title: Clinical use of a digital simulator for rapid setup verification in high dose rate brachytherapy.
abstract: OBJECTIVE
  Fractionated high dose rate (HDR) brachytherapy provides a number of technical advantages over conventional implant therapy in that (a) it can be carried out on an outpatient basis, (b) personnel exposure is reduced to insignificant levels, and (c) patient motion during irradiation is minimized, resulting in a more accurate delivery of the planned radiation dose distribution to the target and critical structures. The patient discomfort associated with the repeated applicator insertions and/or treatment setups can be alleviated to the extent that the setup time is held to a minimum. This work describes the use of a prototype digital simulator to obtain fast, high-quality digital images for rapid setup verification.
  
  
  METHODS
  The digital imaging system of the prototype simulator consists of a charge-coupled device (CCD) camera, which views the x-ray image optically transmitted from a conventional phosphor screen. Treatment is carried out with a remote afterloading HDR unit immediately after setup verification with the patient on the simulator stretcher. The high-resolution digital images are processed and displayed in about 5 s, as opposed to a minimum of approximately 2 min for film.
  
  
  RESULTS
  The imaging system has been evaluated for a variety of implant types, both intracavitary and interstitial. The digital radiographs provided permanent high-resolution images as required in most cases for precise applicator positioning. The gray scale manipulation capabilities were found to be useful for imaging in regions of different density, such as lung and soft tissue, in the same radiograph. The advantages of short image acquisition and display times were observed in all cases, but were most evident in the intraluminal procedures, which sometimes involved several pretreatment applicator adjustments at a time of considerable patient discomfort.
  
  
  CONCLUSIONS
  Pretreatment imaging is necessary to fully exploit the technical advantages of HDR brachytherapy. High-quality digital radiography offers unique advantages in HDR setup and verification by providing fast high-resolution, undistorted images with software manipulation capabilities and permanent storage of images.
authors.affiliation: Radiation Oncology Department, Medical College of Virginia, Richmond 23298-0058, USA.
authors.forename: R D
authors.initials: RD
authors.lastname: Zwicker
authors.forename: N A
authors.initials: NA
authors.lastname: Atari
authors.forename: B D
authors.initials: BD
authors.lastname: Kavanagh
authors.forename: H L
authors.initials: HL
authors.lastname: Gieschen
authors.forename: M R
authors.initials: MR
authors.lastname: Arnfield
authors.forename: S R
authors.initials: SR
authors.lastname: Khandelwal
authors.forename: R K
authors.initials: RK
authors.lastname: Schmidt-Ullrich
mesh_terms: D001918:Brachytherapy / Q000379:methods*; D001984:Bronchial Neoplasms / Q000532:radiotherapy; D003198:Computer Simulation; D016889:Endometrial Neoplasms / Q000532:radiotherapy; D005260:Female; D006801:Humans; D011879:Radiotherapy Dosage; D011881:Radiotherapy, Computer-Assisted / Q000379:methods*