Radiotherapeutic computed tomography with scanned photon beams

Review of image-guided radiation therapy

Image-guided radiation therapy represents a new paradigm in the field of high-precision radiation medicine. A synthesis of recent technological advances in medical imaging and conformal radiation therapy, image-guided radiation therapy represents a further expansion in the recent push for maximizing targeting capabilities with high-intensity radiation dose deposition limited to the true target structures, while minimizing radiation dose deposited in collateral normal tissues. By improving this targeting discrimination, the therapeutic ratio may be enhanced significantly. The principle behind image-guided radiation therapy relies heavily on the acquisition of serial image datasets using a variety of medical imaging platforms, including computed tomography, ultrasound and magnetic resonance imaging. These anatomic and volumetric image datasets are now being augmented through the addition of functional imaging. The current interest in positron-emitted tomography represents a good example of this sort of functional information now being correlated with anatomic localization. As the sophistication of imaging datasets grows, the precise 3D and 4D positions of the target and normal structures become of great relevance, leading to a recent exploration of real- or near-real-time positional replanning of the radiation treatment localization coordinates. This 'adaptive' radiotherapy explicitly recognizes that both tumors and normal tissues change position in time and space during a multiweek course of treatment, and even within a single treatment fraction. As targets and normal tissues change, the attenuation of radiation beams passing through these structures will also change, thus adding an additional level of imprecision in targeting unless these changes are taken into account. All in all, image-guided radiation therapy can be seen as further progress in the development of minimally invasive highly targeted cytotoxic therapies with the goal of substituting remote technologies for direct contact on the part of an operator or surgeon. Although data demonstrating clear-cut superiority of this new high-tech paradigm compared with more conventional radiation treatment approaches are scant, the emergence of preliminary data from several early studies shows that interest in this field is broad based and robust. As outcomes data accumulate, it is very likely that this field will continue to expand greatly. Although at present most of the work is being performed at major academic centers, the enthusiastic adoption of many of the devices and approaches being developed for this field suggest a rapid penetration into the community and the use of the technology by teams of specialists in the fields of radiation medicine, radiation physics and various branches of surgery. A recent survey of practitioners predicted very widespread adoption within the next 10 years.

Anatomical imaging for radiotherapy

The goal of radiation therapy is to achieve maximal therapeutic benefit expressed in terms of a high probability of local control of disease with minimal side effects. Physically this often equates to the delivery of a high dose of radiation to the tumour or target region whilst maintaining an acceptably low dose to other tissues, particularly those adjacent to the target. Techniques such as intensity modulated radiotherapy (IMRT), stereotactic radiosurgery and computer planned brachytherapy provide the means to calculate the radiation dose delivery to achieve the desired dose distribution. Imaging is an essential tool in all state of the art planning and delivery techniques: (i) to enable planning of the desired treatment, (ii) to verify the treatment is delivered as planned and (iii) to follow-up treatment outcome to monitor that the treatment has had the desired effect. Clinical imaging techniques can be loosely classified into anatomic methods which measure the basic physical characteristics of tissue such as their density and biological imaging techniques which measure functional characteristics such as metabolism. In this review we consider anatomical imaging techniques. Biological imaging is considered in another article. Anatomical imaging is generally used for goals (i) and (ii) above. Computed tomography (CT) has been the mainstay of anatomical treatment planning for many years, enabling some delineation of soft tissue as well as radiation attenuation estimation for dose prediction. Magnetic resonance imaging is fast becoming widespread alongside CT, enabling superior soft-tissue visualization. Traditionally scanning for treatment planning has relied on the use of a single snapshot scan. Recent years have seen the development of techniques such as 4D CT and adaptive radiotherapy (ART). In 4D CT raw data are encoded with phase information and reconstructed to yield a set of scans detailing motion through the breathing, or cardiac, cycle. In ART a set of scans is taken on different days. Both allow planning to account for variability intrinsic to the patient. Treatment verification has been carried out using a variety of technologies including: MV portal imaging, kV portal/fluoroscopy, MVCT, conebeam kVCT, ultrasound and optical surface imaging. The various methods have their pros and cons. The four x-ray methods involve an extra radiation dose to normal tissue. The portal methods may not generally be used to visualize soft tissue, consequently they are often used in conjunction with implanted fiducial markers. The two CT-based methods allow measurement of inter-fraction variation only. Ultrasound allows soft-tissue measurement with zero dose but requires skilled interpretation, and there is evidence of systematic differences between ultrasound and other data sources, perhaps due to the effects of the probe pressure. Optical imaging also involves zero dose but requires good correlation between the target and the external measurement and thus is often used in conjunction with an x-ray method. The use of anatomical imaging in radiotherapy allows treatment uncertainties to be determined. These include errors between the mean position at treatment and that at planning (the systematic error) and the day-to-day variation in treatment set-up (the random error). Positional variations may also be categorized in terms of inter- and intra-fraction errors. Various empirical treatment margin formulae and intervention approaches exist to determine the optimum strategies for treatment in the presence of these known errors. Other methods exist to try to minimize error margins drastically including the currently available breath-hold techniques and the tracking methods which are largely in development. This paper will review anatomical imaging techniques in radiotherapy and how they are used to boost the therapeutic benefit of the treatment.

Can megavoltage computed tomography reduce proton range uncertainties in treatment plans for patients with large metal implants?

Treatment planning calculations for proton therapy require an accurate knowledge of radiological path length, or range, to the distal edge of the target volume. In most cases, the range may be calculated with sufficient accuracy using kilovoltage (kV) computed tomography (CT) images. However, metal implants such as hip prostheses can cause severe streak artifacts that lead to large uncertainties in proton range. The purposes of this study were to quantify streak-related range errors and to determine if they could be avoided by using artifact-free megavoltage (MV) CT images in treatment planning. Proton treatment plans were prepared for a rigid, heterogeneous phantom and for a prostate cancer patient with a metal hip prosthesis using corrected and uncorrected kVCT images alone, uncorrected MVCT images and a combination of registered MVCT and kVCT images (the hybrid approach). Streak-induced range errors of 5-12 mm were present in the uncorrected kVCT-based patient plan. Correcting the streaks by manually assigning estimated true Hounsfield units improved the range accuracy. In a rigid heterogeneous phantom, the implant-related range uncertainty was estimated at <3 mm for both the corrected kVCT-based plan and the uncorrected MVCT-based plan. The hybrid planning approach yielded the best overall result. In this approach, the kVCT images provided good delineation of soft tissues due to high-contrast resolution, and the streak-free MVCT images provided smaller range uncertainties because they did not require artifact correction.

The management of imaging dose during image-guided radiotherapy: report of the AAPM Task Group 75

Radiographic image guidance has emerged as the new paradigm for patient positioning, target localization, and external beam alignment in radiotherapy. Although widely varied in modality and method, all radiographic guidance techniques have one thing in common--they can give a significant radiation dose to the patient. As with all medical uses of ionizing radiation, the general view is that this exposure should be carefully managed. The philosophy for dose management adopted by the diagnostic imaging community is summarized by the acronym ALARA, i.e., as low as reasonably achievable. But unlike the general situation with diagnostic imaging and image-guided surgery, image-guided radiotherapy (IGRT) adds the imaging dose to an already high level of therapeutic radiation. There is furthermore an interplay between increased imaging and improved therapeutic dose conformity that suggests the possibility of optimizing rather than simply minimizing the imaging dose. For this reason, the management of imaging dose during radiotherapy is a different problem than its management during routine diagnostic or image-guided surgical procedures. The imaging dose received as part of a radiotherapy treatment has long been regarded as negligible and thus has been quantified in a fairly loose manner. On the other hand, radiation oncologists examine the therapy dose distribution in minute detail. The introduction of more intensive imaging procedures for IGRT now obligates the clinician to evaluate therapeutic and imaging doses in a more balanced manner. This task group is charged with addressing the issue of radiation dose delivered via image guidance techniques during radiotherapy. The group has developed this charge into three objectives: (1) Compile an overview of image-guidance techniques and their associated radiation dose levels, to provide the clinician using a particular set of image guidance techniques with enough data to estimate the total diagnostic dose for a specific treatment scenario, (2) identify ways to reduce the total imaging dose without sacrificing essential imaging information, and (3) recommend optimization strategies to trade off imaging dose with improvements in therapeutic dose delivery. The end goal is to enable the design of image guidance regimens that are as effective and efficient as possible.

Dynamic targeting image-guided radiotherapy

Volumetric imaging and planning for 3-dimensional (3D) conformal radiotherapy and intensity-modulated radiotherapy (IMRT) have highlighted the need to the oncology community to better understand the geometric uncertainties inherent in the radiotherapy delivery process, including setup error (interfraction) as well as organ motion during treatment (intrafraction). This has ushered in the development of emerging technologies and clinical processes, collectively referred to as image-guided radiotherapy (IGRT). The goal of IGRT is to provide the tools needed to manage both inter- and intrafraction motion to improve the accuracy of treatment delivery. Like IMRT, IGRT is a process involving all steps in the radiotherapy treatment process, including patient immobilization, computed tomography (CT) simulation, treatment planning, plan verification, patient setup verification and correction, delivery, and quality assurance. The technology and capability of the Dynamic Targeting IGRT system developed by Varian Medical Systems is presented. The core of this system is a Clinac or Trilogy accelerator equipped with a gantry-mounted imaging system known as the On-Board Imager (OBI). This includes a kilovoltage (kV) x-ray source, an amorphous silicon kV digital image detector, and 2 robotic arms that independently position the kV source and imager orthogonal to the treatment beam. A similar robotic arm positions the PortalVision megavoltage (MV) portal digital image detector, allowing both to be used in concert. The system is designed to support a variety of imaging modalities. The following applications and how they fit in the overall clinical process are described: kV and MV planar radiographic imaging for patient repositioning, kV volumetric cone beam CT imaging for patient repositioning, and kV planar fluoroscopic imaging for gating verification. Achieving image-guided motion management throughout the radiation oncology process requires not just a single product, but a suite of integrated products to manipulate all patient data, including images, efficiently and effectively.

Clinical application of image-guided radiotherapy, IGRT (on the Varian OBI platform)

Image-guided radiation therapy (IGRT) can be used to measure and correct positional errors for target and critical structures immediately prior to or during treatment delivery. Some of the most recent available methods applied for target localization are: transabdominal ultrasound, implanted markers with in room MV or kV X-rays, optical surface tracking systems, implantable electromagnetic markers, in room CT such as kVCT on rail, kilovoltage or megavoltage cone-beam CT (CBCT) and helical megavoltage CT. The verification of the accurate treatment position in conjunction with detailed anatomical information before every fraction can be essential for the outcome of the treatment. In this paper we present the on-board imager (OBI, Varian Medical Systems, Palo Alto, CA) that has been in routine clinical use at the Karolinska University Hospital since June 2004. The OBI has been used for on-line set-up correction of prostate patients using internal gold markers. Displacements of these markers can be monitored radiographically during the treatment course and the registered marker shifts act as a surrogate for prostate motion. For this purpose, on-board kV-kV seems to be an ideal system in terms of image quality. The CBCT function of OBI was installed in March 2005 at our department. It focuses on localizing tumors based on internal anatomy, not just on the conventional external marks or tattoos. The CBCT system provides the capacity for soft tissue imaging in the treatment position and real-time radiographic monitoring during treatment delivery.

Deformable registration of the planning image (kVCT) and the daily images (MVCT) for adaptive radiation therapy

The incorporation of daily images into the radiotherapy process leads to adaptive radiation therapy (ART), in which the treatment is evaluated periodically and the plan is adaptively modified for the remaining course of radiotherapy. Deformable registration between the planning image and the daily images is a key component of ART. In this paper, we report our researches on deformable registration between the planning kVCT and the daily MVCT image sets. The method is based on a fast intensity-based free-form deformable registration technique. Considering the noise and contrast resolution differences between the kVCT and the MVCT, an 'edge-preserving smoothing' is applied to the MVCT image prior to the deformable registration process. We retrospectively studied daily MVCT images from commercial TomoTherapy machines from different clinical centers. The data set includes five head-neck cases, one pelvis case, two lung cases and one prostate case. Each case has one kVCT image and 20-40 MVCT images. We registered the MVCT images with their corresponding kVCT image. The similarity measures and visual inspections of contour matches by physicians validated this technique. The applications of deformable registration in ART, including 'deformable dose accumulation', 'automatic re-contouring' and 'tumour growth/regression evaluation' throughout the course of radiotherapy are also studied.

Monte Carlo and Lambertian light guide models of the light output from scintillation crystals at megavoltage energies

A new model of the light output from single-crystal scintillators in megavoltage energy x-ray beams has been developed, based on the concept of a Lambertian light guide model (LLG). This was evaluated in comparison with a Monte Carlo (MC) model of optical photon transport, previously developed and reported in the literature, which was used as a gold standard. The LLG model was developed to enable optimization of scintillator detector design. In both models the dose deposition and light propagation were decoupled, the scintillators were cuboids, split into a series of cells as a function of depth, with Lambertian side and entrance faces, and a specular exit face. The signal in a sensor placed 1 and 1000 mm beyond the exit face was calculated. Cesium iodide (CSI) crystals of 1.5 and 3 mm square cross section and 1, 5, and 10 mm depth were modeled. Both models were also used to determine detector signal and optical gain factor as a function of CsI scintillator thickness, from 2 to 10 mm. Results showed a variation in light output with position of dose deposition of a factor of up to approximately 5, for long, thin scintillators (such as 10 X 1.5 x 1.5 mm3). For short, fat scintillators (such as 1 X 3 X 3 mm3) the light output was more uniform with depth. MC and LLG generally agreed to within 5%. Results for a sensor distance of 1 mm showed an increase in light output the closer the light originates to the exit face, while a distance of 1000 mm showed a decrease in light output the closer the light originates to the exit face. For a sensor distance of 1 mm, the ratio of signal for a 10 mm scintillator to that for a 2 mm scintillator was 1.98, whereas for the 1000 mm distance the ratio was 3.00. The ratio of quantum efficiency (QE) between 10 and 2 mm thicknesses was 4.62. We conclude that these models may be used for detector optimization, with the light guide model suitable for parametric study.

A technique for on-board CT reconstruction using both kilovoltage and megavoltage beam projections for 3D treatment verification

The technologies with kilovoltage (kV) and megavoltage (MV) imaging in the treatment room are now available for image-guided radiation therapy to improve patient setup and target localization accuracy. However, development of strategies to efficiently and effectively implement these technologies for patient treatment remains challenging. This study proposed an aggregated technique for on-board CT reconstruction using combination of kV and MV beam projections to improve the data acquisition efficiency and image quality. These projections were acquired in the treatment room at the patient treatment position with a new kV imaging device installed on the accelerator gantry, orthogonal to the existing MV portal imaging device. The projection images for a head phantom and a contrast phantom were acquired using both the On-Board Imager kV imaging device and the MV portal imager mounted orthogonally on the gantry of a Varian Clinac 21EX linear accelerator. MV projections were converted into kV information prior to the aggregated CT reconstruction. The multilevel scheme algebraic-reconstruction technique was used to reconstruct CT images involving either full, truncated, or a combination of both full and truncated projections. An adaptive reconstruction method was also applied, based on the limited numbers of kV projections and truncated MV projections, to enhance the anatomical information around the treatment volume and to minimize the radiation dose. The effects of the total number of projections, the combination of kV and MV projections, and the beam truncation of MV projections on the details of reconstructed kV/MV CT images were also investigated.

Initial experience with megavoltage (MV) CT guidance for daily prostate alignments

PURPOSE

The on-board megavoltage (MV) computed tomography (CT) capabilities of a TomoTherapy Hi*ART unit were used to obtain daily MVCT images of prostate cancer patients. For patient alignment the daily MVCT image needs to be registered with the planning CT image to calculate couch shifts. Three manual techniques of registering the MVCT images with the planning kilovoltage (kV) CT images were evaluated. The techniques are based on visual alignment of (1) fiducial prostate markers, (2) CT anatomy, and (3) kVCT contours.

METHODS AND MATERIALS

One hundred and twelve alignments from 3 patients were available for analysis. The radiation therapists visually registered the MVCT images with the planning kVCT images based on fiducial markers for actual patient alignment. Retrospectively, the therapists registered each image set using anatomy and contour-based techniques. In addition to the therapists, a physician retrospectively registered each image set based on each of the three techniques. For each MVCT to kVCT image pair a reference alignment was computed from the center-of-mass (COM) of the three fiducial markers. All registration results were compared with these reference alignments. The physician's image registrations were compared with the radiation therapists' registrations to assess the user variability of the different techniques.

RESULTS

The marker-based registration results agree best with the reference alignments, while the contour-based registrations show the least degree of agreement. Using anatomy and contour-based registrations, the radiation therapist's alignments differed by > or = 3 mm from the reference alignments in 24%, 33%, and 3% and 55%, 48%, and 21% of all registrations in the anterior-posterior, superior-inferior, and lateral directions, respectively. The respective values for the marker-based alignments were 3%, 6%, and 3%. The physician's registrations showed the same general trend. The marker-based registrations showed the least amount of inter-user variability while the contour-based ones showed the most.

CONCLUSION

The use of fiducial markers for MVCT image guidance is advantageous to reduce the inter-user variability of the image registration. If fiducial markers are not used, anatomy-based registrations outperform contour-based registrations in terms of (1) agreement with a reference alignment and (2) inter-user variability.

Emergent Technologies for 3-Dimensional Image-Guided Radiation Delivery

Radiation therapy targeting is being refined to formally accommodate location of gross disease, microscopic extension, and geometric uncertainties in the delivery process. This formalization allows the disciplines in radiation oncology practice to work collaboratively to assure target coverage while attempting to minimize toxicity in adjacent normal structures. There is a growing expectation that the precise and accurate placement of radiation dose is well in hand. The development of volumetric imaging systems integrated with the medical linear accelerator for the specific purpose of guiding therapy will permit localization and targeting of soft-tissue structures at the time of treatment. In this review, the context for development of image-guided radiation therapy is discussed, and the growing expectation of volumetric guidance is portrayed through the various technologies currently being explored in the radiation therapy community.

Developments in megavoltage cone beam CT with an amorphous silicon EPID: Reduction of exposure and synchronization with respiratory gating

We have studied the feasibility of a low-dose megavoltage cone beam computed tomography (MV CBCT) system for visualizing the gross tumor volume in respiratory gated radiation treatments of nonsmall-cell lung cancer. The system consists of a commercially available linear accelerator (LINAC), an amorphous silicon electronic portal imaging device, and a respiratory gating system. The gantry movement and beam delivery are controlled using dynamic beam delivery toolbox, a commercial software package for executing scripts to control the LINAC. A specially designed interface box synchronizes the LINAC, image acquisition electronics, and the respiratory gating system. Images are preprocessed to remove artifacts due to detector sag and LINAC output fluctuations. We report on the output, flatness, and symmetry of the images acquired using different imaging parameters. We also examine the quality of three-dimensional (3D) tomographic reconstruction with projection images of anthropomorphic thorax, contrast detail, and motion phantoms. The results show that, with the proper choice of imaging parameters, the flatness and symmetry are reasonably good with as low as three beam pulses per projection image. Resolution of 5% electron density differences is possible in a contrast detail phantom using 100 projections and 30 MU. Synchronization of image acquisition with simulated respiration also eliminated motion artifacts in a moving phantom, demonstrating the system's capability for imaging patients undergoing gated radiation therapy. The acquisition time is limited by the patient's respiration (only one image per breathing cycle) and is under 10 min for a scan of 100 projections. In conclusion, we have developed a MV CBCT system using commercially available components to produce 3D reconstructions, with sufficient contrast resolution for localizing a simulated lung tumor, using a dose comparable to portal imaging.

Image guidance for precise conformal radiotherapy

PURPOSE

To review the state of the art in image-guided precision conformal radiotherapy and to describe how helical tomotherapy compares with the image-guided practices being developed for conventional radiotherapy.

MATERIALS AND METHODS

Image guidance is beginning to be the fundamental basis for radiotherapy planning, delivery, and verification. Radiotherapy planning requires more precision in the extension and localization of disease. When greater precision is not possible, conformal avoidance methodology may be indicated whereby the margin of disease extension is generous, except where sensitive normal tissues exist. Radiotherapy delivery requires better precision in the definition of treatment volume, on a daily basis if necessary. Helical tomotherapy has been designed to use CT imaging technology to plan, deliver, and verify that the delivery has been carried out as planned. The image-guided processes of helical tomotherapy that enable this goal are described.

RESULTS

Examples of the results of helical tomotherapy processes for image-guided intensity-modulated radiotherapy are presented. These processes include megavoltage CT acquisition, automated segmentation of CT images, dose reconstruction using the CT image set, deformable registration of CT images, and reoptimization.

CONCLUSIONS

Image-guided precision conformal radiotherapy can be used as a tool to treat the tumor yet spare critical structures. Helical tomotherapy has been designed from the ground up as an integrated image-guided intensity-modulated radiotherapy system and allows new verification processes based on megavoltage CT images to be implemented.

Optimization of conformal thoracic radiotherapy using cone-beam CT imaging for treatment verification

PURPOSE

Megavoltage cone-beam computed tomography (MVCBCT) has been proposed for treatment verification in conformal radiotherapy. However, the doses required for such imaging may compromise the quality of the delivered dose distribution. The present paper explores the effect of cone-beam imaging on dose homogeneity and critical organ dose and the use of our new tool, adapted intensity-modulated radiation therapy (AIMRT).

METHODS AND MATERIALS

Three types of treatment plans were devised (3D-CRT [three-dimensional conformal radiotherapy], IMRT [intensity-modulated radiotherapy], and AIMRT) based on 4 patients with thoracic malignancies. MVCBCT fields were then integrated into the plans. The MVCBCT technique used 21 imaging portals at 10 degrees intervals. The MVCBCT apertures were shaped to conform to the planning target volume with a 6-mm margin. In a second set of plans, the field size was expanded by a further 2 cm. The unoptimized MVCBCT dose distribution was incorporated into the IMRT plan using AIMRT.

RESULTS

Normal-tissue complication probability with MVCBCT is acceptable for all plans at the 66.6 Gy level, but exceeds tolerance for both 3D-CRT alone and 3D-CRT with MVCBCT at higher doses. In contrast, the use of AIMRT planning with MVCBCT allowed safe dose escalation to 85 Gy. Expanding the MVCBCT aperture provided better anatomic visibility with an acceptable lung dose. The results using IMRT with MVCBCT fell between the values measured for 3D-CRT and AIMRT with MVCBCT.

CONCLUSION

The present study is the first to demonstrate that MVCBCT can be incorporated into 3D-CRT and IMRT planning with minimal effect on planning target volume homogeneity and dose to critical structures. This paves the way for highly conformal radiotherapy at greater doses delivered with increased confidence and safety.

Megavoltage cone-beam computed tomography using a high-efficiency image receptor

PURPOSE

To develop an image receptor capable of forming high-quality megavoltage CT images using modest radiation doses.

METHODS AND MATERIALS

A flat-panel imaging system consisting of a conventional flat-panel sensor attached to a thick CsI scintillator has been fabricated. The scintillator consists of individual CsI crystals 8 mm thick by 0.38 mm x 0.38-mm pitch. Five sides of each crystal are coated with a reflecting powder/epoxy mixture, and the sixth side is in contact with the flat-panel sensor. A timing interface coordinates acquisition by the imaging system and pulsing of the linear accelerator. With this interface, as little as one accelerator pulse (0.023 cGy at the isocenter) can be used to form projection images. Different CT phantoms irradiated by a 6-MV X-ray beam have been imaged to evaluate the performance of the imaging system. The phantoms have been mounted on a rotating stage and rotated while 360 projection images are acquired in 48 s. These projections have been reconstructed using the Feldkamp cone-beam CT reconstruction algorithm.

RESULTS AND DISCUSSION

Using an irradiation of 16 cGy (360 projections x 0.046 cGy/projection), the contrast resolution is approximately 1% for large objects. High-contrast structures as small as 1.2 mm are clearly visible. The reconstructed CT values are linear (R(2) = 0.98) for electron densities between 0.001 and 2.16 g/cm(3), and the reconstruction time for a 512 x 512 x 512 data set is 6 min. Images of an anthropomorphic phantom show that soft-tissue structures such as the heart, lung, kidneys, and liver are visible in the reconstructed images (16 cGy, 5-mm-thick slices).

CONCLUSIONS

The acquisition of megavoltage CT images with soft-tissue contrast is possible with irradiations as small as 16 cGy.

Cone-beam CT with megavoltage beams and an amorphous silicon electronic portal imaging device: potential for verification of radiotherapy of lung cancer

We investigate the potential of megavoltage (MV) cone-beam CT with an amorphous silicon electronic portal imaging device (EPID) as a tool for patient position verification and tumor/organ motion studies in radiation treatment of lung tumors. We acquire 25 to 200 projection images using a 22 x 29 cm EPID. The acquisition is automatic and requires 7 minutes for 100 projections; it can be synchronized with respiratory gating. From these images, volumetric reconstruction is accomplished with a filtered backprojection in the cone-beam geometry. Several important prereconstruction image corrections, such as detector sag, must be applied. Tests with a contrast phantom indicate that differences in electron density of 2% can be detected with 100 projections, 200 cGy total dose. The contrast-to-noise ratio improves as the number of projections is increased. With 50 projections (100 cGy), high contrast objects are visible, and as few as 25 projections yield images with discernible features. We identify a technique of acquiring projection images with conformal beam apertures, shaped by a multileaf collimator, to reduce the dose to surrounding normal tissue. Tests of this technique on an anthropomorphic phantom demonstrate that a gross tumor volume in the lung can be accurately localized in three dimensions with scans using 88 monitor units. As such, conformal megavoltage cone-beam CT can provide three-dimensional imaging of lung tumors and may be used, for example, in verifying respiratory gated treatments.

Flat-panel cone-beam computed tomography for image-guided radiation therapy

PURPOSE

Geometric uncertainties in the process of radiation planning and delivery constrain dose escalation and induce normal tissue complications. An imaging system has been developed to generate high-resolution, soft-tissue images of the patient at the time of treatment for the purpose of guiding therapy and reducing such uncertainties. The performance of the imaging system is evaluated and the application to image-guided radiation therapy is discussed.

METHODS AND MATERIALS

A kilovoltage imaging system capable of radiography, fluoroscopy, and cone-beam computed tomography (CT) has been integrated with a medical linear accelerator. Kilovoltage X-rays are generated by a conventional X-ray tube mounted on a retractable arm at 90 degrees to the treatment source. A 41 x 41 cm(2) flat-panel X-ray detector is mounted opposite the kV tube. The entire imaging system operates under computer control, with a single application providing calibration, image acquisition, processing, and cone-beam CT reconstruction. Cone-beam CT imaging involves acquiring multiple kV radiographs as the gantry rotates through 360 degrees of rotation. A filtered back-projection algorithm is employed to reconstruct the volumetric images. Geometric nonidealities in the rotation of the gantry system are measured and corrected during reconstruction. Qualitative evaluation of imaging performance is performed using an anthropomorphic head phantom and a coronal contrast phantom. The influence of geometric nonidealities is examined.

RESULTS

Images of the head phantom were acquired and illustrate the submillimeter spatial resolution that is achieved with the cone-beam approach. High-resolution sagittal and coronal views demonstrate nearly isotropic spatial resolution. Flex corrections on the order of 0.2 cm were required to compensate gravity-induced flex in the support arms of the source and detector, as well as slight axial movements of the entire gantry structure. Images reconstructed without flex correction suffered from loss of detail, misregistration, and streak artifacts. Reconstructions of the contrast phantom demonstrate the soft-tissue imaging capability of the system. A contrast of 47 Hounsfield units was easily detected in a 0.1-cm-thick reconstruction for an imaging exposure of 1.2 R (in-air, in absence of phantom). The comparison with a conventional CT scan of the phantom further demonstrates the spatial resolution advantages of the cone-beam CT approach.

CONCLUSIONS

A kV cone-beam CT imaging system based on a large-area, flat-panel detector has been successfully adapted to a medical linear accelerator. The system is capable of producing images of soft tissue with excellent spatial resolution at acceptable imaging doses. Integration of this technology with the medical accelerator will result in an ideal platform for high-precision, image-guided radiation therapy.

A performance comparison of flat-panel imager-based MV and kV cone-beam CT

The use of cone-beam computed tomography (CBCT) has been proposed for guiding the delivery of radiation therapy, and investigators have examined the use of both kilovoltage (kV) and megavoltage (MV) x-ray beams in the development of such CBCT systems. In this paper, the inherent contrast and signal-to-noise ratio (SNR) performance for a variety of existing and hypothetical detectors for CBCT are investigated analytically as a function of imaging dose and object size. Theoretical predictions are compared to the results of experimental investigations employing largearea flat-panel imagers (FPIs) at kV and MV energies. Measurements were performed on two different FPI-based CBCT systems: a bench-top prototype incorporating an FPI and kV x-ray source (100 kVp x rays), and a system incorporating an FPI mounted on the gantry of a medical linear accelerator (6 MV x rays). The SNR in volume reconstructions was measured as a function of dose and found to agree reasonably with theoretical predictions. These results confirm the theoretically predicted advantages of employing kV energy x rays in imaging soft-tissue structures found in the human body. While MV CBCT may provide a valuable means of correcting 3D setup errors and may offer an advantage in terms of simplicity of mechanical integration with a linear accelerator (e.g., implementation in place of a portal imager), kV CBCT offers significant performance advantages in terms of image contrast and SNR per unit dose for visualization of soft-tissue structures. The relatively poor SNR performance at MV energies is primarily a result of the low x-ray quantum efficiencies (approximately a few percent or less) that are currently achieved with FPIs at high energies. Furthermore, kV CBCT with an FPI offers the potential of combined volumetric and radiographic/fluoroscopic imaging using the same device.

On few-view tomographic reconstruction with megavoltage photon beams

Currently portal imaging devices are used to obtain information on patient localization during radiation therapy treatments. Such obtained information is two dimensional in nature, limited to the plane of the captured image. It has been proposed that megavoltage computed tomography images be reconstructed to overcome this limitation. This study explores the feasibility of reconstructing tomographic images from fan-beam projection data acquired with a commercial portal imaging device on a standard radiotherapy linear accelerator. Several CT reconstruction algorithms are examined as to their performance and suitability for applications in radiation therapy verification. The results show that it is possible, using some of the iterative reconstruction techniques, to obtain an image useful for patient localization from only several (< or =10) projection views.

Correction of scatter in megavoltage cone-beam CT

The role of scatter in a cone-beam computed tomography system using the therapeutic beam of a medical linear accelerator and a commercial electronic portal imaging device (EPID) is investigated. A scatter correction method is presented which is based on a superposition of Monte Carlo generated scatter kernels. The kernels are adapted to both the spectral response of the EPID and the dimensions of the phantom being scanned. The method is part of a calibration procedure which converts the measured transmission data acquired for each projection angle into water-equivalent thicknesses. Tomographic reconstruction of the projections then yields an estimate of the electron density distribution of the phantom. It is found that scatter produces cupping artefacts in the reconstructed tomograms. Furthermore, reconstructed electron densities deviate greatly (by about 30%) from their expected values. The scatter correction method removes the cupping artefacts and decreases the deviations from 30% down to about 8%.

Megavoltage CT image reconstruction during tomotherapy treatments

An integrated tomotherapy system allows for improved radiotherapy verification by enabling the collection of megavoltage computed tomography (MVCT) images before or after treatment delivery. In this investigation, the possibility of collecting MV tomographic data and reconstructing images during a tomotherapy treatment is examined. By overcoming difficulties with the normalization of modulated treatment data and with the incompleteness of treatment data, it is possible to use data collected during tomotherapeutic treatments for MVCT reconstruction. The benefits of these techniques include potential increases in patient throughput, reductions in imaging dose, visualization of the patient in the treatment position and improvements in image contrast.

Adaptive portal CT reconstruction: a simulation study

In radiotherapy, radiation treatment beams contain valuable information for patient setup verification. These beams may be used for portal CT reconstruction. However, direct use of the beam data for reconstruction may yield inadequate CT images simply because these beams cover only a part of the patient body. In this study, we use the treatment beams in addition to a set of regular CT projection beams to reconstruct a locally enhanced portal CT image. This approach is called adaptive portal CT reconstruction. A computer simulation demonstrated the advantages of the approach. The image reconstruction was carried out by the multilevel scheme algebraic reconstruction technique. Results indicated that the image quality of adaptive portal CT reconstruction is equivalent to that obtained from a full set of projections. This proposed technique should be not only valuable for three-dimensional radiotherapy verification, but also applicable to diagnostic CT imaging.

Megavoltage CT imaging as a by-product of multileaf collimator leakage

In addition to their potential for the delivery of highly conformal radiation therapy treatments, tomotherapeutic treatments also feature increased potential for verification. For example, megavoltage CT allows one to use the megavoltage linac to generate tomographic images of the patient in the treatment position. This is typically done before or after radiation therapy treatments. However, it is also possible to collect MVCT images entirely during the treatment itself. This process utilizes the leakage radiation through the closed leaves of the Nomos MIMiC MLC, along with slight inefficiencies in treatment delivery, to generate MVCT images during treatment that require neither additional time nor dose. The image quality is limited, yet sufficient to see a patient's external boundary, density differences over 8% for 25.0 mm objects and resolutions of 3.0 mm for high-contrast objects. Such images can potentially be viewed during treatment, used to flag additional CT immediately after the treatment and provide a representation of the patient's exact position during treatment for use with dose reconstruction.

Calibration of a tomotherapeutic MVCT system

Megavoltage CT provides the ability to image the patient before, during or after a radiotherapy treatment. This allows one to verify not only the placement of a patient's external boundary, but also the locations of internal anatomy. In addition, the reconstructed MVCT values are potentially useful for treatment planning inhomogeneity corrections and dose reconstruction. To this end, dosimetric calibration of the University of Wisconsin Tomotherapy Benchtop MVCT system was investigated. It was found that MVCT values correlate extremely well with electron density and that unlike kilovoltage CT, this correlation is well maintained for higher atomic number materials. Improvements of the order of 1% in the dosimetric calculations of high atomic number materials should be possible by deriving input images from MVCT as opposed to kVCT, and calibrating in terms of electron density, as opposed to physical density.

Dose calculations for external photon beams in radiotherapy

Dose calculation methods for photon beams are reviewed in the context of radiation therapy treatment planning. Following introductory summaries on photon beam characteristics and clinical requirements on dose calculations, calculation methods are described in order of increasing explicitness of particle transport. The simplest are dose ratio factorizations limited to point dose estimates useful for checking other more general, but also more complex, approaches. Some methods incorporate detailed modelling of scatter dose through differentiation of measured data combined with various integration techniques. State-of-the-art methods based on point or pencil kernels, which are derived through Monte Carlo simulations, to characterize secondary particle transport are presented in some detail. Explicit particle transport methods, such as Monte Carlo, are briefly summarized. The extensive literature on beam characterization and handling of treatment head scatter is reviewed in the context of providing phase space data for kernel based and/or direct Monte Carlo dose calculations. Finally, a brief overview of inverse methods for optimization and dose reconstruction is provided.

Megavoltage CT on a tomotherapy system

A megavoltage computed tomography (MVCT) system was developed on the University of Wisconsin tomotherapy benchtop. This system can operate either axially or helically, and collect transmission data without any bounds on delivered dose. Scan times as low as 12 s per slice are possible, and scans were run with linac output rates of 100 MU min(-1), although the system can be tuned to deliver arbitrarily low dose rates. Images were reconstructed with clinically reasonable doses ranging from 8 to 12 cGy. These images delineate contrasts below 2% and resolutions of 3.0 mm. Thus, the MVCT image quality of this system should be sufficient for verifying the patient's position and anatomy prior to radiotherapy. Additionally, synthetic data were used to test the potential for improved MVCT contrast using maximum-likelihood (ML) reconstruction. Specifically, the maximum-likelihood expectation-maximization (ML-EM) algorithm and a transmission ML algorithm were compared with filtered backprojection (FBP). It was found that for expected clinical MVCT doses enough imaging photons are used such that little benefit is conferred by the improved noise model of ML algorithms. For significantly lower doses, some quantitative improvement is achieved through ML reconstruction. Nonetheless, the image quality at those lower doses is not satisfactory for radiotherapy verification.

Imaging modalities in x-ray computerized tomography and in selected volume tomography

This review of different principles used in x-ray computerized tomography (CT) starts with attenuation (transmission) CT. The pros and cons of different geometrical solutions, single-ray, fan-beam and cone-beam, are discussed. Attenuation CT measures the spatial distribution of the linear attenuation coefficient, mu. The contributions of different interaction processes to mu have also been used for CT. Fluorescence CT is based on measurements of the contribution, cZtauZ/rho, from an element Z with concentration cZ, to the linear attenuation coefficient. Diffraction CT measures the differential coherent cross section d sigma (theta)(coh)/d omega, Compton CT the incoherent scatter cross section sigma. The usefulness of these modalities is illustrated. CT methods based on secondary photons have a competitor in selected volume tomography. These two tomography methods are compared. A proposal to perform Compton profile tomography is also discussed, as is the promising method of phase-contrast x-ray CT.

Tomotherapeutic portal imaging for radiation treatment verification

In their tomotherapy concept Mackie and co-workers proposed not only a new technique for IMRT but also an appropriate and satisfactory method of treatment verification. This method allows both monitoring of the portal dose distribution and imaging of the patient anatomy during treatment by means of online CT. This would enable the detection of inaccuracies in dose delivery and patient set-up errors. In this paper results are presented showing that a single electronic portal imaging device (EPID) could deliver all data necessary to establish such a complete verification system for tomotherapy and even other IMRT techniques. Consequently it has to be shown that it is able to record both the low-intensity photon fluences encountered in tomographic imaging and the intense photon transmission of each treatment field. The detector under investigation is a video-based EPID, the BIS 710 (manufactured by Wellhöfer Dosimetrie, Schwarzenbruck, Germany). To examine the suitability of the BIS for CT at 6 MV beam quality, different phantoms were scanned and reconstructed. The agreement between a diamond detector and BIS responses is quantitative. Tomographic reconstruction of a complete set of these transmission profiles resulted in images which resolve 3 cm large objects having a (theoretical) contrast to water of less than 9%. Three millimetre objects with a 100% contrast are clearly visible. The BIS signal was shown to measure photon fluence distributions. The reconstructed images possess a spatial and contrast resolution sufficient for accurate imaging of the patient anatomy, needed for treatment verification in many clinical cases.

Feasibility of megavoltage portal CT using an electronic portal imaging device (EPID) and a multi-level scheme algebraic reconstruction technique (MLS-ART)

Although electronic portal imaging devices (EPIDs) are efficient tools for radiation therapy verification, they only provide images of overlapped anatomic structures. We investigated using a fluorescent screen/CCD-based EPID, coupled with a novel multi-level scheme algebraic reconstruction technique (MLS-ART), for a feasibility study of portal computed tomography (CT) reconstructions. The CT images might be useful for radiation treatment planning and verification. We used an EPID, set it to work at the linear dynamic range and collimated 6 MV photons from a linear accelerator to a slit beam of 1 cm wide and 25 cm long. We performed scans under a total of approximately 200 monitor units (MUs) for several phantoms in which we varied the number of projections and MUs per projection. The reconstructed images demonstrated that using the new MLS-ART technique megavoltage portal CT with a total of 200 MUs can achieve a contrast detectibility of approximately 2.5% (object size 5 mm x 5 mm) and a spatial resolution of 2.5 mm.

A cone-beam megavoltage CT scanner for treatment verification in conformal radiotherapy

PURPOSE

A prototype scanner for large-volume megavoltage computed tomography (MVCT) in a clinical set-up is described. The ultimate aim is to improve treatment accuracy in conformal radiotherapy through patient set-up error reduction and transit dosimetry.

MATERIALS AND METHODS

The scanner consists of a custom-built 2D CsI(Tl) crystal array viewed by a lens and a CCD camera. Image acquisition is synchronized with radiation pulses. The 2D projections resulting from a single continuous 360 degrees gantry rotation are reconstructed using a cone-beam tomography algorithm. Prior to reconstruction, the raw projections are calibrated and corrected for centre of rotation movement and accelerator output fluctuation. The performance of the system has been evaluated by reconstructing projections of open fields, test objects and a humanoid phantom.

RESULTS

Hundreds of 2D projections can be acquired with a clinically-acceptable data collection time (about 2 min) and dose (approximately 40 cGy, with a possible four-fold reduction). A maximum density resolution of about 2% is achieved offering some soft tissue discrimination without using image enhancement tools. A spatial resolution of 2.5 mm is obtained. The reconstructed image intensity is linear with electron density over the range of interest. Coronal or sagittal slices through the 3D reconstruction of the humanoid phantom show a better delineation of structures than the corresponding portal images taken at the same orientation.

CONCLUSIONS

A similar image quality to our current single-slice MVCT scanner is achieved with the advantage of providing tens of tomographic slices for a single gantry rotation. This work demonstrates the feasibility of clinical cone-beam MVCT and indicates how this prototype can be improved.

Linear accelerator output variations and their consequences for megavoltage imaging

An experimental study of radiation output intensity fluctuations of a Philips SL25 linear accelerator is presented. Measurements are obtained using an electronic portal imaging device, and the consequences of the measured fluctuations for various different applications of megavoltage imaging including portal imaging, transit dosimetry and megavoltage computed tomography (MVCT) are discussed with examples. Fluctuations in output of +/- 0.7% (1 SD) are seen on every radiation pulse after photon noise and uncertainties caused by the detection system have been accounted for. Large fluctuations are also seen during the initial beam stabilization period (15%), during normal accelerator operation after the beam has been on for more than 1 min (4.5%) and during are therapy as a repeatable function of gantry angle (9%). Such output intensity fluctuations are shown to produce image artifacts in portal imaging devices with scanned detector readout and can also produce systematic errors in detector calibration that would lead to uncertainty in transit dose calculations. The propagation of these intensity fluctuations through MVCT image reconstruction is shown to produce ring artifacts in the reconstructed image. Sample portal and MVCT images are presented. All observed fluctuations in accelerator output are well within the manufacturer's specifications and do not affect the total dose delivered during normal treatment. Finally, megavoltage imaging is shown to be a powerful tool for accelerator quality assurance and treatment verification.

A feasibility study for megavoltage cone beam CT using a commercial EPID

This study used a standard commercial electronic portal imaging device (EPID) area detector attached to an isocentric linear accelerator and the Feldkamp algorithm to produce cone beam tomographic reconstructions. The EPID has a active area of 32.5 x 32.5 cm2, and can record 12-bit images using two monitor units (MU), with a resolution of 2.1 x 2.0 mm2 FWHM. Since the EPID was not large enough to record the full patient projection at about 1.5 geometric magnification, it was necessary to offset the detector to collect half-cone projections. Corrections are required to convert pixel values into units of exit dose and to realign the projections to overcome the +/- 4 mm support arm sag. With a geometric magnification of 1.5 the sensitive volume is a cylinder of radius 21 cm and length 17 cm. Unfortunately, the patient couch contains metal bed support rails that lie just outside this cylinder, and produce streak artefacts in the reconstruction. Using 90 views the system delivers a central dose of 90 cGy, and has a density resolution of 4%.

Real-time beam monitoring in dynamic conformation therapy

PURPOSE

Although portal imaging is a promising method of verification during static multiport irradiation, it cannot be applied directly to dynamic irradiation such as rotational conformation with multileaf collimator movement. A real-time beam monitoring system based on megavoltage computed tomography scanning has been developed to establish a verification method for the rotational conformation technique.

METHODS AND MATERIALS

Exit beam through the patient is extracted by the same detector unit as used for megavoltage scanning during the actual treatment. Beam edge is defined as the 50% level of the maximum dose of the detector array. Megavoltage computed tomography is done after patient setup and just prior to the actual irradiation. Detected beam pathways are overlaid on this image approximately every 1 s. Therapists can monitor correlation between the target and actual beam pathways on a real-time computer display.

RESULTS

The accuracy of field edge detection has been proven to be less than 2 mm from various measurements. Real-time monitoring is more useful in rotational conformation than in static multiport irradiation due to dynamic movement of the collimator. Field errors were identified in two of 54 sessions using this method.

CONCLUSIONS

Although several limitations remain to be solved, the method presented is a useful tool for treatment verification of high accuracy radiation therapy, particularly rotational conformation irradiation.

A megavoltage CT scanner for radiotherapy verification

We have further developed a system for generating megavoltage CT images immediately prior to the administration of external beam radiotherapy. The detector is based on the scanner of Simpson (Simpson et al 1982)--the major differences being a significant reduction in dose required for image formation, faster image formation and greater convenience of use in the clinical setting. Attention has been paid to the problem of ring artefacts in the images. Specifically, a Fourier-space filter has been applied to the sinogram data. After suitable detector calibration, it has been shown that the device operates close to its theoretical specification of 3 mm spatial resolution and a few percent contrast resolution. Ring artefacts continue to be a major source of image degradation. A number of clinical images have been presented. The next stage of this work is to use the system to make clinical measurements of patient set-up inaccuracies building on our work making such measurements from digital portal images (Evans et al 1992).

Design principles and clinical possibilities with a new generation of radiation therapy equipment. A review

The main steps in the development of isocentric megavoltage external beam radiation therapy machines are briefly reviewed identifying three principal types or generations of equipment to date. The new fourth generation of equipment presented here is characterized by considerably increased flexibility in dose delivery through the use of scanned elementary electron and photon beams of very high quality. Furthermore the wide energy range and the possibility of using high resolution multileaf collimation with all beam modalities makes it possible to simplify irradiation techniques and increase the accuracy in dose delivery. The main design features are described including a dual dipole magnet scanning system, a photon beam purging magnet, a helium atmosphere in the treatment head, a beam's eye view video read-out system of the collimator setting and a radiotherapeutic computed tomography facility. Some of the clinical applications of this new type of radiation therapy machine are finally reviewed, such as the ease of performing beam flattening, beam filtering and compensation, and the simplification of many treatment techniques using the wide spectrum of high quality electron and photon beams. Finally the interesting possibility of doing conformation and more general isocentric treatments with non-uniform beams using the multileaf collimator and the scanning system are demonstrated.