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12651274, 2006
Copyright 2006 Elsevier Inc.
Printed in the USA. All rights reserved
0360-3016/06/$see front matter
doi:10.1016/j.ijrobp.2005.11.008
PHYSICS CONTRIBUTION
INTRODUCTION
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3D surface acquisition
The 3D surface-imaging setup analysis was performed on 9
patients over a total of 53 fractions (from 4 to 8 fractions per
patient). Patients were informed and gave written consent. Seven
patients had lesions in the left breast, and 2 patients had lesions in
the right breast. CTV volumes ranged from 10.8 to 88.4 cc, with a
mean standard deviation of 34.8 24.5 cc; breast volumes
ranged between 268.7 and 1,032.0 cc, with a mean standard
deviation of 672.8 275.7 cc. The patients were between 38 and
91 years of age, with a median age of 65 years.
The system accuracy was established by phantom studies and
reported in detail elsewhere (17). A brief summary of the process
is described as follows: surface information is obtained in approximately 10 seconds via 2 camera pods suspended from the treatment room ceiling. Each pod is equipped with a stereovision
camera (2 CCD cameras separated by a known baseline), a texture
camera, a clear flash, a flash used for speckle projection, and a
slide projector for speckle projection. Speckle refers to an optically
projected pseudorandom gray-scale pattern to enable 3D reconstruction of the surface. The setup in the treatment room is shown
in Fig. 1. Each pod acquires 3D surface data over approximately
120 in the axial plane, from midline to posterior flank. On the
basis of a proprietary calibration process, the data are merged to
form a single 3D surface image of the patient. In the overlap region
near midline, the surfaces from the 2 pods merge smoothly with
less than a 1-mm RMS discontinuity. The consistency of this
overlap region is recommended by the vendor to be checked by a
daily calibration verification procedure. This verification step is
easily performed during the linac warm-up period.
The surface model is defined by 3D vertices (vertex spacing was
set to 6 mm at MGH), which form the triangular surface faces (Fig.
2a). Each face is colored with a gray-level video image of the skin
surface acquired from the texture cameras. Typical surface images
are shown in Figs. 2b and 2c.
The system includes software designed to facilitate patient
setup, principally by surface-model acquisition and alignment by
surface matching with a reference. In the clinical workflow, a
reference surface model (SMR) is first acquired. This acquisition
can be done at the time of first treatment session on the linac, in the
simulator room by use of a second imaging system with appropriate intersystem calibration, or by extraction of the reference surface from CT-scan data. At subsequent treatment sessions, the 3D
system can then be used as an alignment tool by comparison of the
SMR with a surface model acquired after initial laser setup (SML) or
any other surface-model acquisition. During the alignment process,
which takes approximately 10 seconds (17), the software calculates
the optimal rigid-body transformation (couch translation and rota-
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Fig. 1. Schematic outline of the surface-imaging system setup in the treatment room.
tion) that brings the SML of the daily treatment fraction into
congruence with the reference surface within a user-defined region
of interest (ROI). The use of an ROI excludes extraneous surface
parts that are not relevant to alignment of the breast to be treated
(e.g., gown). Alignment accuracy is better than 0.8 mm and 0.1
RMS, as shown in phantom studies (17). The system evaluation
used a phantom that assumes the patient is a rigid body. In some
sites, this assumption is appropriate; for other sites, breathing
motion or tissue deformation may alter surface topology.
To minimize breathing-motion artifacts, the system can be used
in a gated-acquisition mode. In this mode, the system monitors
patient respiration for several seconds at a frame rate of 7 Hz,
during which a sequence of surface images is acquired (50
frames). A SM is calculated for one of the frames at a userspecified respiratory phase. Phantom studies on a moving surface
indicate that the system accuracy in determination of amplitude is
better than 0.15 mm RMS (17). Data reported in this study were
acquired at random respiratory phase. We did not use gated acquisition, which was only available toward the end of the study.
Imaging protocol
To assess the performance of the system as a patient-alignment
device, 3D surface models were acquired in parallel to conven-
tional setup and treatment of 9 PBI patients. Because the technology does not use ionizing radiation, multiple surface models were
obtained during each treatment session. The reference surface
model SMR was selected to be the surface model acquired at the
first treatment fraction after portal film alignment. For the remaining fractions, surface data were acquired after alignment by
lasers (SML) and after portal-imaging alignment (treatment
surface model SMT). During development of the portal films, a
dynamic breathing study was recorded to quantify surface motion during light respiration. Figure 3 shows the protocol schematically.
Fig. 2. Surface models of a left female breast. (a) Surfaces are created by triangular tiles with approximately 6 mm of
spacing between intersections (the cube of size 1 cm3 is added for comparison). Texture is achieved for part of this
model by coloring each tile with the appropriate part of a bitmap image. Because of the three-dimensional
representation, each model can be viewed from any direction. For example, a textured patient-surface model is viewed
from (b) frontal and (c) left lateral. The thick black lines enclose the ROI chosen for surface registration. White surface
tiles are caused by missing data, for example, because the breast blocks one camera view (c). The texture data allow
visualization of skin marks, scar, and nipple. In all images, the thin black lines represent virtual lasers.
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Distance measurements
In addition to the software provided by the commercial system,
software was developed in-house to analyze system performance.
These programs were written in C by use of the public-domain
VTK libraries (18). A prerequisite is the ability to import patient
surface data, which was straightforward because all surfaces are
stored in a graphical standard format (Wavefront OBJ format,
http://www.dcs.ed.ac.uk/home/mxr/gfx/3 d/OBJ.spec). For each
patient, an automated analysis was performed. To evaluate the
characteristics of a surface match between surfaces, two general
approaches proved useful, quantitative analysis and visualization.
For quantitative analysis, the distance between SMR and a
second SM within the entire ROI was calculated (Fig. 4b). This
distance metric differs from the proprietary commercial metric
used in the registration cost function. Our distance function is
defined as the distance from the SMR to the SM along the normal
of the reference surface and measured at each vertex of the
reference surface. A positive distance value means the test surface
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Fig. 5. (a) Distance data for 4 fractions and 3 modalities in color-wash representation for a typical patient. Underneath
the color wash is the textured reference surface model from the first fraction. The white lines represent virtual lasers,
and the white crosses indicate positions for distance measurements obtained by use of the axial contours through
isocenter shown in (b). A quick congruence check with respect to the reference surface model is possible if the distance
data are presented in the form of histograms (c).
mode surface capture in principle permits motion analysis at any
surface point. This feature is useful for a qualitative analysis, but
quantitatively, too much data are generated. Distance maps were
used for visualization of the qualitative analysis. They provide an
overview of surface motion during respiration. The distance is
calculated (relative to the first frame) for each of the following 35
to 50 frames of a breathing capture sequence. At each vertex of
the first frame, the mean, absolute mean, and standard deviation
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Fig. 6. (a) Mean distance to the first frame of a typical breathing sequence (50 frames at 7 Hz). For the more quantitative
analysis, the distance values were measured at or in the vicinity of the indicated positions (R). (b) Overlay of 8 surface
models in treatment position (SMT). The arm-position change can be seen in this representation.
RESULTS
Recommended couch shifts
The patient-alignment procedure provides the therapist
with couch shifts to bring the surfaces in an ROI into
alignment. These shifts are based on a rigid-body transformation that minimizes the distance between the SM acquired for setup and the SMR. In off-line analysis, recommended shifts were calculated for all SML, SMT, and SMV
acquisitions. Data from 9 patients and 44 fractions (plus 9 as
reference) are combined in Fig. 7. For each degree of
freedom, the mean, standard deviation, maximum, and minimum of recommended shift are plotted. The resulting 3D
displacements are summarized in Table 1.
Laser
Treatment
Virtual 3D
alignment
Mean
Standard
deviation
Minimum
Maximum
7.3
7.6
4.4
4.2
1
1.7
17.6
19.3
1.2
4.2
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Table 2. Statistical analysis of distance measurements for the patient data shown in Figure 6
Mean (mm)
Fraction
Laser
Portal
3D
Laser
Portal
3D
Laser
Portal
3D
4
6
7
8
0.55
4.64
3.54
0.06
1.99
5.28
1.35
4.50
0.22
0.52
0.38
0.32
1.15
6.16
4.33
1.95
2.53
5.42
2.08
4.95
1.10
2.29
1.45
1.01
3.80
5.99
3.85
3.10
4.77
4.82
3.41
4.12
3.59
4.86
3.11
2.39
Distance measurements
An alternative analysis to recommended couch transformations involves distance calculations, where distances between SMR and SMT at triangle nodes are calculated. Distance maps, distance histograms, and 6 principle plane
contours were generated for all fractions imaged. The volume of image data is too large to be presented here. Instead,
data from a typical patient and combined results from all
patients are presented.
The SMR acquired at the first treatment fraction was used
as the basis of distance-measurement analysis. Distances
were measured over the ROI that included the treated breast.
Figure 5a shows the color-coded distance maps for a typical
patient (5 fractions acquired). A color wash overlays the
textured SMR. For the subsequent 4 fractions, images are
shown after laser alignment, port-film alignment, and virtual
3D surface setup relative to SMR. Each image contains
virtual crosshairs (white lines) to provide a general orientation. Both laser and port-film alignment lead to SMs that
show mispositioning relative to SMR by amounts greater
than 6 mm for some of the fractions (e.g., laser Fractions 6
and 7, port-film Fractions 6 and 8) but can also lead to very
good agreement (e.g., laser Fraction 4). The virtual setup
based on 3D surface matching, after virtual corrections in
couch translation and rotation about the vertical axis, mainly
led to surface congruence within less than 2 mm. The results
for this specific patient are typical for most other patients
analyzed.
Contour representations of patient position are useful for
understanding the distances calculated. Figure 5b shows
axial contours through isocenter of Fraction 7. The arrows
are approximately at the position of the white crosses indicated in Fig. 5a. Distance measurements are performed
normal to the reference surface and, therefore, normal to the
reference contour of Fig. 5b. The measurements show that,
for example, the yellow area in the laser-aligned surface is
slightly above 6 mm at S-I isocenter.
Another method of assessing surface-data congruence is
through distance histograms. Figure 5c displays the same
information as the color-coded images but yields quick
access to quantitative information of the alignment quality.
For example, the comparison of Fractions 4 and 7 for
port-film alignment shows that both are aligned better than
approximately 4 mm, that the Fraction 4 SMT is closer to
isocenter than is the SMR (negative values) in contrast to the
Fraction 7 SMT. Table 2 quantifies the statistical analysis of
the distance measurement.
The distance data from all patients and all fractions can
be globally combined to assess the quality of alignment
methods, as shown in Fig. 8. Laser-guided and port-film
guided alignment yield similar distance histograms. Absolute
mean standard deviations are 3.7 4.9 mm and 4.3 5.6
mm for laser and port-film based alignment, respectively.
Deviations greater than 5 mm were observed in 27.5% of the
vertices for laser alignment and 32.2% for portal-film alignment. In contrast, virtual alignment by 3D surface imaging
produces a narrower distance histogram, with 1.6 2.4 mm
absolute mean standard deviation and 5.0% of the vertices with greater than 5-mm deviation. In this statistical
analysis, the distance difference was cut off at greater than
30 mm to eliminate the effects of bad data, which can
appear when the SM exhibits a blank patch, and the distance
is measured from the SMR through the hole in the SM to the
patients gown further away.
Respiratory motion
Breathing can influence patient setup by introducing a
variation as large as the breathing amplitude of the surface
used. To analyze the effects of breathing motion, the measured-sequence raw data were used to extract breathing
amplitudes at treatment isocenter and at the abdomen (Fig.
6a). The number of fractions with breathing data are not
equally distributed among the total number of patients measured. The results are summarized in Table 3. At isocenter,
the peak-to-peak motion was 1.9 1.1 mm combined for
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Mean (mm)
Standard deviation (mm)
Minimum (mm)
Maximum (mm)
Number of patients
Number of measurements
Isocenter
Abdomen
1.9
1.1
0.6
4.4
7
37
5.7
1.3
3.4
8.8
6
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