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One consideration for the presented method is that the range of pelvic bone rotations that can be estimated is limited by the DRR library that is generated before treatment. In this study, projections with a range of rotations of the pelvis in the R x and R y directions were generated with 0.5° intervals, limiting the precision with which the rotation in these directions could be estimated. In addition, only pelvic rotations in the R x direction ranging from ± 6° were considered in the DRR library, so pelvic rotations larger than this around the R x axis could not be measured in the presented implementation. The search area for consecutive images was also limited to 1 mm and 0.5° which would limit detection of large, abrupt motion. The size of the search window could potentially be modified according to the frequency of image acquisition, such that the search windows are increased for lower image frequencies and decreased for higher imaging frequencies to ensure that any motion occurring between frames is accurately captured. While DRR libraries with a higher angle resolution and a wider range of rotations can be generated to increase the domain of pelvic poses that can be precisely estimated, this would come at the cost of longer DRR generation times and larger memory requirements to load the DRR library at the time of treatment for fast template access. An optimization strategy could also be implemented to speed up the search for the maximum normalized cross‐correlation coefficient to minimize the number of template matches performed. Due to the variations in pelvic bone anatomy between patients, a DRR library will need to be generated for each patient to allow for accurate and precise motion management of bony anatomy. | 39441205_p23 | 39441205 | DISCUSSION | 4.130116 | biomedical | Study | [
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Integrating pelvic bone motion monitoring with the current KIM method would allow for simultaneous motion monitoring for both the prostate and lymph node targets during radiation therapy treatment. KIM was found to have a geometric accuracy and precision of 0.0 ± 0.4 mm, 0.1 ± 0.3 mm, 0.0 ± 0.5 mm in the T LR , T SI , T AP directions, and ‐0.1° ± 1.4°, ‐0.1° ± 1.0°, ‐0.1° ± 0.6° in the R LR , R SI , and R AP directions, respectively for prostate motion monitoring in the TROG 15.01 SPARK trial. 23 Thus, a combination of the methods would be able to achieve both prostate and pelvic bone motion monitoring to within 0.5 mm and 1.4°. While kV images acquired during treatment delivery may have an increased presence of noise compared to projections acquired during the CBCT due to MV scatter, image quality could be improved through temporal averaging, image filtering, or by acquiring kV images between MV pulses. While patient alignment strategies assume that the pelvic lymph nodes are fixed to the bony anatomy and therefore the pelvic bone is a suitable surrogate for pelvic bone motion, 8 , 12 , 37 magnetic resonance imaging (MRI) studies have indicated that there can be mobility of the lymph nodes relative to the bones with mean absolute deviations of up to 1.1, 3.3, and 2.1 mm in the LR, AP, and SI directions. 38 Given the low soft tissue contrast in x‐ray images compared to MRI, the pelvic bone position currently provides the best estimate for the pelvic lymph nodes on standard x‐ray guided linacs, but lymph nodes could potentially be tracked more accurately on MR‐linac systems. | 39441205_p24 | 39441205 | DISCUSSION | 4.300769 | biomedical | Study | [
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Methods to adapt treatment in response to relative multi‐target motion are still limited. While beam gating combined with couch corrections can be used to correct for single‐target motion during treatment, this strategy is not viable for scenarios where multiple targets have undergone differential motion. Online adaptive radiotherapy strategies can be used to account for interfraction displacements that occur between primary targets and the associated lymph nodes by generating a new treatment plan based on the anatomy seen in images acquired on the day of treatment. 12 , 39 , 40 Several studies have seen improvements to the doses delivered to multiple targets simultaneously when modifying the MLC aperture shape and segment weights for intensity‐modulated radiation therapy treatment plans according to relative interfraction shifts. 2 , 11 , 41 , 42 To adapt to intrafraction motion between multiple targets, real‐time MLC tracking has been demonstrated to adapt the radiation beam to prostate and lymph node targets for patients with locally advanced prostate cancer. 15 , 43 As multi‐target MLC tracking can be implemented on standard linear accelerators, 16 it could potentially be integrated with the multi‐target prostate and pelvic bone KIM motion monitoring proposed in this study to allow for real‐time multi‐target adaptive radiation therapy for locally advanced prostate cancer patients. Applying the real‐time 6DoF bony anatomy targeting method could be investigated for other sites, such as the spine, as the accurate delivery of radiation therapy to the spine is even more crucial. Spine position monitoring has been previously investigated during SBRT delivery, however, has been limited to 3D motion 44 , 45 or rotation only in the imaging plane. 46 | 39441205_p25 | 39441205 | DISCUSSION | 4.09394 | biomedical | Study | [
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Further work into multi‐target motion monitoring could expand into monitoring multiple targets for other anatomical sites. The seminal vesicles are typically included in the target volume for prostate cancer patients, however, deformations resulting in relative motion between the prostate and the seminal vesicles are known to occur. 47 , 48 , 49 This motion is not monitored during treatments with the combined volume instead being treated as being rigid, requiring relatively large PTV margins to be used. Relative displacements of targets are also a known problem for lung 50 , 51 and oligometastatic patients. 52 The increase in availability of combined MR‐linac systems 53 , 54 could lead to an improvement in capabilities to simultaneously monitor multiple targets during radiation therapy as well as the motion of nearby organs‐at‐risk to guide further dose‐avoidance during treatment. | 39441205_p26 | 39441205 | DISCUSSION | 4.063088 | biomedical | Study | [
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This study described a method to allow for the displacement of the pelvic bone to be monitored simultaneously with prostate motion in 6DoF using 2D kV images. The method was retrospectively applied to data acquired during patient treatment from the TROG 15.01 SPARK trial and sub‐mm and sub‐degree geometric accuracy and precision of pelvic bone tracking were demonstrated. The integration of an intrafraction pelvic bone motion monitoring method with prostate tracking could enable image‐guided real‐time multi‐target adaptation to occur during radiation therapy for patients with locally advanced disease. | 39441205_p27 | 39441205 | CONCLUSION | 4.10586 | biomedical | Study | [
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P.J. Keall and P.R. Poulsen are inventors on a patent related to the KIM technology that is licensed to Varian Medical Systems by Stanford University and are inventors on additional patents/patent applications related to the KIM technology that have been assigned to the SeeTreat. P.J. Keall is the founder and director of SeeTreat. | 39441205_p28 | 39441205 | CONFLICT OF INTEREST STATEMENT | 0.983974 | other | Other | [
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