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   Table of Contents - Current issue
Coverpage
October-December 2022
Volume 47 | Issue 4
Page Nos. 315-416

Online since Tuesday, January 10, 2023

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ORIGINAL ARTICLES  

Magnetic resonance imaging image-based segmentation of brain tumor using the modified transfer learning method Highly accessed article p. 315
Sandeep Singh, Benoy Kumar Singh, Anuj Kumar
DOI:10.4103/jmp.jmp_52_22  
Purpose: The goal of this study was to improve overall brain tumor segmentation (BraTS) accuracy. In this study, a form of convolutional neural network called three-dimensional (3D) U-Net was utilized to segment various tumor regions on brain 3D magnetic resonance imaging images using a transfer learning technique. Materials and Methods: The dataset used for this study was obtained from the multimodal BraTS challenge. The total number of studies was 2240, obtained from BraTS 2018, BraTS 2019, BraTS 2020, and BraTS 2021 challenges, and each study had five series: T1, contrast-enhanced-T1, Flair, T2, and segmented mask file (seg), all in Neuroimaging Informatics Technology Initiative (NIFTI) format. The proposed method employs a 3D U-Net that was trained separately on each of the four datasets by transferring weights across them. Results: The overall training accuracy, validation accuracy, mean dice coefficient, and mean intersection over union achieved were 99.35%, 98.93%, 0.9875%, and 0.8738%, respectively. Conclusion: The proposed method for tumor segmentation outperforms the existing method.
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Commissioning and dosimetric results of an indigenously developed intra-vaginal template for interstitial plus intracavitary high dose rate image-guided brachytherapy of advanced cervix cancer Highly accessed article p. 322
Venkatesan Kaliyaperumal, Susovan Banerjee, Tejinder Kataria, Susan K Abraham, Dayanithi Kamaraj, Singaravelu Tamilselvan, Deepak Gupta, Shyam Singh Bisht, Kushal Narang, Sorun Shishak
DOI:10.4103/jmp.jmp_50_22  
Aim: The goal of this study is to discuss the commissioning and dosimetric parameters achieved during the clinical implementation of an indigenously developed intracavitary (IC) plus interstitial (IS) template for high dose rate (HDR) image-guided brachytherapy (IGBT) in cancer (Ca) cervix. We want to discuss our achieved values of cumulative equi-effective doses (EQD2) for high-risk clinical target volume (HRCTV) and organ at risk (OAR) and compare it with available published results. Materials and Methods: Medanta anterior oblique/lateral oblique template has a total of 19 needles including the central tandem. For commissioning the template with needles, the indigenously made acrylic phantom was used. Oblique and straight needles were placed inside the acrylic phantom and a computed tomography (CT) scan was performed. Sixteen patients were treated in HDR IGBT using this template after external-beam radiotherapy. The IGBT plans were evaluated based on EQD2 of target coverage i.e., dose received by 98% (D98%_HRCTV), 90% (D90%_HRCTV), and 50% (D50%_HRCTV) volume of HRCTV, and dose received by 2 cc (D2cc) and 0.1 cc (D0.1cc) of OAR using linear quadratic (LQ) radiobiological model. Results: The autoradiographic in radiochromic film shows that the distance between the needle tip and the middle of the source position is 6 mm. The mean D98%_HRCTV and D90%_HRCTV was 76.8 Gy (range: 70-87.7 Gy, P < 0.01) and 84.49 Gy (range: 76.6-96.7 Gy, P < 0.01), respectively. Mean EQD2 of D2cc of the bladder, rectum, and sigmoid was 85.6 Gy (range: 77.5-99.6 Gy, P < 0.03), 74.3 Gy (range: 70.9-76.7 Gy, P < 0.05), and 58.3 Gy (range: 50.6-67.9 Gy, P = 0.01), respectively. The mean total reference air kerma at a 1 m distance is 0.489cGy (range: 0.391-0.681cGy). Conclusions: The indigenously developed template could attain satisfactory standards in terms of set parameters for commissioning and acceptable dose volume relations in our clinical use for treating the advanced Ca cervix patients who need IC + IS type of HDR IGBT. The comparative analysis with contemporary applicators was acceptable.
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Dosimetric effects of the supine and prone positions in proton therapy for prostate cancer p. 331
Takahiro Kato, Masato Kato, Kimihiro Takemasa, Masao Murakami
DOI:10.4103/jmp.jmp_85_22  
Purpose: To quantitatively evaluate how much the doses to organs at risk are affected in the prone position compared to the supine position in the proton therapy (PT) for prostate cancer. Materials and Methods: Fifteen consecutive patients with clinically localized prostate cancer underwent treatment planning computed tomography scans in both the supine and prone positions. The clinical target volume (CTV) consisted of the prostate gland plus the seminal vesicles. The PT plans were designed using the standard lateral opposed fields with passively scattered proton beams for both treatment positions. The prescribed dose for each plan was set to 78 Gy (Relative biological effectiveness)/39 fractions to 50% of the planning target volume. Dose-volume metrics of the rectum and bladder in the two treatment positions were analyzed. Results: It was confirmed that all the parameters of D05, D10, D20, D30, Dmean, and V90 examined in the rectum were significantly reduced in the prone position. There was no significant difference between the two positions in the bladder dose except for Dmean. The distance between the CTV and the rectum tended to increase with the patient in the prone position; at the prostate level, however, the maximum change was approximately 5 mm, and there was significant variation between cases. Conclusions: We confirmed that the rectal doses were significantly lower in the prone compared with the supine position in PT. Although uncertain, the prone position could be an effective method to reduce the rectal dose in PT.
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Does fluence smoothing reduce the complexity of the intensity-modulated radiation therapy treatment plan? A dosimetric analysis p. 336
Dinesh Kumar Saroj, Suresh Yadav, Neetu Paliwal
DOI:10.4103/jmp.jmp_81_22  
Background: Intensity-modulated radiation therapy (IMRT) may have too many peaks and valleys, making the treatment plan undeliverable. When there are too many fluency differences between adjacent pixels in the X or Y directions, the X and Y smoothing factors are utilized as weighting factors to penalize this behavior. Generally, a high degree of complexity is accompanied by many monitor units (MUs), large number of segments, small sized segments, and complex segment shapes. The degree of plan delivery uncertainty can all increase with a higher detailed fluence map. Aim: This study aims to evaluate the dosimetric effects of various smoothing levels on the planning target volume (PTV) and organs at risk (OARs) for cervix cancer. Materials and Methods: IMRT treatment plans were re-optimized by combining several values of the X and Y penalty between 0 and 100. The dose–volume histogram assessed various dosimetric indicators for PTV and OARs. Additionally, gamma passing rates were evaluated and noted as an indicator of the complex treatment plan. Results: At X = 60, Y = 60 fluence map penalty, the conformity index (CI) value reached its highest value of 0.996 ± 0.004. At X = 0, Y = 0, the homogeneity index (HI) was determined to have a maximum value of 0.0628 ± 0.0235. The highest and lowest MU values were 2424.30 ± 471.12 and 1087.80 ± 91.57, respectively, with X = 0, Y = 0 and X = 100, Y = 100. At X = 100, Y = 100, the gamma passing rate reaches its highest value of 99.28% ± 0.44% and minimum value of 85.93% ± 3.87% at X = 0, Y = 0. Conclusion: The CI and HI values showed no discernible fluctuation, and the OAR doses were barely affected as smoothing was increased. When the smoothing factor was raised, the number of MUs sharply dropped, and a decrease in the number of segments and higher gamma passing rates were also seen.
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Comparison of three commercial methods of cone-beam computed tomography-based dosimetric analysis of head-and-neck patients with weight loss p. 344
Satyapal Rathee, Benjamin Burke, Amr Heikal
DOI:10.4103/jmp.jmp_7_22  
Purpose: This investigation compares three commercial methods of cone-beam computed tomography (CBCT)-based dosimetric analysis to a method based on repeat computed tomography (CT). Materials and Methods: Seventeen head-and-neck patients treated in 2020, and with a repeat CT, were included in the analyses. The planning CT was deformed to anatomy in repeat CT to generate a reference plan. Two of the CBCT-based methods generated test plans by deforming the planning CT to CBCT of fraction N using VelocityAI™ and SmartAdapt®. The third method compared directly calculated doses on the CBCT for fraction 1 and fraction N, using PerFraction™. Maximum dose to spinal cord (Cord_dmax) and dose to 95% volume (D95) of planning target volumes (PTVs) were used to assess “need to replan” criteria. Results: The VelocityAI™ method provided results that most accurately matched the reference plan in “need to replan” criteria using either Cord_dmax or PTV D95. SmartAdapt® method overestimated the change in Cord_dmax (6.77% vs. 3.85%, P < 0.01) and change in cord volume (9.56% vs. 0.67%, P < 0.01) resulting in increased false positives in “need to replan” criteria, and performed similarly to VelocityAI™ for D95, but yielded more false negatives. PerFraction™ method underestimated Cord_dmax, did not perform any volume deformation, and missed all “need to replan” cases based on cord dose. It also yielded high false negatives using the D95 PTV criteria. Conclusions: The VelocityAI™-based method using fraction N CBCT is most similar to the reference plan using repeat CT; the other two methods had significant differences.
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Commissioning validation of a brachytherapy treatment planning system with egsnrc monte carlo code and EBT3 GAFChromic film p. 352
Mohammed Lahlabou, Rachid Khelifi
DOI:10.4103/jmp.jmp_30_22  
Aims: Most brachytherapy treatment planning system (TPS) commissioning requires data input based on the American Association of Physicists in Medicine Task Group-43 formalism. The commissioning accuracy is very important for dose calculation. The aim of this study is the implementation of a brachytherapy TPS into a clinical environment and check the TPS calculated dose accuracy. Subjects and Methods: After introducing data of the different catheters (CIS Bio International, Saclay, France), composed of several Cesium-137 Eckert and Ziegler BEBIG CSM-11 radioactive sources; for XiO (CMS, St. Louis) brachytherapy TPS, the TPS dose calculation accuracy was investigated by comparing between the TPS calculated dose distribution (DD) for all the catheters with (1) the measuring DD using EBT3 GAFChromic film and (2) calculating DD by egs_brachy (Electron Gamma Shower, National Research Council of Canada) Monte Carlo simulation. The phantom used for this study consists of six PTW slabs 30 cm × 30 cm × 1 cm of polymethyl methacrylate with a Delouche MEDpro applicator on the top. The TPS DD was calculated on the computed tomography scan of this phantom. Statistical Analysis Used: PTW VeriSoft version 6.0.1.7 (PTW-Freiburg, Germany) software was used for analyzing scanned films and to perform the comparison based on the gamma index distribution. Results: For each catheter, the gamma index distribution showed agreement >95% of all pixels in both verification methods, with gamma ≤1. Conclusions: We confirm the commissioning accuracy and that the TPS can be used for clinical purposes.
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In vivo Dosimetry for dose verification of total skin electron beam therapy using gafchromic® EBT3 film dosimetry p. 362
Misba Hamid Baba, Benoy Kumar Singh, Shaqul Qamar Wani
DOI:10.4103/jmp.jmp_72_22  
Background and Purpose: Total skin electron beam therapy (TSEBT) is an important skin-directed radiotherapeutic procedure done in the treatment of cutaneous T-cell lymphomas, namely, mycosis fungoides (MF). This procedure is usually done at larger source-to-surface distances with the patient standing on a rotatory platform. As the patient has to stand in different positions without any rigid immobilization devices, there are chances that the total skin may not get uniformly irradiated which could lead to nonuniform dose distributions. Therefore, all the necessary arrangements should be made to evaluate the dose for different regions of the skin using suitable in vivo dosimeters at the radiotherapy centers offering these treatments. This study aimed to evaluate the consistency between the delivered and planned doses in vivo during TSEBT using Gafchromic EBT3 film dosimetry. Materials and Methods: The surface dose for the six MF patients treated for TSEBT at our hospital from 2018 to 2022 was measured and evaluated. 2 cm × 2 cm Gafchromic® EBT3 films were used to measure skin dose at reference body positions of clinical interest. All the patients were treated with the modified Stanford technique. The irradiated film strips were analyzed for the dose using the IMRT OmniPro software. The doses at respective positions were expressed as mean dose ± standard deviation and the deviation was calculated as the percentage of the prescribed dose. Results: One hundred and fifty-four Gafchromic® EBT3 film strips irradiated on six TSEBT patients showed a maximum dose variation of 2.00 ± 0.14 Gy, in the central body regions. The dose variation in the peripheral areas such as hands and ears was larger. A variation of 2 ± 0.32 Gy was observed on the hands and ears. The uniformity of the dose delivered to maximum body parts was within −7% and +16% for the peripheral areas like hands. The American Association of Physicists in Medicine recommends a dose uniformity of 8% and 4% in the vertical and horizontal patient plane for direct incident beam; however, for oblique incidences like in the modified Stanford technique, the dose variation is about 15%. Conclusion: In vivo dosimetry using Gafchromic EBT3 film dosimetry for TSEBT yields objective data to find the under or overdose regions. That can be useful to provide quality treatment, especially when treatments tend to be as complex as TSEBT.
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Quality Improvement Process with Incident Learning Program Helped Reducing Transcriptional Errors on Telecobalt Due to Mismatched Parameters in Different Generations p. 367
Rahul Krishnatry, Carlton Johnny, Tahseena Tahmeed, Libin Scaria, Vivek Sutar, Chandrashekhar Tambe, Ritu Raj Upreti, Rajesh Ashok Kinhikar, Jai Prakash Agarwal
DOI:10.4103/jmp.jmp_74_22  
Purpose: Higher frequency of transcriptional errors in the radiotherapy electronic charts for patients on telecobalt was noted. We describe the impact of the quality improvement (QI) initiative under the department's incident learning program (ILP). Materials and Methods: The multidisciplinary quality team under ILP was formed to identify the root cause and introduce methods to reduce (smart goal) the current transcription error rate of 40% to <5% over 12 months. A root cause analysis including a fishbone diagram, Pareto chart, and action prioritization matrix was done to identify key drivers and interventions. Plan-Do-Study-Act (PDSA) Cycle strategy was undertaken. The primary outcome was percentage charts with transcriptional errors per month. The balancing measure was “new errors” due to interventions. All errors were identified and corrected before patient treatment. Results: The average baseline error rate was 44.14%. The two key drivers identified were education of the workforce involved and mechanical synchronization of various machine parameters. PDSA cycle 1 consisted of an education program and sensitization of the staff, post which the error rates dropped to 5.4% (t-test P = 0.03). Post-PDSA cycle 2 (synchronization of machine parameters), 1, 3, and 6 months and 1 year, the error rates were sustained to 5%, 4%, 3%, and 4% (t-test P > 0.05) with no new additional errors. Conclusions: With various generations of machines and technologies that are not synchronized, the proneness of transcription errors can be very high which can be identified and corrected with a typical QI process under ILP.
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Investigation of response of the pixelated CZT SPECT imaging system and comparison with the conventional SPECT system p. 374
Mahsa Noori-Asl, Pooneh Sayyah-Koohi
DOI:10.4103/jmp.jmp_41_22  
Purpose: The aim of this study is to investigate the factors affecting the response of the pixelated CZT SPECT imaging systems and to compare the performance of these systems with the conventional SPECT imaging systems. Materials and Methods: By using the simulation technique, the effect of applied voltage, gap size between the anode pixels, and electron cloud mobility on the response of a pixelated CZT SPECT system are investigated. Then, the response of this system is compared with the conventional SPECT system in both single- and dual-radioisotope imaging. Results: The results of this study show that increasing the applied voltage, electron cloud mobility or decreasing the gap size, in the optimal range of these parameters obtained in this study, leads to reducing the lateral charge diffusion and consequently improving the probability of the complete charge collection by the target anode pixel. In dual-radioisotope imaging by the pixelated CZT SPECT system, although higher energy resolution results in better separation of photopeaks, the presence of a low-energy tail leads to an overestimation of counts in the low-energy photopeak. Conclusion: The use of the optimal values for the applied voltage, gap size, and electron cloud mobility strongly affect the performance of the pixelated CZT SPECT systems. In addition, the presence of a tail restricts the use of these systems for dual-radioisotope imaging and also, the use of the conventional methods for scatter correction.
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Photon interaction coefficients for the colorectal cancer tissue p. 381
Emmanuel Okon Esien-Umo, Joseph Abebe Obu, Ndubuisi Ozoemena Chiaghanam, Theophilus Ipeh Ugbem, Nneoyi Onen Egbe
DOI:10.4103/jmp.jmp_29_22  
Purpose: The application of radiotherapy to the treatment of cancer requires the knowledge of photon interaction coefficients such as mass attenuation (μm) and mass energy-absorption coefficients (μen/ρ). Although these coefficients have been determined for different tissues, it is lacking for the colorectal cancer (CRC) tissue in the literature. This study determines the μm and μen/ρ for the CRC tissue within the radiotherapy energy range. Materials and Methods: The CRC tissue from autopsy patients was freeze-dried, grounded into a fine powder, and made into pellets of 1 cm thickness. The elements detected in the CRC tissue using Rutherford backscattering spectrometry were used in XCOM to determine the theoretical values of μm and μen/ρ. The CRC tissue was again exposed to X-rays of energies of 6 and 15MV, respectively, to determine its experimental values of μm and μen/ρ. Results: Elements detected included carbon, oxygen and nitrogen making up 96.67%, high atomic number and trace elements making up the remaining 3.33% fraction of the CRC tissue. Conclusion: The theoretical and experimental μm and μen/ρ values showed a good agreement of about 2% difference between them. These values can be used to simulate the CRC tissue with respect to μm and μen/ρ.
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TECHNICAL NOTES Top

Denoising using Noise2Void for low-field magnetic resonance imaging: A phantom study p. 387
Shinya Kojima, Toshimune Ito, Tatsuya Hayashi
DOI:10.4103/jmp.jmp_71_22  
To reduce noise for low-field magnetic resonance imaging (MRI) using Noise2Void (N2V) and to demonstrate the N2V validity. N2V is one of the denoising convolutional neural network methods that allows the training of a model without a noiseless clean image. In this study, a kiwi fruit was scanned using a 0.35 Tesla MRI system, and the image qualities at pre- and postdenoising were evaluated. Structural similarity (SSIM), signal-to-noise ratio (SNR), and contrast ratio (CR) were measured, and visual assessment of noise and sharpness was observed. Both SSIM and SNR were significantly improved using N2V (P < 0.05). CR was unchanged between pre- and postdenoising images. The results of visual assessment for noise revealed higher scores in postdenoising images than that in predenoising images. The sharpness scores of postdenoising images were high when SNR was low. N2V provides effective noise reduction and is a useful denoising technique in low-field MRI.
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Reporting of inter fraction dose variations of organs at risk in computed tomography-guided high dose rate intracavitary brachytherapy in carcinoma cervix p. 394
Moujhuri Nandi, Neelima Pokala, Vaishnavi Perumareddy, Sujata Sarkar, Sudeep Chanda
DOI:10.4103/jmp.jmp_91_22  
Assess the interfraction dose variations of the organs at risk (OARs) in carcinoma cervix high dose rate (HDR) computed tomography (CT)-guided intra cavitary brachytherapy (ICBT). 120 CT scans of 40 patients who had undergone three fractions of ICBT (7 Gy/fr) were analyzed. Dose to Point A and the minimum doses to the volumes of 2, 1, and 0.1cc of bladder, rectum and sigmoid colon were recorded. Revised plans were generated in 20 patients. Paired t-test was used to compare the difference in the means. Point “A” mean dose difference was statistically significant between the treated and revised plans. For bladder, the difference in means of dosage to all volumes, whilst for the rectum and sigmoid colon, the low volume dosage (0.1cc) was statistically significant. Absence of individualized planning would have resulted in underdosage of tumor and increased dosage of up to 30% to OARs. CT-guided ICBT should be implemented for each HDR fraction treatment.
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A framework for exactrac dynamic commissioning for stereotactic radiosurgery and stereotactic ablative radiotherapy p. 398
Ben Perrett, Jaysree Ukath, Emma Horgan, Chris Noble, Prabhakar Ramachandran
DOI:10.4103/jmp.jmp_67_22  
This paper aims to provide guidance and a framework for commissioning tests and tolerances for the ExacTrac Dynamic image-guided and surface-guided radiotherapy (SGRT) system. ExacTrac Dynamic includes a stereoscopic X-ray system, a structured light projector, stereoscopic cameras, thermal camera for SGRT, and has the capability to track breath holds and internal markers. The system provides fast and accurate image guidance and intrafraction guidance for stereotactic radiosurgery and stereotactic ablative radiotherapy. ExacTrac Dynamic was commissioned on a recently installed Elekta Versa HD. Commissioning tests are described including safety, isocenter calibration, dosimetry, image quality, data transfer, SGRT stability, SGRT localization, gating, fusion, implanted markers, breath hold, and end-to-end testing. Custom phantom designs have been implemented for assessment of the deep inspiration breath-hold workflow, the implanted markers workflow, and for gating tests where remote-controlled movement of a phantom is required. Commissioning tests were all found to be in tolerance, with maximum translational and rotational deviations in SGRT of 0.3 mm and 0.4°, respectively, and X-ray image fusion reproducibility standard deviation of 0.08 mm. Tolerances were based on published documents and upon the performance characteristics of the system as specified by the vendor. The unique configuration of ExacTrac Dynamic requires the end user to design commissioning tests that validate the system for use in the clinical implementation adopted in the department. As there are multiple customizable workflows available, tests should be designed around these workflows, and can be ongoing as workflows are progressively introduced into departmental procedures.
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BOOK REVIEW Top

Audit methodology for medical physics clinical training programs p. 409
Arun Chougule, Gourav Kumar Jain
DOI:10.4103/jmp.jmp_115_22  
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NEWS Top

News p. 412
Pratik Kumar
DOI:10.4103/jmp.jmp_118_22  
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