On Treatment Verification Imaging A Study Guide for IGRT -
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Library of Congress Cataloging‑in‑Publication Data
Names: Kirby, Mike (Lecturer in radiotherapy physics), author. | Calder,
Kerrie-Anne, author.
Title: On-treatment verification imaging : a study guide for IGRT / Mike
Kirby and Kerrie-Anne Calder.
Other titles: Series in medical physics and biomedical engineering.
Description: Boca Raton, FL : CRC Press, Taylor & Francis Group, [2019] |
Series: Series in medical physics and biomedical engineering
Identifiers: LCCN 2018060146| ISBN 9781138499911 (hbk) | ISBN 1138499919
(hbk) | ISBN 9781351007764 (ebook) | ISBN 1351007769 (ebook)
Subjects: LCSH: Image-guided radiation therapy. | Image processing—Digital
techniques. | Image analysis. | Cancer—Radiotherapy.
Classification: LCC RC271.R3 K57 2019 | DDC 616.99/40642—dc23
LC record available at https://lccn.loc.gov/2018060146
Visit the Taylor & Francis Web site at
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and the CRC Press Web site at
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Contents
Preface, xvii
Acknowledgements, xix
Section I The Basic Foundations in Clinical Practice 1
Chapter 1 ◾ The Concepts and Consequences of Set-up Errors 3
1.1 INTRODUCTION 3
1.2 DEFINITION OF “SET-UP ERROR” AND
HOW THESE ERRORS ARE CLASSIFIED 3
1.2.1 Systematic and Random Errors 5
1.2.2 Gross Errors 5
1.3 CONSEQUENCES OF EACH TYPE OF ERROR
AND THE IMPACT ON TREATMENT DELIVERED 6
1.4 CORRECTION OF SET-UP ERRORS 8
Chapter 2 ◾ The Foundations of Equipment Used
for Radiotherapy Verification 11
2.1 INTRODUCTION 11
2.2 IMMOBILISATION EQUIPMENT 11
2.2.1 Indexing 15
2.3 INTRODUCTION TO IMAGING SCIENCE 15
2.4 PRETREATMENT IMAGING 16
2.4.1 CT 16
2.4.1.1 Considerations When Using CT 16
2.4.2 MRI 18
2.4.3 PET, PET/CT 19
2.4.4 Simulator 19
2.4.5 Reference Images 19
v
vi ◾ Contents
2.5 TREATMENT DELIVERY AND ON-TREATMENT
VERIFICATION IMAGING 20
2.5.1 MV 20
2.5.2 kV 21
2.5.3 CBCT 22
2.5.4 In-room CT 23
2.5.5 MR Linac 24
Chapter 3 ◾ Concepts of On-treatment Verification 25
3.1 INTRODUCTION 25
3.2 HOW TO IMAGE 25
3.2.1 Reference Images 25
3.2.2 Types of Reference Images 26
3.2.2.1 Simulator Image 26
3.2.2.2 DRR—Digitally Reconstructed Radiograph 26
3.2.2.3 DCR—Digital Composite Radiograph 27
3.2.2.4 CT Data Set 27
3.2.3 Verification Technique 27
3.2.3.1 MV Imaging 28
3.2.3.2 kV Imaging 28
3.2.3.3 Cone Beam CT Scans (CBCT) 28
3.3 WHEN TO IMAGE 29
3.4 METHOD OF IMAGE MATCHING 30
3.4.1 Bony Match 30
3.4.2 Fiducial Marker Match 31
3.4.3 Soft Tissue Match 31
3.5 WHEN TO CHECK THE IMAGE 31
3.5.1 On-line Review 31
3.5.2 Off-line Review 32
3.5.3 Review Method 32
Chapter 4 ◾ Clinical Protocols and Imaging Training 33
4.1 INTRODUCTION 33
4.2 IMAGING PROTOCOLS 34
4.3 TRAINING 35
4.3.1 Who to Train? 35
Contents ◾ vii
4.3.2 When to Train? 36
4.3.3 How to Train? 37
4.3.4 Does Training Need to Be Repeated? 39
4.3.5 Student Image Training 40
Chapter 5 ◾ Concomitant Exposures and Legal Frameworks 43
5.1 INTRODUCTION 43
5.2 CONCOMITANT DOSE–DEFINITIONS 43
5.3 LEGAL FRAMEWORKS 47
5.4 INCORPORATION INTO PRACTICAL USE 48
Chapter 6 ◾ Foundational Principles of Protocols, Tolerances,
Action Levels and Corrective Strategies 49
6.1 INTRODUCTION 49
6.2 TOLERANCES 49
6.3 MARGINS 52
6.4 CORRECTIVE STRATEGIES 54
6.4.1 NAL Correction Strategy 54
6.4.2 eNAL Correction Strategy 55
6.4.3 Absolute Correction and Adaptive Radiotherapy (ART) 56
6.5 ACTION LEVELS 57
Section II Technology and Techniques in Clinical Practice 61
Chapter 7 ◾ Imaging Science, Imaging Equipment
(Pretreatment and On-treatment) 63
7.1 INTRODUCTION 63
7.2 IMAGING SCIENCE CONCEPTS 63
7.2.1 Spatial Resolution 64
7.2.2 Contrast 65
7.2.3 Noise 66
7.2.4 Signal-to-Noise (SNR) Ratio 66
7.3 CHARACTERISTICS OF NOTE FOR X-RAY IMAGING 67
7.3.1 X-ray Attenuation 67
7.3.2 Scatter 68
7.3.3 2-D Projection Images 68
7.3.4 Subject Contrast and X-ray Energy 69
viii ◾ Contents
7.3.5 Signal-to-Noise Ratio (SNR) 71
7.3.6 Spatial Resolution 72
7.3.7 Detective Quantum Efficiency 72
7.4 PRETREATMENT IMAGING EQUIPMENT 72
7.4.1 Radioisotope Imaging 73
7.4.2 Positron Emission Tomography 73
7.4.3 Computed Tomography—3-D 74
7.4.4 Computed Tomography—4-D 75
7.4.5 PET-CT Imaging 77
7.4.6 Magnetic Resonance (MR) Imaging 78
7.5 ON-TREATMENT IMAGING ON TRADITIONAL
C-ARM LINACS 79
7.5.1 Why the Need for On-treatment Verification Imaging? 79
7.5.2 Evolution of On-treatment Imaging 80
7.5.3 Initial Challenges 83
7.5.4 The Active Matrix Flat-Panel Imager (AMFPI) 83
7.5.5 Current Methods With MV and kV X-rays—2-D Imaging 85
7.5.5.1 Surrogates 85
7.5.5.2 Surrogates—Skin Markers (Alone) and Bony
Anatomy 85
7.5.5.3 Surrogates—Implanted Fiducial Markers 87
7.5.5.4 Image Reference Points—Measuring Set-Up Error 87
7.5.5.5 2-D Planar Imaging—Bony Anatomy 89
7.5.5.6 2-D Planar Imaging—Fiducials 90
7.5.5.7 2-D Planar Imaging—Other Technological Points 90
7.5.6 Current Methods With MV and kV X-Rays—3-D Imaging 91
7.5.6.1 Evolution of 3-D Imaging Dedicated for C-arm
Linacs 91
7.5.6.2 MV-Based CBCT 91
7.5.6.3 kV-Based CBCT 94
7.5.6.4 kV-Based CBCT: Experience, Advantages, and
Disadvantages 94
7.6 ON-TREATMENT IMAGING USING IN-ROOM X-RAY
TECHNOLOGY ON C-ARM LINACS 95
7.6.1 In-room kV Imaging Technologies 95
7.6.2 CT On Rails 96
7.6.3 2-D kV Stereoscopic In-room Imaging 96
Contents ◾ ix
7.7 ON-TREATMENT IMAGING USING NONIONISING RADIATION
TECHNOLOGY AROUND TRADITIONAL C-ARM LINACS 97
7.7.1 Rationale 97
7.7.2 Technologies and Equipment 98
7.7.2.1 Ultrasound 98
7.7.2.2 Surface Methods 100
7.7.2.3 Implanted Transponders 101
Chapter 8 ◾ Clinical Practice Principles 103
8.1 INTRODUCTION 103
8.2 PRETREATMENT IMAGING EQUIPMENT 103
8.2.1 Radioisotope Imaging 103
8.2.2 PET Imaging and PET/CT 103
8.2.3 Computed Tomography (CT)—3-D 104
8.2.4 Computed Tomography (CT)—4-D 105
8.2.5 MR Imaging 107
8.3 ON-TREATMENT IMAGING ON TRADITIONAL C-ARM LINACS 108
8.3.1 2-D MV Imaging 108
8.3.2 2-D kV Images 110
8.3.3 Cone-Beam CT (CBCT) 110
8.4 CASE EXAMPLES 112
8.5 ON-TREATMENT IMAGING USING IN-ROOM X-RAY
TECHNOLOGY AROUND TRADITIONAL C-ARM LINACS 113
8.5.1 “CT-On-rails” 113
8.5.2 Stereoscopic In-room Imaging 113
8.6 ON-TREATMENT IMAGING USING NONIONISING RADIATION
TECHNOLOGY AROUND TRADITIONAL C-ARM LINACS 115
8.6.1 Ultrasound 115
8.6.2 Case Examples 115
8.6.2.1 Prostate Verification 115
8.6.2.2 Breast Localisation 116
8.6.2.3 Limitations of Ultrasound in Radiotherapy 116
8.6.3 Surface Tracking 117
8.6.4 Case Examples 118
8.6.4.1 SRS 118
8.6.4.2 Limitations of Surface Tracking 118
8.6.5 Implanted Transponders 118
x ◾ Contents
Chapter 9 ◾ Quality Systems and Quality Assurance 121
9.1 INTRODUCTION 121
9.2 DEFINITIONS—QUALITY MANAGEMENT SYSTEMS (QMSs) 121
9.3 DEFINITIONS—QUALITY ASSURANCE (QA) 125
9.4 DEFINITIONS—QA AND QMS PRACTICALITIES
FOR ON-TREATMENT VERIFICATION IMAGING 126
Section III Advanced Issues, Techniques, and Practices 129
Chapter 10 ◾ Alternative Technologies 131
10.1 TOMOTHERAPY 131
10.1.1 Introduction 131
10.1.2 System Overview 131
10.1.3 On-treatment Verification Imaging 133
10.1.4 Some Clinical Perspectives 136
10.2 CYBERKNIFE 137
10.2.1 The Cyberknife System 137
10.2.2 On-treatment Verification Imaging Systems 139
10.2.3 On-treatment Imaging Capabilities 140
10.3 GAMMA KNIFE 142
10.3.1 The Gamma knife System—Introduction 142
10.3.2 On-treatment Verification—First Automation 143
10.3.3 The Gamma Knife Perfexion (GKP) System—Further
Automated Verification 143
10.3.4 On-treatment Imaging—Development of CBCT 144
10.4 HALCYON 145
10.4.1 The Halcyon System—Introduction 145
10.4.2 First Version Imaging Options and Capability 147
10.4.3 Continuing Developments 149
10.5 VERO 150
10.5.1 The Vero 4DRT System—Introduction 150
10.5.2 Imaging Options and Capability; Initial Results 151
10.6 PROTON-BEAM THERAPY 153
10.6.1 Introduction 153
10.6.2 Technology Changes 153
Contents ◾ xi
10.6.3 Clinical Utility 154
10.6.4 Clinical Challenges 155
10.6.5 On-treatment Imaging 157
10.7 MR ON-TREATMENT IMAGING 161
10.7.1 Introduction 161
10.7.2 On-treatment MR Guidance 161
10.7.3 Pretreatment MR and MR-Only Workflows 164
10.8 PET-MR 165
10.8.1 Introduction 165
10.8.2 Initial Investigations and Challenges 165
10.8.3 Clinical Utility 167
10.8.4 Imaging Capability 167
10.9 EMISSION-GUIDED/BIOLOGY-GUIDED
RADIOTHERAPY (EGRT/BGRT) 168
10.9.1 Introduction 168
10.9.2 Initial Design and Clinical Utility 168
10.10 ADAPTIVE RADIOTHERAPY 170
10.10.1 Introduction 170
10.10.2 Adaptive Radiotherapy Performed Off-line 171
10.10.3 Adaptive Radiotherapy Performed On-line 171
10.10.4 Experience With Different On-treatment
Imaging Technologies 172
10.10.5 Adaptive Radiotherapy in Clinical Use 173
Chapter 11 ◾ Incident Reporting 177
11.1 INTRODUCTION 177
11.2 RATIONALE 177
11.3 UK EXPERIENCES 178
11.4 UK LEGISLATION AND GUIDANCE 180
11.5 INTERNATIONAL PERSPECTIVES 182
Chapter 12 ◾ Protocol Development and Training 185
12.1 PROTOCOLS—THE RATIONALE 185
12.2 DEVELOPING PROTOCOLS FOR ON-TREATMENT
VERIFICATION IMAGING 186
12.3 TRAINING—THE RATIONALE 189
xii ◾ Contents
Chapter 13 ◾ Commissioning of New On-treatment Imaging
and Techniques: Integration Into the Oncology
Management System 193
13.1 INTRODUCTION 193
13.2 COMMISSIONING 193
13.3 INTEGRATION INTO THE ONCOLOGY
MANAGEMENT SYSTEM 197
REFERENCES, 203
INDEX, 239
About the Series
The Series in Medical Physics and Biomedical Engineering describes the applications of
physical sciences, engineering, and mathematics in medicine and clinical research.
The series seeks (but is not restricted to) publications in the following topics:
• Artificial organs • Patient monitoring
• Assistive technology • Physiological measurement
• Bioinformatics • Prosthetics
• Bioinstrumentation • Radiation protection, health
physics, and dosimetry
• Biomaterials
• Regulatory issues
• Biomechanics
• Rehabilitation engineering
• Biomedical engineering
• Sports medicine
• Clinical engineering
• Systems physiology
• Imaging
• Telemedicine
• Implants
• Tissue engineering
• Medical computing and mathematics
• Treatment
• Medical/surgical devices
xiii
The International
Organization for
Medical Physics
The International Organization for Medical Physics (IOMP) represents more than 18,000
medical physicists worldwide and has a membership of 80 national and 6 regional organi-
zations, together with a number of corporate members. Individual medical physicists of all
national member organisations are also automatically members.
The mission of IOMP is to advance medical physics practice worldwide by disseminat-
ing scientific and technical information, fostering the educational and professional devel-
opment of medical physics, and promoting the highest quality medical physics services for
patients.
A World Congress on Medical Physics and Biomedical Engineering is held every three
years in cooperation with International Federation for Medical and Biological Engineering
(IFMBE) and International Union for Physics and Engineering Sciences in Medicine
(IUPESM). A regionally based international conference, the International Congress of
Medical Physics (ICMP) is held between world congresses. IOMP also sponsors interna-
tional conferences, workshops and courses.
The IOMP has several programmes to assist medical physicists in developing countries.
The joint IOMP Library Programme supports 75 active libraries in 43 developing coun-
tries, and the Used Equipment Programme coordinates equipment donations. The Travel
Assistance Programme provides a limited number of grants to enable physicists to attend
the world congresses.
IOMP cosponsors the Journal of Applied Clinical Medical Physics. The IOMP publishes
an electronic bulletin, Medical Physics World, twice a year. IOMP also publishes e-Zine, an
electronic news letter about six times a year. IOMP has an agreement with Taylor & Francis
for the publication of the Medical Physics and Biomedical Engineering series of textbooks.
IOMP members receive a discount.
IOMP collaborates with international organizations, such as the World Health
Organization (WHO), the International Atomic Energy Agency (IAEA) and other inter-
national professional bodies, such as the International Radiation Protection Association
xv
xvi ◾ The International Organization for Medical Physics
(IRPA) and the International Commission on Radiological Protection (ICRP), to promote
the development of medical physics and the safe use of radiation and medical devices.
Guidance on education, training, and professional development of medical physicists is
issued by IOMP, which is collaborating with other professional organizations in develop-
ment of a professional certification system for medical physicists that can be implemented
on a global basis.
The IOMP website (www.iomp.org) contains information on all the activities of the
IOMP, policy statements 1 and 2, and the “IOMP: Review and Way Forward,” which out-
lines all the activities of IOMP and plans for the future.
Preface
I mage guided radiotherapy (IGRT) has revolutionized external-beam radiotherapy
over the last few decades, enabling the more conformal techniques of 3DCRT, IMRT,
and VMAT to be delivered with greater accuracy, precision, and confidence. It’s paved the
way for further advancements through adaptive radiotherapy, dose guidance, and particle
therapy, to name but a few. In terms of on-treatment verification imaging, its precursors
were the use of portal films and electronic portal imaging devices to verify geometrically
the patient set-up; the technology and the techniques for doing this have moved on and
continue to be developed, all for the benefit of our patients in terms of clinical effectiveness
and safety.
On-treatment verification imaging is a term that has been used over many years for the
imaging techniques centred around the treatment unit, usually called the linac, although
treatment delivery is achieved through many different technologies now. It is an integral
part of a seminal UK guidance document called Towards Safer Radiotherapy, which helped
focus the minds of the radiotherapy community here in the UK on the many different
aspects involved in the safe and effective delivery of radiotherapy, many strands of which
are covered within this textbook. Because the practice is multifaceted and multidisci-
plinary, it requires many different professional talents (radiographers, physicists, clini-
cians, engineers etc.) along the patient’s pathway to make the treatment safe and effective;
on-treatment verification imaging as part of IGRT plays no small part in that.
For many years, on-treatment verification imaging for IGRT has been an important
aspect of the preregistration (prequalification) teaching and training for radiographers,
physicists, clinicians, and engineers going into professional practice in external-beam radi-
otherapy because its role holds such importance. Its importance is identified as such in the
national and international training programs for all the disciplines, yet there is no detailed
textbook for it. Instead, one presently has to draw upon many excellent global publications
and resources on IGRT primarily addressed at the qualified radiotherapy professional. We
hope with this volume we will help to redress that balance.
This textbook is designed to follow the education and training needs of preregistration
therapeutic radiographers who will go on to work in radiotherapy departments around
the world. It should also be an ideal study aid for those training to be qualified physicists,
clinicians, and engineers in radiotherapy. Broadly, the book comprises three main sec-
tions that mirror the educational needs in on-treatment imaging for the three years of an
xvii
BK-TandF-9781138499911_TEXT_KIRBY-190106-FM.indd 17 09/04/19 1:14 PM
xviii ◾ Preface
undergraduate program of study in radiotherapy. It also contains aspects applicable to both
graduate and postgraduate programs in all the major disciplines involved internationally.
An important aspect of the textbook is the accompanying electronic material that will
be hosted on the publisher’s website or similar, and updated on a regular basis. Within
the classroom, a subject like on-treatment verification imaging for IGRT cannot be suc-
cessfully taught without studying images in many different forms and exercising one’s
mind to think through the technology, the techniques, and the challenges of modern-day
radiotherapy. This electronic resource will include images, videos, documents, and media
that will complement the learning and teaching from within this book, help the student
develop the enquiring mind needed for current professional practice, and help to develop
radiotherapy for the future.
A final word on the terms used in this book. It is written from experience of UK practice,
but with a global audience in mind—the principles and points of learning are applicable
in all countries that practice radiotherapy (radiation therapy), independent of their devel-
opment profile. When we use the term radiographer, we mean Therapeutic Radiographer
(UK) and Radiation Therapist (RTT); when we use the term physicist, we mean trainee
Radiotherapy Physicist (or Clinical Scientist) (UK) and Medical Physicist; and when we use
the term clinician, we mean trainee Clinical Oncologist (UK), Physician, and Radiation
Oncologist.
If you are studying and training to work in radiotherapy (radiation therapy), this book
is for you!
Please visit the CRC Press website (https://www.crcpress.com/9781138499911) for col-
our versions of figures and further electronic resources to support learning and under-
standing alongside this textbook.
