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DOE OSTI2017

From Computed Tomography–Guided to Magnetic Resonance Imaging–Guided Intracavitary Brachytherapy for Cervical Cancer: What Do the Key Stakeholders Have to Say about the Transition?

International brachytherapy consortiums are advocating for the incorporation of magnetic resonance imaging (MRI) into the cervical brachytherapy process as a standard-of-care. Although some evaluations have been performed to quantify the effect on procedural time, little is known about the views and experiences of key stakeholders during the transition from computed tomography to MR-guided brachytherapy. This qualitative research project explored insights from key stakeholders related to a change in the gynaecologic brachytherapy process.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

DOE OSTI2015

Unified continuum damage model for matrix cracking in composite rotor blades

This paper deals with modeling of the first damage mode, matrix micro-cracking, in helicopter rotor/wind turbine blades and how this effects the overall cross-sectional stiffness. The helicopter/wind turbine rotor system operates in a highly dynamic and unsteady environment leading to severe vibratory loads present in the system. Repeated exposure to this loading condition can induce damage in the composite rotor blades. These rotor/turbine blades are generally made of fiber-reinforced laminated composites and exhibit various competing modes of damage such as matrix micro-cracking, delamination, and fiber breakage. There is a need to study the behavior of the composite rotor system under various key damage modes in composite materials for developing Structural Health Monitoring (SHM) system. Each blade is modeled as a beam based on geometrically non-linear 3-D elasticity theory. Each blade thus splits into 2-D analyzes of cross-sections and non-linear 1-D analyzes along the beam reference curves. Two different tools are used here for complete 3-D analysis: VABS for 2-D cross-sectional analysis and GEBT for 1-D beam analysis. The physically-based failure models for matrix in compression and tension loading are used in the present work. Matrix cracking is detected using two failure criterion: Matrix Failure in Compression and Matrix Failure in Tension which are based on the recovered field. A strain variable is set which drives the damage variable for matrix cracking and this damage variable is used to estimate the reduced cross-sectional stiffness. The matrix micro-cracking is performed in two different approaches: (i) Element-wise, and (ii) Node-wise. The procedure presented in this paper is implemented in VABS as matrix micro-cracking modeling module. Three examples are presented to investigate the matrix failure model which illustrate the effect of matrix cracking on cross-sectional stiffness by varying the applied cyclic load.

36 MATERIALS SCIENCE↗

DOE OSTI2015

TU-F-201-03: Applications in Brachytherapy

Since the introduction of radiochromic films (RCF) for radiation dosimetry, the scope of RCF dosimetry has expanded steadily to include many medical applications, such as radiation therapy and diagnostic radiology. The AAPM Task Group (TG) 55 published a report on the recommendations for RCF dosimetry in 1998. As the technology is advancing rapidly, and its routine clinical use is expanding, TG 235 has been formed to provide an update to TG-55 on radiochromic film dosimetry. RCF dosimetry applications in clinical radiotherapy have become even more widespread, expanding from primarily brachytherapy and radiosurgery applications, and gravitating towards (but not limited to) external beam therapy (photon, electron and protons), such as quality assurance for IMRT, VMAT, Tomotherapy, SRS/SRT, and SBRT. In addition, RCF applications now extend to measurements of radiation dose in particle beams and patients undergoing medical exams, especially fluoroscopically guided interventional procedures and CT. The densitometers/scanners used for RCF dosimetry have also evolved from the He-Ne laser scanner to CCD-based scanners, including roller-based scanner, light box-based digital camera, and flatbed color scanner. More recently, multichannel RCF dosimetry introduced a new paradigm for external beam dose QA for its high accuracy and efficiency. This course covers in detail the recent advancements in RCF dosimetry. Learning Objectives: Introduce the paradigm shift on multichannel film dosimetry Outline the procedures to achieve accurate dosimetry with a RCF dosimetry system Provide comprehensive guidelines on RCF dosimetry for various clinical applications One of the speakers has a research agreement from Ashland Inc., the manufacturer of Gafchromic film.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2016

Usefulness of Cone-Beam Computed Tomography and Automatic Vessel Detection Software in Emergency Transarterial Embolization

BackgroundThis study was designed to evaluate the utility of dual phase cone beam computed tomography (DP-CBCT) and automatic vessel detection (AVD) software to guide transarterial embolization (TAE) of angiographically challenging arterial bleedings in emergency settings.MethodsTwenty patients with an arterial bleeding at computed tomography angiography and an inconclusive identification of the bleeding vessel at the initial 2D angiographic series were included. Accuracy of DP-CBCT and AVD software were defined as the ability to detect the bleeding site and the culprit arterial bleeder, respectively. Technical success was defined as the correct positioning of the microcatheter using AVD software. Clinical success was defined as the successful embolization. Total volume of iodinated contrast medium and overall procedure time were registered.ResultsThe bleeding site was not detected by initial angiogram in 20 % of cases, while impossibility to identify the bleeding vessel was the reason for inclusion in the remaining cases. The bleeding site was detected by DP-CBCT in 19 of 20 (95 %) patients; in one case CBCT-CT fusion was required. AVD software identified the culprit arterial branch in 18 of 20 (90 %) cases. In two cases, vessel tracking required manual marking of the candidate arterial bleeder. Technical success was 95 %. Successful embolization was achieved in all patients. Mean contrast volume injected for each patient was 77.5 ml, and mean overall procedural time was 50 min.ConclusionsC-arm CBCT and AVD software during TAE of angiographically challenging arterial bleedings is feasible and may facilitate successful embolization. Staff training in CBCT imaging and software manipulation is necessary.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

DOE OSTI2021

Interdisciplinary Clinical Target Volume Generation for Cardiac Radioablation: Multicenter Benchmarking for the RAdiosurgery for VENtricular TAchycardia (RAVENTA) Trial

Cardiac radioablation is a novel treatment option for therapy-refractory ventricular tachycardia (VT) ineligible for catheter ablation. Three-dimensional clinical target volume (CTV) definition is a key step, and this complex interdisciplinary procedure includes VT-substrate identification based on electroanatomical mapping (EAM) and its transfer to the planning computed tomography (PCT). Benchmarking of this process is necessary for multicenter clinical studies such as the RAVENTA trial.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

DOE OSTI2012

CR mammography: Design and implementation of a quality control program

Despite the recent acquisition of significant quantities of computed radiography CR equipment for mammography, Mexican regulations do not specify the performance requirements for digital systems such as those of CR type. The design of a quality control program QCP specific for CR mammography systems was thus considered relevant. International protocols were taken as reference to define tests, procedures and acceptance criteria. The designed QCP was applied in three CR mammography facilities. Important deficiencies in spatial resolution, noise, image receptor homogeneity, artifacts and breast thickness compensation were detected.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

DOE OSTI2018

Polarization Tomography of Residual Stresses in Cylindrical Gradient-Index Lenses

In most cases, cylindrical structures with a gradient refractive index (GRIN) are formed on the basis of diffusion technology. The refractive index and the residual stresses in them are axially symmetrical. The distortion determined by diffusion and the thermal internal stresses in them are simulated by the fictive temperature of residual stresses. The use of the integral photoelasticity for the reconstruction of residual stresses in GRIN lenses is usually limited to the case of a planar deformed state. In this study, this algorithm is extended to the case of the axial change of residual stresses. It is assumed that the illumination procedure is carried out in the sample cross section. The optical problem is solved within the quasi-isotropic approximation. The reconstruction is based on measuring the characteristic parameters of polarized light passed through the sample and on the combined solution of the thermoelasticity problem.

71 CLASSICAL AND QUANTUM MECHANICS, GENERAL PHYSIC↗

DOE OSTI2019

Transcatheter Arterial Embolization of Spontaneous Soft Tissue Hematomas: A Systematic Review

Background: Severe spontaneous soft tissue hematomas (SSTH) are usually treated with transcatheter arterial embolization (TAE) although only limited retrospective studies exist evaluating this treatment option. The aim of this study was to systematically assess the efficacy and safety of TAE for the management of SSTH. Methods: Medline, EMBASE, PubMed and Cochrane Library were searched from inception to July 2017 using MeSH headings and a combination of keywords. Eligibility was restricted to original studies with patients suffering from SSTH treated with TAE. Patients with traumatic hematomas or who were treated with solely conservative or surgical management were excluded. For each publication, clinical success based on the control of the bleed, rebleeding rates and complications (including mortality) was collected, as well as technical details. Results: Sixty-three studies met the inclusion criteria, with an aggregate total of 267 patients. Follow-up extended from 1 day to 10 years. Bleeding was mainly localized to the iliopsoas (n = 113/267, 42.3%) and anterior abdominal wall (n = 145/266, 54.7%). When information was available, 81.0% (n = 158/195) of patients were on anticoagulant therapy prior to the bleeding episode. Initial stabilization with control of the bleed was obtained in 93.1% (n = 242 patients, n = 60 studies). The most common embolic materials were coils (n = 129, 54.4%). Rebleeding was reported in 25 patients (9.4%). Only two embolization complications were reported (0.7%). The 30-day mortality was 22.7% (n = 42/1857). Conclusion: TAE represents a safe and effective procedure in the management of SSTH. We present a management algorithm based on these data, but further studies are needed to address the knowledge gap.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

DOE OSTI2019

Transgraft sac Embolization Combined with Graft Reinforcement for Refractory Mixed-Type Endoleak

An 80-year-old female underwent EVAR 4 years ago. She presented type II endoleak with sac expansion from 68 to 80 mm during 3-year follow-up after EVAR. Although she underwent translumbar percutaneous sac embolization, the AAA sac continued to enlarge, suggesting mixed-type endoleak including type I, II, and III. Transgraft direct sac angiography revealed endoleak cavity without demonstrable feeding vessel. Transgraft sac embolization using n-butyl cyanoacrylate and graft reinforcement was performed concurrently, without complications. The graft reinforcement consisted of graft extension for eliminating occult type I endoleak, and relining for eliminating occult type III endoleak. Six months after the procedure, CT showed no signs of sac expansion. Transgraft sac embolization combined with graft reinforcement is one of the available options for persistent and refractory mixed-type endoleak.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

DOE OSTI2016

SU-C-202-05: Pilot Study of Online Treatment Evaluation and Adaptive Re-Planning for Laryngeal SBRT

Purpose: We have instigated a phase I trial of 5-fraction stereotactic body radiotherapy (SBRT) for advanced-stage laryngeal cancer. We conducted this pilot dosimetric study to confirm the potential utility of online adaptive re-planning to preserve treatment quality. Methods: Ten cases of larynx cancer were evaluated. Baseline and daily SBRT treatment plans were generated per trial protocol. Daily volumetric images were acquired prior to every fraction of treatment. Reference simulation CT images were deformably registered to daily volumetric images using Eclipse. Planning contours were then deformably propagated to daily images. Reference SBRT plans were directly copied to calculate delivered dose distributions on deformed reference CT images. In-house software platform has been developed to calculate cumulative dose over a course of treatment in four steps: 1) deforming delivered dose grid to reference CT images using deformation information exported from Eclipse; 2) generating tetrahedrons using deformed dose grid as vertices; 3) resampling dose to a high resolution within every tetrahedron; 4) calculating dose-volume histograms. Our inhouse software was benchmarked with a commercial software, Mirada. Results: In all ten cases including 49 fractions of treatments, delivered daily doses were completely evaluated and treatment could be re-planned within 10 minutes. Prescription dose coverage of PTV was less than intended in 53% of fractions of treatment (mean: 94%, range: 84%–98%) while minimum coverage of CTV and GTV was 94% and 97%, respectively. Maximum bystander point dose limits to arytenoids, parotids, and spinal cord remained respected in all cases, although variances in carotid artery doses were observed in a minority of cases. Conclusion: Although GTV and CTV coverage is preserved by in-room 3D image guidance of larynx SBRT, PTV coverage can vary significantly from intended plans. Online adaptive treatment evaluation and re-planning is potentially necessary and our procedure is clinically applicable to fully preserve treatment quality. This project is supported by CPRIT Individual Investigator Research Award RP150386.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2019

Spectral–Dynamic Model of the Hot Plasma Layer Expansion

We propose a theoretical model describing the expansion of a plasma layer into vacuum for an arbitrary electron plasma component temperature. Comparison with the known limiting cases of the quasi-neutral outflow and the Coulomb explosion, as well as with the results of the 1D electrostatic simulation, has revealed a high accuracy of the proposed model in the description of the spectral–energy and spatial characteristics of ions accelerated during the plasma expansion. The procedure for obtaining the relations between the characteristics of accelerated ions and the laser pulse and target parameters is described with regard to qualitative predictions and the description of the results of numerical kinetic simulation and experiments on the laser and plasma acceleration of ions.

70 PLASMA PHYSICS AND FUSION TECHNOLOGY↗

DOE OSTI2012

Percutaneous Extraction of Cement Leakage After Vertebroplasty Under CT and Fluoroscopy Guidance: A New Technique

Purpose: We report a new minimally invasive technique of extraction of cement leakage following percutaneous vertebroplasty in adults. Methods: Seven adult patients (five women, two men; mean age: 81 years) treated for vertebral compression fractures by percutaneous vertebroplasty had cement leakage into perivertebral soft tissues along the needle route. Immediately after vertebroplasty, the procedure of extraction was performed under computed tomography (CT) and fluoroscopy guidance: a Chiba needle was first inserted using the same route as the vertebroplasty until contact was obtained with the cement fragment. This needle was then used as a guide for an 11-gauge Trocar t'am (Thiebaud, France). After needle withdrawal, a 13-gauge endoscopy clamp was inserted through the cannula to extract the cement fragments. The whole procedure was performed under local anesthesia. Results: In each patient, all cement fragments were withdrawn within 10 min, without complication. Conclusions: This report suggests that this CT- and fluoroscopy-guided percutaneous technique of extraction could reduce the rate of cement leakage-related complications.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

DOE OSTI2015

Optical eye tracking system for real-time noninvasive tumor localization in external beam radiotherapy

Purpose: External beam radiotherapy currently represents an important therapeutic strategy for the treatment of intraocular tumors. Accurate target localization and efficient compensation of involuntary eye movements are crucial to avoid deviations in dose distribution with respect to the treatment plan. This paper describes an eye tracking system (ETS) based on noninvasive infrared video imaging. The system was designed for capturing the tridimensional (3D) ocular motion and provides an on-line estimation of intraocular lesions position based on a priori knowledge coming from volumetric imaging. Methods: Eye tracking is performed by localizing cornea and pupil centers on stereo images captured by two calibrated video cameras, exploiting eye reflections produced by infrared illumination. Additionally, torsional eye movements are detected by template matching in the iris region of eye images. This information allows estimating the 3D position and orientation of the eye by means of an eye local reference system. By combining ETS measurements with volumetric imaging for treatment planning [computed tomography (CT) and magnetic resonance (MR)], one is able to map the position of the lesion to be treated in local eye coordinates, thus enabling real-time tumor referencing during treatment setup and irradiation. Experimental tests on an eye phantom and seven healthy subjects were performed to assess ETS tracking accuracy. Results: Measurements on phantom showed an overall median accuracy within 0.16 mm and 0.40° for translations and rotations, respectively. Torsional movements were affected by 0.28° median uncertainty. On healthy subjects, the gaze direction error ranged between 0.19° and 0.82° at a median working distance of 29 cm. The median processing time of the eye tracking algorithm was 18.60 ms, thus allowing eye monitoring up to 50 Hz. Conclusions: A noninvasive ETS prototype was designed to perform real-time target localization and eye movement monitoring during ocular radiotherapy treatments. The device aims at improving state-of-the-art invasive procedures based on surgical implantation of radiopaque clips and repeated acquisition of X-ray images, with expected positive effects on treatment quality and patient outcome.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2015

TU-F-201-02: Applications in SRS, SBRT, IMRT, VMAT, and KV Imaging

60 APPLIED LIFE SCIENCES↗

DOE OSTI2018

Electronics Upgrades to the Green is Clean Phoswich Detector Systems and Programmatic Implementation at LANL - Phase II Completion - 18403

Los Alamos National Laboratory (LANL) radiological facilities produce low-density room trash that, in many cases, is not contaminated with radioactivity. It has been estimated that 50 to 90% of low-density room trash is free of radioactive contamination and eligible for inclusion in LANL's Green is Clean (GIC) program. The GIC program is a verification program for non-regulated waste from radiation controlled areas that has been actively segregated as nonradioactive through the use of the waste generator's acceptable knowledge. The GIC program has employed two large area Phoswich gamma ray detector systems (HERCULES and ZEUS) to verify that GIC candidate low-density waste contains no radioactivity above background. The large area (127 cm{sup 2}) Phoswich detectors consist of a thin NaI front crystal (3 mm thick) that is optically coupled to a thick CsI back crystal (50 mm thick). The scintillation properties of the two crystals are different enough to allow the system's electronic components to identify the origin of any pulse. The original systems utilize Nuclear Instrumentation Module (NIM) electronics to process the detector signals. The electronics currently in use by the systems are out of date and some components are no longer manufactured. In 2015, phase I upgrades to the GIC detector systems were completed. Phase I objectives included identifying more modern commercially available electronics that could replace the NIM electronics. A pulse shape discriminator (PSD) module, the Digital Gamma Finder (DGF) Pixie-4 made by XIA LLC, that fits in a compact National Instruments{sup TM} PXI chassis was identified to replace the majority of the original NIM bin electronics - a single Pixie-4 module replaces four NIM amplifiers and four NIM pulse shape analyzers (PSAs). Another phase I objective was to show that that new PSD could separate out the NaI and CsI detector signals in a manner equivalent to or better than the NIM electronics. Proof of concept was achieved in 2015 when a prototype upgrade system on ZEUS was built and tested and gating parameter settings were determined that successfully separated the NaI and CsI signals. Phase II required establishing a LabVIEW software interface with Pixie-4 electronics in lieu of the manufacturer provided Pixie-4 software called the Pixie Viewer. In addition, phase II included 1) final optimization of the gating parameters on the prototype Pixie-4 ZEUS system, 2) finalizing Requirements, Design and Test Plan documents, 3) LabVIEW software interface quality assurance (QA) testing, 4) setting up the HERCULES system with the Pixie-4 upgrade electronics, 5) check source and background calibration of both systems, 6) absolute efficiency determination on both systems and 7) procedure revisions and implementation of both systems into routine operations. In 2017 phase II was completed including the preparation of detailed Requirements, Design and Test Plan documents. The LabVIEW interface software that communicates and controls the Pixie-4 has been completed, merged with the preexisting LabVIEW operations software and fully tested. Gating parameter optimization, configuration of HERCULES with the Pixie-4 electronics, check source and background calibrations and absolute efficiency determinations have all been performed - quantitative results are presented in the full paper. For performance validation, comparison measurements of actual GIC bags on both the HERCULES system using the old NIM Bin electronics and the ZEUS system using the upgraded Pixie-4 electronics have been done and evaluated. Finally, procedure revisions and implementation of both systems into routine operations is currently in process and planned to be complete by the end of calendar year 2017. (authors)

12 MANAGEMENT OF RADIOACTIVE AND NON-RADIOACTIVE W↗

DOE OSTI2013

Temporary Arterial Balloon Occlusion as an Adjunct to Yttrium-90 Radioembolization

Purpose. This study was designed to describe the technique of arterial occlusion using a temporary occlusion balloon system as an alternative to coil occlusion during Yttrium-90 radioembolization of hepatic tumors. Methods. Review of charts, angiography, and follow-up imaging studies of consecutive patients undergoing oncological embolization procedures in which a HyperForm system (ev3 Neurovascular, Irvine, CA) was used. Intraprocedural target vessel occlusion and patency of the target vessel on follow-up were recorded. Clinical data and Bremsstrahlung scans were reviewed for evidence of nontarget embolization. Results. Four radioembolization procedures were performed in three patients (all female, age 48-54 (mean 52) years). Five arteries were temporarily occluded (three gastroduodenal arteries, one right gastric artery, and one cystic artery). All radioembolization procedures were successfully completed. Follow-up imaging (either digital subtraction angiography (DSA) or computed tomography angiography (CTA)) was available for all patients between 28-454 (mean 183) days following the procedure, demonstrating all five vessels to be patent. No clinical or imaging evidence for nontarget embolization was found. Conclusions. Temporary balloon occlusion of small and medium-sized arteries during radioembolization allows safe therapy with preserved postprocedural vessel patency on early and midterm follow-up.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

DOE OSTI2013

The Residual Setup Errors of Different IGRT Alignment Procedures for Head and Neck IMRT and the Resulting Dosimetric Impact

Purpose: To assess residual setup errors during head and neck radiation therapy and the resulting consequences for the delivered dose for various patient alignment procedures. Methods and Materials: Megavoltage cone beam computed tomography (MVCBCT) scans from 11 head and neck patients who underwent intensity modulated radiation therapy were used to assess setup errors. Each MVCBCT scan was registered to its reference planning kVCT, with seven different alignment procedures: automatic alignment and manual registration to 6 separate bony landmarks (sphenoid, left/right maxillary sinuses, mandible, cervical 1 [C1]-C2, and C7-thoracic 1 [T1] vertebrae). Shifts in the different alignments were compared with each other to determine whether there were any statistically significant differences. Then, the dose distribution was recalculated on 3 MVCBCT images per patient for every alignment procedure. The resulting dose-volume histograms for targets and organs at risk (OARs) were compared to those from the planning kVCTs. Results: The registration procedures produced statistically significant global differences in patient alignment and actual dose distribution, calling for a need for standardization of patient positioning. Vertically, the automatic, sphenoid, and maxillary sinuses alignments mainly generated posterior shifts and resulted in mean increases in maximal dose to OARs of >3% of the planned dose. The suggested choice of C1-C2 as a reference landmark appears valid, combining both OAR sparing and target coverage. Assuming this choice, relevant margins to apply around volumes of interest at the time of planning to take into account for the relative mobility of other regions are discussed. Conclusions: Use of different alignment procedures for treating head and neck patients produced variations in patient setup and dose distribution. With concern for standardizing practice, C1-C2 reference alignment with relevant margins around planning volumes seems to be a valid option.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

DOE OSTI2016

Fast Megavoltage Computed Tomography: A Rapid Imaging Method for Total Body or Marrow Irradiation in Helical Tomotherapy

Purpose: Megavoltage computed tomographic (MVCT) imaging has been widely used for the 3-dimensional (3-D) setup of patients treated with helical tomotherapy (HT). One drawback of MVCT is its very long imaging time, the result of slow couch speeds of approximately 1 mm/s, which can be difficult for the patient to tolerate. We sought to develop an MVCT imaging method allowing faster couch speeds and to assess its accuracy for image guidance for HT. Methods and Materials: Three cadavers were scanned 4 times with couch speeds of 1, 2, 3, and 4 mm/s. The resulting MVCT images were reconstructed using an iterative reconstruction (IR) algorithm with a penalty term of total variation and with a conventional filtered back projection (FBP) algorithm. The MVCT images were registered with kilovoltage CT images, and the registration errors from the 2 reconstruction algorithms were compared. This fast MVCT imaging was tested in 3 cases of total marrow irradiation as a clinical trial. Results: The 3-D registration errors of the MVCT images reconstructed with the IR algorithm were smaller than the errors of images reconstructed with the FBP algorithm at fast couch speeds (2, 3, 4 mm/s). The scan time and imaging dose at a speed of 4 mm/s were reduced to 30% of those from a conventional coarse mode scan. For the patient imaging, faster MVCT (3 mm/s couch speed) scanning reduced the imaging time and still generated images useful for anatomic registration. Conclusions: Fast MVCT with the IR algorithm is clinically feasible for large 3-D target localization, which may reduce the overall time for the treatment procedure. This technique may also be useful for calculating daily dose distributions or organ motion analyses in HT treatment over a wide area. Automated integration of this imaging is at least needed to further assess its clinical benefits.

62 RADIOLOGY AND NUCLEAR MEDICINE↗