Multimodality & 4 D Imaging
-
Upload
fondas-vakalis -
Category
Health & Medicine
-
view
484 -
download
0
Transcript of Multimodality & 4 D Imaging
![Page 1: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/1.jpg)
Multimodality & 4D Imaging:Registration and Fusion for
Treatment Planning and Delivery
Multimodality & 4D Imaging:Registration and Fusion for
Treatment Planning and Delivery
Marc L Kessler, PhD The University of MichiganMarc L Kessler, PhD The University of Michigan
ASTRO 2007 - 49th Annual MeetingWednesday, October 31, 2007
1:30 – 2:45 PM
ASTRO 2007 - 49th Annual MeetingWednesday, October 31, 2007
1:30 – 2:45 PM
Laura A Dawson, MD Princess Margaret HospitalLaura A Dawson, MD Princess Margaret Hospital
![Page 2: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/2.jpg)
DisclosuresDisclosures
• Research Grant- Varian Medical Systems
![Page 3: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/3.jpg)
ObjectivesObjectives
Understand the basic mechanics of multimodality and 4D image registration techniques
Understand the different techniques used to combine, display and interact with multimodality and 4D image and dose data
Understand the clinical use and limitations of these techniques for Tx planning, Txdelivery and plan adaptation
Understand the basic mechanics of multimodality and 4D image registration techniques
Understand the different techniques used to combine, display and interact with multimodality and 4D image and dose data
Understand the clinical use and limitations of these techniques for Tx planning, Txdelivery and plan adaptation
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 4: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/4.jpg)
OutlineOutline
Motivation
Mechanics!
Clinical Use
Motivation
Mechanics!
Clinical Use
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 5: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/5.jpg)
MotivationMotivation
Precision radiation therapy requires accurate delineation of the tumor and normal tissues in the planning phase and accurate localization of these structures during the delivery phase
Precision radiation therapy requires accurate delineation of the tumor and normal tissues in the planning phase and accurate localization of these structures during the delivery phase
…with the aid of imaging…with the aid of imaging
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 6: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/6.jpg)
MotivationMotivation
DeliveryDelivery
ImagingImaging
PlanningPlanningImagingImaging
entireentireOptimization of the radiotherapy process requires that we anticipate, measure & adapt to changes in the patient
Optimization of the radiotherapy process requires that we anticipate, measure & adapt to changes in the patient
on-lineon-line
off-lineoff-line
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 7: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/7.jpg)
Multimodality TargetingMultimodality TargetingGregoire / St-LucGregoire / St-Luc
??
We now have many cameras available… which provide complementary data! We now have many cameras available… which provide complementary data!
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
X-ray CTX-ray CT MRIMRI Nuc MedNuc Med
![Page 8: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/8.jpg)
??
??
Normal TissuesNormal Tissues Target VolumesTarget VolumesMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
Repeat ImagingRepeat Imaging
![Page 9: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/9.jpg)
Balter / UMBalter / UM
4-D Imaging4-D Imaging
… assess motion… assess motion
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 10: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/10.jpg)
Varian OBI™Varian OBI™
Elekta Synergy™
Elekta Synergy™
Siemens PRIMATOM™
Siemens PRIMATOM™
TomoTherapyHi-Art™
TomoTherapyHi-Art™
ViewRayRenaissance™
ViewRayRenaissance™
Resonant Restitu™Resonant Restitu™
Image Guided TreatmentImage Guided TreatmentDawson / PMHDawson / PMH
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 11: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/11.jpg)
The Big PictureThe Big Picture
MRMR
Tx Plan3D DoseTx Plan3D Dose
NMNM
CTCT
CBCT1…n
CBCT1…n
PortalImagesPortal
Images
4D CBCT4D
CBCT
USUS
3D DoseDay n
3D DoseDay nUSUS
“Adapting”PatientModel
“Adapting”PatientModel
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 12: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/12.jpg)
The GoalThe Goal
Ideally, we would like to have a timedependent vector of information for every “point” in an anatomic object
Ideally, we would like to have a timedependent vector of information for every “point” in an anatomic object
image information (MR, CT, NM, … )
physiologic information ( )
anatomic label information
dose information … with time stamp !
image information (MR, CT, NM, … )
physiologic information ( )
anatomic label information
dose information … with time stamp !
ττ
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 13: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/13.jpg)
The GoalThe Goal
Scalar DataScalar DataCT+ MR + NM + Dose CT+ MR + NM + Dose (τ)(τ)
PET
MR
CT
4-D Vectors4-D VectorsMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 14: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/14.jpg)
MechanicsMechanics… determine the geometric transformation that maps corresponding points from one image series to another
… determine the geometric transformation that maps corresponding points from one image series to another
Form of the transformation TForm of the transformation T
Number of degrees of freedoms βNumber of degrees of freedoms β
… from rigid to fully freeform… from rigid to fully freeform
… from 3 to 3 x N*… from 3 to 3 x N*
*N = number of voxels*N = number of voxelsMarc L Kessler, PhD - ASTRO 2007 Refresher Course Marc L Kessler, PhD - ASTRO 2007 Refresher Course
![Page 15: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/15.jpg)
TransformationTransformation… determine the geometric transformation that maps corresponding points from one image series to another
… determine the geometric transformation that maps corresponding points from one image series to another
XB = T ( XA , { ß })XB = T ( XA , { ß })(x,y,z) coordinates of a point in Series B(x,y,z) coordinates of a point in Series B (x,y,z) coordinates
of a point in Series A(x,y,z) coordinates of a point in Series A
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 16: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/16.jpg)
Degrees of FreedomDegrees of Freedom
FewFew ManyManyNone ?None ?
PET/CTPET/CT MR - CTMR - CT 4D CT4D CT
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 17: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/17.jpg)
What is T ?What is T ?
Rigid / Affine
Full 3D / 4D Deformation
Parametric models
Free-form models
Rigid / Affine
Full 3D / 4D Deformation
Parametric models
Free-form models
Global, regional, or piecewiseGlobal, regional, or piecewise
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 18: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/18.jpg)
What is T ?What is T ?
Rigid / Affine Rigid / Affine
Global, regional, or piecewiseGlobal, regional, or piecewise
xB = A xA + b (up to 12 DOF)xB = A xA + b (up to 12 DOF)
y = m x + b … in 3Dy = m x + b … in 3D
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 19: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/19.jpg)
A SquareA Square
Study AStudy A
Study BStudy B
Affine TransformationsAffine Transformationswww.gnome.orgwww.gnome.org
RotationRotation ScalingScaling ShearingShearingTranslationTranslation
Parallel lines stay parallel !Parallel lines stay parallel !
3 3 3 3
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 20: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/20.jpg)
A SquareA Square
Study AStudy A
Study BStudy B
Affine TransformationsAffine Transformationswww.gnome.orgwww.gnome.org
RotationRotation ScalingScaling ShearingShearingTranslationTranslation
Parallel lines stay parallel !Parallel lines stay parallel !
6 DOF6 DOF
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 21: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/21.jpg)
A SquareA Square
Study AStudy A
Study BStudy B
Affine TransformationsAffine Transformationswww.gnome.orgwww.gnome.org
RotationRotation ScalingScaling ShearingShearingTranslationTranslation
Parallel lines stay parallel !Parallel lines stay parallel !3 or 4 DOF3 or 4 DOF
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 22: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/22.jpg)
Affine TransformationsAffine Transformationsnon-non-
Parallel lines don’t stay parallel!Parallel lines don’t stay parallel!
Study AStudy A Study BStudy B
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 23: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/23.jpg)
Affine TransformationsAffine Transformationsnon-non-
XB = T ( XA , { ß })XB = T ( XA , { ß })
Study AStudy A Study BStudy B
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 24: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/24.jpg)
Affine TransformationsAffine Transformationsnon-non-
XB = T ( XA , { ß(XA)})XB = T ( XA , { ß(XA)})
Study AStudy A Study BStudy B
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 25: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/25.jpg)
Study AStudy A Study BStudy B
Affine TransformationsAffine Transformationsnon-non-
XB = T ( XA , { ß(XA)})XB = T ( XA , { ß(XA)})
Transformation parameters to apply to a particular point depends on the location of the point !
Transformation parameters to apply to a particular point depends on the location of the point !
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 26: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/26.jpg)
Balter / UMBalter / UM
Affine TransformationsAffine Transformationsnon-non-
phase dependent ?phase dependent ?
XB = T ( XA , { ß(XA, φ )})XB = T ( XA , { ß(XA, φ )})Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 27: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/27.jpg)
Full 3D / 4D DeformationFull 3D / 4D Deformation
ParametricParametric FreeformFreeform
… up to 3 x N… up to 3 x N
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 28: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/28.jpg)
Full 3D / 4D DeformationFull 3D / 4D Deformation
Various splines ( TPS , B-splines )
Other basis functions
Various splines ( TPS , B-splines )
Other basis functions
ParametricParametric
Finite element models
Flow models ( optical, viscous )
Finite element models
Flow models ( optical, viscous )
FreeformFreeform
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 29: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/29.jpg)
Full 3D / 4D DeformationFull 3D / 4D Deformation
B-Splines … local
Thin-Plate splines … global
Finite element … bio-mechanical
Intensity flow … image forces
B-Splines … local
Thin-Plate splines … global
Finite element … bio-mechanical
Intensity flow … image forces
Each have some distinct propertiesEach have some distinct properties
( mono-modality )( mono-modality )
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 30: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/30.jpg)
Full 3D / 4D DeformationFull 3D / 4D Deformation
ParametricParametric FreeformFreeform
Warp Space /… Drag Objects
Warp Space /… Drag Objects
Warp Objects /… Drag Space
Warp Objects /… Drag Space
Brock / PMH
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 31: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/31.jpg)
How Do We Compute { } ?How Do We Compute { } ?
Construct a metric that measures the mismatch (or similarity) between a pair of datasets
Construct a metric that measures the mismatch (or similarity) between a pair of datasets
Apply an optimization algorithm to determine the parameters (DOF) that minimize (maximize) this metric
Apply an optimization algorithm to determine the parameters (DOF) that minimize (maximize) this metric
22
11
ββ
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 32: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/32.jpg)
How Do We Compute { } ?How Do We Compute { } ?ββ
{ β }Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 33: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/33.jpg)
Registration MetricsRegistration Metrics
Geometry-basedGeometry-based Intensity-basedIntensity-based
??
??
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 34: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/34.jpg)
Geometry-Based MetricsGeometry-Based Metrics
Point MatchingLeast Squares
Point MatchingLeast Squares
( XB - XA ) 2( XB - XA ) 2ΣΣ
min distance 2min distance 2ΣΣSurface MatchingChamfer Matching
Surface MatchingChamfer Matching
… depends on image segmentation!… depends on image segmentation!Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 35: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/35.jpg)
Intensity-Based MetricsIntensity-Based Metrics
Mono-modalitySum Squared Difference
Mono-modalitySum Squared Difference
( IB - IA ) 2( IB - IA ) 2ΣΣ
Multimodality DataMutual Information
Multimodality DataMutual Information
p(IA, IB)p(IA, IB)
p(IA) p(IB)p(IA) p(IB)ΣΣ p(IA, IB)p(IA, IB) loglog
… depends on the image characteristics!… depends on the image characteristics!Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 36: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/36.jpg)
How About An Example?How About An Example?
CTCT
PETPETTransformation
Rotate - Translate
Registration Metric
Mutual Information
Optimizer
Simplex Algorithm
Transformation
Rotate - Translate
Registration Metric
Mutual Information
Optimizer
Simplex Algorithm
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 37: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/37.jpg)
How About An Example?How About An Example?
CTCT
PETPET
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 38: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/38.jpg)
How About An Example?How About An Example?
CTCT
PETPET
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 39: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/39.jpg)
How About Deformations ?How About Deformations ?Balter / UMBalter / UM
Multiphasic CT DataMultiphasic CT Data
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 40: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/40.jpg)
Exhale StateExhale State Inhale StateInhale State
Transformation
B-Splines ( multi-resolution )
Registration Metric
Sum Squared Difference
Optimizer
Gradient decent
Transformation
B-Splines ( multi-resolution )
Registration Metric
Sum Squared Difference
Optimizer
Gradient decent
How About Deformations ?How About Deformations ?
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 41: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/41.jpg)
Multiresolution DeformationsMultiresolution Deformations
Only small additional computation cost when increasing the number of knots. Only small additional computation cost when increasing the number of knots.
Successively increase the resolution of the knot spacingSuccessively increase the resolution of the knot spacing
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 42: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/42.jpg)
Multiresolution DeformationsMultiresolution DeformationsSuccessively increase the resolution of the image dataSuccessively increase the resolution of the image data
CoarseCoarse
¼ Resolution¼ Resolution Full ResolutionFull Resolution
FineFineMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 43: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/43.jpg)
Multiresolution DeformationsMultiresolution DeformationsSuccessively increase the resolution of the image dataSuccessively increase the resolution of the image data
60 x 60 x 48 mm60 x 60 x 48 mm 4 x 4 x 3 mm4 x 4 x 3 mm
CoarseCoarse FineFineMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 44: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/44.jpg)
Multiresolution DeformationsMultiresolution Deformations
1.81.8
1.91.9
2.02.0
2.12.1
2.22.2
2.32.3
2.42.4
2.52.5
00 2020 4040 6060 8080 100100 120120 140140 160160 180180
Iteration NumberIteration Number
1.81.8
1.91.9
2.02.0
2.12.1
2.22.2
2.32.3
2.42.4
2.52.5
00 2020 4040 6060 8080 100100 120120 140140 160160 1801801.81.8
1.91.9
2.02.0
2.12.1
2.22.2
2.32.3
2.42.4
2.52.5
00 2020 4040 6060 8080 100100 120120 140140 160160 180180
Iteration NumberIteration Number
Reg
istr
atio
n M
etri
cR
egis
trat
ion
Met
ric
Registration Metric vs. IterationRegistration Metric vs. Iteration
Change inknot spacing Change inknot spacing
Low ResLow Res
High ResHigh Res
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 45: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/45.jpg)
Multiresolution B-SplinesMultiresolution B-Splines
Exhale StateExhale State Inhale Statedeformed
Inhale Statedeformed
Multiphasic CT DataMultiphasic CT Data
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 46: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/46.jpg)
Multiresolution B-SplinesMultiresolution B-Splines
Exhale StateExhale State Inhale Statedeformed
Inhale Statedeformed
Multiphasic CT DataMultiphasic CT Data
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 47: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/47.jpg)
We Are Not Really Splines !We Are Not Really Splines !Ruan / UMRuan / UM
No “stiffness”information
No “stiffness”information
ExtractedRibcageExtractedRibcage
ExhaleExhaleDeform InhaleDeform Inhale
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 48: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/48.jpg)
Add Some Physics?Add Some Physics?
tissue-dependent regularizationtissue-dependent regularization
Etotal = Esimilarity + α EstiffnessEtotal = Esimilarity + α Estiffness
intensity similarity measureintensity similarity measure
∫∫ wc(x) |det JT(x) – 1|2 dxwc(x) |det JT(x) – 1|2 dxEvol = Evol =
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 49: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/49.jpg)
Spatially Variant StiffnessSpatially Variant Stiffness
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 50: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/50.jpg)
“Stiffness” Weighting“Stiffness” Weighting
wc(x)wc(x)
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 51: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/51.jpg)
using “stiffness”information
using “stiffness”information
Using “Prior” InformationUsing “Prior” InformationRuan / UMRuan / UM
ExtractedRibcageExtractedRibcage
ExhaleExhaleDeform InhaleDeform Inhale
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 52: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/52.jpg)
Tissue SlidingTissue SlidingBalter / UMBalter / UM
Deal with different organs individually?Deal with different organs individually?
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 53: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/53.jpg)
Tissue SlidingTissue SlidingBalter / UMBalter / UM
Deal with different organs individually?Deal with different organs individually?
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 54: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/54.jpg)
Ribs driven by large lung deformations
Ribs driven by large lung deformations
Ribs not affected by lung registrationRibs not affected
by lung registration
Segmentation + RegistrationSegmentation + Registration
No maskingNo masking MaskingMasking
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 55: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/55.jpg)
Finite Element ModelingFinite Element ModelingBrock / UMBrock / UM
ExhaleExhale
InhaleInhale
Take into account physical tissue properties (directly)Take into account physical tissue properties (directly)
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 56: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/56.jpg)
Finite Element ModelingFinite Element ModelingBrock / PMHBrock / PMH
… thorough segmentation is necessary… thorough segmentation is necessaryMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 57: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/57.jpg)
The Future ?The Future ?
Family of Generalized, Customizable,Patient Models
Family of Generalized, Customizable,Patient Models
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 58: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/58.jpg)
Is The Future Here Already?Is The Future Here Already?
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributePresenter has no commercial interest in this companyPresenter has no commercial interest in this company
![Page 59: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/59.jpg)
…from Atlas to Individual…from Atlas to Individualwww.mimvista.comwww.mimvista.com
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributePresenter has no commercial interest in this companyPresenter has no commercial interest in this company
![Page 60: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/60.jpg)
…from Individuals to Atlas…from Individuals to AtlasThompson / UCLAThompson / UCLA
Brain Mapping: The Disorders, Academic Press, 1999Brain Mapping: The Disorders, Academic Press, 1999
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 61: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/61.jpg)
Meyer/UMMeyer/UM
Segment /register / averageSegment /register / average
withoutwithout withwith
Segment using atlasSegment using atlasMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 62: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/62.jpg)
In The Meantime …In The Meantime …
ImageImage DoseDoseAnatomyAnatomyMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 63: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/63.jpg)
Anatomy MappingAnatomy Mapping
Boolean ORBoolean OR
… map to CT… map to CT
Use superior MR contrast for targetingUse superior MR contrast for targetingMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 64: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/64.jpg)
Anatomy MappingAnatomy MappingDong / MDACCDong / MDACC
Planning CTPlanning CT “Delivery” CT“Delivery” CT
Drawn ContoursDrawn Contours Simple Overlay(no transform)Simple Overlay(no transform)
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 65: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/65.jpg)
Anatomy MappingAnatomy MappingDong / MDACCDong / MDACC
Planning CTPlanning CT
Drawn ContoursDrawn Contours Transformed andresampled
Transformed andresampled
“Delivery” CT“Delivery” CTSegmentation done w/ the aid of a registration!Segmentation done w/ the aid of a registration!Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 66: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/66.jpg)
More Than DeformationsMore Than Deformations
… not just deformation!… not just deformation!
deformationdeformation
resectionresection
weight lossweight loss
Δ vascularΔ vascular
shrinkageshrinkage
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 67: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/67.jpg)
Dose MappingDose MappingDealing with volume elements that may:Dealing with volume elements that may:
change shape / appear / disappear
… need proper spatial re-sampling
don’t necessarily add in a linear fashion
… need some sort of radiobiology
exist in homogenous intensity regions
… hard to evaluate registration
change shape / appear / disappear
… need proper spatial re-sampling
don’t necessarily add in a linear fashion
… need some sort of radiobiology
exist in homogenous intensity regions
… hard to evaluate registration
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 68: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/68.jpg)
ValidationValidation
How do we know how well these registration methods perform?
build phantoms and test them
we can know the truth!
provide tools to examine results
we don’t know the truth!
How do we know how well these registration methods perform?
build phantoms and test them
we can know the truth!
provide tools to examine results
we don’t know the truth!
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 69: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/69.jpg)
Validation PhantomsValidation PhantomsCTCT
MRMR
19861986
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 70: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/70.jpg)
Validation PhantomsValidation PhantomsKashani / UMKashani / UM
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 71: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/71.jpg)
Validation ToolsValidation ToolsQualitative ToolsQualitative Tools
Color gel or wash overlay
Split /dual screen displays
Anatomic boundary overlay!
Color gel or wash overlay
Split /dual screen displays
Anatomic boundary overlay!
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 72: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/72.jpg)
Validation ToolsValidation Tools
all values in cm.all values in cm.
Point DescriptionX Y Z X Y Z
1 2nd branch of bronchial tree -5.37 0.98 -3.42 -4.62 -0.22 -2.922 3rd branch of bronchial tree -5.73 2.12 -5.42 -5.40 0.74 -5.923 4th branch of bronchial tree -6.50 2.77 -8.42 -6.24 0.80 -9.424 Vessel bifurcation 1 -8.12 3.37 -9.92 -8.12 1.40 -11.425 Vessel bifurcation 2 -8.06 -1.95 -4.42 -7.67 -3.20 -3.926 Vessel bifurcation 3 -10.69 2.47 0.58 -10.78 1.16 1.08
ΔX ΔY ΔZ-4.71 -0.47 -3.36 -0.09 -0.25 -0.44-5.35 0.58 -5.83 0.05 -0.16 0.09-6.27 0.69 -9.51 -0.03 -0.11 -0.09-8.19 0.91 -11.60 -0.07 -0.49 -0.18-7.27 -2.83 -3.63 0.40 0.37 0.29-10.85 0.87 1.24 -0.07 -0.29 0.16
σ 0.19 0.29 0.26
Exhale Inhale
Exhale' ( w/ TPS alignment )Exhale' - Inhale
Study AStudy AStudy A
*(xA, yA, zA)
*(xA, yA, zA)
Study BStudy BStudy B
*(xB, yB, zB)
*(xB, yB, zB)
Quantitative ToolsQuantitative Tools
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 73: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/73.jpg)
AAPM Task Group 132AAPM Task Group 132
Methods to assess the accuracy of image registration and fusion
Issues related to acceptance testing and quality assurance for image registration and fusion
Methods to assess the accuracy of image registration and fusion
Issues related to acceptance testing and quality assurance for image registration and fusion
Use of Image Registration and Data Fusion Algorithms and Techniques in Radiotherapy
Use of Image Registration and Data Fusion Algorithms and Techniques in Radiotherapy
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 74: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/74.jpg)
Opportunities & ChallengesOpportunities & ChallengesT2T2 FlairFlair
T1T1 GdGd DiffDiff
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 75: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/75.jpg)
More than just mechanics!More than just mechanics!What Now ?What Now ?
MR volumes mapped to CT studyMR volumes mapped to CT studyMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 76: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/76.jpg)
SummarySummary
GeometryGeometry IntensityIntensity
InteractiveInteractive AutomatedAutomated
AffineAffine non-Affinenon-Affine
Taxonomy of Registration ProcessTaxonomy of Registration Process
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 77: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/77.jpg)
SummarySummaryTools are now available to register and integrate image, anatomy & dose for both Tx planning and Tx delivery
These tools can be used to help build better models of the patient and to help customize and adapt therapy
Work towards more standard and robust tools and validations methods (for non-rigid) situations continues
Tools are now available to register and integrate image, anatomy & dose for both Tx planning and Tx delivery
These tools can be used to help build better models of the patient and to help customize and adapt therapy
Work towards more standard and robust tools and validations methods (for non-rigid) situations continues
Marc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistributeMarc L Kessler, PhD - ASTRO 2007 Refresher Course - Please do not redistribute
![Page 78: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/78.jpg)
Multimodality and 4D Imaging: Multimodality and 4D Imaging: Registration and Fusion for Registration and Fusion for
Treatment Planning and Treatment Planning and Delivery: The clinical Delivery: The clinical
perspectiveperspective……
Laura Dawson, TorontoLaura Dawson, TorontoMarc Kessler, Ann ArborMarc Kessler, Ann Arbor
ASTRO 2007 ASTRO 2007 –– 4949thth meeting; Wed Oct 31, 2007, 1:30 meeting; Wed Oct 31, 2007, 1:30 –– 2:45 PM2:45 PM
![Page 79: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/79.jpg)
DisclosuresDisclosures
• Research Grant, Elekta
![Page 80: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/80.jpg)
Challenges in Radiation TherapyChallenges in Radiation Therapy
1. Seeing the tumor2. Defining the target3. Hitting the target4. Knowing when the tumor is dead
Imaging and image registration is key for addressing these
challenges
![Page 81: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/81.jpg)
• Planning– Planning CT-MR– Planning CT-Contrast CT– Planning CT-PET– Planning CT-SPECT
• Delivery– kV simulation film-MV EPI– DRR - MV or kV PI
• Bones• Fiducial markers
– Planning CT - MV or kV volumetric imaging
Spatial change Temporal change
• Planning– 4D CT
• Delivery– MV / kV fluoroscopy– 4D cone beam CT – Shape change during RT
• Follow-up– Diagnostic CT/ MR/ PET
to planning CT– Dose accumulation– Patterns of recurrence– NTCP, TCP
Clinical Use of Image RegistrationClinical Use of Image Registration
![Page 82: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/82.jpg)
• Planning– Facilitate contouring
(e.g. map atlases to pt dataset)
Spatial change Temporal change
• Planning– Accumulating daily dose(e.g. adaptive therapy)
Other Future Uses of Image Other Future Uses of Image RegistrationRegistration
![Page 83: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/83.jpg)
Planning: PETCTPlanning: PETCT--MRMR
• 56 yo man with clinical T3N0 SCC of oropharynx• PET-CT and MR obtained in treatment position,
on hard table top with mask, on study• Rigid image registration in region of interest
including vertebral bodies
• Benefits:• MR helped define primary tumor superiorly in
region of CT with dental artifact• PET helped confirm suspicious node on CT as
high risk
![Page 84: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/84.jpg)
Courtesy of John Waldron and Stephen Breen, PMH
CT
![Page 85: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/85.jpg)
Courtesy of John Waldron and Stephen Breen, PMH
MR
![Page 86: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/86.jpg)
Courtesy of John Waldron and Stephen Breen, PMH
PET
? physiologic
uptake
GTV
?tumor
![Page 87: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/87.jpg)
Courtesy of John Waldron and Stephen Breen, PMH
PET-CT
physiologic uptake:• muscle • tonsil• vesselGTV
muscle
The fused images are most useful when all information can be
evaluated together
![Page 88: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/88.jpg)
Good alignment in region of tumorAlignment in base of skull not perfect
Good alignment in region of tumor
Courtesy of John Waldron and Stephen Breen, PMH
![Page 89: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/89.jpg)
Planning: CTPETPlanning: CTPET--MRMR
• Looking at CT-PET fusion far more helpful than PET alone
• CT-PET registration not perfect in entire field of view, due to residual rotations, deformation
• Many normal variances of PET
Clinical interpretation of fused images important!
![Page 90: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/90.jpg)
Planning: CTPlanning: CT--MR ProstateMR Prostate
• Advantages of MR for prostate cancer RT– Improve inter-observer variability– Provide more anatomy for organ /nerve sparing
approaches etc.
• New opportunities with MRS, diffusion MR, …– Better knowledge of gross disease– ‘Functional imaging’– Dose painting– Monitoring of change during RT and adaptation
![Page 91: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/91.jpg)
Planning: CTPlanning: CT--MR ProstateMR Prostate
• MR can improve contouring in patients with bilateral hip replacements
Charnley et al, British J Radiology, 2005
![Page 92: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/92.jpg)
Excellent localization of ‘sensitive’ structuresExcellent localization of ‘sensitive’ structures
Allows delineation not possible or difficult on CT aloneAllows delineation not possible or difficult on CT alone
McLaughlin / UMMcLaughlin / UM
… potency sparing?… potency sparing?
Planning: CTPlanning: CT--MR ProstateMR Prostate
![Page 93: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/93.jpg)
MR with endorectal coilMR with endorectal coil
Courtesy of Cynthia Menard and Kristy Brock, PMH
1. MRI, no endorectal coil2. Planning CT3. MRI, endorectal coil
Deformable registration to planning CT
4. Regions of tumor burden, functional data can then be visualized in planning CT space
![Page 94: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/94.jpg)
Liver cancer: MRI can show different volumes, more foci of tumor, especially for HCC
Tumors often easier to see
Necessary for GTV definition if CT contrast allergy
Planning: CTPlanning: CT--MR LiverMR Liver
![Page 95: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/95.jpg)
Auto-fuse whole field of view
Planning: CTPlanning: CT--MR for liver cancerMR for liver cancer
CT MR CT MR
![Page 96: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/96.jpg)
Vertebral body match
Planning: CTPlanning: CT--MR for liver cancerMR for liver cancer
CT MR CT MR
![Page 97: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/97.jpg)
Liver match
Planning: CTPlanning: CT--MR for liver cancerMR for liver cancer
CT MR
![Page 98: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/98.jpg)
• Once CT and MR liver are registered, the GTV on both can be compared
• Different phases of CT and MR can be complimentary
CT-arterial CT-venous MR-venous
Voroney, et al, IJROBP, 2006
Planning: CTPlanning: CT--MR for liver cancerMR for liver cancer
![Page 99: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/99.jpg)
Before AfterLiver Deformable Registration
coronal
sagittal
Prior to Deformable Registration
GTV VolumeCT = 13.9 ccMR = 6.7 ccΔVol = 7.2 cc
(52%)
Planning: CTPlanning: CT--MR for liver cancerMR for liver cancerLiver deformation ?
MR and CT GTV comparison
GTV VolumeCT = 13.9 ccMR = 6.7 ccΔVol = 7.2 cc
(52%)FEM deformable IR, Kristy Brock, PMH
![Page 100: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/100.jpg)
Planning: CTPlanning: CT--MR liver GTV MR liver GTV comparisoncomparison
• 26 patients with liver cancer investigated• GTV defined on CT and MR• CT Liver-MR Liver deformable registration• Med % surface of GTVs differed > 5 mm = 26%• Largest differences for HCC and
cholangiocarcinoma
Voroney, et al, IJROBP, 2006
![Page 101: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/101.jpg)
DeformationDeformation
• Even though deformation is ‘scary’ and challenging to validate, measure,describe, we need to be aware that deformation and other volumetric change exists.
• Volume change and deformation is another source of error and there are strategies to deal with it
• Deformable image registration tools not available commercially.
![Page 102: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/102.jpg)
MV EPID kV Fluoroscopy + markers Ultrasound kV CT
MV CT kV Cone-beam CT
Image Guided Radiotherapy (IGRT)
MV cone beam CT
and more… Dawson, Jaffray, JCO, 2007
![Page 103: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/103.jpg)
Electronic Portal Imaging DevicesElectronic Portal Imaging Devices
• Types of image registration– In your head – Manual– Dot gradicule– Template– Automated– Limited ROI
• Even if you didn’t know it, you have been doing image registration for years
![Page 104: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/104.jpg)
A B
C
x
x
x
x
xx
Courtesy of Kristy Brock, Peter Chung, PMH
• Manual point matching
• Automated matching
EPIDsEPIDs -- FiducialsFiducials
![Page 105: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/105.jpg)
Volumetric imaging: kV cone beam Volumetric imaging: kV cone beam CTCTBone match, then prostate match using
prostate contour from cone beam CT
![Page 106: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/106.jpg)
Head & Neck kV Cone-beam
CT
![Page 107: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/107.jpg)
IGRT: Head and neck cancerIGRT: Head and neck cancer• T4N2 NPC for combined modality therapy. GTV
‘hugging’ brainstem and chiasm• Clivus and cavernous sinus chosen as ROI
![Page 108: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/108.jpg)
IGRT: Head and neck cancerIGRT: Head and neck cancer• Spine curvature not reproducible• Change in tumor• Dosimetric consequence?
L Johnston, J Waldron, PMH
![Page 109: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/109.jpg)
Week 3
Dose Difference (%) >5%>10%
Week 1Doses
25 Gy45 Gy54 Gy70 Gy74 Gy
Courtesy of J Pouliot, UCSF
IGRT Head and Neck: MV Cone Beam CT
Change in shape
Increased cord dose
![Page 110: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/110.jpg)
CBCT Fx #1CBCT Fx #1
Reconstructed CBCT Dataset sent to
Pinnacle
Reconstructed CBCT Dataset sent to
Pinnacle
Verification by MV Portal Imaging and/or
kV Fluoroscopy
Verification by MV Portal Imaging and/or
kV Fluoroscopy
CBCT DatasetRegistered w/ GTV
from Planning
CBCT DatasetRegistered w/ GTV
from Planning
Determine Couch ShiftDetermine Couch Shift
Lung Cancer IGRT (SBRT 20Gyx3)Lung Cancer IGRT (SBRT 20Gyx3)
GTVGTVPTVPTV
Verification by MV Portal Imaging and/or kV Fluoroscopy and/or
CBCT
Verification by MV Portal Imaging and/or kV Fluoroscopy and/or
CBCT
Cone beam CT #1
Courtesy of T Purdie, PMH
![Page 111: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/111.jpg)
Non peripheral lung tumors not always well visualized
Surrogates for tumor can improve setup accuracy
e.g carina for central tumors
Non peripheral lung tumors not always well visualized
Surrogates for tumor can improve setup accuracy
e.g carina for central tumors
Lung Cancer IGRTLung Cancer IGRT
Courtesy of J Higgins,PMH
![Page 112: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/112.jpg)
Setup based on skinSetup based on skinLung Cancer IGRTLung Cancer IGRT
Courtesy of J Higgins, PMH
![Page 113: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/113.jpg)
Carina MatchCarina MatchLung Cancer IGRTLung Cancer IGRT
Courtesy of J Higgins, PMH
![Page 114: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/114.jpg)
Bone matchBone matchLung Cancer IGRTLung Cancer IGRT
![Page 115: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/115.jpg)
Carina MatchCarina MatchLung Cancer IGRTLung Cancer IGRT
![Page 116: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/116.jpg)
Pre-correction setup (online & template)Courtesy of G Hugo, WBH, Michigan
Prior to IGRT
![Page 117: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/117.jpg)
residuals (online & template)Courtesy of G Hugo, WBH, MichiganTumor IGRT
![Page 118: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/118.jpg)
A note of cautionA note of caution
• When region of interest for image matchigis small, watch what happens to critical normal tissues outside of matching volume!
![Page 119: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/119.jpg)
Respiratory Correlated CT (4DCT) for Planning
Respiration Correlated CBCT on Treatment Unit
4D image matching4D image matching
![Page 120: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/120.jpg)
Liver Cancer IGRT Liver Cancer IGRT -- PMHPMH• MV, kV orthogonal imaging
– Diaphragm, exhale – CC positioning– Vertebral body – ML and AP positioning
• kV CBCT - liver and/or liver tumor for 3D guidance• Real time MV BEV images
MV imaging kV fluoroscopy kV CBCT
![Page 121: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/121.jpg)
MV Orthogonal Image Alignment
MV Orthogonal Image Alignment
DRR (exhale) MV Portal Image (exhale)
Diaphragm used for CC alignment
Vertebral bodies used for AP,ML alignment
AP
Lat
+ +
+ +
![Page 122: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/122.jpg)
MV Real Time ImagingMV Real Time Imaging
• 47 MV BEV movies from treatment fields including air-diaphragm interface– Manual check – Automated comparison of MV exit field to
planned field
BEV DRR BEV PI
Dawson, IJROBP, 2005
![Page 123: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/123.jpg)
kV Orthogonal Image Alignment kV Orthogonal Image Alignment DRR (exhale) kV image (exhale)
Diaphragm used for CC alignment
Vertebral bodies used for AP,ML alignment
AP
Lat
Repositioning for offsets > 3 mm
![Page 124: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/124.jpg)
Liver-liver registration for planning and IGRT
Liver-liver registration for planning and IGRT
• The liver can be used as a surrogate for the GTV, as it is most often not visible on cone beam CT
Planning CT MR kV cone beam CT
![Page 125: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/125.jpg)
Volumetric Image Guidance automated liver to liver
registration
![Page 126: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/126.jpg)
Pre-RT Post-RTPre-RT Post-RTIntraIntra--fraction Change in positionfraction Change in position
Difference Display
Free breathing cone beam CT
![Page 127: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/127.jpg)
Planning CT: Metastases with calcifications
kV Cone beam CT
Natural Natural fiducialfiducial markersmarkers
![Page 128: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/128.jpg)
Iatrogenic fiducial markersIatrogenic fiducial markers• TACE: Trans hepatic arterial chemo-embolizationLipiodol contrast stable in tumor for > 1 year
![Page 129: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/129.jpg)
• Ave. residual deformation: 95% volume deforming < 2.3 mm in each direction
• 4 cases : deformation > 5mm in CC and ML
Liver position following MV Liver position following MV guidanceguidance
Hawkins, Dawson et al, IJROBP 2006
![Page 130: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/130.jpg)
Challenges with Registration in Challenges with Registration in IGRTIGRT
• Rotations• Deformations• New artifacts• Free breathing changes • Need for clinical input as to what region of interest
matters most for registration• Do not forget rest of tissues, as they may move
MORE as smaller volume is used for registration
![Page 131: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/131.jpg)
What do differences in images What do differences in images mean?mean?
![Page 132: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/132.jpg)
Daisne et al. 233 (1): 93. (2004) Daisne et al. 233 (1): 93. (2004)
![Page 133: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/133.jpg)
Daisne / St -LucDaisne / St -Luc
Ceci est une tumeur?Ceci est une tumeur?FD
G-P
ET
C
T Sc
an
M
acro
scop
yFD
G-P
ET
C
T Sc
an
M
acro
scop
y
Jean-François Daisne MD, et al. Radiology 2004;233:93-100Jean-François Daisne MD, et al. Radiology 2004;233:93-100
![Page 134: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/134.jpg)
RadiologyRadiology--pathology correlation: pathology correlation: LiverLiver
Dawson, ASTRO 2007Dawson, ASTRO 2007
![Page 135: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/135.jpg)
ConclusionsConclusions• Image registration (IR) is a mandatory tool for
multi-modality planning and IGRT.• IR is not perfect; impossible to represent the
‘whole patient’ at ‘all times’.• As volume for matching is smaller, critical organ
doses outside matching volume may increase.• IR can facilitate research in rad-path correlation
studies, patterns of recurrence analysis, autocontouring, dose accumulation, adaptive therapy, observer variability studies,…
• Clinical input and QA important despite technological advances and automation in IR.
![Page 136: Multimodality & 4 D Imaging](https://reader034.fdocuments.net/reader034/viewer/2022042717/55d4e5aabb61ebad5f8b46aa/html5/thumbnails/136.jpg)
AcknowledgementsPMHCynthia MenardAndrea BezjakJohn WaldronCharles CattonDavid Jaffray Mike SharpeDoug MoseleyJeff SiewerdsenTom PurdieJean Pierre BissonnetteKristy BrockCynthia EcclesJane HigginsRobert Case Regina TseMaria HawkinsMark Lee
Outside PMHJJ Sonke, NKIGeoff Hugo, WBHJake Van Dyk, LondonJean Pouliot, UCSF
The 100s of people we have ever discussed image registration, multimodality imaging or IGRT with
Funding:ASCO CDANCICCanadian Cancer SocietyElekta