High-performance intraoperative imaging is essential to an ever-expanding scope of therapeutic procedures ranging from
tumor surgery to interventional radiology. The need for precise visualization of bony and soft-tissue structures with
minimal obstruction to the therapy setup presents challenges and opportunities in the development of novel imaging
technologies specifically for image-guided procedures. Over the past ~5 years, a mobile C-arm has been modified in
collaboration with Siemens Medical Solutions for 3D imaging. Based upon a Siemens PowerMobil, the device includes:
a flat-panel detector (Varian PaxScan 4030CB); a motorized orbit; a system for geometric calibration; integration with
real-time tracking and navigation (NDI Polaris); and a computer control system for multi-mode fluoroscopy,
tomosynthesis, and cone-beam CT. Investigation of 3D imaging performance (noise-equivalent quanta), image quality
(human observer studies), and image artifacts (scatter, truncation, and cone-beam artifacts) has driven the development
of imaging techniques appropriate to a host of image-guided interventions. Multi-mode functionality presents a valuable
spectrum of acquisition techniques: i.) fluoroscopy for real-time 2D guidance; ii.) limited-angle tomosynthesis for fast
3D imaging (e.g., ~10 sec acquisition of coronal slices containing the surgical target); and iii.) fully 3D cone-beam CT
(e.g., ~30-60 sec acquisition providing bony and soft-tissue visualization across the field of view). Phantom and cadaver
studies clearly indicate the potential for improved surgical performance - up to a factor of 2 increase in challenging
surgical target excisions. The C-arm system is currently being deployed in patient protocols ranging from brachytherapy
to chest, breast, spine, and head and neck surgery.
In this work Monte Carlo (MC) simulations are used to correct kilovoltage (kV) cone-beam computed tomographic (CBCT) projections for scatter radiation. All images were acquired using a kV CBCT bench-top system composed of an x-ray tube, a rotation stage and a flat-panel imager. The EGSnrc MC code was used to model the system. BEAMnrc was used to model the x-ray tube while a modified version of the DOSXYZnrc program was used to transport the particles through various phantoms and score phase space files with identified scattered and primary particles. An analytical program was used to read the phase space files and produce image files. The scatter correction was implemented by subtracting Monte Carlo predicted scatter distribution from measured projection images; these projection images were then reconstructed. Corrected reconstructions showed an important improvement in image quality. Several approaches to reduce the simulation time were tested. To reduce the number of simulated scatter projections, the effect of varying the projection angle on the scatter distribution was evaluated for different geometries. It was found that the scatter distribution does not vary significantly over a 30-degree interval for the geometries tested. It was also established that increasing the size of the voxels in the voxelized phantom does not affect the scatter distribution but reduces the simulation time. Different techniques to smooth the scatter distribution were also investigated.
The application of high-performance flat-panel detectors (FPDs) to dual-energy (DE) imaging offers the potential for dramatically improved detection and characterization of subtle lesions through reduction of "anatomical noise," with applications ranging from thoracic imaging to image-guided interventions. In this work, we investigate DE imaging performance from first principles of image science to preclinical implementation, including: 1.) generalized task-based formulation of NEQ and detectability as a guide to system optimization; 2.) measurements of imaging performance on a DE imaging benchtop; and 3.) a preclinical system developed in our laboratory for cardiac-gated DE chest imaging in a research cohort of 160 patients. Theoretical and benchtop studies directly guide clinical implementation, including the advantages of double-shot versus single-shot DE imaging, the value of differential added filtration between low- and high-kVp projections, and optimal selection of kVp pairs, filtration, and dose allocation. Evaluation of task-based NEQ indicates that the detectability of subtle lung nodules in double-shot DE imaging can exceed that of single-shot DE
imaging by a factor of 4 or greater. Filter materials are investigated that not only harden the high-kVp beam (e.g., Cu or
Ag) but also soften the low-kVp beam (e.g., Ce or Gd), leading to significantly increased contrast in DE images. A preclinical imaging system suitable for human studies has been constructed based upon insights gained from these theoretical and experimental studies. An important component of the system is a simple and robust means of cardiac-gated DE image acquisition, implemented here using a fingertip pulse oximeter. Timing schemes that provide cardiac-gated
image acquisition on the same or successive heartbeats is described. Preclinical DE images to be acquired under research protocol will afford valuable testing of optimal deployment, facilitate the development of DE CAD, and support comparison of DE diagnostic imaging performance to low-dose CT and radiography.
When an imaging task is specified, the design of a cone-beam CT scanner includes specifications of the scanning trajectory and corresponding image reconstruction algorithms, requirements on the detector size, and requirements on the x-ray tubes. Given the limited flat-panel detector readout speed and the need of short scanning time in a clinical setting, the available number of total view angles is normally limited to several hundred. It is known that when all the focal spots are distributed along a circular trajectory, the cone-beam artifacts are present in the reconstructed out-of-plane images when the cone-angle is relatively large. In order to mitigate or eliminate the cone-beam artifacts, the source trajectory should be complete in the sense of satisfying the so-called Tuy data sufficiency condition. However, assuming a constant number of view angles, a complete source trajectory will potentially lead to a lower view sampling rate and cause view aliasing artifacts. Therefore, for a given imaging task and a given total number of view angles, it is important to study the tradeoff between the view sampling rate and the completeness of the scanning source trajectories. In this paper, we numerically and experimentally studied the above tradeoff. Specifically, numerical simulations were conducted to study this tradeoff using three different source trajectories: (1) a circular trajectory, (2) a helical trajectory, and (3) a two-concentric-orthogonal-circle trajectory. A single x-ray tube and a flat panel imager mounted on an optical bench was utilized to experimentally study the tradeoff between the circular source trajectory and the helical source trajectory. For the complete source trajectories, some novel cone-beam image reconstruction algorithms have been utilized to reconstruct images and compare image quality in numerical simulations and benchtop experiments.
This study represents the first reported use of photodynamic therapy (PDT) for metastatic bone lesions and specifically, as a treatment for spinal metastases. A model of bone metastasis in rat confirmed the efficacy of benzoporphyrin derivative-monoacid-mediated PDT for treating lesions within the spine and appendicular bone. Fluorimetry confirmed the selective accumulation of drug into the tumor(s) at 3 h post-injection. 48 h post-light delivery into the vertebral body of the rat spine loss of bioluminescent signal and histological analyses of sectioned spine confirmed MT-1 tumor cell kill in vivo as previously confirmed in vitro using an established cell viability assay. Porcine vertebrae provided a model comparable to that of human for light propagation and PDT response. Histological examination of vertebrae 48 h post-PDT revealed a necrotic radius of 0.6 cm with an average fluence rate of 4.3 mW/cm2. Non-necrotic tissue damage was evident up to 2 cm out from the treatment fiber. Results support the application of PDT to the treatment of primary or metastatic lesions within bone.
In image-guided procedures high-contrast objects often appear in the imaging field-of-view for the purpose of guiding treatment (e.g., markers intended to localize the target) or delivering treatment (e.g., surgical tools, or in the case of brachytherapy, radioactive seeds). In cone-beam CT reconstructions, these high-contrast objects cause severe streak artifacts, CT number inaccuracy and loss of soft-tissue visibility. We have developed an iterative approach by which high-contrast objects are localized in the 2-D projection set by re-projecting conspicuities from the first-pass 3-D reconstruction. The projection operator, which finds the unique mapping from the world coordinate system to the detector coordinate system for each view angle, is computed from a geometric calibration of the system. In each projection, a two-dimensional 2nd order Taylor series is used to interpolate over the high-contrast objects. The interpolated surface is further modified using a local noise estimate to completely mask the objects. The algorithm has been applied to remove artifacts resulting from a small number of gold fiducial markers in patients being imaged daily with cone-beam CT for guidance of prostate radiotherapy. The algorithm has also been applied to post-operative images of a prostate brachytherapy patient in which the number of seeds can exceed ~100. In each case, the method provides excellent attenuation of image artifact and restoration of soft-tissue visibility. Using a local voxel based metric it was shown that the 2nd order Taylor series with added noise performed best at removing the high-contrast objects from the reconstruction volume.
Dual-energy (DE) imaging is a promising x-ray modality for the screening and early detection of lung cancer but has seen limited application primarily due to the lack of an adequate image detector. Recent development of flat-panel detectors (FPDs) for advanced imaging applications provide a promising technology for DE imaging, and a theoretical framework to quantify the imaging performance of FPD-based DE imaging systems is useful for system design and optimization. Traditional methods employed to describe imaging performance in radiographic systems [i.e., detective quantum efficiency (DQE) and noise-equivalent quanta (NEQ)] are extended in this paper to DE imaging systems using FPDs. To quantify the essential advantage imparted by DE imaging, we incorporate a spatial-frequency-dependent “anatomical noise” term associated with overlying structures to yield the generalized DQE and NEQ. We estimate anatomical noise in DE images through measurements using an anthropomorphic chest phantom and parameterize the measurements using a 1/f model. Cascaded systems analysis of the generalized NEQ is shown to reveal the tradeoffs between anatomical noise and quantum noise in DE image reconstructions. The generalized dual-energy NEQ is combined with idealized task functions to compute the detectability index, providing an estimate of ideal observer performance in a variety of detection and discrimination tasks. The generalized analysis is employed to investigate optimal tissue cancellation and kVp selection as a function of dose and imaging task.
Cone-beam computed tomography (CBCT) presents a highly promising and challenging advanced application of flat-panel detectors (FPDs). The great advantage of this adaptable technology is in the potential for sub-mm 3D spatial resolution in combination with soft-tissue detectability. While the former is achieved naturally by CBCT systems incorporating modern FPD designs (e.g., 200 - 400 um pixel pitch), the latter presents a significant challenge due to limitations in FPD dynamic range, large field of view, and elevated levels of x-ray scatter in typical CBCT configurations. We are investigating a two-pronged strategy to maximizing soft-tissue detectability in CBCT: 1) front-end solutions, including novel beam modulation designs (viz., spatially varying compensators) that alleviate detector dynamic range requirements, reduce x-ray scatter, and better distribute imaging dose in a manner suited to soft-tissue visualization throughout the field of view; and 2) back-end solutions, including implementation of an advanced FPD design (Varian PaxScan 4030CB) that features dual-gain and dynamic gain switching that effectively extends detector dynamic range to 18 bits. These strategies are explored quantitatively on CBCT imaging platforms developed in our laboratory, including a dedicated CBCT bench and a mobile isocentric C-arm (Siemens PowerMobil). Pre-clinical evaluation of improved soft-tissue visibility was carried out in phantom and patient imaging with the C-arm device. Incorporation of these strategies begin to reveal the full potential of CBCT for soft-tissue visualization, an essential step in realizing broad utility of this adaptable technology for diagnostic and image-guided procedures.
A promising imaging platform for combined low-dose fluoroscopy and cone-beam CT (CBCT) guidance of interventional procedures has been developed in our laboratory. Based on a mobile isocentric C-arm (Siemens PowerMobil) incorporating a high-performance flat-panel detector (Varian PaxScan 4030CB), the system demonstrates sub-mm 3D spatial resolution and soft-tissue visibility with field of view sufficient for head and body sites. For pre-clinical studies in head neck tumor surgery, we hypothesize that the 3D intraoperative information provided by CBCT permits precise, aggressive techniques with improved avoidance of critical structures. The objectives include: 1) quantify improvement in surgical performance achieved with CBCT guidance compared to open and endoscopic techniques; and 2) investigate specific, challenging surgical tasks under CBCT guidance. Investigations proceed from an idealized phantom model to cadaveric specimens. A novel surgical performance evaluation method based on statistical decision theory is applied to excision and avoidance tasks. Analogous to receiver operating characteristic (ROC) analysis in medical imaging, the method quantifies surgical performance in terms of Lesion-Excised (True-Positve), Lesion-Remaining (False-Negative), Normal-Excised (False-Positive), and Normal-Remaining (True-Negative) fractions. Conservative and aggressive excision and avoidance tasks are executed in 12 cadaveric specimens with and without CBCT guidance, including: dissection through dura, preservation of posterior lamina, ethmoid air cells removal, exposure of peri-orbita, and excision of infiltrated bone in the skull base (clivus). Intraoperative CBCT data was found to dramatically improve surgical performance and confidence in the execution of such tasks. Pre-clinical investigation of this platform in head and neck surgery, as well as spinal, trauma, biopsy, and other nonvascular procedures, is discussed.
This study represents the first reported use of photodynamic therapy in bone and specifically, as a treatment for spinal
metastases. A metastatic model in rat confirmed the efficacy of benzoporphyrin derivative-monoacid-mediated PDT for
treating lesions within the spine and appendicular bone. Fluorimetry confirmed the selective accumulation of drug into
the tumor(s) at 3 hours post-injection. 48 hrs post light delivery into the vertebral body of the rat spine loss of
bioluminescent signal and histological analyses of sectioned spine confirmed MT-1 tumor cell kill in vivo as previously
confirmed in vitro using an established cell viability assay. Porcine vertebrae provided a model comparable to that of
human for light propagation and PDT response. Light measurements were recorded at 2.5 mm increments as the detector
probe was retracted out of the vertebral body away from a diffusing fiber at 70-90° planar angle to it. At 30 minutes or
1hr post BPD-MA administration (6 mg/m2), light (648 J, 150 mW/cm, 690 nm) was delivered to vertebrae L1 and/or
L2. Vertebrae were harvested and sectioned for histology 48 hrs following PDT. Light propagation was plotted as
distance (μm) from the emitting source. Results support the application of PDT to the treatment of primary or metastatic
lesions within bone.
While analysis of the image noise-power spectrum (NPS) and noise-equivalent quanta (NEQ) are important aspects of imaging system characterization, such metrics are in themselves insufficient descriptions of imaging performance in that they make no account of the imaging task. This paper seeks to quantitatively incorporate imaging task in imaging performance evaluation by combining NEQ with a variety of idealized spatial-frequency-dependent task functions to yield the model observer detectability index. The approach is applied to the case of fully 3D volumetric imaging by flat-panel detector cone-beam CT through analysis of 3D detectability for conditions of varying dose, reconstruction filter, and voxel size. Generalization of the NEQ through incorporation of background "anatomical" noise suggests significant degradation in model observer performance, and the effect is quantified for a variety of detection and discrimination tasks. For anatomical noise modeled according to 1/f b statistics in power-spectral density, the effect is shown to be most severe for low-frequency detection tasks, and somewhat less for mid-to-high spatial frequency tasks, such as discrimination and localization. By considering the fully 3D NEQ, which is known to be asymmetric for cone-beam CT, a compelling hypothesis is realized regarding the detection of structures in volumetric CT images - specifically, that the detectability is different in axial versus sagittal / coronal domains due to asymmetry in the NEQ between these domains, compared to the case in which 3D data are fully interrogated (e.g., by a machine algorithm). This has significant implications for 3-D imaging modalities, including flat-panel cone-beam CT, where the NPS exhibits asymmetric frequency characteristics [viz., high-pass (filtered-ramp) in the transverse domain and low-pass in the longitudinal]. The impact of asymmetric NPS characteristics on detectability was investigated by analysis of the 3D detectability for imaging tasks corresponding to detection and discrimination of fine and low-contrast structures.
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