold standard full density CT plan. The optimal bulk density for bone was calculated using effective depth measurements. The plans were evaluated using ICRU point doses, dose volume histograms, and Chi comparisons. Differences in spatial uniformity were investigated for the CT and MR scans. The calculated dose for CT bulk bone and tissue density plans was 0.1±0.6% (mean±1 SD) higher than the corresponding full density CT plan. MR bulk bone and tissue density plans were 1.3±0.8% lower than the full density CT plan. CT uniform density plans and MR uniform density plans were 1.4±0.9% and 2.6±0.9% lower, respectively. Paired t-tests performed on specific points on the DVH graphs showed that points on DVHs for all bulk electron density plans were equivalent with two exceptions. There was no significant difference between doses calculated on Pinnacle and Eclipse. The dose distributions of six patients produced Chi values outside the acceptable range of values when MR-based plans were compared to the full density plan. MR-alone bulk density planning is feasible provided bone is assigned a density, however, manual segmentation of bone on MR images will have to be replaced with automatic methods. The major dose differences for MR bulk density plans are due to differences in patient external contours introduced by the MR couch-top and pelvic coil.
Article
Organ motion is recognized as the principal source of inaccuracy in bladder radiotherapy (RT), but there is currently little information on intrafraction bladder motion. We used cine-magnetic resonance imaging (cine-MRI) to study bladder motion relevant to intrafraction RT delivery. On two occasions, a 28 minute cine-MRI sequence was acquired from 10 bladder cancer patients and 5 control participants immediately after bladder emptying, after abstinence from drinking for the preceding hour. From the resulting cine sequences, bladder motion was subjectively assessed. To quantify bladder motion, the bladder was contoured in imaging volume sets at 0, 14, and 28 min to measure changes to bladder volumes, wall displacements, and center of gravity (COG) over time. The dominant source of bladder motion during imaging was bladder filling (up to 101% volume increase); rectal and small bowel movements were transient, with minimal impact. Bladder volume changes were similar for all participants. However for bladder cancer patients, wall displacements were larger (up to 58 mm), less symmetrical, and more variable compared with nondiseased control bladders. Significant and individualized intrafraction bladder wall displacements may occur during bladder RT delivery. This important source of inaccuracy should be incorporated into treatment planning and verification.
Article
To introduce a novel technology arrangement in an integrated environment and outline the logistics model needed to incorporate dedicated magnetic resonance (MR) imaging in the radiotherapy workflow. An initial attempt was made to analyze the value and feasibility of MR-only imaging compared to computed tomography (CT) imaging, testing the assumption that MR is a better choice for target and healthy tissue delineation in radiotherapy. A 1.5-T MR unit with a 70-cm-bore size was installed close to a linear accelerator, and a special trolley was developed for transporting patients who were fixated in advance between the MR unit and the accelerator. New MR-based workflow procedures were developed and evaluated. MR-only treatment planning has been facilitated, thus avoiding all registration errors between CT and MR scans, but several new aspects of MR imaging must be considered. Electron density information must be obtained by other methods. Generation of digitally reconstructed radiographs (DRR) for x-ray setup verification is not straight forward, and reliable corrections of geometrical distortions must be applied. The feasibility of MR imaging virtual simulation has been demonstrated, but a key challenge to overcome is correct determination of the skeleton, which is often needed for the traditional approach of beam modeling. The trolley solution allows for a highly precise setup for soft tissue tumors without the invasive handling of radiopaque markers. The new logistics model with an integrated MR unit is efficient and will allow for improved tumor definition and geometrical precision without a significant loss of dosimetric accuracy. The most significant development needed is improved bone imaging.
Article
Geometric distortion in MR imaging predominantly arises from the inhomogeneity of the static field and the nonlinearity of the gradients. It is the purpose of this paper to analyse the object and machine related contributions to geometric distortion in order to determine which corrections are necessary for attaining a specified precision. System related imperfections were measured by systematic variation of the strength, direction, and polarity of the read-out gradient in imaging experiments on a grid of cylindrical sample tubes. For the 1.5-T system used in this study, static field related errors up to 7 mm and gradient related errors up to 4 mm were observed (midcoronal plane, FOV 400-mm, G-read between 0.5 and 3.0 mT/m). Field related errors were shown to be inversely proportional to gradient strength, whereas gradient related errors turned out to be virtually independent of gradient strength. It therefore seems recommendable to always apply the strongest available selection and read-out gradients when geometric fidelity is given preference to signal-to-noise considerations. Correction of system related geometric distortions in MR images can readily be performed by table lookup. Object-induced distortions of the gradient fields were studied by experiments on a grid of sample tubes immersed into a cylindrical water bath of variable saline concentration. These experiments revealed a negligible influence of the object on the gradient error distribution, and lead to the conclusion that correction for the nonlinearity of the gradients only requires the application of system dependent correction factors. Object-related distortions of B0 were studied by conventional SE and fat-suppressed IR experiments on phantoms and human subjects. In these experiments the polarity of the read-out gradient was reversed. Subtraction images showed significant object-induced inhomogeneities of the static field at tissue-air interfaces and in the immediate vicinity of the object being imaged. A first attempt to correct for object related B0 inhomogeneities was made by contour analysis of the source images. At present this correction still has to be done manually.
Article
To investigate whether the use of transaxial and coronal MR imaging improves the ability to localize the apex of the prostate and the anterior part of the rectum compared to the use of transaxial CT alone, and whether the incorporation of MR could improve the coverage of the prostate by the radiotherapy field and change the volume of rectum irradiated. Ten consecutive patients with localized prostate carcinoma underwent a CT and an axial and coronal MR scan in treatment position. The CT and MR images were mathematically aligned, and three observers were asked to contour independently the prostate and the rectum on CT and on MR. The interobserver variability of the prostatic apex location and of the delineation of the anterior rectal wall were assessed for each image modality. A dosimetry study was performed to evaluate the dose to the rectum when MR was used in addition to CT to localize the pelvic organs. The interobserver variation of the prostatic apex location was largest on CT ranging from 0.54 to 1.07 cm, and smallest on coronal MR ranging from 0.17 to 0.25 cm. The interobserver variation of the delineation of the anterior rectum on MR was small and constant along the whole length of the prostate (0.09+/-0.02 cm), while for CT it was comparable to that for the MR delineation at the base of the prostate, but it increased gradually towards the apex, where the variation reached 0.39 cm. The volume of MR rectum receiving more than 80% of the prescribed dose was on average reduced by 23.8+/-11.2% from the CT to the MR treatment plan. It can be concluded that the additional use of axial and coronal MR scans, in designing the treatment plan for localized prostate carcinoma, improves substantially the localization accuracy of the prostatic apex and the anterior aspect of the rectum, resulting in a better coverage of the prostate and a potential to reduce the volume of the rectum irradiated to a high dose.
Article
To quantify the dosimetric consequences of external patient contour distortions produced on low-field and high-field MRIs for external beam radiation of prostate cancer. A linearity phantom consisting of a grid filled with contrast material was scanned on a spiral CT, a 0.23 T open MRI, and a 1.5 T closed bore system. Subsequently, 12 patients with prostate cancer were scanned on CT and the open MRI. A gradient distortion correction (GDC) program was used to postprocess the MRI images. Eight of the patients were also scanned on the 1.5 T MRI with integrated GDC correction. All data sets were fused according to their bony landmarks using a chamfer-matching algorithm. The prostate volume was contoured on an MRI image, irrespective of the apparent prostate location in those sets. Thus, the same target volume was planned and used for calculating the anterior-posterior (AP) and lateral separations. The number of monitor units required for treatment using a four-field conformal technique was compared. Because there are also setup variations in patient outer contours, two different CT scans from 20 different patients were fused, and the differences in AP and lateral separations were measured to obtain an estimate of the mean interfractional separation variation. All AP separations measured on MRI were statistically indistinguishable from those on CT within the interfractional separation variations. The mean differences between CT and low-field MRI and CT and high-field MRI lateral separations were 1.6 cm and 0.7 cm, respectively, and were statistically significantly different from zero. However, after the GDC was applied to the low-field images, the difference became 0.4 +/- 0.4 mm (mean +/- standard deviation), which was statistically insignificant from the CT-to-CT variations. The mean variations in the lateral separations from the low-field images with GDC would result in a dosimetric difference of <1%, assuming an equally weighted four-field 18-MV technique for patient separations up to approximately 40 cm. For patients with lateral separations <40 cm, a homogeneous calculation simulated using a 1.5 T MRI or a 0.23 T MRI with a gradient distortion correction will yield a monitor unit calculation indistinguishable from that generated using CT simulation.
Article
To evaluate the impact of two different methods of geometric distortion correction of MR images from a Siemens Magnetom Open Viva 0.2T resistive MR unit on the process of external beam radiotherapy treatment planning for prostate cancer. A method for correction of system related and object induced distortions and one for correction of purely system related distortions have been evaluated. The latter used information extracted from MR images of a 3D phantom specifically designed for geometric distortion evaluation. An active shim procedure was performed prior to all phantom and patient scans. For each of five patients five standard treatment plans were compared using uncorrected and corrected MR images alone (density=water) and CT images alone. Finally internal anatomical landmarks were used for image registration between MR images (corrected and uncorrected) and CT images to evaluate the impact of distortion correction on the image registration process. Maximum distortions of 28 mm (mean 2.2 mm) were found within the FOV in frequency encode direction. Maximum distortions could be reduced by a factor of two (mean factor four) by our phantom measurement based technique. Distortion patterns were found to be stable and reproducible over several weeks with this MR unit. For 4/5 patients, relative doses at the normalization point as calculated on the distortion corrected MR images only (all tissues taken water equivalent) were all within 1% of the corresponding value from the standard CT-based plan (actual Hounsfield units). The largest differences in isocentric dose found in one case were 3.1% MR uncorrected vs. CT and 2.6% MR corrected vs. CT. Typical sites of internal anatomical landmarks chosen for image registration show distortions up to 3 mm. Object induced distortions are negligible at such low field strengths compared to system related distortions. Treatment plans for prostate cancer do not seem to differ significantly from "standard" plans calculated on CT images when calculated on distortion corrected MR images, even if all tissues are assigned the electron density of water. Distortion correction of MR images can theoretically improve the starting point for image registration of MR and CT images.
Article
A phantom that can be used for mapping geometric distortion in magnetic resonance imaging (MRI) is described. This phantom provides an array of densely distributed control points in three-dimensional (3D) space. These points form the basis of a comprehensive measurement method to correct for geometric distortion in MR images arising principally from gradient field non-linearity and magnet field inhomogeneity. The phantom was designed based on the concept that a point in space can be defined using three orthogonal planes. This novel design approach allows for as many control points as desired. Employing this novel design, a highly accurate method has been developed that enables the positions of the control points to be measured to sub-voxel accuracy. The phantom described in this paper was constructed to fit into a body coil of a MRI scanner, (external dimensions of the phantom were: 310 mm x 310 mm x 310 mm), and it contained 10,830 control points. With this phantom, the mean errors in the measured coordinates of the control points were on the order of 0.1 mm or less, which were less than one tenth of the voxel's dimensions of the phantom image. The calculated three-dimensional distortion map, i.e., the differences between the image positions and true positions of the control points, can then be used to compensate for geometric distortion for a full image restoration. It is anticipated that this novel method will have an impact on the applicability of MRI in both clinical and research settings, especially in areas where geometric accuracy is highly required, such as in MR neuro-imaging.