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

A kV-MV approach to CBCT metal artifact reduction using multi-layer MV-CBCT

Objective. To demonstrate that complete cone beam CT (CBCT) scans from both MV-energy and kV-energy LINAC sources can reduce metal artifacts in radiotherapy guidance, while maintaining standard-of-care x-ray doses levels.Approach. MV-CBCT and kV-CBCT scans are acquired at half normal dose. The impact of lowered dose on MV-CBCT data quality is mitigated by the use of a 4-layer MV-imager prototype and reduced LINAC energy settings (2.5 MV) to improve photon capture. Additionally, the MV-CBCT is used to determine the 3D position and pose of metal implants, which in turn is used to guide model-based poly-energetic correction and interleaving of the kV-CBCT and MV-CBCT data. Certain edge-preserving regularization steps incorporated into the model-based correction algorithm further reduce MV data noise.Main results. The method was tested in digital phantoms and a real pelvis phantom with large 2.5″ spherical inserts, emulating hip replacements of different materials. The proposed method demonstrated an appealing compromise between the high contrast of kV-CBCT and low artifact content of MV-CBCT. Contrast-to-noise improved 3-fold compared to MV-CBCT with a clinical 1-layer architecture at matched dose (37 mGy) and edge blur levels. Visual delineation of the bladder and prostate improved noteably over kV- or MV-CBCT alone.Significance. The proposed method demonstrates that a full MV-CBCT scan can be combined with kV-CBCT to reduce metal artifacts without resorting to complicated beam collimation strategies to limit the MV-CBCT dose contribution. Additionally, significant improvements in CNR can be achieved as compared to metal artifact reduction through current clinical MV-CBCT practices.

Abbreviated on-treatment CBCT using roughness penalized mono-energization of kV-MV data and a multi-layer MV imager

Simultaneous acquisition of cone beam CT (CBCT) projections using both the kV and MV imagers of an image guided radiotherapy system reduces set-up scan times-a benefit to lung cancer radiation oncology patients-but increases noise in the 3D reconstruction. In this article, we present a kV-MV scan time reduction technique that uses two noise-reducing measures to achieve superior performance. The first is a high-DQE multi-layer MV imager prototype. The second is a beam hardening correction algorithm which combines poly-energetic modeling with edge-preserving, regularized smoothing of the projections. Performance was tested in real acquisitions of the Catphan 604 and a thorax phantom. Percent noise was quantified from voxel values in a soft tissue volume of interest (VOI) while edge blur was quantified from a VOI straddling a boundary between air and soft material. Comparisons in noise/resolution performance trade-off were made between our proposed approach, a dose-equivalent kV-only scan, and a kV-MV reconstruction technique previously published by Yinet al(2005Med. Phys.329). The proposed technique demonstrated lower noise as a function of spatial resolution than the baseline kV-MV method, notably a 50% noise reduction at typical edge blur levels. Our proposed method also exhibited fainter non-uniformity artifacts and in some cases superior contrast. Overall, we find that the combination of a multi-layer MV imager, acquiring at a LINAC source energy of 2.5 MV, and a denoised beam hardening correction algorithm enables noise, resolution, and dose performance comparable to standard kV-imager only set-up CBCT, but with nearly half the gantry rotation time.

Positioning errors of metal localization devices with motion artifacts on kV and MV cone beam CT

OBJECTIVE

To investigate motion artifacts on kV CBCT and MV CBCT images with metal localization devices for image-guided radiation therapy.

METHODS

The 8 μ pelvis CBCT template for the Siemens Artiste MVision and Pelvis template for the Varian IX on-board Exact Arms kV were used to acquire CBCT images in this study. Images from both CBCT modalities were compared in CNRs, metal landmark absolute positions, and image volume distortion on three different planes of view. The images were taken on a breathing-simulated thoracic phantom in which several typical metal localization devices were implanted, including clips and wires for breast patients, gold seeds for prostate patients, and BBs as skin markers. To magnify the artifacts, a 4 cm diameter metal ball was also implanted into the thoracic phantom to mimic the metal artifacts.

RESULTS

For MV CBCT, the CNR at a 4 sec breathing cycle with 1 cm breathing amplitude was 5.0, 3.4 and 4.6 for clips, gold seeds and BBs, respectively while it was 1.5, 2.0 and 1.6 for the kV CBCT. On the images, the kV CBCT showed symmetric streaking artifacts both in the transverse and longitudinal directions relative to the motion direction. The kV CBCT images predicted 89 % of the expected volume, while the MV CBCT images predicted 95 % of the expected volume. The simulated soft tissue observed in the MVCT could not be detected in the kV CBCT.

CONCLUSION

The MV CBCT images showed better volume prediction, less streaking effects and better CNRs of a moving metal target, i.e. clips, BBs, gold seeds and metal balls than on the kV CBCT images. The MV CBCT was more advantageous compared to the kV CBCT with less motion artifacts for metal localization devices.

ADVANCES IN KNOWLEDGE

This study would benefit clinicians to prescribe MV CBCT as localization modality for radiation treatment with moving target when metal markers are implanted.

Automated ultrafast kilovoltage-megavoltage cone-beam CT for image guided radiotherapy of lung cancer: System description and real-time results

PURPOSE

To establish a fully automated kV-MV CBCT imaging method on a clinical linear accelerator that allows image acquisition of thoracic targets for patient positioning within one breath-hold (∼15s) under realistic clinical conditions.

METHODS AND MATERIALS

Our previously developed FPGA-based hardware unit which allows synchronized kV-MV CBCT projection acquisition is connected to a clinical linear accelerator system via a multi-pin switch; i.e. either kV-MV imaging or conventional clinical mode can be selected. An application program was developed to control the relevant linac parameters automatically and to manage the MV detector readout as well as the gantry angle capture for each MV projection. The kV projections are acquired with the conventional CBCT system. GPU-accelerated filtered backprojection is performed separately for both data sets. After appropriate grayscale normalization both modalities are combined and the final kV-MV volume is re-imported in the CBCT system to enable image matching. To demonstrate adequate geometrical accuracy of the novel imaging system the Penta-Guide phantom QA procedure is performed. Furthermore, a human plastinate and different tumor shapes in a thorax phantom are scanned. Diameters of the known tumor shapes are measured in the kV-MV reconstruction.

RESULTS

An automated kV-MV CBCT workflow was successfully established in a clinical environment. The overall procedure, from starting the data acquisition until the reconstructed volume is available for registration, requires ∼90s including 17s acquisition time for 100° rotation. It is very simple and allows target positioning in the same way as for conventional CBCT. Registration accuracy of the QA phantom is within ±1mm. The average deviation from the known tumor dimensions measured in the thorax phantom was 0.7mm which corresponds to an improvement of 36% compared to our previous kV-MV imaging system.

CONCLUSIONS

Due to automation the kV-MV CBCT workflow is speeded up by a factor of >10 compared to the manual approach. Thus, the system allows a simple, fast and reliable imaging procedure and fulfills all requirements to be successfully introduced into the clinical workflow now, enabling single-breath-hold volume imaging.

[A Proposal for Evaluating the Positional Accuracy of Add-on Six-degrees-of-freedom Radiotherapy Couch in Couch Rotation for Image-guided Radiotherapy]

PURPOSE

In this study, we proposed and evaluated position correction accuracy assessment method with a phantom for IGRT system with add-on six-degrees-of-freedom radiotherapy (6D) couches in couch rotation.

METHODS AND MATERIALS

A phantom was used in a self-build phantom. We were scanned with computed tomography (CT) for radiotherapy planning and planned treatment isocenter to fall in line with CT center by treatment planning system. At first, we examined data of CT slice thickness for digitally reconstructed radiograph of QA phantom. Next, we measured uncertainty for IGRT system. We performed position correction accuracy for IGRT system with QA phantom and digital angle meter.

RESULTS

Detection and correction errors for pitch and roll direction were within 0.3 degree in all verifications.

CONCLUSIONS

We proposed a quality control method for position correction accuracy of 6D couch. The method was able to evaluate the accuracy of detection and correction of 6D couch and revealed the deviation of the origin of the couch rotation.

Phantom-based evaluation of dose exposure of ultrafast combined kV-MV-CBCT towards clinical implementation for IGRT of lung cancer

PURPOSE

Combined ultrafast 90°+90° kV-MV-CBCT within single breath-hold of 15s has high clinical potential for accelerating imaging for lung cancer patients treated with deep inspiration breath-hold (DIBH). For clinical feasibility of kV-MV-CBCT, dose exposure has to be small compared to prescribed dose. In this study, kV-MV dose output is evaluated and compared to clinically-established kV-CBCT.

METHODS

Accurate dose calibration was performed for kV and MV energy; beam quality was determined. For direct comparison of MV and kV dose output, relative biological effectiveness (RBE) was considered. CT dose index (CTDI) was determined and measurements in various representative locations of an inhomogeneous thorax phantom were performed to simulate the patient situation.

RESULTS

A measured dose of 20.5mGE (Gray-equivalent) in the target region was comparable to kV-CBCT (31.2mGy for widely-used, and 9.1mGy for latest available preset), whereas kV-MV spared healthy tissue and reduced dose to 6.6mGE (30%) due to asymmetric dose distribution. The measured weighted CTDI of 12mGE for kV-MV lay in between both clinical presets.

CONCLUSIONS

Dosimetric properties were in agreement with established imaging techniques, whereas exposure to healthy tissue was reduced. By reducing the imaging time to a single breath-hold of 15s, ultrafast combined kV-MV CBCT shortens patient time at the treatment couch and thus improves patient comfort. It is therefore usable for imaging of hypofractionated lung DIBH patients.

Clinical Study of Orthogonal-View Phase-Matched Digital Tomosynthesis for Lung Tumor Localization

Background and Purpose:

Compared to cone-beam computed tomography, digital tomosynthesis imaging has the benefits of shorter scanning time, less imaging dose, and better mechanical clearance for tumor localization in radiation therapy. However, for lung tumors, the localization accuracy of the conventional digital tomosynthesis technique is affected by the lack of depth information and the existence of lung tumor motion. This study investigates the clinical feasibility of using an orthogonal-view phase-matched digital tomosynthesis technique to improve the accuracy of lung tumor localization.

Materials and Methods:

The proposed orthogonal-view phase-matched digital tomosynthesis technique benefits from 2 major features: (1) it acquires orthogonal-view projections to improve the depth information in reconstructed digital tomosynthesis images and (2) it applies respiratory phase-matching to incorporate patient motion information into the synthesized reference digital tomosynthesis sets, which helps to improve the localization accuracy of moving lung tumors. A retrospective study enrolling 14 patients was performed to evaluate the accuracy of the orthogonal-view phase-matched digital tomosynthesis technique. Phantom studies were also performed using an anthropomorphic phantom to investigate the feasibility of using intratreatment aggregated kV and beams’ eye view cine MV projections for orthogonal-view phase-matched digital tomosynthesis imaging. The localization accuracy of the orthogonal-view phase-matched digital tomosynthesis technique was compared to that of the single-view digital tomosynthesis techniques and the digital tomosynthesis techniques without phase-matching.

Results:

The orthogonal-view phase-matched digital tomosynthesis technique outperforms the other digital tomosynthesis techniques in tumor localization accuracy for both the patient study and the phantom study. For the patient study, the orthogonal-view phase-matched digital tomosynthesis technique localizes the tumor to an average (± standard deviation) error of 1.8 (0.7) mm for a 30° total scan angle. For the phantom study using aggregated kV–MV projections, the orthogonal-view phase-matched digital tomosynthesis localizes the tumor to an average error within 1 mm for varying magnitudes of scan angles.

Conclusion:

The pilot clinical study shows that the orthogonal-view phase-matched digital tomosynthesis technique enables fast and accurate localization of moving lung tumors.

Reducing scan angle using adaptive prior knowledge for a limited-angle intrafraction verification (LIVE) system for conformal arc radiotherapy

The purpose of this study is to develop an adaptive prior knowledge guided image estimation technique to reduce the scan angle needed in the limited-angle intrafraction verification (LIVE) system for 4D-CBCT reconstruction. The LIVE system has been previously developed to reconstruct 4D volumetric images on-the-fly during arc treatment for intrafraction target verification and dose calculation. In this study, we developed an adaptive constrained free-form deformation reconstruction technique in LIVE to further reduce the scanning angle needed to reconstruct the 4D-CBCT images for faster intrafraction verification. This technique uses free form deformation with energy minimization to deform prior images to estimate 4D-CBCT based on kV-MV projections acquired in extremely limited angle (orthogonal 3°) during the treatment. Note that the prior images are adaptively updated using the latest CBCT images reconstructed by LIVE during treatment to utilize the continuity of the respiratory motion. The 4D digital extended-cardiac-torso (XCAT) phantom and a CIRS 008A dynamic thoracic phantom were used to evaluate the effectiveness of this technique. The reconstruction accuracy of the technique was evaluated by calculating both the center-of-mass-shift (COMS) and 3D volume-percentage-difference (VPD) of the tumor in reconstructed images and the true on-board images. The performance of the technique was also assessed with varied breathing signals against scanning angle, lesion size, lesion location, projection sampling interval, and scanning direction. In the XCAT study, using orthogonal-view of 3° kV and portal MV projections, this technique achieved an average tumor COMS/VPD of 0.4  ±  0.1 mm/5.5  ±  2.2%, 0.6  ±  0.3 mm/7.2  ±  2.8%, 0.5  ±  0.2 mm/7.1  ±  2.6%, 0.6  ±  0.2 mm/8.3  ±  2.4%, for baseline drift, amplitude variation, phase shift, and patient breathing signal variation, respectively. In the CIRS phantom study, this technique achieved an average tumor COMS/VPD of 0.7  ±  0.1 mm/7.5  ±  1.3% for a 3 cm lesion and 0.6  ±  0.2 mm/11.4  ±  1.5% for a 2 cm lesion in the baseline drift case. The average tumor COMS/VPD were 0.5  ±  0.2 mm/10.8  ±  1.4%, 0.4  ±  0.3 mm/7.3  ±  2.9%, 0.4  ±  0.2 mm/7.4  ±  2.5%, 0.4  ±  0.2 mm/7.3  ±  2.8% for the four real patient breathing signals, respectively. Results demonstrated that the adaptive prior knowledge guided image estimation technique with LIVE system is robust against scanning angle, lesion size, location and scanning direction. It can estimate on-board images accurately with as little as 6 projections in orthogonal-view 3° angle. In conclusion, adaptive prior knowledge guided image reconstruction technique accurately estimates 4D-CBCT images using extremely-limited angle and projections. This technique greatly improves the efficiency and accuracy of LIVE system for ultrafast 4D intrafraction verification of lung SBRT treatments.

Generation of hybrid sinograms for the recovery of kV-CT images with metal artifacts for helical tomotherapy

PURPOSE

The overall goal of this study is to restore kilovoltage computed tomography (kV-CT) images which are disfigured by patients' metal prostheses. By generating a hybrid sinogram that is a combination of kV and megavoltage (MV) projection data, the authors suggest a novel metal artifact-reduction (MAR) method that retains the image quality to match that of kV-CT and simultaneously restores the information of metal prostheses lost due to photon starvation.

METHODS

CT projection data contain information about attenuation coefficients and the total length of the attenuation. By normalizing raw kV projections with their own total lengths of attenuation, mean attenuation projections were obtained. In the same manner, mean density projections of MV-CT were obtained by the normalization of MV projections resulting from the forward projection of density-calibrated MV-CT images with the geometric parameters of the kV-CT device. To generate the hybrid sinogram, metal-affected signals of the kV sinogram were identified and replaced by the corresponding signals of the MV sinogram following a density calibration step with kV data. Filtered backprojection was implemented to reconstruct the hybrid CT image. To validate the authors' approach, they simulated four different scenarios for three heads and one pelvis using metallic rod inserts within a cylindrical phantom. Five inserts describing human body elements were also included in the phantom. The authors compared the image qualities among the kV, MV, and hybrid CT images by measuring the contrast-to-noise ratio (CNR), the signal-to-noise ratio (SNR), the densities of all inserts, and the spatial resolution. In addition, the MAR performance was compared among three existing MAR methods and the authors' hybrid method. Finally, for clinical trials, the authors produced hybrid images of three patients having dental metal prostheses to compare their MAR performances with those of the kV, MV, and three existing MAR methods.

RESULTS

The authors compared the image quality and MAR performance of the hybrid method with those of other imaging modalities and the three MAR methods, respectively. The total measured mean of the CNR (SNR) values for the nonmetal inserts was determined to be 14.3 (35.3), 15.3 (37.8), and 25.5 (64.3) for the kV, MV, and hybrid images, respectively, and the spatial resolutions of the hybrid images were similar to those of the kV images. The measured densities of the metal and nonmetal inserts in the hybrid images were in good agreement with their true densities, except in cases of extremely low densities, such as air and lung. Using the hybrid method, major streak artifacts were suitably removed and no secondary artifacts were introduced in the resultant image. In clinical trials, the authors verified that kV and MV projections were successfully combined and turned into the resultant hybrid image with high image contrast, accurate metal information, and few metal artifacts. The hybrid method also outperformed the three existing MAR methods with regard to metal information restoration and secondary artifact prevention.

CONCLUSIONS

The authors have shown that the hybrid method can restore the overall image quality of kV-CT disfigured by severe metal artifacts and restore the information of metal prostheses lost due to photon starvation. The hybrid images may allow for the improved delineation of structures of interest and accurate dose calculations for radiation treatment planning for patients with metal prostheses.

Towards clinical implementation of ultrafast combined kV-MV CBCT for IGRT of lung cancer : Evaluation of registration accuracy based on phantom study

PURPOSE

Combined kV-MV cone-beam CT (CBCT) is a promising approach to accelerate imaging for patients with lung tumors treated with deep inspiration breath-hold. During a single breath-hold (15 s), a 3D kV-MV CBCT can be acquired, thus minimizing motion artifacts and increasing patient comfort. Prior to clinical implementation, positioning accuracy was evaluated and compared to clinically established imaging techniques.

METHODS AND MATERIALS

An inhomogeneous thorax phantom with four tumor-mimicking inlays was imaged in 10 predefined positions and registered to a planning CT. Novel kV-MV CBCT imaging (90° arc) was compared to clinically established kV-chest CBCT (360°) as well as nonclinical kV-CBCT and low-dose MV-CBCT (each 180°). Manual registration, automatic registration provided by the manufacturer and an additional in-house developed manufacturer-independent framework based on the MATLAB registration toolkit were applied.

RESULTS

Systematic setup error was reduced to 0.05 mm by high-precision phantom positioning with optical tracking. Stochastic mean displacement errors were 0.5 ± 0.3 mm in right-left, 0.4  ± 0.4 mm in anteroposterior and 0.0 ± 0.4 mm in craniocaudal directions for kV-MV CBCT with manual registration (maximum errors of no more than 1.4 mm). Clinical kV-chest CBCT resulted in mean errors of 0.2 mm (other modalities: 0.4-0.8 mm). Similar results were achieved with both automatic registration methods.

CONCLUSION

The comparison study of repositioning accuracy between novel kV-MV CBCT and clinically established volume imaging demonstrated that registration accuracy is maintained below 1 mm. Since imaging time is reduced to one breath-hold, kV-MV CBCT is ideal for image guidance, e.g., in lung stereotactic ablative radiotherapy.

Development of a real-time monitoring system for intra-fractional motion in intracranial treatment using pressure sensors

This study developed a dedicated real-time monitoring system to detect intra-fractional head motion in intracranial radiotherapy using pressure sensors. The dedicated real-time monitoring system consists of pressure sensors with a thickness of 0.6 mm and a radius of 9.1 mm, a thermoplastic mask, a vacuum pillow, and a baseplate. The four sensors were positioned at superior-inferior and right-left sides under the occipital area. The sampling rate of pressure sensors was set to 5 Hz. First, we confirmed that the relationship between the force and the displacement of the vacuum pillow follows Hook's law. Next, the spring constant for the vacuum pillow was determined from the relationship between the force given to the vacuum pillow and the displacement of the head, detected by Cyberknife target locating system (TLS) acquisitions in clinical application. Finally, the accuracy of our system was evaluated by using the 2  ×  2 confusion matrix. The regression lines between the force, y, and the displacement, x, of the vacuum pillow were given by y = 3.8x, y = 4.4x, and y = 5.0x when the degree of inner pressure was  -12 kPa,-20 kPa, and  -27 kPa, respectively. The spring constant of the vacuum pillow was 1.6 N mm(-1) from the 6D positioning data of a total of 2999 TLS acquisitions in 19 patients. Head motions of 1 mm, 1.5 mm, and 2 mm were detected in real-time with the accuracies of 67%, 84%, and 89%, respectively. Our system can detect displacement of the head continuously during every interval of TLS with a resolution of 1-2 mm without any radiation exposure.

Metal artifact correction for x-ray computed tomography using kV and selective MV imaging

PURPOSE

The overall goal of this work is to improve the computed tomography (CT) image quality for patients with metal implants or fillings by completing the missing kilovoltage (kV) projection data with selectively acquired megavoltage (MV) data that do not suffer from photon starvation. When both of these imaging systems, which are available on current radiotherapy devices, are used, metal streak artifacts are avoided, and the soft-tissue contrast is restored, even for regions in which the kV data cannot contribute any information.

METHODS

Three image-reconstruction methods, including two filtered back-projection (FBP)-based analytic methods and one iterative method, for combining kV and MV projection data from the two on-board imaging systems of a radiotherapy device are presented in this work. The analytic reconstruction methods modify the MV data based on the information in the projection or image domains and then patch the data onto the kV projections for a FBP reconstruction. In the iterative reconstruction, the authors used dual-energy (DE) penalized weighted least-squares (PWLS) methods to simultaneously combine the kV/MV data and perform the reconstruction.

RESULTS

The authors compared kV/MV reconstructions to kV-only reconstructions using a dental phantom with fillings and a hip-implant numerical phantom. Simulation results indicated that dual-energy sinogram patch FBP and the modified dual-energy PWLS method can successfully suppress metal streak artifacts and restore information lost due to photon starvation in the kV projections. The root-mean-square errors of soft-tissue patterns obtained using combined kV/MV data are 10-15 Hounsfield units smaller than those of the kV-only images, and the structural similarity index measure also indicates a 5%-10% improvement in the image quality. The added dose from the MV scan is much less than the dose from the kV scan if a high efficiency MV detector is assumed.

CONCLUSIONS

The authors have shown that it is possible to improve the image quality of kV CTs for patients with metal implants or fillings by completing the missing kV projection data with selectively acquired MV data that do not suffer from photon starvation. Numerical simulations demonstrated that dual-energy sinogram patch FBP and a modified kV/MV PWLS method can successfully suppress metal streak artifacts and restore information lost due to photon starvation in kV projections. Combined kV/MV images may permit the improved delineation of structures of interest in CT images for patients with metal implants or fillings.

A limited-angle intrafraction verification (LIVE) system for radiation therapy

PURPOSE

Currently, no 3D or 4D volumetric x-ray imaging techniques are available for intrafraction verification of target position during actual treatment delivery or in-between treatment beams, which is critical for stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) treatments. This study aims to develop a limited-angle intrafraction verification (LIVE) system to use prior information, deformation models, and limited angle kV-MV projections to verify target position intrafractionally.

METHODS

The LIVE system acquires limited-angle kV projections simultaneously during arc treatment delivery or in-between static 3D/IMRT treatment beams as the gantry moves from one beam to the next. Orthogonal limited-angle MV projections are acquired from the beam's eye view (BEV) exit fluence of arc treatment beam or in-between static beams to provide additional anatomical information. MV projections are converted to kV projections using a linear conversion function. Patient prior planning CT at one phase is used as the prior information, and the on-board patient volume is considered as a deformation of the prior images. The deformation field is solved using the data fidelity constraint, a breathing motion model extracted from the planning 4D-CT based on principal component analysis (PCA) and a free-form deformation (FD) model. LIVE was evaluated using a 4D digital extended cardiac torso phantom (XCAT) and a CIRS 008A dynamic thoracic phantom. In the XCAT study, patient breathing pattern and tumor size changes were simulated from CT to treatment position. In the CIRS phantom study, the artificial target in the lung region experienced both size change and position shift from CT to treatment position. Varian Truebeam research mode was used to acquire kV and MV projections simultaneously during the delivery of a dynamic conformal arc plan. The reconstruction accuracy was evaluated by calculating the 3D volume percentage difference (VPD) and the center of mass (COM) difference of the tumor in the true on-board images and reconstructed images.

RESULTS

In both simulation and phantom studies, LIVE achieved substantially better reconstruction accuracy than reconstruction using PCA or FD deformation model alone. In the XCAT study, the average VPD and COM differences among different patient scenarios for LIVE system using orthogonal 30° scan angles were 4.3% and 0.3 mm when using kV+BEV MV. Reducing scan angle to 15° increased the average VPD and COM differences to 15.1% and 1.7 mm. In the CIRS phantom study, the VPD and COM differences for the LIVE system using orthogonal 30° scan angles were 6.4% and 1.4 mm. Reducing scan angle to 15° increased the VPD and COM differences to 51.9% and 3.8 mm.

CONCLUSIONS

The LIVE system has the potential to substantially improve intrafraction target localization accuracy by providing volumetric verification of tumor position simultaneously during arc treatment delivery or in-between static treatment beams. With this improvement, LIVE opens up a new avenue for margin reduction and dose escalation in both fractionated treatments and SRS and SBRT treatments.

Generation of virtual monochromatic CBCT from dual kV∕MV beam projections

PURPOSE

To develop a novel on-board imaging technique which allows generation of virtual monochromatic (VM) cone-beam CT (CBCT) with a selected energy from combined kilovoltage (kV)∕megavoltage (MV) beam projections.

METHODS

With the current orthogonal kV∕MV imaging hardware equipped in modern linear accelerators, both MV projections (from gantry angle of 0°-100°) and kV projections (90°-200°) were acquired as gantry rotated a total of 110°. A selected range of overlap projections between 90° to 100° were then decomposed into two material projections using experimentally determined parameters from orthogonally stacked aluminum and acrylic step-wedges. Given attenuation coefficients of aluminum and acrylic at a predetermined energy, one set of VM projections could be synthesized from two corresponding sets of decomposed projections. Two linear functions were generated using projection information at overlap angles to convert kV and MV projections at nonoverlap angles to approximate VM projections for CBCT reconstruction. The contrast-to-noise ratios (CNRs) were calculated for different inserts in VM CBCTs of a CatPhan phantom with various selected energies and compared with those in kV and MV CBCTs. The effect of overlap projection number on CNR was evaluated. Additionally, the effect of beam orientation was studied by scanning the CatPhan sandwiched with two 5 cm solid-water phantoms on both lateral sides and an electronic density phantom with two metal bolt inserts.

RESULTS

Proper selection of VM energy [30 and 40 keV for low-density polyethylene (LDPE), polymethylpentene, 2 MeV for Delrin] provided comparable or even better CNR results as compared with kV or MV CBCT. An increased number of overlap kV and MV projection demonstrated only marginal improvements of CNR for different inserts (with the exception of LDPE) and therefore one projection overlap was found to be sufficient for the CatPhan study. It was also evident that the optimal CBCT image quality was achieved when MV beams penetrated through the heavy attenuation direction of the object.

CONCLUSIONS

A novel technique was developed to generate VM CBCTs from kV∕MV projections. This technique has the potential to improve CNR at selected VM energies and to suppress artifacts at appropriate beam orientations.

Optimization of the performance of segmented scintillators for radiotherapy imaging through novel binning techniques

Thick, segmented crystalline scintillators have shown increasing promise as replacement x-ray converters for the phosphor screens currently used in active matrix flat-panel imagers (AMFPIs) in radiotherapy, by virtue of providing over an order of magnitude improvement in the detective quantum efficiency (DQE). However, element-to-element misalignment in current segmented scintillator prototypes creates a challenge for optimal registration with underlying AMFPI arrays, resulting in degradation of spatial resolution. To overcome this challenge, a methodology involving the use of a relatively high resolution AMFPI array in combination with novel binning techniques is presented. The array, which has a pixel pitch of 0.127 mm, was coupled to prototype segmented scintillators based on BGO, LYSO and CsI:Tl materials, each having a nominal element-to-element pitch of 1.016 mm and thickness of ∼ 1 cm. The AMFPI systems incorporating these prototypes were characterized at a radiotherapy energy of 6 MV in terms of modulation transfer function, noise power spectrum, DQE, and reconstructed images of a resolution phantom acquired using a cone-beam CT geometry. For each prototype, the application of 8 × 8 pixel binning to achieve a sampling pitch of 1.016 mm was optimized through use of an alignment metric which minimized misregistration and thereby improved spatial resolution. In addition, the application of alternative binning techniques that exclude the collection of signal near septal walls resulted in further significant improvement in spatial resolution for the BGO and LYSO prototypes, though not for the CsI:Tl prototype due to the large amount of optical cross-talk resulting from significant light spread between scintillator elements in that device. The efficacy of these techniques for improving spatial resolution appears to be enhanced for scintillator materials that exhibit mechanical hardness, high density and high refractive index, such as BGO. Moreover, materials that exhibit these properties as well as offer significantly higher light output than BGO, such as CdWO4, should provide the additional benefit of preserving DQE performance.

A dual cone-beam CT system for image guided radiotherapy: initial performance characterization

PURPOSE

The purpose of this study is to evaluate the performance of a recently developed benchtop dual cone-beam computed tomography (CBCT) system with two orthogonally placed tube∕detector sets.

METHODS

The benchtop dual CBCT system consists of two orthogonally placed 40 × 30 cm flat-panel detectors and two conventional x-ray tubes with two individual high-voltage generators sharing the same rotational axis. The x-ray source to detector distance is 150 cm and x-ray source to rotational axis distance is 100 cm for both subsystems. The objects are scanned through 200° of rotation. The dual CBCT system utilized 110° of projection data from one detector and 90° from the other while the two individual single CBCTs utilized 200° data from each detector. The system performance was characterized in terms of uniformity, contrast, spatial resolution, noise power spectrum, and CT number linearity. The uniformities, within the axial slice and along the longitudinal direction, and noise power spectrum were assessed by scanning a water bucket; the contrast and CT number linearity were measured using the Catphan phantom; and the spatial resolution was evaluated using a tungsten wire phantom. A skull phantom and a ham were also scanned to provide qualitative evaluation of high- and low-contrast resolution. Each measurement was compared between dual and single CBCT systems.

RESULTS

Compared to single CBCT, the dual CBCT presented: (1) a decrease in uniformity by 1.9% in axial view and 1.1% in the longitudinal view, as averaged for four energies (80, 100, 125, and 150 kVp); (2) comparable or slightly better contrast (0∼25 HU) for low-contrast objects and comparable contrast for high-contrast objects; (3) comparable spatial resolution; (4) comparable CT number linearity with R(2) ≥ 0.99 for all four tested energies; (5) lower noise power spectrum in magnitude. Dual CBCT images of the skull phantom and the ham demonstrated both high-contrast resolution and good soft-tissue contrast.

CONCLUSIONS

The performance of a benchtop dual CBCT imaging system has been characterized and is comparable to that of a single CBCT.

Low-dose megavoltage cone-beam CT imaging using thick, segmented scintillators

Megavoltage, cone-beam computed tomography (MV CBCT) employing an electronic portal imaging device (EPID) is a highly promising technique for providing soft-tissue visualization in image-guided radiotherapy. However, current EPIDs based on active matrix flat-panel imagers (AMFPIs), which are regarded as the gold standard for portal imaging and referred to as conventional MV AMFPIs, require high radiation doses to achieve this goal due to poor x-ray detection efficiency (∼2% at 6 MV). To overcome this limitation, the incorporation of thick, segmented, crystalline scintillators, as a replacement for the phosphor screens used in these AMFPIs, has been shown to significantly improve the detective quantum efficiency (DQE) performance, leading to improved image quality for projection imaging at low dose. Toward the realization of practical AMFPIs capable of low dose, soft-tissue visualization using MV CBCT imaging, two prototype AMFPIs incorporating segmented scintillators with ∼11 mm thick CsI:Tl and Bi(4)Ge(3)O(12) (BGO) crystals were evaluated. Each scintillator consists of 120 × 60 crystalline elements separated by reflective septal walls, with an element-to-element pitch of 1.016 mm. The prototypes were evaluated using a bench-top CBCT system, allowing the acquisition of 180 projection, 360° tomographic scans with a 6 MV radiotherapy photon beam. Reconstructed images of a spatial resolution phantom, as well as of a water-equivalent phantom, embedded with tissue equivalent objects having electron densities (relative to water) varying from ∼0.28 to ∼1.70, were obtained down to one beam pulse per projection image, corresponding to a scan dose of ∼4 cGy--a dose similar to that required for a single portal image obtained from a conventional MV AMFPI. By virtue of their significantly improved DQE, the prototypes provided low contrast visualization, allowing clear delineation of an object with an electron density difference of ∼2.76%. Results of contrast, noise and contrast-to-noise ratio are presented as a function of dose and compared to those from a conventional MV AMFPI.

Clinical application of varian OBI CBCT system and dose reduction techniques in breast cancer patients setup

PURPOSE

To characterize the standard modes of Varian on board imaging (OBI) v1.4 system and identify techniques to further optimize imaging parameters, in particular, for breast treatment setup.

METHODS

A male anthropomorphic torso phantom was used for image quality assessment and a simpler thorax phantom for dose measurements. Both phantoms had artificial breasts attached. Doses were measured with an ion chamber in seven locations in the thorax and the breast. Evaluation of image quality was performed in terms of contrast-to-noise ratio (CNR) and in combination with the dose-to-contrast-to-noise (CNRD) parameter. The effect of kVp and mAs on the image quality, dose, and CNRD parameter was analyzed. In addition, image geometry with noncentral isocenter location with start and stop imaging angles adjusted for greater sparing of the contralateral breast was evaluated in terms of image quality and dose.

RESULTS

The measurements showed doses between 0.02 and 1.6 cGy for the three full-fan modes and 0.6-3.2 cGy for half-fan modes. This is a reduction of over 80% and 30%-50% compared to OBI v.1.3 modes for full-fan and half-fan modes, respectively. The CNRD is the highest for both low dose modes (low dose thorax and low dose head). Optimal ranges for an averaged sized thorax are tube voltages not higher than 100 kVp and current-time products between 100 and 400 mAs. For the contralateral breast and lung, a dose less than 0.03 cGy per scan was measured for the optimized image geometry with the noncentral isocenter location.

CONCLUSIONS

The OBI v1.4 system allows for imaging with a larger variety of imaging parameters compared to previous OBI v1.3 systems. The largest doses (up to 4 cGy) were measured in a phantom when OBI v1.4 system was used for imaging with half-fan modes. Using full-fan modes resulted in the doses less than 1.6 cGy. Further decrease in dose may be achieved by reducing mAs while preserving acceptable image quality. Organ specific sparing (e.g., contralateral breast) may be achieved by proper selection of the start and stop angles. For thorax imaging, the use of Low Dose Thorax mode is recommended.

Fast kilovoltage/megavoltage (kVMV) breathhold cone-beam CT for image-guided radiotherapy of lung cancer

Long image acquisition times of 60-120 s for cone-beam CT (CBCT) limit the number of patients with lung cancer who can undergo volume image guidance under breathhold. We developed a low-dose dual-energy kilovoltage-megavoltage-cone-beam CT (kVMV-CBCT) based on a clinical treatment unit reducing imaging time to < or =15 s. Simultaneous kVMV-imaging was achieved by dedicated synchronization hardware controlling the output of the linear accelerator (linac) based on detector panel readout signals, preventing imaging artifacts from interference of the linac's MV-irradiation and panel readouts. Optimization was performed to minimize the imaging dose. Single MV-projections, reconstructed MV-CBCT images and images of simultaneous 90 degrees kV- and 90 degrees MV-CBCT (180 degrees kVMV-CBCT) were acquired with different parameters. Image quality and imaging dose were evaluated and compared to kV-imaging. Hardware-based kVMV synchronization resulted in artifact-free projections. A combined 180 degrees kVMV-CBCT scan with a total MV-dose of 5 monitor units was acquired in 15 s and with sufficient image quality. The resolution was 5-6 line pairs cm(-1) (Catphan phantom). The combined kVMV-scan dose was equivalent to a kV-radiation scan dose of approximately 33 mGy. kVMV-CBCT based on a standard linac is promising and can provide ultra-fast online volume image guidance with low imaging dose and sufficient image quality for fast and accurate patient positioning for patients with lung cancer under breathhold.

Breath-hold target localization with simultaneous kilovoltage/megavoltage cone-beam computed tomography and fast reconstruction

PURPOSE

Hypofractionated high-dose radiotherapy for small lung tumors has typically been based on stereotaxy. Cone-beam computed tomography and breath-hold techniques have provided a noninvasive basis for precise cranial and extracranial patient positioning. The cone-beam computed tomography acquisition time of 60 s, however, is beyond the breath-hold capacity of patients, resulting in respiratory motion artifacts. By combining megavoltage (MV) and kilovoltage (kV) photon sources (mounted perpendicularly on the linear accelerator) and accelerating the gantry rotation to the allowed limit, the data acquisition time could be reduced to 15 s.

METHODS AND MATERIALS

An Elekta Synergy 6-MV linear accelerator, with iViewGT as the MV- and XVI as the kV-imaging device, was used with a Catphan phantom and an anthropomorphic thorax phantom. Both image sources performed continuous image acquisition, passing an angle interval of 90° within 15 s. For reconstruction, filtered back projection on a graphics processor unit was used. It reconstructed 100 projections acquired to a 512 × 512 × 512 volume within 6 s.

RESULTS

The resolution in the Catphan phantom (CTP528 high-resolution module) was 3 lines/cm. The spatial accuracy was within 2-3 mm. The diameters of different tumor shapes in the thorax phantom were determined within an accuracy of 1.6 mm. The signal-to-noise ratio was 68% less than that with a 180°-kV scan. The dose generated to acquire the MV frames accumulated to 82.5 mGy, and the kV contribution was <6 mGy.

CONCLUSION

The present results have shown that fast breath-hold, on-line volume imaging with a linear accelerator using simultaneous kV-MV cone-beam computed tomography is promising and can potentially be used for image-guided radiotherapy for lung cancer patients in the near future.

Evaluation of Inter-fractional Setup Shifts for Site-specific Helical Tomotherapy Treatments

This paper proposes to summarize and analyze the daily patient setup shifts based on megavoltage computed tomography (MVCT) image registration results for Helical TomoTherapy® (HT) treatment. One hundred and fifty-five consecutive treatment plans for a total of 137 patients delivered by the HT unit through one year were collected in this study. The patient data included pelvis (26%), abdomen (23%), lung (21%), head and neck (10%), prostate (8%), and others (12%). All the translational and roll rotational shifts made via auto MVCT and kilovoltage computed tomography (kVCT) image registration were recorded at each fraction. Manual fine-tuning was followed if automatic registration result was not satisfactory. The mean shift ± one standard deviation (1 SD) was calculated for each patient based on the entire treatment course. For each treatment site, the average shift was analyzed as well as displacement in 3D vector. Statistical tests were performed to analyze the relationship of patient-specific, tumor site-specific, and fraction number association with the patient setup shifts. For all the treatment sites, the largest average shift was found in the anterior-posterior direction. The population standard deviations were between 1.2 and 5.6 mm for the X, Y, and Z directions and ranged from 0.2 to 0.6 degrees for the roll rotational correction. The largest standard deviations of the setup reproducibility in X, Y, and Z directions were found in lung patients (4.2 mm), abdomen, lung and spine patients (4.4 mm), and prostate patients (5.6 mm), respectively. The maximum 3D displacement was 10.9 mm for prostate patients' setup. ANOVA tests demonstrated the setup shifts were statistically different between patients even for those that were treated at the same tumor site in the translational directions. No strong correlation between the setup and the fraction number was found. In conclusion, the MVCT guided function in the HT treatment enables us to generate relatively accurate daily setup through registration with KVCT data sets. Our results indicate that lung, prostate, and abdominal patients are more prone to setup uncertainty and should be carefully evaluated.

A phantom study on target localization accuracy using cone-beam computed tomography

The purpose of this study is to evaluate the 3-dimensional target localization accuracy of cone-beam computed tomography (CBCT) using an on-board imager (OBI). An anthropomorphic pelvis phantom was used to simulate a range of offsets in the three translational directions and rotations around each of the three axes. After a translational or rotational offset was applied, a CBCT scan of the phantom was followed by image registration to detect the offsets in six degrees. The detected offsets were compared to the offset actually applied to give the detection error of the phantom position. Afterwards, the phantom was positioned by automatically moving the couch based on the detected offsets. A second CBCT scan followed by image registration was performed to give the residual error of the phantom positioning. On the average the detection errors and their standard deviations along the lateral, longitudinal and vertical axis are 0.3 ± 0.1, 0.3 ± 0.1 and 0.4 ± 0.1 mm respectively with respect to translational shifts ranging from 0 to 10 mm. The corresponding residual errors after positioning are 0.3 ± 0.1, 0.5 ± 0.1 and 0.3 ± 0.1 mm. For simulated rotational shifts ranging from 0 to 5 degrees, the average detection error and their standard deviation around lateral, longitudinal, and vertical axes are 0.1 ± 0.0, 0.2 ± 0.0, and 0.2 ± 0.0 degrees respectively. The residual errors after positioning are 0.4 ± 0.1, 0.6 ± 0.1, and 0.3 ± 0.1 mm along the lateral, longitudinal and vertical directions. These results indicate that target localization based on CBCT is capable of achieving sub-millimeter accuracy.

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.

Commissioning and quality assurance of the X-ray volume Imaging system of an image-guided radiotherapy capable linear accelerator

An Image-Guided Radiotherapy-capable linear accelerator (Elekta Synergy) was installed at our hospital, which is equipped with a kV x-ray volume imaging (XVI) system and electronic portal imaging device (iViewGT). The objective of this presentation is to describe the results of commissioning measurements carried out on the XVI facility to verify the manufacturer's specifications and also to evolve a QA schedule which can be used to test its performance routinely.The QA program consists of a series of tests (safety features, geometric accuracy, and image quality). These tests were found to be useful to assess the performance of the XVI system and also proved that XVI system is very suitable for image-guided high-precision radiation therapy.

Monte Carlo investigations of megavoltage cone-beam CT using thick, segmented scintillating detectors for soft tissue visualization

Megavoltage cone-beam computed tomography (MV CBCT) is a highly promising technique for providing volumetric patient position information in the radiation treatment room. Such information has the potential to greatly assist in registering the patient to the planned treatment position, helping to ensure accurate delivery of the high energy therapy beam to the tumor volume while sparing the surrounding normal tissues. Presently, CBCT systems using conventional MV active matrix flat-panel imagers (AMFPIs), which are commonly used in portal imaging, require a relatively large amount of dose to create images that are clinically useful. This is due to the fact that the phosphor screen detector employed in conventional MV AMFPIs utilizes only approximately 2% of the incident radiation (for a 6 MV x-ray spectrum). Fortunately, thick segmented scintillating detectors can overcome this limitation, and the first prototype imager has demonstrated highly promising performance for projection imaging at low doses. It is therefore of definite interest to examine the potential performance of such thick, segmented scintillating detectors for MV CBCT. In this study, Monte Carlo simulations of radiation energy deposition were used to examine reconstructed images of cylindrical CT contrast phantoms, embedded with tissue-equivalent objects. The phantoms were scanned at 6 MV using segmented detectors having various design parameters (i.e., detector thickness as well as scintillator and septal wall materials). Due to constraints imposed by the nature of this study, the size of the phantoms was limited to approximately 6 cm. For such phantoms, the simulation results suggest that a 40 mm thick, segmented CsI detector with low density septal walls can delineate electron density differences of approximately 2.3% and 1.3% at doses of 1.54 and 3.08 cGy, respectively. In addition, it was found that segmented detectors with greater thickness, higher density scintillator material, or lower density septal walls exhibit higher contrast-to-noise performance. Finally, the performance of various segmented detectors obtained at a relatively low dose (1.54 cGy) was compared with that of a phosphor screen similar to that employed in conventional MV AMFPIs. This comparison indicates that for a phosphor screen to achieve the same contrast-to-noise performance as the segmented detectors approximately 18 to 59 times more dose is required, depending on the configuration of the segmented detectors.

Quality Assurance of Image-Guidance Technologies

The introduction of image-guided radiotherapy systems (IGS) allows improved management of geometric variations in patient setup and internal organ motion. Commercially available technologies, based on ultrasound, projection radiography, or cone-beam CT, have been widely adopted in radiation therapy. All rely on the comparison of daily images with reference images of the patient anatomy to ensure coincidence of the treatment and planned isocenters. This article reviews how IGS hardware and software are commissioned for clinical release and what quality control checks are required to ensure consistent and reproducible geometric accuracy. As image guidance significantly modifies conventional radiotherapy processes, recommendations and potential issues are discussed to facilitate the introduction of image guidance into the clinical environment.

Commissioning experience with cone-beam computed tomography for image-guided radiation therapy

This paper reports on the commissioning of an Elekta cone‐beam computed tomography (CT) system at one of the first U.S. sites to install a “regular,” off‐the‐shelf Elekta Synergy (Elekta, Stockholm, Sweden) accelerator system. We present the quality assurance (QA) procedure as a guide for other users. The commissioning had six elements: (1) system safety, (2) geometric accuracy (agreement of megavoltage and kilovoltage beam isocenters), (3) image quality, (4) registration and correction accuracy, (5) dose to patient and dosimetric stability, and (6) QA procedures. The system passed the safety tests, and agreement of the isocenters was found to be within 1 mm. Using a precisely moved skull phantom, the reconstruction and alignment algorithm was found to be accurate within 1 mm and 1 degree in each dimension. Of 12 measurement points spanning a 9×9×15‐cm volume in a Rando phantom (The Phantom Laboratory, Salem, NY), the average agreement in the x, y, and z coordinates was 0.10 mm, −0.12 mm, and 0.22 mm [standard deviations (SDs): 0.21 mm, 0.55 mm, 0.21 mm; largest deviations: 0.6 mm, 1.0 mm, 0.5 mm] respectively. The larger deviation for the y component can be partly attributed to the CT slice thickness of 1 mm in that direction. Dose to the patient depends on the machine settings and patient geometry. To monitor dose consistency, air kerma (output) and half‐value layer (beam quality) are measured for a typical clinical setting. Air kerma was 6.3 cGy (120 kVp, 40 mA, 40 ms per frame, 360‐degree scan, S20 field of view); half value layer was 7.1 mm aluminum (120 kV, 40 mA).

We suggest performing items 1, 2, and 3 monthly, and 4 and 5 annually. In addition, we devised a daily QA procedure to verify agreement of the megavoltage and kilovoltage isocenters using a simple phantom containing three small steel balls. The frequency of all checks will be reevaluated based on data collected during about 1 year.

PACS number: 87.53.Xd

Technical and clinical experience with spine radiosurgery: a new technology for management of localized spine metastases

This study is to demonstrate the technical and clinical experience of applying image guided spinal radiosurgery for treatment of localized spinal metastasis. A dedicated shaped beam radiosurgery unit with intensity modulated radiotherapy (IMRT) and x-ray based image-guided radiotherapy (IGRT) were used for the radiosurgery procedure. A total of 196 patients with 270 lesions of spinal metastases were treated with this procedure from May 2001 to October 2005. All patients received single dose radiosurgery to the involved spine only. The radiosurgery dose was escalated from 10 to 18 Gy in 2 Gy increments. The technical experience using IMRT planning and IGRT implementation has been summarized. Clinical results reporting pain relief responses have been analyzed for the first 49 patients treated with this procedure. For IMRT treatment planning, seven posterior/oblique fields were generally used for spinal radiosurgery as the optimal setup to balance conformality versus complexity. A criterion of 10 Gy to 10% of the adjacent spinal cord volume has been met with satisfactory target dose coverage for most of the cases. When the spinal cord dose exceeded this constraint, the tumor coverage was somewhat compromised. Accurate target localization has been achieved for all patients using the x-ray image-guided system. The preliminary clinical results have demonstrated that pain response was achieved in 85% of patients, with neurological improvement in patients with spinal cord compression. Patients tolerated the treatment well without major acute toxicities. Image guided spinal radiosurgery can be successfully applied to treat patients with focal spine metastases.

Evaluation of on-board kV cone beam CT (CBCT)-based dose calculation

On-board CBCT images are used to generate patient geometric models to assist patient setup. The image data can also, potentially, be used for dose reconstruction in combination with the fluence maps from treatment plan. Here we evaluate the achievable accuracy in using a kV CBCT for dose calculation. Relative electron density as a function of HU was obtained for both planning CT (pCT) and CBCT using a Catphan-600 calibration phantom. The CBCT calibration stability was monitored weekly for 8 consecutive weeks. A clinical treatment planning system was employed for pCT- and CBCT-based dose calculations and subsequent comparisons. Phantom and patient studies were carried out. In the former study, both Catphan-600 and pelvic phantoms were employed to evaluate the dosimetric performance of the full-fan and half-fan scanning modes. To evaluate the dosimetric influence of motion artefacts commonly seen in CBCT images, the Catphan-600 phantom was scanned with and without cyclic motion using the pCT and CBCT scanners. The doses computed based on the four sets of CT images (pCT and CBCT with/without motion) were compared quantitatively. The patient studies included a lung case and three prostate cases. The lung case was employed to further assess the adverse effect of intra-scan organ motion. Unlike the phantom study, the pCT of a patient is generally acquired at the time of simulation and the anatomy may be different from that of CBCT acquired at the time of treatment delivery because of organ deformation. To tackle the problem, we introduced a set of modified CBCT images (mCBCT) for each patient, which possesses the geometric information of the CBCT but the electronic density distribution mapped from the pCT with the help of a BSpline deformable image registration software. In the patient study, the dose computed with the mCBCT was used as a surrogate of the 'ground truth'. We found that the CBCT electron density calibration curve differs moderately from that of pCT. No significant fluctuation was observed in the calibration over the period of 8 weeks. For the static phantom, the doses computed based on pCT and CBCT agreed to within 1%. A notable difference in CBCT- and pCT-based dose distributions was found for the motion phantom due to the motion artefacts which appeared in the CBCT images (the maximum discrepancy was found to be approximately 3.0% in the high dose region). The motion artefacts-induced dosimetric inaccuracy was also observed in the lung patient study. For the prostate cases, the mCBCT- and CBCT-based dose calculations yielded very close results (<2%). Coupled with the phantom data, it is concluded that the CBCT can be employed directly for dose calculation for a disease site such as the prostate, where there is little motion artefact. In the prostate case study, we also noted a large discrepancy between the original treatment plan and the CBCT (or mCBCT)-based calculation, suggesting the importance of inter-fractional organ movement and the need for adaptive therapy to compensate for the anatomical changes in the future.

Direct aperture deformation: An interfraction image guidance strategy

A new scheme, called direct aperture deformation (DAD), for online correction of interfraction geometric uncertainties under volumetric imaging guidance is presented. Using deformable image registration, the three-dimensional geometric transformation matrix can be derived that associates the planning image set and the images acquired on the day of treatment. Rather than replanning or moving the patient, we use the deformation matrix to morph the treatment apertures as a potential online correction method. A proof-of-principle study using an intensity-modulated radiation therapy plan for a prostate cancer patient was conducted. The method, procedure, and algorithm of DAD are described. The dose-volume histograms from the original plan, reoptimized plan, and rigid-body translation plan are compared with the ones from the DAD plan. The study showed the feasibility of the DAD as a general method for both target dislocation and deformation. As compared with using couch translation to move the patient, DAD is capable of correcting both target dislocation and deformations. As compared with reoptimization, online correction using the DAD scheme could be completed within a few minutes rather than tens of minutes and the speed gain would be at a very small cost of plan quality.

Impact of patient-specific factors, irradiated left ventricular volume, and treatment set-up errors on the development of myocardial perfusion defects after radiation therapy for left-sided breast cancer

PURPOSE

The aim of this study was to assess the impact of patient-specific factors, left ventricle (LV) volume, and treatment set-up errors on the rate of perfusion defects 6 to 60 months post-radiation therapy (RT) in patients receiving tangential RT for left-sided breast cancer.

METHODS AND MATERIALS

Between 1998 and 2005, a total of 153 patients were enrolled onto an institutional review board-approved prospective study and had pre- and serial post-RT (6-60 months) cardiac perfusion scans to assess for perfusion defects. Of the patients, 108 had normal pre-RT perfusion scans and available follow-up data. The impact of patient-specific factors on the rate of perfusion defects was assessed at various time points using univariate and multivariate analysis. The impact of set-up errors on the rate of perfusion defects was also analyzed using a one-tailed Fisher's Exact test.

RESULTS

Consistent with our prior results, the volume of LV in the RT field was the most significant predictor of perfusion defects on both univariate (p = 0.0005 to 0.0058) and multivariate analysis (p = 0.0026 to 0.0029). Body mass index (BMI) was the only significant patient-specific factor on both univariate (p = 0.0005 to 0.022) and multivariate analysis (p = 0.0091 to 0.05). In patients with very small volumes of LV in the planned RT fields, the rate of perfusion defects was significantly higher when the fields set-up "too deep" (83% vs. 30%, p = 0.059). The frequency of deep set-up errors was significantly higher among patients with BMI > or =25 kg/m2 compared with patients of normal weight (47% vs. 28%, p = 0.068).

CONCLUSIONS

BMI > or =25 kg/m2 may be a significant risk factor for cardiac toxicity after RT for left-sided breast cancer, possibly because of more frequent deep set-up errors resulting in the inclusion of additional heart in the RT fields. Further study is necessary to better understand the impact of patient-specific factors and set-up errors on the development of RT-induced perfusion defects.

A quality assurance program for the on-board imager®

To develop a quality assurance (QA) program for the On-Board Imager (OBI) system and to summarize the results of these QA tests over extended periods from multiple institutions. Both the radiographic and cone-beam computed tomography (CBCT) mode of operation have been evaluated. The QA programs from four institutions have been combined to generate a series of tests for evaluating the performance of the On-Board Imager. The combined QA program consists of three parts: (1) safety and functionality, (2) geometry, and (3) image quality. Safety and functionality tests evaluate the functionality of safety features and the clinical operation of the entire system during the tube warm-up. Geometry QA verifies the geometric accuracy and stability of the OBI/CBCT hardware/software. Image quality QA monitors spatial resolution and contrast sensitivity of the radiographic images. Image quality QA for CBCT includes tests for Hounsfield Unit (HU) linearity, HU uniformity, spatial linearity, and scan slice geometry, in addition. All safety and functionality tests passed on a daily basis. The average accuracy of the OBI isocenter was better than 1.5 mm with a range of variation of less than 1 mm over 8 months. The average accuracy of arm positions in the mechanical geometry QA was better than 1 mm, with a range of variation of less than 1 mm over 8 months. Measurements of other geometry QA tests showed stable results within tolerance throughout the test periods. Radiographic contrast sensitivity ranged between 2.2% and 3.2% and spatial resolution ranged between 1.25 and 1.6 lp/mm. Over four months the CBCT images showed stable spatial linearity, scan slice geometry, contrast resolution (1%; <7 mm disk) and spatial resolution (>6 lp/cm). The HU linearity was within +/-40 HU for all measurements. By combining test methods from multiple institutions, we have developed a comprehensive, yet practical, set of QA tests for the OBI system. Use of the tests over extended periods show that the OBI system has reliable mechanical accuracy and stable image quality. Nevertheless, the tests have been useful in detecting performance deficits in the OBI system that needed recalibration. It is important that all tests are performed on a regular basis.

Physics and imaging for targeting of oligometastases

Oligometastases refer to metastases that are limited in number and location and are amenable to regional treatment. The majority of these metastases appear in the brain, lung, liver, and bone. Although the focus of interest in the past within radiation oncology has been on the treatment of intracranial metastases, there has been growing interest in extracranial sites such as the liver and lung. This is largely because of the rapid development of targeting techniques for oligometastases such as intensity-modulated and image-guided radiation therapy, which has made it possible to deliver single or a few fractions of high-dose radiation treatments, highly conformal to the target. The clinical decision to use radiation to treat oligometastases is based on both radiobiological and physics considerations. The radiobiological considerations involve improvement of treatment schema for time, dose, and volume. Areas of interests are hypofractionation, tumor and normal tissue tolerance, and hypoxia. The physics considerations for oligometastases treatment are focused mainly on ensuring treatment accuracy and precision. This article discusses the physics and imaging aspects involved in each step of the radiation treatment process for oligometastases, including target definition, treatment simulation, treatment planning, pretreatment target localization, radiation delivery, treatment verification, and treatment evaluation.

Digital tomosynthesis with an on-board kilovoltage imaging device

PURPOSE

To generate on-board digital tomosynthesis (DTS) and reference DTS images for three-dimensional image-guided radiation therapy (IGRT) as an alternative to conventional portal imaging or on-board cone-beam computed tomography (CBCT).

METHODS AND MATERIALS

Three clinical cases (prostate, head-and-neck, and liver) were selected to illustrate the capabilities of on-board DTS for IGRT. Corresponding reference DTS images were reconstructed from digitally reconstructed radiographs computed from planning CT image sets. The effect of scan angle on DTS slice thickness was examined by computing the mutual information between coincident CBCT and DTS images, as the DTS scan angle was varied from 0 degrees to 165 degrees . A breath-hold DTS acquisition strategy was implemented to remove respiratory motion artifacts.

RESULTS

Digital tomosynthesis slices appeared similar to coincident CBCT planes and yielded substantially more anatomic information than either kilovoltage or megavoltage radiographs. Breath-hold DTS acquisition improved soft-tissue visibility by suppressing respiratory motion.

CONCLUSIONS

Improved bony and soft-tissue visibility in DTS images is likely to improve target localization compared with radiographic verification techniques and might allow for daily localization of a soft-tissue target. Breath-hold DTS is a potential alternative to on-board CBCT for sites prone to respiratory motion.

Dose comparison of megavoltage cone-beam and orthogonal-pair portal images

The technique of megavoltage cone‐beam computed tomography (MV CBCT) is available for image‐guided radiation therapy to improve the accuracy of patient setup and tumor localization. However, development of strategies to efficiently and effectively implement this technique or to replace the current orthogonal portal images technique remains challenging in the clinical environment. It is useful to compare the difference in absorbed dose between the MV CBCT technique and the orthogonal portal images technique, the current standard practice for treatment verification. Our study analyzed the doses generated from these two imaging techniques for six treatment sites (pelvis, abdomen, lung, head and neck, breast, prostate). The analysis was made by simulating the MV CBCT technique with an arc beam and a beam‐on time of 9 monitor units (MUs), and the orthogonal pair technique with a double‐exposure anterior–posterior and lateral pair and a beam‐on time of 4 MUs. The results are presented as dose per MU (cGy/MU) and absolute dose (cGy). The isocenter doses, integral doses, maximum doses, and mean doses to tumor and critical organs, and the two‐dimensional isodose distributions and dose–volume histograms of each critical organ were investigated. The absolute dose difference between MV CBCT and orthogonal pair at the isocenter was 4.02±0.59 cGy. Major differences were seen between the two techniques in critical organs whose locations are away from the tumor. These organs, such as the contralateral breast (difference: 0.17±0.10 cGy/MU) and lung (difference: 0.15±0.20 cGy/MU), receive a higher dose from MV CBCT images than from orthogonal portal images. Additionally, higher doses and larger dose areas involving more normal tissues were observed for MV CBCT images than for orthogonal portal images in our analysis methodology, which used 200 beam projections delivered from various angles for the MV CBCT simulation and from just two perpendicular angles for the orthogonal pair simulation. In our selected clinical cases, the high‐dose area from the orthogonal pair technique was always located inside the tumor; with MV CBCT, the high‐dose area will most likely be outside the tumor. Therefore, the potentially higher doses to critical organs from MV CBCT images should be properly analyzed to ensure that they do not exceed the tolerance dose when therapy is delivered using that technique. On the other hand, to obtain good image quality, the higher MUs with MV CBCT images may be necessary. The absorbed dose for the tumor and for other critical organs should be calculated accordingly in the treatment plans. Images by MV CBCT are a great tool for three‐dimensional verification of patient treatment position. The trade‐off is that the MV CBCT technique for patient treatment verification might have a higher chance of increasing the dose to normal tissue during image acquisition.

PACS number: 87.53.Oq