Visibility of fiducial markers used for image-guided radiation therapy on optical coherence tomography for registration with CT: An esophageal phantom study.

PURPOSE: Optical coherence tomography (OCT) is of interest to visualize microscopic esophageal tumor extensions to improve tumor delineation for radiation therapy (RT) planning. Fiducial marker placement is a common method to ensure target localization during planning and treatment. Visualization of these fiducial markers on OCT permits integrating OCT and computed tomography (CT) images used for RT planning via image registration. We studied the visibility of 13 (eight types) commercially available solid and liquid fiducial markers in OCT images at different depths using dedicated esophageal phantoms and evaluated marker placement depth in clinical practice.

MATERIALS AND METHODS: We designed and fabricated dedicated esophageal phantoms, in which three layers mimic the anatomical wall structures of a healthy human esophagus. We successfully implanted 13 commercially available fiducial markers that varied in diameter and material property at depths between 0.5 and 3.0 mm. The resulting esophageal phantoms were imaged with OCT, and marker visibility was assessed qualitatively and quantitatively using the contrast-to-background-noise ratio (CNR). The CNR was defined as the difference between the mean intensity of the fiducial markers and the mean intensity of the background divided by the standard deviation of the background intensity. To determine whether, in current clinical practice, the implanted fiducial markers are within the OCT visualization range (up to 3.0 mm depth), we retrospectively measured the distance of 19 fiducial markers to the esophageal lumen on CT scans of 16 esophageal cancer patients.

RESULTS: In the esophageal phantoms, all the included fiducial markers were visible on OCT at all investigated depths. Solid fiducial markers were better visible on OCT than liquid fiducial markers with a 1.74-fold higher CNR. Although fiducial marker identification per type and size was slightly easier for superficially implanted fiducial markers, we observed no difference in the ability of OCT to visualize the markers over the investigated depth range. Retrospective distance measurements of 19 fiducial markers on the CT scan of esophageal cancer patients showed that 84% (distance from the closest border of the marker to the lumen) and 53% (distance from the center of the marker to the lumen) of the fiducial markers were located within the OCT visualization range of up to 3.0 mm.

CONCLUSIONS: We studied the visibility of eight types of commercially available fiducial markers at different depths on OCT using dedicated esophageal phantoms. All tested fiducial markers were visible at depths ≤3.0 mm and most, but not all, clinically implanted markers were at a depth accessible to OCT. Consequently, the use of fiducial markers as a reference for OCT to CT registration is feasible.