Review articles
Image fusion techniques in permanent seed implantation

Over the last twenty years major software and hardware developments in brachytherapy treatment planning, intra­operative navigation and dose delivery have been made. Image-guided brachytherapy has emerged as the ultimate conformal radiation therapy, allowing precise dose deposition on small volumes under direct image visualization. In this process imaging plays a central role and novel imaging techniques are being developed (PET, MRI-MRS and power Doppler US imaging are among them), creating a new paradigm (dose-guided brachytherapy), where imaging is used to map the exact coordinates of the tumour cells, and to guide applicator insertion to the correct position. Each of these modalities has limitations providing all of the physical and geometric information required for the brachytherapy workflow. Therefore, image fusion can be used as a solution in order to take full advantage of the information from each modality in treatment planning, intraoperative navigation, dose delivery, verification and follow-up of interstitial irradiation. Image fusion, understood as the visualization of any morphological volume (i.e. US, CT, MRI) together with an additional second morpholo­gical volume (i.e. CT, MRI) or functional dataset (functional MRI, SPECT, PET), is a well known method for treatment planning, verification and follow-up of interstitial irradiation. The term image fusion is used when multiple patient image datasets are registered and overlaid or merged to provide additional information. Fused images may be created from multiple images from the same imaging modality taken at different moments (multi-temporal approach), or by combining information from multiple modalities. Quality means that the fused images should provide additional information to the brachythe­rapy process (diagnosis and staging, treatment planning, intraoperative imaging, treatment delivery and follow-up) that cannot be obtained in other ways. In this review I will focus on the role of image fusion for permanent seed implantation.