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

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The goal of this work is to quantify the impact of image-guided conformal radiation therapy (CRT) on the dose distribution by correcting patient setup uncertainty and inter-fraction tumour motion. This was a retrospective analysis that used five randomly selected prostate cancer patients that underwent approximately 15 computed tomography (CT) scans during their radiation treatment course. The beam arrangement from the treatment plan was imported into each repeat CT study and the dose distribution was recalculated for the new beam setups. Various setup scenarios were then compared to assess the impact of image guidance on radiation treatment precision. These included (1) daily alignment to skin markers, thus representing a conventional beam setup without image guidance, (2) alignment to bony anatomy for correction of daily patient setup error, thus representing on-line portal image guidance, and (3) alignment to the 'CTV of the day' for correction of inter-fraction tumour motion, thus representing on-line CT or ultrasound image guidance. Treatment scenarios (1) and (3) were repeated with a reduced CTV to PTV margin, where the former represents a treatment using small margins without daily image guidance. Daily realignment of the treatment beams to the prostate showed an average increase in minimum tumour dose of 1.5 Gy, in all cases where tumour 'geographic miss' without image guidance was apparent. However, normal tissue sparing did not improve unless the PTV margin was reduced. Daily realignment to the tumour combined with reducing the margin size by a factor of 2 resulted in an average escalation in tumour dose of 9.0 Gy for all five static plans. However, the prescription dose could be escalated by 13.8 Gy when accounting for changes in anatomy by accumulating daily doses using nonlinear image registration techniques. These results provide quantitative information on the effectiveness of image-guided radiation treatment of prostate cancer and demonstrate that the dosimetric impact is patient dependent.

We have investigated the dosimetric properties of a commercial kilovoltage cone beam computerised tomography (kV-CBCT) system. The kV-CBCT doses were measured in 16 and 32 cm diameter standard cylindrical Perspex computerised tomography (CT) and Rando anthropomorphic phantoms using 125 kVp and 1.0-2.0 mA s per projection. We also measured skin doses using thermoluminescence dosimeters placed on the skin surfaces of prostate cancer patients undergoing kV-kV image matching for daily set-up. The skin doses from kV-kV image matching of prostate cancer patients on the anterior and lateral skin surfaces ranged from 0.03 +/- 0.01 to 0.64 +/- 0.01 cGy depending on the beam filtration and technique factors employed. The mean doses on the Rando phantom ranged from 3.0 +/- 0.1 to 5.1 +/- 0.3 cGy for full-fan scans and from 3.8 +/- 0.1 to 6.6 +/- 0.2 cGy for half-fan scans using 125 kVp and 2 mA s per projection. The isocentre cone beam dose index (CBDI) in the 16 and 32 cm Perspex phantoms is 4.65 and 1.81 cGy, respectively (using a 0.6 cm(3) Capintec PR06C Farmer chamber) for full-fan scans, and the corresponding normalised CBDIs are 0.72 and 0.28 cGy/100 mA s, respectively. The mean weighted CBDIs are 4.93 and 2.14 cGy, and the normalised weighted CBDIs are 0.76 and 0.33 cGy/100 mA s for the 16 and 32 cm phantoms, respectively (full-fan scans). The normalised weighted CBDI for the half-fan scan is 0.41 cGy/100 mA s for the 32 cm diameter phantom. All measurements of the CBDI using the 0.6 cm(3) Farmer chamber are within 2-5% of measurements taken with the 100 mm CT chamber. The CBDI technique and definitions can be used to benchmark CBCT systems and to provide estimates of imaging doses to patients undergoing on-board imager (OBI)/CBCT image guided radiation therapy.

The goal of this work was to evaluate the efficacy of various image-guided adaptive radiation therapy (IGART) techniques to deliver and escalate dose to the prostate in the presence of geometric uncertainties. Five prostate patients with 15-16 treatment CT studies each were retrospectively analyzed. All patients were planned with an 18 MV, six-field conformal technique with a 10 mm margin size and an initial prescription of 70 Gy in 35 fractions. The adaptive strategy employed in this work for patient-specific dose escalation was to increase the prescription dose in 2 Gy-per-fraction increments until the rectum normal tissue complication probability (NTCP) reached a level equal to that of the nominal plan NTCP (i.e., iso-NTCP dose escalation). The various target localization techniques simulated were: (1) daily laser-guided alignment to skin tattoo marks that represents treatment without image-guidance, (2) alignment to bony landmarks with daily portal images, and (3) alignment to the clinical target volume (CTV) with daily CT images. Techniques (1) and (3) were resimulated with a reduced margin size of 5 mm to investigate further dose escalation. When delivering the original clinical prescription dose of 70 Gy in 35 fractions, the "CTV registration" technique yielded the highest tumor control probability (TCP) most frequently, followed by the "bone registration" and "tattoo registration" techniques. However, the differences in TCP among the three techniques were minor when the margin size was 10 mm (< or = 1.1 %). Reducing the margin size to 5 mm significantly degraded the TCP values of the "tattoo registration" technique in two of the five patients, where a large difference was found compared to the other techniques (< or = 11.8 %). The "CTV registration" technique, however, did maintain similar TCP values compared to their 10 mm margin counterpart. In terms of normal tissue sparing, the technique producing the lowest NTCP varied from patient to patient. Reducing the margin size seemed the only sure way to reduce the NTCP significantly, irrespective of the IGART technique employed. In escalating the dose with the iso-NTCP constraint, the largest average gain in dose was observed with the "tattoo registration" technique, followed by the "CTV registration" and "bone registration" techniques. This is attributed to the fact that in three of the five patients, the "tattoo registration" technique yielded the lowest NTCP, hence a greater window of opportunity to escalate the dose was possible with this technique. However, the variation among the five patients was also largest with the "tattoo registration" technique where, in the case of one patient, the required dose actually needed to be below the original prescription dose of 70 Gy to satisfy the iso-NTCP constraint. This was not the case with the "CTV registration" technique where positive and similar dose escalation was allowed on all five patients. Based on these data, an attractive dose escalation strategy may be to implement the "CTV registration" technique (f...

The goal of this study is to validate a deformable model using contour-driven thin-plate splines for application to radiation therapy dose mapping. Our testing includes a virtual spherical phantom as well as real computed tomography (CT) data from ten prostate cancer patients with radio-opaque markers surgically implanted into the prostate and seminal vesicles. In the spherical mathematical phantom, homologous control points generated automatically given input contour data in CT slice geometry were compared to homologous control point placement using analytical geometry as the ground truth. The dose delivered to specific voxels driven by both sets of homologous control points were compared to determine the accuracy of dose tracking via the deformable model. A 3D analytical spherically symmetric dose distribution with a dose gradient of approximately 10% per mm was used for this phantom. This test showed that the uncertainty in calculating the delivered dose to a tissue element depends on slice thickness and the variation in defining homologous landmarks, where dose agreement of 3-4% in high dose gradient regions was achieved. In the patient data, radio-opaque marker positions driven by the thin-plate spline algorithm were compared to the actual marker positions as identified in the CT scans. It is demonstrated that the deformable model is accurate (approximately 2.5 mm) to within the intra-observer contouring variability. This work shows that the algorithm is appropriate for describing changes in pelvic anatomy and for the dose mapping application with dose gradients characteristic of conformal and intensity modulated radiation therapy.

During radiation therapy of head and neck cancer, the decision to consider replanning a treatment because of anatomical changes has significant resource implications. We developed an algorithm that compares cone‐beam computed tomography (CBCT) image pairs and provides an automatic alert as to when remedial action may be required. Retrospective CBCT data from ten head and neck cancer patients that were replanned during their treatment was used to train the algorithm on when to recommend a repeat CT simulation (re‐CT). An additional 20 patients (replanned and not replanned) were used to validate the predictive power of the algorithm. CBCT images were compared in 3D using the gamma index, combining Hounsfield Unit (HU) difference with distance‐to‐agreement (DTA), where the CBCT study acquired on the first fraction is used as the reference. We defined the match quality parameter (MQP x) as a difference between the x th percentiles of the failed‐pixel histograms calculated from the reference gamma comparison and subsequent comparisons, where the reference gamma comparison is taken from the first two CBCT images acquired during treatment. The decision to consider re‐CT was based on three consecutive MQP values being less than or equal to a threshold value, such that re‐CT recommendations were within ±3 fractions of the actual re‐CT order date for the training cases. Receiver‐operator characteristic analysis showed that the best trade‐off in sensitivity and specificity was achieved using gamma criteria of 3 mm DTA and 30 HU difference, and the 80th percentile of the failed‐pixel histogram. A sensitivity of 82% and 100% was achieved in the training and validation cases, respectively, with a false positive rate of ~30%. We have demonstrated that gamma analysis of CBCT‐acquired anatomy can be used to flag patients for possible replanning in a manner consistent with local clinical practice guidelines.