text:
|N�mero de publicaci�n
|Tipo de publicaci�n
|N�mero de solicitud
|Fecha de publicaci�n
|10 Ene 2012
|Fecha de presentaci�n
|25 Jul 2005
|Fecha de prioridad
|23 Jul 2004
|Tambi�n publicado como
|N�mero de publicaci�n
|J. Nelson Wright, Steven C. Dimmer, Stephen C. Phillips, Ryan K. Seghers
|Cesionario original
|Varian Medical Systems, Inc.
|Exportar cita
|BiBTeX, EndNote, RefMan
|Citas de patentes (163), Otras citas (5), Citada por (1), Clasificaciones (10), Eventos legales (3)
|Enlaces externos: USPTO, Cesi�n de USPTO, Espacenet
This application claims the benefit of U.S. patent application Ser. No. 60/590,693 filed Jul. 23, 2004, which is hereby incorporated by reference in its entirety.
The present invention is directed to the field of software systems for processing real-time information.
Radiation therapy can be used to treat localized cancer. In a typical application, a radiation delivery system has an ionizing radiation device mounted to a movable gantry. The radiation delivery system controls the motion of the radiation device to direct an ionizing radiation beam to a specific point in space commonly referred to as the "machine isocenter."
One aspect of radiation therapy is positioning a patient so that the patient's tumor is located at the machine isocenter during treatment. Conventional patient positioning systems use various technologies to locate the tumor, including optically locating visual markers applied to the patient's skin, or using X-ray imaging to locate metal fiducials subcutaneously implanted in the patient. Conventional patient positioning systems are typically used only to align patients in preparation for the delivery of radiation energy.
To ensure that radiation energy is delivered to a patient's tumor as planned, though, it would be useful to provide patient location information during the delivery of radiation energy. It can be difficult to successfully apply conventional approaches to patient tracking to provide patient location information during the delivery of radiation, however.
Using conventional X-ray based tracking techniques, each tracking measurement exposes the patient to an additional dose of X-ray imaging radiation. Were the use of X-ray based tracking expanded to operate throughout the course of radiation therapy, the patient would be exposed to potentially harmful levels of X-ray imaging radiation. Additionally, in some implementations, the delivery of energy during radiation therapy can interrupt the efficacy of X-ray based tracking techniques. For instance, the presence of radiation therapy radiation may interfere with the sensing of imaging radiation. As another example, the presence of the X-ray imaging emitter and/or sensor may physically interrupt the radiation treatment energy beam.
It can also be difficult to successfully apply conventional optical tracking techniques during the delivery of radiation. Here too, the presence of optical tracking sensors may interrupt the radiation treatment energy beam. Conversely, radiation treatment equipment may intervene between the patient and the optical tracking sensors, blocking their view of the patient. Also, as optical tracking techniques typically rely on 2-dimensional tracking of the exterior surface of the patient's body, their accuracy depends on the consistency of such factors as the shape of the exterior surface of the patient's body, and the location of the tumor relative to the locations of the visual markers. Because these factors are inherently variable, positioning data obtained using conventional optical tracking techniques can be inaccurate.
In view of the foregoing, a patient tracking system that provided useful patient tracking information during the delivery of radiation energy, and that promptly acted on such information, would have significant utility.
In the drawings, identical reference numbers identify similar elements or components. The sizes and relative positions of elements in the drawings are not necessarily drawn to scale. For example, the shapes of various elements and angles are not drawn to scale, and some of these elements are arbitrarily enlarged and positioned to improve drawing legibility. Further, the particular shapes of the elements as drawn, are not intended to convey any information regarding the actual shape of the particular elements, and have been solely selected for ease of recognition in the drawings.
A software facility that performs real-time or near-real-time processing of patient tracking information during radiation therapy ("the facility") is described. As one illustrative example, some embodiments of the facility perform processing for patient tracking information generated in real-time or near-real-time by combining (1) information about the location of subcutaneously-implanted markers—such as passive magnetic transponders—relative to the sensor device used to locate the markers—such as an electromagnetic excitation and sensing array—with (2) information about the location of the sensor device relative to a machine isocenter to which radiation energy is delivered. One or more suitable, exemplary patient localization systems are described in the following, each of which is hereby incorporated by reference in its entirety: U.S. patent application Ser. No. 10/334,700, entitled PANEL-TYPE SENSOR/SOURCE ARRAY ASSEMBLY, filed Dec. 30, 2002; U.S. patent application Ser. No. 09/877,498, entitled GUIDED RADIATION THERAPY SYSTEM, filed Jun. 8, 2001; U.S. patent application Ser. No. 10/679,801, entitled METHOD AND SYSTEM FOR MARKER LOCALIZATION, filed Oct. 6, 2003; U.S. patent application Ser. No. 10/746,888, entitled IMPLANTABLE MARKER WITH WIRELESS SIGNAL TRANSMITTAL, filed Dec. 24, 2003; and U.S. patent application Ser. No. 10/749,478, entitled RECEIVER USED IN MARKER LOCALIZATION SENSING SYSTEM, filed Dec. 31, 2003.
In some embodiments, the facility uses a publish and subscribe scheme to promptly distribute patient tracking information for one or more real-time or near-real-time uses. For example, the facility may use the publish and subscribe scheme to distribute patient tracking information to a user interface component to display the patient's position for monitoring and/or to a treatment control component to adapt the treatment process to changes in the patient's position. In some embodiments, published patient tracking information is cached for lower-frequency uses of patient tracking information, and/or fixed-frequency uses of patient tracking information, such as displaying.
In some embodiments, the facility uses a bulk transfer scheme to less-frequently distribute patient tracking information, such as at the end of a session. The bulk transfer scheme may be used to distribute an entire session's patient tracking information, for example for non-volatile storage or use in planning a future treatment session.
By processing patient tracking information in some or all of the ways discussed above, the facility enables a variety of valuable uses of patient tracking information in connection with radiation therapy.
Processing Patient Tracking Information
In some embodiments, the patient tracking component computes patient tracking records with no more than a maximum latency after the time of the underlying measurements, such as a maximum latency of 50 milliseconds, or a maximum latency of 200 milliseconds. In some embodiments, the patient tracking component generates patient tracking records at at least a minimum frequency, such as a minimum frequency of 20 hertz. Additional detail about the generation of patient tracking records is discussed in U.S. patent application Ser. No. 11/166,801 entitled SYSTEMS AND METHODS FOR REAL TIME TRACKING OF TARGETS IN RADIATION THERAPY AND OTHER MEDICAL APPLICATIONS, filed Jun. 24, 2005 and incorporated by reference in its entirety.
For each set of patient tracking information it computes, the patient tracking component stores a patient tracking record in a transcript 109 maintained by the patient tracking component, and publishes a patient tracking record object 101 containing the patient tracking record.
In some embodiments, the patient tracking component truncates, or "prunes" the contents of the patient tracking records included in the patient tracking record objects to reduce the communication resources needed to publish patient tracking record objects containing the pruned patient tracking records.
The patient tracking record objects published by the patient tracking component are subscribed to by components seeking real-time or near-real-time patient tracking information during the course of a radiation treatment session. For example, a treatment control component 130 may subscribe to the patient tracking record objects, and use the enclosed patient tracking records to control a variety of radiation treatment parameters. For example, in response to the patient tracking information, the treatment control component may alter the shape, direction, or intensity of the radiation energy being used to treat the patient; alter the location or orientation of the patient relative to the beam, such as by automatically moving the patient (or a table supporting the patient) or the beam; or switch the beam on or off, or pulse the beam. Additional details regarding the treatment control component's control of radiation treatment parameters are discussed in the patent applications incorporated by reference above.
In some embodiments, a caching component 140 also subscribes to the patient tracking record objects. The caching component 140 stores the patient tracking record contained in the most recently published patient tracking record object in a cache 149. Periodically, in some embodiments, one or more user interface components 150 send the caching component a cached patient tracking record request 151. (In some embodiments, however, some or all of the user interface components directly subscribe to the patient tracking record objects.) When the caching component receives a cached patient tracking record request from one of the user interface components, the caching component replies with a cached patient tracking record 141—i.e., the patient tracking record presently contained in the cache. As is discussed in additional detail in U.S. Patent Application No. 60/590,699, entitled USER INTERFACE FOR GUIDED RADIATION THERAPY, filed Jul. 23, 2004 and U.S. patent application Ser. No. 11/189,542 entitled USER INTERFACE FOR GUIDED RADIATION THERAPY, filed concurrently herewith, each of which is hereby incorporated by reference in its entirety, the user interfaces use the patient tracking records contained in the cached patient tracking record response to present a visual or other user interface reporting the patient tracking information, such as to radiation treatment attendants, in a graph or other form.
When a patient treatment session is completed, the patient tracking component sends a patient tracking transcript transmission 102, containing the transcript of the patient tracking records generated during the session. The patient tracking transcript transmission is sent to such recipients as a database 164 that stores the transcript in a non-volatile manner, and a treatment planning component 170 that uses the transcript to plan future treatment sessions for the same patient. Such adaptive treatment planning is discussed in additional detail in U.S. Patent Application Ser. No. 60/590,503, filed Jul. 23, 2004, entitled DYNAMIC/ADAPTIVE TREATMENT PLANNING FOR RADIATION THERAPY, and U.S. patent application Ser. No. 11/189,431, entitled DYNAMIC/ADAPTIVE TREATMENT PLANNING FOR RADIATION THERAPY, filed concurrently herewith, each of which is hereby incorporated by reference in its entirety.
The components shown in
Simultaneously, in step 411, the caching component receives a request for the cached patient tracking record, such as a request submitted by one of the user interface components. In step 412, the caching component replies to the request received in step 411 with the patient tracking record currently contained in the cache. After step 412, the caching component continues in step 411 to receive the next request.
In some embodiments, the data shown in
TABLE 1 <SessionTargetData> <TargetPosition> <X>−0.43109733458214217</X> <Y>−0.066685713198866473</Y> <Z>−0.37997479402471651</Z> </TargetPosition> <ConfidenceIndex>0</ConfidenceIndex> <ResultCode>Okay</ResultCode> <Psi>90.000002504478161</Psi> <Phi>0</Phi> <Theta>0</Theta> <MeasurementDateTime>2004-05-25T14:47:45.5468750-07:00 </MeasurementDateTime> </SessionTargetData>
Those skilled in the art will appreciate that a variety of other formats, including other tag-based markup languages, may be used to store and communicate this information.
In some embodiments, information stored by the facility in the transcript provides a basis for revisiting the treatment session, such as by replaying the user interface display of the session. In some embodiments, the contents of a transcript may be used to perform various forms of retrospective analysis of the session, such as identifying the smallest volume containing every target position throughout the session; determining the percentage of the session during which the target was within a prescribed volume; determining a total dosage of radiation received at the target; etc.
In some embodiments, the facility stores more detailed tracking information than is shown in
In some embodiments, the facility passes a transcript or similar data structure to a record and verify system in order to verify that radiation treatment was delivered in accordance with a plan. In some embodiments, the facility itself performs this verification function. For example, in some embodiments, the facility uses the timestamps of the patient location records in the data structure to correlate the patient tracking records with time-indexed information about the status of various radiation treatment parameters, such as those prescribed in the radiation therapy session plan for the session. The facility then uses this time-correlated information to verify that treatment was delivered in accordance with the plan.
Techniques for Sensing Location
A. Overview
Several embodiments of the invention are directed towards methods for tracking a target, i.e., measuring the position and/or the rotation of a target in substantially real time, in a patient in medical applications. One embodiment of such a method comprises collecting position data of a marker that is substantially fixed relative to the target. This embodiment further includes determining the location of the marker in an external reference frame (i.e., a reference frame outside the patient) and providing an objective output in the external reference frame that is responsive to the location of the marker. The objective output is repeatedly provided at a frequency/periodicity that adequately tracks the location of the target in real time within a clinically acceptable tracking error range. As such, the method for tracking the target enables accurate tracking of the target during diagnostic, planning, treatment or other types of medical procedures. In many specific applications, the objective output is provided within a suitably short latency after collecting the position data and at a sufficiently high frequency to use the data for such medical procedures.
Another specific embodiment is a method for treating a target in a patient with an ionizing radiation beam that includes collecting position information of a marker implanted within a patient at a site relative to the target at a time tn, and providing an objective output indicative of the location of the target based on the position information collected at time tn. The objective output is provided to a memory device, user interface, and/or radiation delivery machine within 2 seconds or less of the time tn when the position information was collected. This embodiment of the method can further include providing the objective output at a periodicity of 2 seconds or less during at least a portion of a treatment procedure. For example, the method can further include generating a beam of ionizing radiation and directing the beam to a machine isocenter, and continuously repeating the collecting procedure and the providing procedure every 10-200 ms while irradiating the patient with the ionizing radiation beam.
Another embodiment of a method for tracking a target in a patient includes obtaining position information of a marker situated within the patient at a site relative to the target, and determining a location of the marker in an external reference frame based on the position information. This embodiment further includes providing an objective output indicative of the location of the target to a user interface at (a) a sufficiently high frequency so that pauses in representations of the target location at the user interface are not readily discernable by a human, and (b) a sufficiently low latency to be at least substantially contemporaneous with obtaining the position information of the marker.
Another embodiment of the invention is directed toward a method of treating a target of a patient with an ionizing radiation beam by generating a beam of ionizing radiation and directing the beam relative to the target. This method further includes collecting position information of a marker implanted within the patient at a site relative to the target while directing the beam toward the beam isocenter. Additionally, this method includes providing an objective output indicative of a location of the target relative to the beam isocenter based on the collected position information. This method can further include correlating the objective output with a parameter of the beam, and controlling the beam based upon the objective output. For example, the beam can be gated to only irradiate the patient when the target is within a desired irradiation zone. Additionally, the patient can be moved automatically and/or the beam can be shaped automatically according to the objective output to provide dynamic control in real time that maintains the target at a desired position relative to the beam isocenter while irradiating the patient.
Various embodiments of the invention are described in this section to provide specific details for a thorough understanding and enabling description of these embodiments. A person skilled in the art, however, will understand that the invention may be practiced without several of these details, or that additional details can be added to the invention. Where the context permits, singular or plural terms may also include the plural or singular term, respectively. Moreover, unless the word "or" is expressly limited to mean only a single item exclusive from the other items in reference to a list of at least two items, then the use of "or" in such a list is to be interpreted as including (a) any single item in the list, (b) all of the items in the list, or (c) any combination of items in the list. Additionally, the term "comprising" is used throughout to mean including at least the recited feature(s) such that any greater number of the same feature and/or types of other features or components are not precluded.
B. Radiation Therapy Systems with Real Time Tracking Systems
The radiation delivery source of the illustrated embodiment is an ionizing radiation device 20 (i.e., a linear accelerator). Suitable linear accelerators are manufactured by Varian Medical Systems, Inc. of Palo Alto, Calif.; Siemens Medical Systems, Inc. of Iselin, N.J.; Elekta Instruments, Inc. of Iselin, N.J.; or Mitsubishi Denki Kabushik Kaisha of Japan. Such linear accelerators can deliver conventional single or multi-field radiation therapy, 3D conformal radiation therapy (3D CRT), intensity modulated radiation therapy (IMRT), stereotactic radiotherapy, and tomo therapy. The radiation delivery source 20 can deliver a gated, contoured or shaped beam 21 of ionizing radiation from a movable gantry 22 to an area or volume at a known location in an external, absolute reference frame relative to the radiation delivery source 20. The point or volume to which the ionizing radiation beam 21 is directed is referred to as the machine isocenter.
The tracking system includes the localization system 10 and one or more markers 40. The localization system 10 determines the actual location of the markers 40 in a three-dimensional reference frame, and the markers 40 are typically implanted within the patient 6. In the embodiment illustrated in
C. General Aspects of Markers and Localization Systems
1. Localization Systems
The localization system 10 includes an excitation source 60 (e.g., a pulsed magnetic field generator), a sensor assembly 70, and a controller 80 coupled to both the excitation source 60 and the sensor assembly 70. The excitation source 60 generates an excitation energy to energize at least one of the markers 40 a-c in the patient 6 (
The sensor assembly 70 can include a plurality of coils to sense the location signals L1-3 from the markers 40 a-c. The sensor assembly 70 can be a flat panel having a plurality of coils that are at least substantially coplanar relative to each other. In other embodiments, the sensor assembly 70 may be a non-planar array of coils.
The controller 80 includes hardware, software or other computer-operable media containing instructions that operate the excitation source 60 to multiplex the excitation energy at the different frequencies E1-3. For example, the controller 80 causes the excitation source 60 to generate the excitation energy at the first frequency E1 for a first excitation period, and then the controller 80 causes the excitation source 60 to terminate the excitation energy at the first frequency E1 for a first sensing phase during which the sensor assembly 70 senses the first location signal L1 from the first marker 40 a without the presence of the excitation energy at the first frequency E1. The controller 80 then causes the excitation source 60 to: (a) generate the second excitation energy at the second frequency E2 for a second excitation period; and (b) terminate the excitation energy at the second frequency E2 for a second sensing phase during which the sensor assembly 70 senses the second location signal L2 from the second marker 40 b without the presence of the second excitation energy at the second frequency E2. The controller 80 then repeats this operation with the third excitation energy at the third frequency E3 such that the third marker 40 c transmits the third location signal L3 to the sensor assembly 70 during a third sensing phase. As such, the excitation source 60 wirelessly transmits the excitation energy in the form of pulsed magnetic fields at the resonant frequencies of the markers 40 a-c during excitation periods, and the markers 40 a-c wirelessly transmit the location signals L1-3 to the sensor assembly 70 during sensing phases. It will be appreciated that the excitation and sensing phases can be repeated to permit averaging of the sensed signals to reduce noise.
The computer-operable media in the controller 80, or in a separate signal processor, or other computer also includes instructions to determine the absolute positions of each of the markers 40 a-c in a three-dimensional reference frame. Based on signals provided by the sensor assembly 70 that correspond to the magnitude of each of the location signals L1-3, the controller 80 and/or a separate signal processor calculates the absolute coordinates of each of the markers 40 a-c in the three-dimensional reference frame. The absolute coordinates of the markers 40 a-c are objective data that can be used to calculate the coordinates of the target in the reference frame. When multiple markers are used, the rotation of the target can also be calculated.
2. Real Time Tracking
The localization system 10 and at least one of a marker 40 enables real time tracking of the target 2 relative to the machine isocenter or another external reference frame outside of the patient during treatment planning, set up, radiation sessions, and at other times of the radiation therapy process. In many embodiments, real time tracking means collecting position data of the markers, determining the locations of the markers in an external reference frame, and providing an objective output in the external reference frame that is responsive to the location of the markers. The objective output is provided at a frequency that adequately tracks the target in real time and/or a latency that is at least substantially contemporaneous with collecting the position data (e.g., within a generally concurrent period of time).
For example, several embodiments of real time tracking are defined as determining the locations of the markers and calculating the location of the target relative to the machine isocenter at (a) a sufficiently high frequency so that pauses in representations of the target location at a user interface do not interrupt the procedure or are readily discernable by a human, and (b) a sufficiently low latency to be at least substantially contemporaneous with the measurement of the location signals from the markers. Alternatively, real time means that the location system 10 calculates the absolute position of each individual marker 40 and/or the location of the target at a periodicity of 1 ms to 5 seconds, or in many applications at a periodicity of approximately 10-100 ms, or in some specific applications at a periodicity of approximately 20-50 ms. In applications for user interfaces, for example, the periodicity can be 12.5 ms (i.e., a frequency of 80 Hz), 16.667 ms (60 Hz), 20 ms (50 Hz), and/or 50 ms (20 Hz).
Alternatively, real time tracking can further mean that the location system 10 provides the absolute locations of the markers 40 and/or the target 2 to a memory device, user interface, linear accelerator or other device within a latency of 10 ms to 5 seconds from the time the localization signals were transmitted from the markers 40. In more specific applications, the location system generally provides the locations of the markers 40 and/or target 2 within a latency of about 20-50 ms. The location system 10 accordingly provides real time tracking to monitor the position of the markers 40 and/or the target 2 with respect to an external reference frame in a manner that is expected to enhance the efficacy of radiation therapy because higher radiation doses can be applied to the target and collateral effects to healthy tissue can be mitigated.
Alternatively, real-time tracking can further be defined by the tracking error. Measurements of the position of a moving target are subject to motion-induced error, generally referred to as a tracking error. According to aspects of the present invention, the localization system 10 and at least one marker 4 enable real time tracking of the target 2 relative to the machine isocenter or another external reference frame with a tracking error that is within clinically meaningful limits.
Tracking errors are due to two limitations exhibited by any practical measurement system, specifically (a) latency between the time the target position is sensed and the time the position measurement is made available, and (b) sampling delay due to the periodicity of measurements. For example, if a target is moving at 5 cm/s and a measurement system has a latency of 200 ms, then position measurements will be in error by 1 cm. The error in this example is due to latency alone, independent of any other measurement errors, and is simply due to the fact that the target has moved between the time its position is sensed and the time the position measurement is made available for use. If this exemplary measurement system further has a sampling periodicity of 200 ms (i.e., a sampling frequency of 5 Hz), then the peak tracking error increases to 2 cm, with an average tracking error of 1.5 cm.
For a real time tracking system to be useful in medical applications, it is desirable to keep the tracking error within clinically meaningful limits. For example, in a system for tracking motion of a tumor in a lung for radiation therapy, it may be desirable to keep the tracking error within 5 mm. Acceptable tracking errors may be smaller when tracking other organs for radiation therapy. In accordance with aspects of the present invention, real time tracking refers to measurement of target position and/or rotation with tracking errors that are within clinically meaningful limits.
In some embodiments, the system temporally filters the measurements of the marker locations, or the calculated location of the target, in order to reduce the effects of additive noise or other measurement errors. Such filtering has the effect of increasing the latency, hence the tracking error, of the system. Conversely, reducing the filtering has the effect of reducing the tracking error, at the price of increasing the effects of noise. In some embodiments, the system periodically measures the vector velocity (or a similar state variable) of the markers or the target, in addition to their locations. Such an approach can improve the accuracy of subsequent location measurements. In this case, filtering can be applied to measurements of vector velocity as well. Techniques to implement temporal filtering are well known to those skilled in the art, and include recursive and non-recursive digital filters, and Kalman and other non-linear filters. References herein to location data, or digital location indications, or the like, include those data which have been filtered, or derived from filtered measurements.
The system described herein uses one or more markers to serve as registration points to characterize target location, rotation, and motion. In accordance with aspects of the invention, the markers have a substantially fixed relationship with the target. If the markers did not have a substantially fixed relationship with the target another type of tracking error would be incurred. This generally requires the markers to be fixed or implanted sufficiently close to the target in order that tracking errors be within clinically meaningful limits, thus, the markers may be placed in tissue or bone that exhibits representative motion of the target. For example, with respect to the prostate, tissue that is representative of the target's motion would include tissue in close proximity or adjacent to the prostate. Tissue adjacent to a target involving the prostate may include the prostate gland, the tumor itself, or tissue within a specified radial distance from the target. With respect to the prostate, tracking tissue that is a 5 cm radial distance from the target would provide representative motion that is clinically useful to the motion of the target. In accordance with alternative target tracking locations, the radial distance may be greater or lesser.
According to aspects of the present invention, the marker motion is a surrogate for the motion of the target. Accordingly, the marker is placed such that it moves in direct correlation to the target being tracked. Depending on the target being tracked, the direct correlation relationship between the target and the marker will vary. For example, in long bones, the marker may be place anywhere along the bone to provide motion that directly correlate to target motion in the bone. With respect to soft tissue that moves substantially in response to the bony anatomy, for example, the head and neck, the marker may be placed in a bite block to provide surrogate motion in direct correlation with target motion. With respect to soft tissue and as discussed in detail above, the target may be placed in adjacent soft tissue to provide a surrogate having direct correlation to target motion.
The radiation planning procedure 91 can also include tracking the targets using the localization system 10 (
The localization system 10 and the markers 40 enable an automated patient setup process for delivering the radiation. After developing a treatment plan, the method 90 includes a setup procedure 92 in which the patient is positioned on a movable support table so that the target and markers are generally adjacent to the sensor assembly. As described above, the excitation source is activated to energize the markers, and the sensors measure the strength of the signals from the markers. The computer controller then (a) calculates objective values of the locations of the markers and the target relative to the machine isocenter, and (b) determines an objective offset value between the position of the target and the machine isocenter. Referring to
One aspect of several embodiments of the localization system 10 is that the objective values are provided to the user interface or other device by processing the position data from the field sensor 70 in the controller 80 or other computer without human interpretation of the data received by the field sensor 70. If the offset value is outside of an acceptable range, the computer automatically activates the control system of the support table to move the tabletop relative to the machine isocenter until the target isocenter is coincident with the machine isocenter. The computer controller generally provides the objective output data of the offset to the table control system in real time as defined above. For example, because the output is provided to the radiation delivery device, it can be at a high rate (1-20 ms) and a low latency (10-20 ms). If the output data is provided to a user interface in addition to or in lieu of the table controller, it can be at a relatively lower rate (20-50 ms) and higher latency (50-200 ms).
In one embodiment, the computer controller also determines the position and orientation of the markers relative to the position and orientation of simulated markers. The locations of the simulated markers are selected so that the target will be at the machine isocenter when the real markers are at the selected locations for the simulated markers. If the markers are not properly aligned and oriented with the simulated markers, the support table is adjusted as needed for proper marker alignment. This marker alignment properly positions the target along six dimensions, namely X, Y, Z, pitch, yaw, and roll. Accordingly, the patient is automatically positioned in the correct position and rotation relative to the machine isocenter for precise delivery of radiation therapy to the target.
Referring back to
The localization system provides the objective data of the offset and/or rotation to the linear accelerator and/or the patient support table in real time as defined above. For example, as explained above with respect to automatically positioning the patent support table during the setup procedure 92, the localization system generally provides the objective output to the radiation delivery device at least substantially contemporaneously with obtaining the position data of the markers and/or at a sufficient frequency to track the target in real time. The objective output, for example, can be provided at a short periodicity (1-20 ms) and a low latency (10-20 ms) such that signals for, controlling the beam 21 can be sent to the radiation delivery device 20 in the same time periods during a radiation session. In another example of real time tracking, the objective output is provided a plurality of times during an "on-beam" period (e.g., 2, 5, 10 or more times while the beam is on). In the case of terminating or activating the radiation beam, or adjusting the leafs of a beam collimator, it is generally desirable to maximize the refresh rate and minimize the latency. In some embodiments, therefore, the localization system may provide the objective output data of the target location and/or the marker locations at a periodicity of 10 ms or less and a latency of 10 ms or less.
The method 90 further includes a verification procedure 94 in which the real time objective output data from the radiation session 93 is compared to the status of the parameters of the radiation beam. For example, the target locations can be correlated with the beam intensity, beam position, and collimator configuration at corresponding time intervals during the radiation session 93. This correlation can be used to determine the dose of radiation delivered to discrete regions in and around the target. This information can also be used to determine the effects of radiation on certain areas of the target by noting changes in the target configuration or the target trajectory.
The method 90 can further include a first decision (Block 95) in which the data from the verification procedure 94 is analyzed to determine whether the treatment is complete. If the treatment is not complete, the method 90 further includes a second decision (Block 96) in which the results of the verification procedure are analyzed to determine whether the treatment plan should be revised to compensate for changes in the target. If revisions are necessary, the method can proceed with repeating the planning procedure 91. On the other hand, if the treatment plan is providing adequate results, the method 90 can proceed by repeating the setup procedure 92, radiation session 93, and verification procedure 94 in a subsequent fraction of the radiation therapy.
The localization system 10 provides several features, either individually or in combination with each other, that enhance the ability to accurately deliver high doses of radiation to targets within tight margins. For example, many embodiments of the localization system use leadless markers that are implanted in the patient so that they are substantially fixed with respect to the target. The markers accordingly move either directly with the target or in a relationship proportional to the movement of the target. As a result, internal movement of the target caused by respiration, organ filling, cardiac functions, or other factors can be identified and accurately tracked before, during and after medical procedures. Moreover, many aspects of the localization system 10 use a non-ionizing energy to track the leadless markers in an external, absolute reference frame in a manner that provides objective output. In general, the objective output is determined in a computer system without having a human interpret data (e.g., images) while the localization system 10 tracks the target and provides the objective output. This significantly reduces the latency between the time when the position of the marker is sensed and the objective output is provided to a device or a user. For example, this enables an objective output responsive to the location of the target to be provided at least substantially contemporaneously with collecting the position data of the marker. The system also effectively eliminates inter-user variability associated with subjective interpretation of data (e.g., images).
D. Specific Embodiments of Markers and Localization Systems
The following specific embodiments of markers, excitation sources, sensors and controllers provide additional details to implement the systems and processes described above with reference to
1. Markers
The magnetic transponder 1420 can include a resonating circuit that wirelessly transmits a location signal in response to a wirelessly transmitted excitation field as described above. In this embodiment, the magnetic transponder 1420 comprises a coil 1422 defined by a plurality of windings of a conductor 1424. Many embodiments of the magnetic transponder 1420 also include a capacitor 1426 coupled to the coil 1422. The coil 1422 resonates at a selected resonant frequency. The coil 1422 can resonate at a resonant frequency solely using the parasitic capacitance of the windings without having a capacitor, or the resonant frequency can be produced using the combination of the coil 1422 and the capacitor 1426. The coil 1422 accordingly generates an alternating magnetic field at the selected resonant frequency in response to the excitation energy either by itself or in combination with the capacitor 1426. The conductor 1424 of the illustrated embodiment can be hot air or alcohol bonded wire having a gauge of approximately 45-52. The coil 1422 can have 800-1000 turns, and the windings are preferably wound in a tightly layered coil. The magnetic transponder 1420 can further include a core 1428 composed of a material having a suitable magnetic permeability. For example, the core 1428 can be a ferromagnetic element composed of ferrite or another material. The magnetic transponder 1420 can be secured to the casing 1410 by an adhesive 1429.
The marker 1400 also includes an imaging element that enhances the radiographic image of the marker to make the marker more discernible in radiographic images. The imaging element also has a radiographic profile in a radiographic image such that the marker has a radiographic centroid at least approximately coincident with the magnetic centroid of the magnetic transponder 1420. As explained in more detail below, the radiographic and magnetic centroids do not need to be exactly coincident with each other, but rather can be within an acceptable range.
The first and second contrast elements 1432 and 1434 illustrated in
The radiographic centroid of the image produced by the imaging element 1430 does not need to be absolutely coincident with the magnetic centroid Mc, but rather the radiographic centroid and the magnetic centroid should be within an acceptable range. For example, the radiographic centroid Rc can be considered to be at least approximately coincident with the magnetic centroid Mc when the offset between the centroids is less than approximately 5 mm. In more stringent applications, the magnetic centroid Mc and the radiographic centroid Rc are considered to be at least substantially coincident with each other when the offset between the centroids is 2 mm, or less than 1 mm. In other applications, the magnetic centroid Mc is at least approximately coincident with the radiographic centroid Rc when the centroids are spaced apart by a distance not greater than half the length of the magnetic transponder 1420 and/or the marker 1400.
The imaging element 1430 can be made from a material and configured appropriately to absorb a high fraction of incident photons of a radiation beam used for producing the radiographic image. For example, when the imaging radiation has high acceleration voltages in the megavoltage range, the imaging element 1430 is made from, at least in part, high density materials with sufficient thickness and cross-sectional area to absorb enough of the photon fluence incident on the imaging element to be visible in the resulting radiograph. Many high energy beams used for therapy have acceleration voltages of 6 MV-25 MV, and these beams are often used to produce radiographic images in the 5 MV-10 MV range, or more specifically in the 6 MV-8 MV range. As such, the imaging element 1430 can be made from a material that is sufficiently absorbent of incident photon fluence to be visible in an image produced using a beam with an acceleration voltage of 5 MV-10 MV, or more specifically an acceleration voltage of 6 MV-8 MV.
Several specific embodiments of imaging elements 1430 can be made from gold, tungsten, platinum and/or other high density metals. In these embodiments the imaging element 1430 can be composed of materials having a density of 19.25 g/cm3 (density of tungsten) and/or a density of approximately 21.4 g/cm3 (density of platinum). Many embodiments of the imaging element 1430 accordingly have a density not less than 19 g/cm3. In other embodiments, however, the material(s) of the imaging element 1430 can have a substantially lower density. For example, imaging elements with lower density materials are suitable for applications that use lower energy radiation to produce radiographic images. Moreover, the first and second contrast elements 1432 and 1434 can be composed of different materials such that the first contrast element 1432 can be made from a first material and the second contrast element 1434 can be made from a second material.
Referring to
One specific process of using the marker involves imaging the marker using a first modality and then tracking the target of the patient and/or the marker using a second modality. For example, the location of the marker relative to the target can be determined by imaging the marker and the target using radiation. The marker and/or the target can then be localized and tracked using the magnetic field generated by the marker in response to an excitation energy.
The marker 1400 shown in
The marker 1500 is expected to operate in a manner similar to the marker 1400 described above. The marker 1500, however, does not have two separate contrast elements that provide two distinct, separate points in a radiographic image. The imaging element 1530 is still highly useful in that it identifies the radiographic centroid of the marker 1500 in a radiographic image, and it can be configured so that the radiographic centroid of the marker 1500 is at least approximately coincident with the magnetic centroid of the magnetic transponder 1420.
Additional embodiments of markers in accordance with the invention can include imaging elements incorporated into or otherwise integrated with the casing 1410, the core 1428 (
The markers described above with reference to
2. Localization Systems
The excitation source 1910 is adjustable to generate a magnetic field having a waveform with energy at selected frequencies to match the resonant frequencies of the markers 40. The magnetic field generated by the excitation source 1910 energizes the markers at their respective frequencies. After the markers 40 have been energized, the excitation source 1910 is momentarily switched to an "off" position so that the pulsed magnetic excitation field is terminated while the markers wirelessly transmit the location signals. This allows the sensor assembly 1912 to sense the location signals from the markers 40 without measurable interference from the significantly more powerful magnetic field from the excitation source 1910. The excitation source 1910 accordingly allows the sensor assembly 1912 to measure the location signals from the markers 40 at a sufficient signal-to-noise ratio so that the signal processor 1914 or the controller 1916 can accurately calculate the absolute location of the markers 40 relative to a reference frame.
a. Excitation Sources
Referring still to
The energy storage device 1942 is capable of storing adequate energy to reduce voltage drop in the energy storage device while having a low series resistance to reduce power losses. The energy storage device 1942 also has a low series inductance to more effectively drive the coil assembly 1946. Suitable capacitors for the energy storage device 1942 include aluminum electrolytic capacitors used in flash energy applications. Alternative energy storage devices can also include NiCd and lead acid batteries, as well as alternative capacitor types, such as tantalum, film, or the like.
The switching network 1944 includes individual H-bridge switches 1950 (identified individually by reference numbers 1950 a-d), and the coil assembly 1946 includes individual source coils 1952 (identified individually by reference numbers 1952 a-d). Each H-bridge switch 1950 controls the energy flow between the energy storage device 1942 and one of the source coils 1952. For example, H-bridge switch #1 1950 a independently controls the flow of the energy to/from source coil #1 1952 a, H-bridge switch #2 1950 b independently controls the flow of the energy to/from source coil #2 1952 b, H-bridge switch #3 1950 c independently controls the flow of the energy to/from source coil #3 1952 c, and H-bridge switch #4 1950 d independently controls the flow of the energy to/from source coil #4 1952 d. The switching network 1944 accordingly controls the phase of the magnetic field generated by each of the source coils 1952 a-d independently. The H-bridges 1950 can be configured so that the electrical signals for all the source coils 1952 are in phase, or the H-bridge switches 1950 can be configured so that one or more of the source coils 1952 are 180� out of phase. Furthermore, the H-bridge switches 1950 can be configured so that the electrical signals for one or more of the source coils 1952 are between 0 and 180� out of phase to simultaneously provide magnetic fields with different phases.
The source coils 1952 can be arranged in a coplanar array that is fixed relative to the reference frame. Each source coil 1952 can be a square, planar winding arranged to form a flat, substantially rectilinear coil. The source coils 1952 can have other shapes and other configurations in different embodiments. In one embodiment, the source coils 1952 are individual conductive lines formed in a stratum of a printed circuit board, or windings of a wire in a foam frame. Alternatively, the source coils 1952 can be formed in different substrates or arranged so that two or more of the source coils are not planar with each other. Additionally, alternate embodiments of the invention may have fewer or more source coils than illustrated in
The selected magnetic fields from the source coils 1952 combine to form an adjustable excitation field that can have different three-dimensional shapes to excite the markers 40 at any spatial orientation within an excitation volume. When the planar array of the source coils 1952 is generally horizontal, the excitation volume is positioned above an area approximately corresponding to the central region of the coil assembly 1946. The excitation volume is the three-dimensional space adjacent to the coil assembly 1946 in which the strength of the magnetic field is sufficient to adequately energize the markers 40.
In the embodiment of
The spatial configuration of the excitation field in the excitation volume 2009 can be quickly adjusted by manipulating the switching network to change the phases of the electrical signals provided to the source coils 1952 a-d. As a result, the overall magnetic excitation field can be changed to be oriented in either the X, Y or Z directions within the excitation volume 2009. This adjustment of the spatial orientation of the excitation field reduces or eliminates blind spots in the excitation volume 2009. Therefore, the markers 40 within the excitation volume 2009 can be energized by the source coils 1952 a-d regardless of the spatial orientations of the leadless markers.
In one embodiment, the excitation source 1910 is coupled to the sensor assembly 1912 so that the switching network 1944 (
The excitation source 1910 illustrated in
b. Sensor Assemblies
The panel 2504 may be a substantially non-conductive material, such as a sheet of KAPTON� produced by DuPont. KAPTON� is particularly useful when an extremely stable, tough, and thin film is required (such as to avoid radiation beam contamination), but the panel 2504 may be made from other materials and have other configurations. For example, FR4 (epoxy-glass substrates), GETEK or other Teflon-based substrates, and other commercially available materials can be used for the panel 2504. Additionally, although the panel 2504 may be a flat, highly planar structure, in other embodiments, the panel may be curved along at least one axis. In either embodiment, the field sensors (e.g., coils) are arranged in a locally planar array in which the plane of one field sensor is at least substantially coplanar with the planes of adjacent field sensors. For example, the angle between the plane defined by one coil relative to the planes defined by adjacent coils can be from approximately 0� to 10�, and more generally is less than 5�. In some circumstances, however, one or more of the coils may be at an angle greater than 100 relative to other coils in the array.
The sensor assembly 1912 shown in
The sensor assembly 1912 can further include a first exterior cover 2530 a on one side of the sensing subsystem and a second exterior cover 2530 b on an opposing side. The first and second exterior covers 2530 a-b can be thin, thermally stable layers, such as Kevlar or Thermount films. Each of the first and second exterior covers 2530 a-b can include electric shielding 2532 to block undesirable external electric fields from reaching the coils 2502. The electric shielding 2532 can be a plurality of parallel legs of gold-plated, copper strips to define a comb-shaped shield in a configuration commonly called a Faraday shield. It will be appreciated that the shielding can be formed from other materials that are suitable for shielding. The electric shielding can be formed on the first and second exterior covers using printed circuit board manufacturing technology or other techniques.
The panel 2504 with the coils 2502 is laminated to the core 2520 using a pressure sensitive adhesive or another type of adhesive. The first and second exterior covers 2530 a-b are similarly laminated to the assembly of the panel 2504 and the core 2520. The laminated assembly forms a rigid structure that fixedly retains the arrangement of the coils 2502 in a defined configuration over a large operating temperature range. As such, the sensor assembly 1912 does not substantially deflect across its surface during operation. The sensor assembly 1912, for example, can retain the array of coils 2502 in the fixed position with a deflection of no greater than �0.5 mm, and in some cases no more than �0.3 mm. The stiffness of the sensing subsystem provides very accurate and repeatable monitoring of the precise location of leadless markers in real time.
In still another embodiment, the sensor assembly 1912 can further include a plurality of source coils that are a component of the excitation source 1910. One suitable array combining the sensor assembly 1912 with source coils is disclosed in U.S. patent application Ser. No. 10/334,700, entitled PANEL-TYPE SENSOR/SOURCE ARRAY ASSEMBLY, filed on Dec. 30, 2002, which is herein incorporated by reference.
The coils 2502 may be conductive traces or depositions of copper or another suitably conductive metal formed on the panel 2504. Each coil 2502 has a trace with a width of approximately 0.15 mm and a spacing between adjacent turns within each coil of approximately 0.13 mm. The coils 2502 can have approximately 15 to 90 turns, and in specific applications each coil has approximately 40 turns. Coils with less than 15 turns may not be sensitive enough for some applications, and coils with more than 90 turns may lead to excessive voltage from the source signal during excitation and excessive settling times resulting from the coil's lower self-resonant frequency. In other applications, however, the coils 2502 can have less than 15 turns or more than 90 turns.
As shown in
The pitch of the coils 2502 in the array 2505 is a function of, at least in part, the minimum distance between the marker and the coil array. In one embodiment, the coils are arranged at a pitch of approximately 67 mm. This specific arrangement is particularly suitable when the wireless markers 40 are positioned approximately 7-27 cm from the sensor assembly 1912. If the wireless markers are closer than 7 cm, then the sensing subsystem may include sensor coils arranged at a smaller pitch. In general, a smaller pitch is desirable when wireless markers are to be sensed at a relatively short distance from the array of coils. The pitch of the coils 2502, for example, is approximately 50%-200% of the minimum distance between the marker and the array.
In general, the size and configuration of the array 2505 and the coils 2502 in the array depend on the frequency range in which they are to operate, the distance from the markers 40 to the array, the signal strength of the markers, and several other factors. Those skilled in the relevant art will readily recognize that other dimensions and configurations may be employed depending, at least in part, on a desired frequency range and distance from the markers to the coils.
The array 2505 is sized to provide a large aperture to measure the magnetic field emitted by the markers. It can be particularly challenging to accurately measure the signal emitted by an implantable marker that wirelessly transmits a marker signal in response to a wirelessly transmitted energy source because the marker signal is much smaller than the source signal and other magnetic fields in a room (e.g., magnetic fields from CRTs, etc.). The size of the array 2505 can be selected to preferentially measure the near field of the marker while mitigating interference from far field sources. In one embodiment, the array 2505 is sized to have a maximum dimension D1 or D2 across the surface of the area occupied by the coils that is approximately 100% to 300% of a predetermined maximum sensing distance that the markers are to be spaced from the plane of the coils. Thus, the size of the array 2505 is determined by identifying the distance that the marker is to be spaced apart from the array to accurately measure the marker signal, and then arrange the coils so that the maximum dimension of the array is approximately 100% to 300% of that distance. The maximum dimension of the array 2505, for example, can be approximately 200% of the sensing distance at which a marker is to be placed from the array 2505. In one specific embodiment, the marker 40 has a sensing distance of 20 cm and the maximum dimension of the array of coils 2502 is between 20 cm and 60 cm, and more specifically 40 cm.
A coil array with a maximum dimension as set forth above is particularly useful because it inherently provides a filter that mitigates interference from far field sources. As such, one aspect of several embodiments of the invention is to size the array based upon the signal from the marker so that the array preferentially measures near field sources (i.e., the field generated by the marker) and filters interference from far field sources.
The coils 2502 are electromagnetic field sensors that receive magnetic flux produced by the wireless markers 40 and in turn produce a current signal representing or proportional to an amount or magnitude of a component of the magnetic field through an inner portion or area of each coil. The field component is also perpendicular to the plane of each coil 2502. Each coil represents a separate channel, and thus each coil outputs signals to one of 32 output ports 2506. A preamplifier, described below, may be provided at each output port 2506. Placing preamplifiers (or impedance buffers) close to the coils minimizes capacitive loading on the coils, as described herein. Although not shown, the sensing unit 2501 also includes conductive traces or conductive paths routing signals from each coil 2502 to its corresponding output port 2506 to thereby define a separate channel. The ports in turn are coupled to a connector 2508 formed on the panel 2504 to which an appropriately configured plug and associated cable may be attached.
The sensing unit 2501 may also include an onboard memory or other circuitry, such as shown by electrically erasable programmable read-only memory (EEPROM) 2510. The EEPROM 2510 may store manufacturing information such as a serial number, revision number, date of manufacture, and the like. The EEPROM 2510 may also store per-channel calibration data, as well as a record of run-time. The run-time will give an indication of the total radiation dose to which the array has been exposed, which can alert the system when a replacement sensing subsystem is required.
Although shown in one plane only, additional coils or electromagnetic field sensors may be arranged perpendicular to the panel 2504 to help determine a three-dimensional location of the wireless markers 40. Adding coils or sensors in other dimensions could increase the total energy received from the wireless markers 40, but the complexity of such an array would increase disproportionately. The inventors have found that three-dimensional coordinates of the wireless markers 40 may be found using the planar array shown in
Implementing the sensor assembly 1012 may involve several considerations. First, the coils 2502 may not be presented with an ideal open circuit. Instead, they may well be loaded by parasitic capacitance due largely to traces or conductive paths connecting the coils 2502 to the preamplifiers, as well as a damping network (described below) and an input impedance of the preamplifiers (although a low input impedance is preferred). These combined loads result in current flow when the coils 2502 link with a changing magnetic flux. Any one coil 2502, then, links magnetic flux not only from the wireless marker 40, but also from all the other coils as well. These current flows should be accounted for in downstream signal processing.
A second consideration is the capacitive loading on the coils 2502. In general, it is desirable to minimize the capacitive loading on the coils 2502. Capacitive loading forms a resonant circuit with the coils themselves, which leads to excessive voltage overshoot when the excitation source 1910 is energized. Such a voltage overshoot should be limited or attenuated with a damping or "snubbing" network across the coils 2502. A greater capacitive loading requires a lower impedance damping network, which can result in substantial power dissipation and heating in the damping network.
Another consideration is to employ preamplifiers that are low noise. The preamplification can also be radiation tolerant because one application for the sensor assembly 1912 is with radiation therapy systems that use linear accelerators (LINAC). As a result, PNP bipolar transistors and discrete elements may be preferred. Further, a DC coupled circuit may be preferred if good settling times cannot be achieved with an AC circuit or output, particularly if analog to digital converters are unable to handle wide swings in an AC output signal.
c. Signal Processors and Controllers
The signal processor 1914 and the controller 1916 illustrated in
An experimental phantom based study was conducted to determine effectiveness of this system for real-time tracking. In this experiment, a custom 4D stage was constructed to allow arbitrary motion in three axes for speeds up to 10 cm/sec in each dimension, with accuracy to 0.3 mm. Position accuracy was measured by a 3D digitizing arm attached to the stage system. As shown in
Experiment Summary
As shown in
Those skilled in the art will appreciate that the above-described facility may be straightforwardly adapted or extended in various ways. For example, the facility may operate in a wide variety of radiation treatment and treatment planning environments, and in conjunction with a wide variety of different patient tracking technologies. The facility may use a set of modules that is different from those shown and described herein. The facility may use a variety of different communication mechanisms to communicate patient position information. Patient position information may be provided to various consumers at various different levels of latency and/or frequency. In some embodiments, the facility can be used to perform patient tracking at times when the patient is not being subjected to radiation therapy treatment, such as (1) to position the patient before radiation therapy commences, or (2) to observe changes in the location, volume, shape, and/or orientation of the patient's tumor outside the radiation therapy vault. While the foregoing description makes reference to preferred embodiments, the scope of the invention is defined solely by the claims that follow and the elements recited therein.
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|Method and apparatus for irradiating a target
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|Varian Medical Systems Technologies, Inc.
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|Implantable marker with a leadless signal transmitter compatible for use in magnetic resonance devices
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|Systems and methods for communicating between a decision-support system and one or more mobile information devices
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|ImQuant LLC
|Dynamic tumor diagnostic and treatment system
|18 Oct 2001
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|Wei Ding
|Computer assisted radiotherapy dosimeter system and a method therefor
|10 Ene 2002
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|Cosman Eric R.
|Surgical positioning system
|25 Ene 2002
|7 Nov 2002
|Yasuhiro Mori
|Vital signs detection system, vital signs detection method, vital signs processing apparatus, and health control method
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|Sherwood Services Ag
|Surgical positioning system
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|Guided Radiation Therapy System
|2 Jul 2001
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|Method and system for providing radiation treatment to a patient
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|Position sensing system with integral location pad and position display
|14 Sep 2001
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|Miniature resonating marker assembly
|2 Nov 2001
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|Owens Timothy R
|Method and apparatus for computer modified magnetic resonance imaging
|25 Nov 2002
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|Disposable single-use external dosimeters for use in radiation therapies
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|Kinamed, Inc.
|Non-imaging, computer assisted navigation system for hip replacement surgery
|14 May 2003
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|Systems and methods for locating and defining a target location within a human body
|23 Sep 2002
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|Collins William F.
|Patient positioning system
|30 Ene 2001
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|Kendrick Lance A.
|Method and apparatus for alignment of medical radiation beams using a body frame
|16 Abr 2003
|29 Ene 2004
|Vanderbilt University
|Method and apparatus for collecting and processing physical space data for use while performing image-guided surgery
|18 Sep 2002
|8 Abr 2004
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|Digitally reconstruced portal image and radiation therapy workflow incorporating the same
|5 Sep 2003
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|Radiation process and apparatus
|3 Oct 2003
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|Method and system for radiation application
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|31 Dic 2001
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|DFT leakage removal for non-coherently sampled signals
|30 Dic 2002
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|31 Dic 2003
|14 Jul 2005
|Wright J. N.
|Method and system for calibration of a marker localization sensing array
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|14 Jul 2005
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|System for spatially adjustable excitation of leadless miniature marker
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|Method of computer-assisted ligament balancing and component placement in total knee arthroplasty
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|Modular software system for guided radiation therapy
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|Integrated radiation therapy systems and methods for treating a target in a patient
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|General Electric Company
|Tracking system to follow the position and orientation of a device with radiofrequency fields
|T�tulo no disponible
|U.S. Appl. No. 10/416,827, filed Nov. 17, 2000, Krag.
|U.S. Appl. No. 60/590,503, filed Jul. 23, 2004, Wright et al.
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|Patente citante
|Fecha de presentaci�n
|Fecha de publicaci�n
|4 Oct 2012
|Varian Medical Systems International Ag
|Method and system for automated evaluation of multiple portal dose images in radiation therapy
|Clasificaci�n de EE.UU.
|600/426, 600/437, 600/410, 600/407
|Clasificaci�n internacional
|Clasificaci�n cooperativa
|Clasificaci�n europea
|17 Ene 2006
Owner name: CALYPSO MEDICAL TECHNOLOGIES, INC., WASHINGTON
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNORS:WRIGHT, J. NELSON;DIMMER, STEVEN C.;PHILLIPS, STEPHEN C.;AND OTHERS;REEL/FRAME:017483/0938;SIGNING DATES FROM 20051018 TO 20051019
Owner name: CALYPSO MEDICAL TECHNOLOGIES, INC., WASHINGTON
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNORS:WRIGHT, J. NELSON;DIMMER, STEVEN C.;PHILLIPS, STEPHEN C.;AND OTHERS;SIGNING DATES FROM 20051018 TO 20051019;REEL/FRAME:017483/0938
|16 Nov 2011
Owner name: VARIAN MEDICAL SYSTEMS, INC., CALIFORNIA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:CALYPSO MEDICAL TECHNOLOGIES, INC.;REEL/FRAME:027238/0145
Effective date: 20111115
|10 Jul 2015
|Fee payment
Year of fee payment: 4


text:
Chimcare can fix all of your Fireplace Flue Damper problems. We service the Greater Portland Metro and rural areas such as Silverton, Molalla, Sandy, Clackamas, Newberg, Canby, Woodburn, Oregon City and many more smaller communities. We DO NOT CHARGE any travel fee's!! So don't hesitate to call the best!
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3 Reviews
Terrific recipe...simple, easy-to-follow and great results! Thanks.
Every aspect of this recipe is supreme. I made the garlic confit several days ago, and have used it on everything I could think of ever since. Yum-yum-o! I'm down to one last lonely bulb, but will make another batch soon. The confit is not fiddly -- just make it a few days (or a few hours) before you think you'll need it. Luckily I have fresh thyme in the garden. The steaks were divine with this addition, but truly feel free to use the garlic confit liberally.
This is a great recipe and will be a favourite. Actually cooked the steak in the connoisseur select, as I always cook my steaks since I have had it, for 11 mins, and they were perfect. Served this with a mesculan mix salad with avocado.


text: ×Close Product Image 1 of 1 Babylon Revisited And Other Stories See image Babylon Revisited And Other Stories By F. Scott Fitzgerald Written between 1920 and 1937, when F. Scott Fitzgerald was at the height of his creative powers, these ten lyric tales represent some of the author's finest fiction. In them, Fitzgerald creates vivid, timeless characters -- a dissatisfied southern belle seeking adventure in the north; the tragic hero of the title story who lost more than money in the stock market; giddy and dissipated young men and women of the interwar period. From the lazy town of Tarleton, Georgia, to the glittering cosmopolitan centers of New York and Paris, Fitzgerald brings the society of the "Lost Generation" to life in these masterfully crafted gems, showcasing the many gifts of one of our most popular writers. × Added to Cart List Price $11.99 Your Cart ( items) Cart total Continue Shopping CHECKOUT NOW Choose a format: Trade Paperback eBook Choose a format: eBook Trade Paperback eBook Scribner | 272 pages | ISBN 9780743247382 | June 2008 Add to Cart List Price $11.99 In Stock: Available for immediate download Browse Related Books Fiction > LiteraryFiction > ClassicsFiction > General Buy from another retailer • see more retailers Amazon's Kindle Store Apple iBookstore Barnes & Noble Blio Books-a-Million Google ebookstore Kobo see more retailers Get a FREE eBook when you join our mailing list. Plus, receive updates on new releases, recommended reads and more from Simon & Schuster. Email Address Free eBook available to NEW subscribers only. Offer redeemable at Simon & Schuster's ebook fulfillment partner.Offer expires in three months, unless otherwise indicated.See full terms and conditions and this month's choices. More Books from this Author Trimalchio Trimalchio By F. Scott FitzgeraldBy F. Scott Fitzgerald Three Novels Three Novels By F. Scott FitzgeraldBy F. Scott Fitzgerald The Beautiful and Damned The Beautiful and Damned By F. Scott FitzgeraldBy F. Scott Fitzgerald Thank You for the Light Thank You for the Light By F. Scott FitzgeraldBy F. Scott Fitzgerald See more by F. Scott Fitzgerald About the Author Photograph © Hulton Archive F. Scott Fitzgerald F. Scott Fitzgerald was born in St. Paul, Minnesota, in 1896, attended Princeton University, and published his first novel, This Side of Paradise, in 1920. That same year he married Zelda Sayre and the couple divided their time among New York, Paris, and the Riviera, becoming a part of the American expatriate circle that included Gertrude Stein, Ernest Hemingway, and John Dos Passos. Fitzgerald was a major new literary voice, and his masterpieces include The Beautiful and Damned, The Great Gatsby, and Tender Is the Night. He died of a heart attack in 1940 at the age of forty-four, while working on The Love of the Last Tycoon. For his sharp social insight and breathtaking lyricism, Fitzgerald is known as one of the most important American writers of the twentieth century. BECOME A FAN BOOKSVIDEOS


text: [Author Prev][Author Next][Thread Prev][Thread Next][Author Index][Thread Index] Re: New York State Ed Cracks Subject: Re: New York State Ed Cracks From: Rick Parkany <firstname.lastname@example.com> Date: Mon, 25 Feb 2002 13:49:28 GMT Reply-to: Assessment Reform Network Mailing List <email@example.com> Sender: Assessment Reform Network Mailing List <firstname.lastname@example.com> George tells a fine story: > 2/25/02 > > So balance, ball-ance (pun intended, see below), balance. > > Last year, my sixth (now seventh) grade son Danny took the SAT as part of the > Gifted Talent Search and scored high enough to get invited to those summer > programs at Northwestern, Purdue, or Johns Hopkins. > > Danny's mother and I are divorced. I prayed she would agree that he had > worked hard enough on academics during the school year and was entitled to a > summer of baseball and similar stuff. > > She agreed that summer was for summer stuff. We happily ignored formal > schooling for ten weeks ..SNIP... Thank you, George, for these ruminations. Somehow, public schooling has become the end-all and be-all of every sort of socialization and *enrichment/remdiation* academic process known to man and woman. I believe that a public education should not be about channeling every moment of a child's time into these schools. A balance should be struck. IF services need to be or opt to be provided beyond a guarantee of *the basics* (locally defined and state-wide endorsed), all other services need to be considered optional. IF families cannot or decide they will not provide services beyond these basics, then optional supplemental programming ought to be offered in these schools under the *community schools* rubric. Though a rabid advocate of the *public schooling misssion*, ss a parent who IS involved w/their children far and beyond the basics, I resent the call for *more time* away from my children. My wife and I have sacrificed in our catreers and our own betterment materially to ensure the presence of our flesh in their lives. I don't need the extra help, but want to offer it when it IS needed for children not so well blessed w/parents such as we... ;-} rap. --------------------------------------------- This message was sent via the BiznessOnline.com webmail system. http://www.biznessonline.com -------------------------------------------------------------------------- To unsubscribe from the ARN-L list, send command SIGNOFF ARN-L to firstname.lastname@example.com. Prev by Author: Re: missing columns Next by Author: Re: New York State Ed Cracks Previous by thread: Re: New York State Ed Cracks Next by thread: Re: New York State Ed Cracks Index(es): Author Thread


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How many times will God take me back?
ScandalousGrace replied to Maralenn's topic in Outer CourtMaraleen, One more thought from someone who is the Prodigal Son Poster Child: Coming back to God is initiated by God; He is the one drawing you back. So if you "feel" the drawing of God, your responsibility is simply to receive His grace and mercy. No matter what your kids do to you, even storm off and yell, "I don't want to be your child anymore" does not negate the fact that they are still your child. God always takes the initiative, and where sin abounds, His grace abounds all the more. If you have received Christ by faith, your standing and relationship before God is based on what Christ did on your behalf, not on what you do. Remember: We respond to what God does for us, not what we do for Him. Just trust Him to forgive you, because He has. Peace...
What it takes to be A christian
ScandalousGrace replied to a topic in Seekers LoungeHi Sean, Thanks for your openness and candor. Like yourself, I was raised in the church and became very familiar with the Bible and Christian teachings, etc. One thing I realized is that I needed to be able to stand alone on my faith, not just accept what I was raised to believe. In my 20's I had my own crisis of faith, and fortunately God was able to reveal Himself to me and show me who He really is. That kind of personal understanding and faith is something all the years of sunday school could never give. And you are right, Jesus was so open in His associating with sinners, (prostitutes), thieves and the "losers" of society that He was routinely criticized by the religious teachers of the day. Jesus' response was formed in such a way that it defined His relationship with these "sinners" when he said in response to the criticism, "It is not the healthy who need a doctor, but the sick", obviously identifying the people's need for salvation and His ability to provide it. Now what your girlfriend is saying is coming from the Apostle Paul, when he warned Christians in the early church not to associate with people not of the Christian faith. Paul went on to state in other places that he was not advocating a retreat from the world and for all Christians to join a monastery; that is not a correct interpretation of the passage. But Paul did make it clear that the type of associations he was referring to were those relationships that are interpersonal, where we rely on others and they rely on us, including emotional bonds. The principle makes sense if you think about it: As Christians, we claim to be committed to Christ and His teachings, and when any relationship stands in opposition to those teachings or calls on us to do things we cannot do in faith, we are to always choose to be obedient to Christ. That principle will, without exception, cause conflict and tension in our relationships. But we must follow Christ above everything else. Relationships, especially romantic ones, are the most prone to disruption by a believer in Christ and a non-believer being together, because a romantic relationship involves opening ourselves up to the other person and being emotionally vulnerable. A verse in Proverbs states: "Above all else, guard your heart, for it is the wellspring of life". Even two Christians in a relationship are prone to tension, so for two people who hold opposite views on the most important question of life are doomed to suffer. I know this is not what you wanted to hear and it is true that being a Christian requires us to love even our enemies, but in life we are always forced to choose who we ally ourselves with: People, materialism, money, values, etc. And by choosing one set of values over another, we are saying yes to one thing and no to another. If you say you are exclusive in your relationship with your girlfriend, you are by default saying "no" to all other girls. By a Christian saying they belong to Christ implies that they are in a process of brining everything else in their life under His authority. And if He tells us not to do something, then we obey (or try to obey, although imperfectly), trusting in faith that He is doing so for our own good. Just some thoughts, and I hope this helps clarify your dilemma. And as a person who was raised in the church, walked away from His faith, and was eventually came back to God by His kindness and mercy, I would encourage you to examine the true person and work of Christ. I guarantee you that you will meet a person you never knew.
Deserving Eternal Torture/Torment
ScandalousGrace replied to Copper Scroll's topic in Doctrinal QuestionsMay I suggest a website that gives a good overview of controversial topics, while maintaining a solid evangelical base? Theopedia.com covers many topics such as these from some of today's most outstanding Christian authors, theologians and apologists. links is Theopedia


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Back in early October, actor Hugh Jackman was rumored to be in negotiations to star in DreamWorks' robot boxing movie, Real Steel. Now it's confirmed, according to Variety.
Director Shawn Levy (Night at the Museum) will direct Real Steel, DreamWorks' first motion picture since receiving $850 million in much-needed financing following the split with Paramount last year.
Jackman will play an ex-fighter in a near-future world where human boxers have been replaced by robots. Jackman's character discovers a junked robot that has a knack for winning and begins promoting the electronic fighter on the Robot Boxing circuit. Along the way, he gets acquainted with the 11-year-old son that he never knew he had.
DreamWorks co-president of production Mark Sourian said that DreamWorks will "put the pedal to metal" on making the movie. Described by Levy as a "rousing sports movie," Real Steel's original script, written by Dan Gilroy, has been reworked twice, most recently by John Gatins.