A randomized control trial evaluating fluorescent ink <i>versus</i> dark ink tattoos for breast radiotherapy

Landeg, S.; Kirby, Anna M.; Lee, Steven F.; Bartlett, F.; Titmarsh, Kumud; Donovan, Ellen M.; Griffin, Clare; Gothard, Lone; Locke, Imogen; McNair, Helen

doi:10.1259/bjr.20160288

Cited by 37 publications

(42 citation statements)

References 12 publications

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“…This approach has been heavily discussed among SGRT users at various professional conferences, but very few publications exist in the literature. However, there is published work showing that breast patients have improved body image scores at 1 and 6 months‐post therapy when UV tattoos (invisible in ambient lighting) are used versus conventional dark ink skin marks . This indicates that bypassing tattoos as part of the setup workflow can potentially improve patient experience.…”

Section: Discussionmentioning

confidence: 99%

Impact of use of optical surface imaging on initial patient setup for stereotactic body radiotherapy treatments

Leong

Padilla

2019

J Applied Clin Med Phys

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PurposeTo evaluate the effectiveness of surface image guidance (SG) for pre‐imaging setup of stereotactic body radiotherapy (SBRT) patients, and to investigate the impact of SG reference surface selection on this process.Methods and materials284 SBRT fractions (SG‐SBRT = 113, non‐SG‐SBRT = 171) were retrospectively evaluated. Differences between initial (pre‐imaging) and treatment couch positions were extracted from the record‐and‐verify system and compared for the two groups. Rotational setup discrepancies were also computed. The utility of orthogonal kVs in reducing CBCT shifts in the SG‐SBRT/non‐SG‐SBRT groups was also calculated. Additionally, the number of CBCTs acquired for setup was recorded and the average for each cohort was compared. These data served to evaluate the effectiveness of surface imaging in pre‐imaging patient positioning and its potential impact on the necessity of including orthogonal kVs for setup. Since reference surface selection can affect SG setup, daily surface reproducibility was estimated by comparing camera‐acquired surface references (VRT surface) at each fraction to the external surface of the planning CT (DICOM surface) and to the VRT surface from the previous fraction.ResultsThe reduction in all initial‐to‐treatment translation/rotation differences when using SG‐SBRT was statistically significant (Rank‐Sum test, α = 0.05). Orthogonal kV imaging kept CBCT shifts below reimaging thresholds in 19%/51% of fractions for SG‐SBRT/non‐SG‐SBRT cohorts. Differences in average number of CBCTs acquired were not statistically significant. The reference surface study found no statistically significant differences between the use of DICOM or VRT surfaces.ConclusionsSG‐SBRT improved pre‐imaging treatment setup compared to in‐room laser localization alone. It decreased the necessity of orthogonal kV imaging prior to CBCT but did not affect the average number of CBCTs acquired for setup. The selection of reference surface did not have a significant impact on initial patient positioning.

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Section: Discussionmentioning

confidence: 99%

Impact of use of optical surface imaging on initial patient setup for stereotactic body radiotherapy treatments

Leong

Padilla

2019

J Applied Clin Med Phys

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“…The active compounds that exist within these inks are commonly undocumented due to the nature of the tattoo industry. Previous reports of similar UV inks indicate the active compound was coumarin-based, 5 but the spectral properties coumarins generally absorb UV and emit wavelengths under 530 nm, 11,12 which does not explain the red emission observed in some of these inks or the microsecond lifetime. Nevertheless, these inks provide a potentially low-cost method for patient alignment, and also direct verification of radiation delivery, either by scintillation or Cherenkov-excited luminescence.…”

Section: Discussionmentioning

confidence: 90%

“…1,2 Utilizing UV-excited ink provides patients with a cosmetically appealing option of a tattoo that is less visible, resulting in improved self-image. 5 In these instances the patient is aligned under the aid of a UV light source by the therapist, who uses UV-A and visible light in the range 385-405 nm to visualize the ink. At these wavelengths there is minimal carcinogenic potential to the therapist and safety glasses can be worn to minimize any adverse effects of prolonged ocular exposure.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3] The use of UV-sensitive fluorescent ink has been studied in human trials to assess the value for preserving positional alignment accuracy while allowing for near invisible appearance to the patient. 4,5 These inks are less noticeable under normal room or day light conditions, while still being visible by eye under UV "black light" (~395 nm) illumination. While these markings are used as an initial coarse alignment, and modern systems use kV imaging for final positioning, this is not always the case, especially in low-and middle-income countries.…”

Section: Introductionmentioning

confidence: 99%

“…6 Tattoo pigments have been shown to be approximately 0.2-5 lm in diameter. 5,6 The set of UV-sensitive inks investigated in this study does not have an exact composition that is well documented, but they are manufactured and sold for human use, however, in the United States the inks are not regulated by the FDA. The inks under investigation all exhibit luminescent properties under x-ray excitation.…”

Section: Introductionmentioning

confidence: 99%

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Imaging luminescent tattoo inks for direct visualization of linac and cobalt irradiation

et al. 2020

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Purpose: Tattoo fiducials are commonly used in radiotherapy patient alignment, and recent studies have examined the use of UV-excited luminescent tattoo ink as a cosmetic substitute to make these visible under UV illumination. The goal of this study was to show how luminescent tattoo inks could be excited with MV radiation and imaged during beam delivery for direct visualization of field position. Methods: A survey of nine UV-sensitive tattoo inks with various emission spectra were investigated using both UV and MV excitation. Images of liquid solutions were collected under MV excitation using an intensified-CMOS imager. Solid skin-simulating phantoms were imaged with both surfacepainted ink and in situ tattooing during dose delivery by both a clinical linear accelerator and cobalt-60 source. Results: The UV inks have peak fluorescence emission ranging from approximately 440 to 600 nm with lifetimes near 11-16 ls. The luminescence intensity is approximately 6x higher during the x-ray pulse than after the pulse, however, the signal-to-noise is only approximately twice as large. Spatial resolution for imaging was achieved at 1.6 mm accuracy in a skin test phantom. Optical filtering allows for continuous imaging using a cobalt source and provides a mechanism to discriminate ink colors using a monochromatic image sensor. Conclusions: This study demonstrates how low-cost inks can be used as fiducial markers and imaged both using time-gated and continuous modes during MV dose delivery. Phantom studies demonstrate the potential application of real-time field verification. Further studies are required to understand if this technique could be used as a tool for radiation dosimetry.

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Comparison of initial patient setup accuracy between surface imaging and three point localization: A retrospective analysis

Stanley

McConnell

Kirby

et al. 2017

J Applied Clin Med Phys

109

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PurposeHistorically, the process of positioning a patient prior to imaging verification used a set of permanent patient marks, or tattoos, placed subcutaneously. After aligning to these tattoos, plan specific shifts are applied and the position is verified with imaging, such as cone‐beam computed tomography (CBCT). Due to a variety of factors, these marks may deviate from the desired position or it may be hard to align the patient to these marks. Surface‐based imaging systems are an alternative method of verifying initial positioning with the entire skin surface instead of tattoos. The aim of this study was to retrospectively compare the CBCT‐based 3D corrections of patients initially positioned with tattoos against those positioned with the C‐RAD CatalystHD surface imager system.MethodsA total of 6000 individual fractions (600–900 per site per method) were randomly selected and the post‐CBCT 3D corrections were calculated and recorded. For both positioning methods, four common treatment site combinations were evaluated: pelvis/lower extremities, abdomen, chest/upper extremities, and breast. Statistical differences were evaluated using a paired sample Wilcoxon signed‐rank test with significance level of <0.01.ResultsThe average magnitudes of the 3D shift vectors for tattoos were 0.9 ± 0.4 cm, 1.0 ± 0.5 cm, 0.9 ± 0.6 cm and 1.4 ± 0.7 cm for the pelvis/lower extremities, abdomen, chest/upper extremities and breast, respectively. For the CatalystHD, the average magnitude of the 3D shifts for the pelvis/lower extremities, abdomen, chest/upper extremities and breast were 0.6 ± 0.3 cm, 0.5 ± 0.3 cm, 0.5 ± 0.3 cm and 0.6 ± 0.2 cm, respectively. Statistically significant differences (P < 0.01) in the 3D shift vectors were found for all four sites.ConclusionThis study shows that the overall 3D shift corrections for patients initially aligned with the C‐RAD CatalystHD were significantly smaller than those aligned with subcutaneous tattoos. Surface imaging systems can be considered a viable option for initial patient setup and may be preferable to permanent marks for specific clinics and patients.

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A randomized control trial evaluating fluorescent ink versus dark ink tattoos for breast radiotherapy

Cited by 37 publications

References 12 publications

Impact of use of optical surface imaging on initial patient setup for stereotactic body radiotherapy treatments

Impact of use of optical surface imaging on initial patient setup for stereotactic body radiotherapy treatments

Imaging luminescent tattoo inks for direct visualization of linac and cobalt irradiation

Comparison of initial patient setup accuracy between surface imaging and three point localization: A retrospective analysis

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