title: Telerobotic system concept for real-time soft-tissue imaging during radiotherapy beam delivery.
abstract: OBJECTIVE
  The curative potential of external beam radiation therapy is critically dependent on having the ability to accurately aim radiation beams at intended targets while avoiding surrounding healthy tissues. However, existing technologies are incapable of real-time, volumetric, soft-tissue imaging during radiation beam delivery, when accurate target tracking is most critical. The authors address this challenge in the development and evaluation of a novel, minimally interfering, telerobotic ultrasound (U.S.) imaging system that can be integrated with existing medical linear accelerators (LINACs) for therapy guidance.
  
  
  METHODS
  A customized human-safe robotic manipulator was designed and built to control the pressure and pitch of an abdominal U.S. transducer while avoiding LINAC gantry collisions. A haptic device was integrated to remotely control the robotic manipulator motion and U.S. image acquisition outside the LINAC room. The ability of the system to continuously maintain high quality prostate images was evaluated in volunteers over extended time periods. Treatment feasibility was assessed by comparing a clinically deployed prostate treatment plan to an alternative plan in which beam directions were restricted to sectors that did not interfere with the transabdominal U.S. transducer. To demonstrate imaging capability concurrent with delivery, robot performance and U.S. target tracking in a phantom were tested with a 15 MV radiation beam active.
  
  
  RESULTS
  Remote image acquisition and maintenance of image quality with the haptic interface was successfully demonstrated over 10 min periods in representative treatment setups of volunteers. Furthermore, the robot's ability to maintain a constant probe force and desired pitch angle was unaffected by the LINAC beam. For a representative prostate patient, the dose-volume histogram (DVH) for a plan with restricted sectors remained virtually identical to the DVH of a clinically deployed plan. With reduced margins, as would be enabled by real-time imaging, gross tumor volume coverage was identical while notable reductions of bladder and rectal volumes exposed to large doses were possible. The quality of U.S. images obtained during beam operation was not appreciably degraded by radiofrequency interference and 2D tracking of a phantom object in U.S. images obtained with the beam on/off yielded no significant differences.
  
  
  CONCLUSIONS
  Remotely controlled robotic U.S. imaging is feasible in the radiotherapy environment and for the first time may offer real-time volumetric soft-tissue guidance concurrent with radiotherapy delivery.
authors.affiliation: Department of Mechanical Engineering, Stanford University, Stanford, California 94305, USA.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Schlosser
authors.forename: Kenneth
authors.initials: K
authors.lastname: Salisbury
authors.forename: Dimitre
authors.initials: D
authors.lastname: Hristov
mesh_terms: D005240:Feasibility Studies; D057918:Fiducial Markers; D006801:Humans; D008297:Male; D009038:Motion; D011471:Prostatic Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy; D011881:Radiotherapy, Computer-Assisted / Q000295:instrumentation*; D050397:Radiotherapy, Intensity-Modulated; D012371:Robotics / Q000379:methods*; D012449:Safety; D013997:Time Factors; D014463:Ultrasonography / Q000295:instrumentation* / Q000592:standards