Motion gating and tracking techniques: overview and recent developments

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Motion gating and tracking techniques: overview and recent developments Gig S Mageras, PhD, FAAPM Department of Medical Physics Memorial Sloan Kettering Cancer Center, New York MSK/gsm 15-Jun-2018 1

Disclosure Research support from Varian Medical Systems MSK/gsm 15-Jun-2018 2

Respiratory gating some basics Intermittent delivery of radiation occurring within a portion of breathing cycle (gate) Gate onset/duration determined by respiratory monitoring, either external signal, imaging of internal markers, or electromagnetic tracking Usually gate set around end expiration: tumor motion In some apps (e.g. left breast), gate set at enhanced inspiration with coached deep breathing: normal tissue sparing MSK/gsm 15-Jun-2018 3

Gating external monitors MSK/gsm 15-Jun-2018 4

Gating external monitors Irradiation synchronized with respiration gate Univ. Tsukuba, Japan Equipment/signal processing Triggered exposure on simulator Expiration Inspiration Ohara et al. IJROBP 1989; 17:853 MSK/gsm 15-Jun-2018 5

Gating external monitors Respiratory gated irradiation system for heavy-ion radiotherapy, Chiba, Japan Minohara et al. IJROBP 2000; 47:1097 MSK/gsm 15-Jun-2018 6

Gating external monitors Breathing-synchronized RT program at Univ. California, Davis Video camera-based breathing signal Breath signal synchronized with fluoroscopy Expiration Inspiration Kubo et al. Med Phys 2000; 27:346 MSK/gsm 15-Jun-2018 7

Gating external monitors Varian Real-time Position Management (RPM) Infrared video camera Reflective marker block Gating threshold levels (amplitude based) Beam enable intervals MSK/gsm 15-Jun-2018 8

Gating external monitors Prospective RPM-triggered CT acquisition Acquisition in axial mode (1 slice with couch stationary, couch index to next position) RPM triggers issued to contrast injector port Each gate triggers 1 slice 100 slices takes ~ 9min Philips PQ5000 single slice CT MSK/gsm 15-Jun-2018 9

Comparison standard vs respiration-triggered CT - NSCLC Free Breathing Expiration #1 Inspiration Expiration #2 mskcc/gsm 10

Gating external monitors RPM-gated RT exhibits interfractional external-internal variation Voice + visual instruction achieves consistent RPM marker motion Observed diaphragm deviations from plan: NSCLC, n=21: Systematic -0.1±0.6 cm, random 0.4±0.1 cm (similar in liver) Daily IGRT a necessity Yorke et al, JACMP 2003; 6:19 MSK/gsm 15-Jun-2018 11

Gating external monitors Inconsistent gating accuracy may occur within 1 RT session even with daily IGRT Studied implanted fiducials in abdomen, RPM amplitude-gated, n=12 accuracy in 44% of daily fluoro movies Recommend > 2.5mm safety margin Ge et al, IJROBP 2013; 85:854 MSK/gsm 15-Jun-2018 12

Gating external monitors Breathing adapted RT of breast cancer: reduction of cardiac and pulmonary doses using voluntary inspiration breath-hold Pedersen et al. Radiother Oncol 2004; 72:53 MSK/gsm 15-Jun-2018 13

Gating internal fiducials MSK/gsm 15-Jun-2018 14

Gating internal fiducials Mitsubishi/Hokkaido Real-Time Tumor-Tracking (RTRT) system Image intensifiers X-ray tubes (3) Detected marker Planned position Allowed displacement Shirato et al, IJROBP 2000; 48:1187 MSK/gsm 15-Jun-2018 15

Gating electromagnetic tracking Prospective Cohort Study of Gated SBRT Using Continuous Internal Electromagnetic Motion Monitoring Calypso monitor screen Worm et al. IJROBP 2018; 101:366 MSK/gsm 15-Jun-2018 16

Gating electromagnetic tracking Patient example at one session Gray: CBCT scan. Green: beam-on. Red: couch adjustments Gated Motion in sagittal plane during CBCT (black) and last field of nongated RT (red) Not gated Mean drift: 8mm sup, 5mm post Worm et al. IJROBP 2018; 101:366 MSK/gsm 15-Jun-2018 17

Gating electromagnetic tracking Gated vs simulated Not gated, n=15, 3 fx Worm et al. IJROBP 2018; 101:366 MSK/gsm 15-Jun-2018 18

Calypso-gated RT in lung @MSK (protocol) MSK/gsm 15-Jun-2018 19

Calypso-gated RT in lung @MSK (protocol) MSK/gsm 15-Jun-2018 20

Calypso-gated RT in lung 4DCT at expiration Axial Coronal MSK/gsm 15-Jun-2018 21

Calypso-gated RT in lung Orthogonal kv pair with tracking templates overlaid (blue) MSK/gsm 15-Jun-2018 22

Calypso-gated RT in lung Formation of respiratory motion-corrected CBCT CBCT scan Dzyubak et al. Med Phys 2014; 41:101918 Track beacons in projection images Amplitude sort into 10 bins, reconstruct each bin Motion-corrected CBCT Deform each reconstructed bin to expiration state (model from 4DCT) Sum MSK/gsm 15-Jun-2018 23

Calypso-gated RT in lung Verify beacon positions in lung relative to tumor, with motion-corrected CBCT Axial Calypso beacon Coronal Plan CT (FB) CBCT 4DCT end-expiration CBCT TrueBeam Motion corrected MSK/gsm 15-Jun-2018 24

Calypso-gated RT in lung Couch adjustment Beam on (gated) MSK/gsm 15-Jun-2018 25

Gated CBCT uses a script to gate gantry rotation & kv image acquisition Developer Mode, Varian TrueBeam Kincaid et al, Med Phys 2013; 40:041717 Video courtesy Michelle Svatos 26 MSK/gsm 15-Jun-2018

Gated CBCT improves tumor visibility in lung, Standard CBCT Gated CBCT Kincaid et al, Med Phys 2013; 40:041717 27 MSK/gsm 15-Jun-2018

and soft tissue visibility in pancreas. Standard CBCT Gated CBCT Kincaid et al, Med Phys 2013; 40:041717 28 MSK/gsm 15-Jun-2018

Motion tracking MSK/gsm 15-Jun-2018 29

Motion tracking Some basics Continuous adjustment of radiation beam or patient position to follow the changing position of the target or its surrogate A means of localizing the target in real-time is coupled to a target alignment control system Instructions to alignment control includes correction for system latency (motion prediction) Dieterich et al. Med Phys 2008; 35:5684 MSK/gsm 15-Jun-2018 30

Motion tracking Ozhazoglu et al. Med Dosim 2008; 33:117 MSK/gsm 15-Jun-2018 31

SD intra-fx error (mm) SD prediction error (mm) Motion tracking Accuracy of Cyberknife lung tumor tracking: analysis of log files Correlates external optical signal with kv imaging of internal fiducials every 30-60 s Correlation may fail with irregular breathing, baseline drift, or large target rotation Analysis of treatment log files, early-stage NSCLC or isolated lung met, n=44: Motion amplitude (mm) Motion amplitude (mm) Hoogeman et al. IJROBP 2009; 74:297 MSK/gsm 15-Jun-2018 32

Motion tracking Real-time image-guided adaptive RT in prostate using a standard linac KIM 2D-to-3D transformation assumes correlation of motion between observed & unobserved directions. Unobserved motion based on prior observations. Keall et al. Radiother Oncol 2018; 127:6 MSK/gsm 15-Jun-2018 33

Motion tracking worst-motion case with drift in all 3 directions Keall et al. Radiother Oncol 2018; 127:6 MSK/gsm 15-Jun-2018 34

MV/kV Intratreatment Imaging for Prostate SBRT MSK/gsm 15-Jun-2018 35

Simultaneous MV-kV intra-fractional motion management VMAT in prostate Modification of MLC control-point (CP) sequence to increase fiducial visibility Copy of TxCP2 Copy of TxCP2 Plan hot spot increases 0.5-1.0% Slide courtesy Perry Zhang Zhang et al. Med. Phys. 2016; 43:2024 MSK/gsm 15-Jun-2018 36

MV/kV clinical process patient setup Hunt et al. J Appl Clin Med Phys 2016;17:473 Position-of-the-day 3D correction kv/kv setup pair Before After MSK/gsm 15-Jun-2018 38

MV/kV clinical process treatment Hunt et al. J Appl Clin Med Phys 2016;17:473 Triggered kv + MV short-arc digital tomosynthesis @ 20⁰ intervals Audio/visual alert if 2 mm tolerance is exceeded Manual interruption and correction of position if needed kv trigger during VMAT 3 MV-DTS MSK/gsm 15-Jun-2018 39

First treatment of electromagnetic-guided real-time adaptive RT using MLC tracking for lung SABR Booth et al. Radiother Oncol 2016; 121:19 MSK/gsm 15-Jun-2018 40

(VIDEO) Booth et al. Radiother Oncol 2016; 121:19 MSK/gsm 15-Jun-2018 41

MR-guided tracking and beam gating MSK/gsm 15-Jun-2018 42

Implementation of real-time, real anatomy tracking and radiation beam gating Workflow: 3D MRI acquisition Expiration breath hold Select sagittal plane to track relevant anatomical feature (target contour) Assign boundary: Expand target contour or any encompassing contour (e.g. PTV) Cine: preview acquisition prior to start of delivery (40 s) Evaluate: does target contour deform accurately with observed anatomy for tracking? Select ROI: Based on observed tracking, what % of target is allowed outside boundary? Start radiation delivery with continuous imaging at 4 Hz Gate off/on when anatomy of interest outside/inside boundary Green et al. Med Phys 2018 (accepted) MSK/gsm 15-Jun-2018 43

MR acquisition, anatomy tracking and beam gating Green et al. Med Phys 2018 (accepted) MSK/gsm 15-Jun-2018 44

Commercial Systems, current and near future Gated linac + External monitor: Varian + RPM, Elekta + Catalyst X-ray imaging implanted markers: Mitsubishi/Hokkaido RTRT Electromagnetic tracking: Varian + Calypso MR-guided: ViewRay MRIdian, Elekta Unity (future: add gating) Motion tracking Robotic beam : Cyberknife Synchrony Couch tracking: experimental MLC: customized systems MSK/gsm 15-Jun-2018 45

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