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01 Introduction to the Transition to 3D HDR Brachytherapy.Pptx IAEA 3D image-based female pelvis anatomy by ultrasound IAEA Aims To present an overview of the role of ultrasound in gynaecological brachytherapy • Prior knowledge of female anatomy presumed • Prior knowledge of ultrasound presumed • Information presented is intended only as a basic introduction to female pelvic anatomy, the use of ultrasound to image the female pelvis, and the use of ultrasound in gynaecological brachytherapy and is no way a substitute for formal education and training. Where possible clinically obtained images are used to illustrate concepts. IAEA Specific Learning Objectives • To present an introduction to ultrasound (terminology, concepts, techniques) • To present an overview of female pelvic anatomy as seen on ultrasound • To present an introduction to ultrasound use in gynaecological brachytherapy IAEA Contents • Overview of ultrasound • Normal female pelvic anatomy • Sonographic techniques - image orientation • Normal sonographic anatomy • Anatomical variations • Anatomical anomalies • Common pathologies • Accuracy of ultrasound - comparing modalities and techniques • Using ultrasound in brachytherapy - assess response to EBRT - identifying applicators - bladder filling - intra-operative technique - intrafraction / interfraction movement - applicator and volume verification - planning with ultrasound • Future - 3D ultrasound IAEA 3D image-based female pelvis anatomy by Ultrasound (US) • Overview of ultrasound • Normal female pelvic anatomy • Sonographic techniques - image orientation • Normal sonographic anatomy • Anatomical variations • Common pathologies • Using ultrasound in brachytherapy • Future - 3D ultrasound IAEA Ultrasound Ultrasound is the detection and display of acoustic energy reflected from interfaces within the body Use of ultrasound requires: • good knowledge of anatomy and pathology • understanding of the principles of ultrasound production • understanding of ultrasound instrumentation and image optimisation • three dimensional interpretational ability Rumack Wilson Charboneau (eds) 2005 Diagnostic Ultrasound Vol 1,3rd Ed, Elsevier Mosby, St Louis, Missouri Gent R 1997 Applied physics and technology of diagnostic ultrasound Openbook publishers Prospect Sth Australia • Ultrasound is a non-ionising imaging modality available in compact units. This makes it widely accessible and available. • It is ‘easy' to create an image with ultrasound by placing the transducer against the body, but the difficulty lies in optimising and orientating the image so that the information in it is of use and is correctly interpreted and understood. • Ultrasound is often perceived as a simple and unsophisticated imaging modality because of its wide availability and so called ease of image production, but this is a fallacy. • Interpreting ultrasound correctly involves good knowledge of anatomy and pathology, understanding of ultrasound physics and instrumentation and image optimisation, and three dimensional interpretational ability. • Competent performance of ultrasound examinations involves good knowledge of anatomy and pathology; understanding of ultrasound physics and instrumentation and image optimisation; three dimensional interpretational ability; a high level of hand-eye co-ordination, and good transducer skills. • Using ultrasound to guide and verify brachytherapy applicator placement and plan isodose coverage requires all of the above knowledge and skills and thorough knowledge of the dimensions, geometry and composition of brachytherapy applicators and how they are represented in an ultrasound image. IAEA Understanding the ultrasound image • The central axis of the transducer always appears vertical in the image, in the centre of the field of view • This is regardless of the positioning or orientation of the transducer on the patient and regardless of the position of the patient • Think of the transducer as a torch, the torch shines into the pelvis. The beam of light can be shone in any direction within the patient but the centre of the image will always be the central axis of the beam, not necessarily the central axis of the patient. Gent R 1997 Applied physics and technology of diagnostic ultrasound Openbook publishers Prospect Sth Australia • Understanding 3D volumetric data from CT scanners and MR scanners is intuitive as these data sets contain fixed frames of reference that enable us to spatially allocate the structures we are seeing. The data sets also contain a centre of reconstruction from which all images can be referenced. Most scans are taken with patients in standard positions and these are annotated on the image to assist in correct orientation. • Ultrasound used in gynaecology relies on free hand acquisition (no frame of reference, no 3D co-ordinate system). • The transducer can be held in an infinite range of positions which may not relate to standard anatomical reference planes. • The image itself is a keyhole view rather than a full body section and can be difficult to interpret. • It is important to remember this when scanning; when using ultrasound to guide applicator placement (the uterine canal may be in the centre of the ultrasound screen but may not be in the anatomical midline of the patient); and when interpreting ultrasound images. • If using ultrasound to guide applicator placement it is imperative that there is good communication between the sonographer imaging the patient and the doctor placing the applicator. Guidance is not only provided by the image but also by verbal communication. The sonographer can verbally instruct the doctor as to where the uterine canal is located based on where the sonographer is scanning. IAEA B-mode ultrasound • B mode - so called because it came after A-mode (widely referred to as brightness mode) • Real time B-mode is the most familiar format • Reflectors in image are depicted as dots with a brightness corresponding to the amplitude of the returning echo • An image produced by B-mode is a two dimensional representation of a volume of tissue, not a true two dimensional plane Gent R 1997 Applied physics and technology of diagnostic ultrasound Openbook publishers Prospect Sth Australia IAEA Real time vs static • Limits of human visual perception cause the appearance of structural boundaries on real time images • Same boundaries disappear on static freeze frame images • Ultrasound is an INTERACTIVE MODALITY - need to keep watching the screen Gent R 1997 Applied physics and technology of diagnostic ultrasound Openbook publishers Prospect Sth Australia • Taking images with ultrasound is quite different to taking images with other imaging modalities. • Protocols are set on CT and MRI and there is little interaction from the operator. • When using ultrasound the operator has a range of controls and settings available to them to optimise the ultrasound image. It is imperative that the operator stay focussed on the ultrasound image to improve the image as much as possible. • A good sonographer asks the following questions: can I identify all the structures displayed can I improve the image have I scanned the entire area of interest have I documented the relevant findings • Taking images with ultrasound is a dynamic process. Gent R 1997 Applied physics and technology of diagnostic ultrasound Openbook publishers Prospect Sth Australia • Being able to see in real-time is one of the most powerful aspects of ultrasound. • It is possible to adjust settings and probe position during image acquisition to obtain the best quality image and the most appropriate view of the area under investigation. • It is necessary to ‘volume scan' the region of interest to ensure that the correct planes have been identified. Volume scanning means using and moving the transducer across the region to examine not only the organ of interest but the surrounding anatomy. This will result in identifying the most optimal view of the region of interest and may also alert us to other unexpected findings. • Ultrasound offers good soft tissue information in real time. • This is extremely advantageous when using ultrasound to guide applicator placement in brachytherapy. • Applicator insertion can be performed and assessed with real time feedback • Ultrasound is the most accessible imaging modality. It is portable and accessible. • An ultrasound unit can be taken to the patient (theatre suite, brachytherapy suite, treatment room) without need to move the patient • Ultrasound is a low cost installation compared to MRI • There are pre- set factors associated with transducers, but the operator is able to optimise image settings on an individual patient basis • It can be used intraprocedurally - for example in gynae brachytherapy, it can be used to guide applicator insertion, to verify applicator position within uterus, to verify anatomical volume and to adapt the treatment plan • Real time imaging during applicator insertion allows optimal applicator selection (flow on effect -minimal changes to applicator in subsequent insertions makes for more efficient planning and treatment- replans are less necessary) • This reduces the rate of abandoned procedures due to unsuitable applicator position • The applicator acts as a fiducial marker that can be manipulated into an optimal position • It also acts as an internal calibration device authenticating the measurements' taken as it is of known geometry -aslong as this geometry is known and understood and then identified on the image • Serial images can give indication of changes in volume over time • Ultrasound imagescan now be uploaded to Treatment
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