Fiducial marker guided prostate radiotherapy: a review

O’Neill, A.; Jain, Suneil; Hounsell, Alan R.; O’Sullivan, Joe M.

doi:10.1259/bjr.20160296

Cited by 77 publications

(63 citation statements)

References 77 publications

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“…The same inherent uncertainties were assumed to exist in the sCTDRR cohort. Measured distances from the CTDRR cohort were, however, similar compared to previously reported mean values of 0.8–1.2 mm GFM migration . This suggests that the inherent uncertainties in the proposed evaluation method could be considered minor and the dominating effect in the measurements of the CTDRR cohort was due to GFM migration.…”

Section: Discussionsupporting

confidence: 82%

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Using C‐Arm X‐ray images from marker insertion to confirm the gold fiducial marker identification in an MRI‐only prostate radiotherapy workflow

Gustafsson

Persson

Gunnlaugsson

et al. 2018

J Applied Clin Med Phys

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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 workflows 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.

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Section: Discussionsupporting

confidence: 82%

“…The usefulness of this information relies on the assumption of negligible GFM migration between GFM insertion and imaging of the patient for prostate radiotherapy treatment planning purposes. Mean marker migration has previously been reported to be 0.8 (daily)–1.2 mm (over the entire treatment course) …”

Section: Introductionmentioning

confidence: 95%

Using C‐Arm X‐ray images from marker insertion to confirm the gold fiducial marker identification in an MRI‐only prostate radiotherapy workflow

Gustafsson

Persson

Gunnlaugsson

et al. 2018

J Applied Clin Med Phys

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“…IGRT for PCa frequently employs surgically implanted fiducial markers (FMs) as an aid to target verification. While they are not used universally they are an evidence based approach [4] and are recommended in a current clinical trial comparing surgery and stereotactic ablative radiotherapy (SABR) for PCa (PACE trial ISRCTN1762721).…”

Section: Introductionmentioning

confidence: 99%

Observed high incidence of prostatic calculi with the potential to act as natural fiducials for prostate image guided radiotherapy

O’Neill

Osman

Jain

et al. 2019

Technical Innovations & Patient Support in Radiation Oncolo

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This study aims to quantify the incidence and distribution of prostatic calculi in a population of prostate radiotherapy patients and assess their potential role in prostate image guided radiotherapy (IGRT). Methods & materials: A retrospective analysis of trans-rectal ultrasound (TRUS), computed tomography (CT) planning and treatment verification cone beam CT (CBCT) scans from radical prostate radiotherapy patients (external beam and brachytherapy) between 2012 and 2014 was undertaken by a single experienced observer. An internationally validated schema from the Prostate Imaging Reporting and Data system (PIRADS) was used to map the location of calculi. The association of calculi with patient and disease characteristics was explored. Data was analysed using SPSS (IBM version 22.0) using descriptive statistical methods and logistic binary regression analysis. Results: 389 scan sets from 254 patients were included in the analysis. The overall incidence of calculi was 85% (n = 218) of which 79% (n = 201) were intra-prostatic calculi. The mean number of intraprostatic calculi was 2 (range 1-10) and the mean size of calculi was 3.7 mm (range 0.5-15 mm). Calculi were most frequently observed in the posterior of the mid-gland (PI-RADs 3p, 9p) and posterior of the apex (PI-RADs 5p, 11p). 99% (n = 135) of CT planning scans with a corresponding CBCT had calculi in the same PIRADs location and all calculi were visible at the last fraction. There was no statistically significant association of calculi and N stage, M stage or Gleason score. Conclusions: A significant proportion of prostate radiotherapy patients have prostatic calculi detectable on pre radiotherapy imaging. Calculi observed on CT were also detectable on CBCT in 99% of cases and remain visible at the end of treatment. These findings add to the growing evidence base supporting the potential of calculi as an alternative to fiducial markers to aid prostate IGRT.

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“…Utilizing flattening filter free treatment beams could help to reduce treatment times and, therefore, the number of acquired images or, equivalently, the additional imaging dose associated with this triggered imaging technique. Other intrafraction motion monitoring systems include CyberKnife (Accuray, Sunnyvale, CA) and ExacTrac X‐ray 6D system (BrainLAB AG, Feldkirchen, Germany), which rely on ionizing radiation as in our approach . However, these approaches have the advantage of a six degree of freedom couch, which may not be available in most clinics.…”

Section: Discussionmentioning

confidence: 99%

“…Other intrafraction motion monitoring systems include CyberKnife (Accuray, Sunnyvale, CA) and ExacTrac Xray 6D system (BrainLAB AG, Feldkirchen, Germany), which rely on ionizing radiation as in our approach. [14][15][16][17] However, these approaches have the advantage of a six degree of freedom couch, which may not be available in most clinics.…”

Section: Discussionmentioning

confidence: 99%

Utilizing the TrueBeam Advanced Imaging Package to monitor intrafraction motion with periodic kV imaging and automatic marker detection during VMAT prostate treatments

Korpics

Rokni

Degnan

et al. 2020

J Applied Clin Med Phys

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Background Fiducial markers are frequently used before treatment for image‐guided patient setup in radiation therapy (RT), but can also be used during treatment for image‐guided intrafraction motion detection. This report describes our implementation of automatic marker detection with periodic kV imaging (TrueBeam v2.5) to monitor and correct intrafraction motion during prostate RT. Methods We evaluated the reproducibility and accuracy of software fiducial detection using a phantom with 3 implanted fiducial markers. Clinical implementation for patients with intraprostatic fiducials receiving volumetric modulated arc therapy (VMAT) utilized periodic on‐board kV imaging with 10 s intervals during treatment delivery. For each image, the software automatically identified fiducial locations and determined whether their distance relative to planned locations were within a 3 mm tolerance. Motion was corrected if either ≥2 fiducials in a single image or ≥1 fiducial in sequential images were out of tolerance. Results Phantom studies demonstrated poorer performance of linear fiducials compared to collapsible fiducials, and wide variability to accurately detect fiducials across eight software settings. For any given setting, results were relatively reproducible and precise to ~0.5 mm. Across 17 patients treated with a median of 20 fractions, the software recommended a shift in 44% of fractions, and a shift was actually implemented after visual confirmation of movement greater than the 3 mm threshold in 20% of fractions. Adjustment of our approach led to improved accuracy for the latter (n = 7) patient subset. On average, table repositioning added 3.0 ± 0.3 min to patient time on table. Periodic kV imaging increased skin dose by an estimated 1 cGy per treatment arc. Conclusions Periodic kV imaging with automatic detection of motion during VMAT prostate treatments is commercially available, and can be successfully implemented to mitigate effects of intrafraction motion with careful attention to software settings.

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Fiducial marker guided prostate radiotherapy: a review

Cited by 77 publications

References 77 publications

Using C‐Arm X‐ray images from marker insertion to confirm the gold fiducial marker identification in an MRI‐only prostate radiotherapy workflow

Using C‐Arm X‐ray images from marker insertion to confirm the gold fiducial marker identification in an MRI‐only prostate radiotherapy workflow

Observed high incidence of prostatic calculi with the potential to act as natural fiducials for prostate image guided radiotherapy

Utilizing the TrueBeam Advanced Imaging Package to monitor intrafraction motion with periodic kV imaging and automatic marker detection during VMAT prostate treatments

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