Point/Counterpoint. Kilovoltage imaging is more suitable than megavoltage imaging for guiding radiation therapy

Cone-beam computed tomography (CBCT) dose optimization technique and image quality assessment scoring

INTRODUCTION

Linear accelerator (LINAC) embedded with kV source-imager system is capable to do image-guided radiotherapy. The only disadvantage of cone-beam computed tomography image acquisition during treatment is the extra radiation dose to the patient. The aim of this study is to optimize the CBCT imaging doses likely to be received by the patient undergoing radiotherapy without affecting image quality.

MATERIAL AND METHODS

The imaging dose to the patient was estimated on CTDI phantoms. The effect of additional filters of different materials (copper, brass, aluminum of thickness 0.1 mm each) was evaluated to find the optimized dose imaging technique. For the pelvis, a single imaging protocol available on the machine was used, whereas for the head and neck region, two protocols, high-quality head and standard-dose head were used. The image quality was assessed on CATPHAN-504 phantom using Owl CATPHAN® QA online tool. A new term "Image Assessment score" (IAS) was introduced to evaluate the image quality.

RESULT

In the pelvis protocol, CBCT imaging doses with an additional 0.1-mm brass, copper, and aluminum filter were measured to be reduced by 7.1%, 4.7%, and 2.5%, respectively, whereas for high-quality head protocol, the dose reduction was 25.4% (with brass filter), 22% (with copper filter), and 3.1% (with aluminum filter). For the standard-dose head protocol, doses were reduced by 7.5%, 2.8%, and 2.1% with additional 0.1-mm brass copper and aluminum filters, respectively. Acceptable image quality was observed with all the filters.

CONCLUSION

Although the reconstructed images were found somewhat noisier, they did not affect the purpose of imaging, that is, treatment position verification. It was observed that these extra filters further reduce the imaging dose without much affecting the image quality.

Evaluation and validation of tungsten fiducial marker-based image-guided radiotherapy

In this research work, a simple homemade cubic phantom was designed to validate the Image-Guided Radiotherapy (IGRT) set up and verified with the help of tungsten fiducial markers (size 2-3 mm) inserted into the cubic phantom. Phantom made up of Styrofoam, was scanned with the help of 16 slice Toshiba CT scanner where each slice was of 1 mm thickness and HU level set to -1000. A radio-opaque contrast medium was rubbed on the phantom to visualize the scanner images. Once the iso-center had been marked on a phantom with the help of in-room positioning laser and the fields (RT-LAT and AP) were applied on the contoured body of the phantom in Varian's ARIA-11 Eclipse dosimeter software, the same position of the phantom was reproduced on Varian's Linear Accelerator DHX. Known shifts of 3.0 to 30.0 mm from the marked iso-center were applied on the phantom by moving the couch in all six directions one by one. On each applied couch shift, an x-ray image of the phantom was acquired with the help of an MV portal imager of Linac in AP and RT-LAT direction. This image was superimposed with a reference image of phantom and shift accuracy calculated by ARIA-11 software was noted down. It turned out that irrespective of the position of the phantom on the couch, the calculated corrected shift and deviation from reference position was always between ± 1-2 mm which is the required accuracy for IGRT according to International Atomic Energy Agency (IAEA). This process was repeated 40 times and each time, the corrected shift came out to be ± 1-2 mm. We can conclude that our system is safe and accurate enough to perfectly position the actual patient for IGRT.

Contrast enhancement for portal images by combination of subtraction and reprojection processes for Compton scattering

For patient setup of the IGRT technique, various imaging systems are currently available. MV portal imaging is performed in identical geometry with the treatment beam so that the portal image provides accurate geometric information. However, MV imaging suffers from poor image contrast due to larger Compton scatter photons. In this work, an original image processing algorithm is proposed to improve and enhance the image contrast without increasing the imaging dose. Scatter estimation was performed in detail by MC simulation based on patient CT data. In the image processing, scatter photons were eliminated and then they were reprojected as primary photons on the assumption that Compton interaction did not take place. To improve the processing efficiency, the dose spread function within the EPID was investigated and implemented on the developed code. Portal images with and without the proposed image processing were evaluated by the image contrast profile. By the subtraction process, the image contrast was improved but the EPID signal was weakened because 15.2% of the signal was eliminated due to the contribution of scatter photons. Hence, these scatter photons were reprojected in the reprojection process. As a result, the tumor, bronchi, mediastinal space and ribs were observed more clearly than in the original image. It was clarified that image processing with the dose spread functions provides stronger contrast enhancement while maintaining a sufficient signal‐to‐noise ratio. This work shows the feasibility of improving and enhancing the contrast of portal images.

Evaluation of imaging performance of major image guidance systems

Purpose:

The imaging characteristics of two popular kV cone-beam CT (CBCT) and two MVCT systems utilised in image-guided radiation therapy (IGRT) were evaluated.

Materials and methods:

The study was performed on Varian Clinac iX, Elekta Synergy S, Siemens Oncor, and Tomotherapy. A CT phantom (Catphan-504, Phantom Laboratory, Salem, NY) was scanned for measurements of image quality including image noise, uniformity, density accuracy, spatial resolution, contrast linearity, and contrast resolution. The measurement results were analysed using in-house image analysis software. Reproducibility, position correction, and geometric accuracy were also evaluated with markers in a smaller alignment phantom. The performance evaluation compared volumetric image properties from these four systems with those from a conventional diagnostic CT (CCT).

Results:

It was shown that the linearity of the two kV CBCT was fairly consistent with CCT. The Elekta CBCT with half-circle 27-cm FOV had higher CT numbers than the other three systems. The image noises of the Elekta kV CBCT, Siemens MV CBCT, and Tomotherapy fan-beam CT (FBCT) are about 2–4 times higher than that of the Varian CBCT. The spatial resolutions of two kV CBCTs and two MV CBCTs were 8-11 lp/cm and 3-5 lp/cm, respectively.

Conclusion:

Elekta CBCT provided a faster image reconstruction and low dose per scan for half-circle scanning. Varian CBCT had relatively lower image noise. Tomotherapy FBCT had the best uniformity.

Mega-voltage versus kilo-voltage cone beam CT used in image guided radiation therapy: comparative study of microdosimetric properties

Mega-voltage computed tomography (MVCT) and kilo-voltage cone beam CT (CBCT) are routinely used in image-guided radiation therapy. In current practice, doses from MVCT and CBCT are reported with no correction for radiation quality. In this study, we compared microdosimetric properties as well as doses for MVCT and CBCT. Monte Carlo simulation codes BEAMnrc and DOSXYZnrc were used to simulate a Varian CBCT 125 kVp photon beam and primary electron spectra for CT sets of two patients. The revised Oak Ridge Electron transport Code (NOREC) was used to simulate electron tracks in liquid water. C++ code was developed to compute lineal energy in a sphere of 1 μm diameter. Dose-mean lineal energy-based quality factors were calculated for critical organs in-field. The estimated quality factor for CBCT is up to a factor of 1.3 times that of MV beams.

A dosimetric analysis of 6 MV versus 15 MV photon energy plans for intensity modulated radiation therapy (IMRT) of carcinoma of cervix

BACKGROUND

Intensity modulated radiotherapy (IMRT) is being used to treat carcinoma of cervix (Ca Cx). Integral dose to normal tissue and increased leakage are the concern about IMRT. 6 MV photon beam is a good choice of energy for Ca Cx IMRT treatment.

AIM

The objective of this study was to compare intensity modulated radiotherapy (IMRT) plans generated by 6 MV and 15 MV photon energies for carcinoma of cervix (Ca Cx) with regards to dosimetric parameters of planning target volume (PTV) and organs at risk (OAR), homogeneity index (HI), conformity index at 98% level (CI 98%), integral dose to normal tissue (NTID) and total number of monitor units (MUs).

MATERIAL AND METHODS

A cohort of 16 patients was selected for this study. All patients were to receive a dose of 50 Gy in 25 fractions. IMRT plans were generated for both energies using same dose-volume constraints.

RESULTS

Our results show a comparable coverage of planning target volume (PTV) for both energies. Volume of PTV receiving a prescription dose is 97.8 ± 0.5% and 98.8 ± 0.4% for the 6 MV and the 15 MV plans. Volume of PTV receiving a dose of 107% is 4.4 ± 7.8% and 16.1 ± 22.2%. Bladder and rectum mean doses for the 6 MV and the 15 MV photon plans were 39.8 ± 3.0 Gy and 40.0 ± 3.2 Gy, and 35.8 ± 3.1 Gy and 36.0 ± 3.1 Gy, respectively. Homogeneity index (HI) for both energies was 1.04. The conformity indices at 98% isodose (CI 98%) were 1.3 ± 0.1 and 1.4 ± 0.1 for 6 MV and 15 MV photon plans, respectively.

CONCLUSIONS

We conclude that a 6 MV photon is a good choice for Ca Cx IMRT as it produces a highly conformal, homogeneous plan with superior target coverage and better OAR sparing.

Evaluation of the effects of sagging shifts on isocenter accuracy and image quality of cone-beam CT from kV on-board imagers

To investigate the effects of sagging shifts of three on-board kV imaging systems (OBI) on the isocenter positioning accuracy and image quality of cone-beam CT (CBCT). A cubical phantom having a metal marker in the center that can be aligned with the radiation isocenter was used to measure sagging shifts and their variation with gantry angle on three Varian linacs with kV on-board imaging systems. A marker-tracking algorithm was applied to detect the shadow of the metal marker and localize its center in the two-dimensional cone-beam radiographic projections. This tracking algorithm is based on finding the position of maximum cross-correlation between a region-of-interest from a template image (including the metal marker) and the projections containing the shadow of the metal marker. Sagging shifts were corrected by mapping the center of the metal marker to a reference position for all projections acquired over a full gantry rotation (0-360 degrees). The sag-corrected radiographic projections were then used to reconstruct CBCT using Feldkamp back-projection. A standard quality assurance phantom was used to evaluate the image quality of CBCT before and after sagging correction. Sagging affects both the positioning accuracy of the OBI isocenter and the CBCT image quality. For example, on one linac, the position of the marker on the cone-beam radiographic projections depends on the angular view and has maximal shifts of about 2 mm along the imager x-direction (patient's cross-plane). Sagging produces systematic shifts of the OBI isocenter as large as 1 mm posterior and 1 mm left in patient coordinates relative to the radiation isocenter. Further, it causes spatial distortion and blurring in CBCT image reconstructed from radiographic projections that are not corrected for OBI sagging. CBCT numbers vary by about 1% in full-fan scans and up to 3.5% in half-fan scans because of sagging. In order to achieve better localization accuracy in image-guided radiation therapy, sagging shifts of the kV OBI need to be corrected. In addition, correction of sagging improves image and provides better visualization of internal structures. Frequent quality assurance is required to monitor and maintain standards of variations in the mechanical accuracy of isocenter and image quality of CBCT because of sagging shifts.

[Quality control of a kV cone beam computed tomography imaging system]

PURPOSE

This work presents the introduction of a quality assurance program for the On-Board Imager (OBI, Varian) kVCBCT system, together with the results of 1 year monthly testing.

MATERIALS AND METHODS

Firstly the geometric precision and stability of the equipment and of the associated software were evaluated using the Marker phantom. The coincidence of the accelerator isocenter and the imager isocenter was verified as well as the accuracy of the registration of kVCBCT with reference CT images. Then, the kVCBCT image quality was evaluated using the Catphan 504 phantom and ArtiScan software (Aquilab) for both full-fan (FF) and half-fan (HF) imaging modes.

RESULTS

The kVCBCT isocenter and image registration with correction of the table position were found to be within a tolerance of 2.0mm. Concerning the kVCBCT image quality, image noise and uniformity, the Hounsfield units (HU) stability and linearity, geometric distorsion and high contrast resolution were all found to be within the manufacturer's recommendations for both FF and HF modes. However, the low contrast resolution for the HF mode did not meet the manufacturer's specifications.

CONCLUSION

The quality assurance tests introduced have defined the initial system characteristics and their evolution during a period of 1 year, demonstrating the stability of the OBI.