Low dose megavoltage cone beam computed tomography with an unflattened 4 MV beam from a carbon target

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.

Improving image quality and reducing dose with 2.5 MV diamond target volume-of-interest cone beam CT imaging

PURPOSE

Over the past decades, continuous efforts have been made to improve megavoltage (MV) image quality versus dose characteristics, including the implementation of low atomic number (Z) targets in MV beamlines and the development of more efficient detectors. Recently, a diamond target beam within a commercial radiotherapy treatment platform demonstrated improved planar contrast-to-noise-ratio (CNR) per unit dose using a novel 2.5 MV sintered diamond target beam, which enabled image acquisition on the order of mGy. The present work assesses cone beam CT (CBCT) image quality characteristics for the novel 2.5 MV diamond target beam and the effects of volume-of-interest (VOI) collimation on the image quality and imaging dose distribution.

METHODS

A sintered diamond target was incorporated into the target arm of the linear accelerator, replacing the 2.5 MV commercial copper imaging target. CBCT image quality was evaluated against the commercial imaging beam with regard to spatial resolution and CNR versus dose. In addition to full-field acquisitions, we investigated VOI techniques that collimate the imaging beam to preselected anatomy, to determine potential image quality improvements and dose sparing capacity. Using an anthropomorphic phantom, VOI regions were defined to encompass the maxillary and ethmoid sinuses and ranged in dimension from 3 cm to 4.85 cm equivalent radius. The MLC was fit to each VOI structure throughout a full CBCT arc and the corresponding MLC sequences were produced as XML scripts for acquisition. Calibrated radiochromic film was used in phantom to measure cumulative axial dose distributions during each CBCT acquisition.

RESULTS

In full-field CBCT, the 2.5 MV diamond target beam demonstrated improved CNR versus dose compared to the commercial imaging beam, by factors of up to 1.7. The calculated modulation transfer function (MTF) displayed an increase of nearly 30% in f₅₀ for the 2.5 MV diamond target beam compared to the commercial beam. Using VOI techniques, CNR increased monotonically as a function of equivalent radius at the bone-tissue interface. At the bone-sinus interface, the CNR for the full-field case was slightly decreased compared to the largest VOI case. Imaging dose in the anteroposterior direction increased with increasing VOI equivalent radius.

CONCLUSION

The novel 2.5 MV sintered diamond target beam presents a simple modification to the commercial imaging beam which provides improved image quality in full-field CBCT and the potential for simultaneous dose sparing and CNR improvement at high-contrast interfaces using VOI acquisition techniques.

Treatment planning with a 2.5 MV photon beam for radiation therapy

PURPOSE

The shallow depth of maximum dose and higher dose fall-off gradient of a 2.5 MV beam along the central axis that is available for imaging on linear accelerators is investigated for treatment of shallow tumors and sparing the organs at risk (OARs) beyond it. In addition, the 2.5 MV beam has an energy bridging the gap between kilo-voltage (kV) and mega-voltage (MV) beams for applications of dose enhancement with high atomic number (Z) nanoparticles.

METHODS

We have commissioned and utilized a MATLAB-based, open-source treatment planning software (TPS), matRad, for intensity-modulated radiation therapy (IMRT) dose calculations. Treatment plans for prostate, liver, and head and neck (H&N), nasal cavity, two orbit cases, and glioblastoma multiforme (GBM) were performed and compared to a conventional 6 MV beam. Additional Monte Carlo calculations were also used for benchmarking the central axis dose.

RESULTS

Both beams had similar planning target volume (PTV) dose coverage for all cases. However, the 2.5 MV beam deposited 6%-19% less integral doses to the nasal cavity, orbit, and GBM cases than 6 MV photons. The mean dose to the heart in the liver plan was 10.5% lower for 2.5 MV beam. The difference between the doses to OARs of H&N for two beams was under 3%. Brain mean dose, brainstem, and optic chiasm max doses were, respectively, 7.5%-14.9%, 2.2%-8.1%, and 2.5%-19.0% lower for the 2.5 MV beam in the nasal cavity, orbit, and GBM plans.

CONCLUSIONS

This study demonstrates that the 2.5 MV beam can produce clinically relevant treatment plans, motivating future efforts for design of single-energy LINACs. Such a machine will be capable of producing beams at this energy beneficial for low- and middle-income countries, and investigations on dose enhancement from high-Z nanoparticles.

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.

Investigation of planar image quality for a novel 2.5 MV diamond target beam from a radiotherapy linear accelerator

Background and purpose

A commercial 2.5 MV beam has been clinically available for beam’s-eye-view imaging in radiotherapy, offering improved contrast-to-noise ratio (CNR) compared to therapeutic beams, due to the softer spectrum. Previous research suggested that imaging performance could be improved using a low-Z diamond target to reduce the self-absorption of diagnostic energy photons. The aim of this study was to 1) investigate the feasibility of two 2.5 MV diamond target beamline configurations and 2) characterize the dosimetry and planar image quality of these novel low-Z beams.

Materials and methods

The commercial 2.5 MV beam was modified by replacing the copper target with sintered diamond. Two beamlines were investigated: a carousel-mounted diamond target beamline and a ‘conventional’ beamline, with the diamond target in the target arm. Planar image quality was assessed in terms of spatial resolution and CNR.

Results

Due to image artifacts, image quality could not be assessed for the carousel-mounted low-Z target beam. The ‘conventional’ 2.5 MV low-Z beam quality was softer by 2.7% compared to the commercial imaging beam, resulting in improved CNR by factors of up to 1.3 and 1.7 in thin and thick phantoms, respectively. In regard to spatial resolution, the ‘conventional’ 2.5 MV low-Z beam slightly outperformed the commercial imaging beam.

Conclusion

With a simple modification to the 2.5 MV commercial beamline, we produced an improved energy spectrum for imaging. This 2.5 MV diamond target beam proved to be an advantageous alternative to the commercial target configuration, offering both superior resolution and CNR.

Management of radiotherapy patients with implanted cardiac pacemakers and defibrillators: A Report of the AAPM TG-203†

Managing radiotherapy patients with implanted cardiac devices (implantable cardiac pacemakers and implantable cardioverter-defibrillators) has been a great practical and procedural challenge in radiation oncology practice. Since the publication of the AAPM TG-34 in 1994, large bodies of literature and case reports have been published about different kinds of radiation effects on modern technology implantable cardiac devices and patient management before, during, and after radiotherapy. This task group report provides the framework that analyzes the potential failure modes of these devices and lays out the methodology for patient management in a comprehensive and concise way, in every step of the entire radiotherapy process.

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.

Image guidance and positioning accuracy in clinical practice: influence of positioning errors and imaging dose on the real dose distribution for head and neck cancer treatment

BACKGROUND

Modern radiotherapy offers the possibility of highly accurate tumor treatment. To benefit from this precision at its best, regular positioning verification is necessary. By the use of image-guided radiotherapy and the application of safety margins the influence of positioning inaccuracies can be counteracted. In this study the effect of additional imaging dose by set-up verification is compared with the effect of dose smearing by positioning inaccuracies for a collective of head-and-neck cancer patients.

METHODS

This study is based on treatment plans of 40 head-and-neck cancer patients. To evaluate the imaging dose several image guidance scenarios with different energies, techniques and frequencies were simulated and added to the original plan. The influence of the positioning inaccuracies was assessed by the use of real applied table shifts for positioning. The isocenters were shifted back appropriately to these values to simulate that no positioning correction had been performed. For the single fractions the shifted plans were summed considering three different scenarios: The summation of only shifted plans, the consideration of the original plan for the fractions with set-up verification, and the addition of the extra imaging dose to the latter. For both effects (additional imaging dose and dose smearing), plans were analyzed and compared considering target coverage, sparing of organs at risk (OAR) and normal tissue complication probability (NTCP).

RESULTS

Daily verification of the patient positioning using 3D imaging with MV energies result in non-negligible high doses. kV imaging has only marginal influence on plan quality, primarily related to sparing of organs at risk, even with daily 3D imaging. For this collective, sparing of organs at risk and NTCP are worse due to potential positioning errors.

CONCLUSION

Regular set-up verification is essential for precise radiation treatment. Relating to the additional dose, the use of kV modalities is uncritical for any frequency and technique. Dose smearing due to positioning errors for this collective mainly resulted in a decrease of OAR sparing. Target coverage also suffered from the positioning inaccuracies, especially for individual patients. Taking into account both examined effects the relevance of an extensive IGRT is clearly present, even at the expense of additional imaging dose and time expenditure.

Comparison between manual and automatic image registration in image-guided radiation therapy using megavoltage cone-beam computed tomography with an imaging beam line for prostate cancer

This study aimed to compare and assess the compatibility of the bone-structure-based manual and maximization of mutual information (MMI)-algorithm-based automatic image registration using megavoltage cone-beam computed tomography (MV-CBCT) images acquired with an imaging beam line. A total of 1163 MV-CBCT images from 30 prostate cancer patients were retrospectively analyzed. The differences between setup errors in three directions (left-right, LR; superior-inferior, SI; anterior-posterior, AP) of both registration methods were investigated. Pearson's correlation coefficients (r) and Bland-Altman agreements were evaluated. Agreements were defined by a bias close to zero and 95% limits of agreement (LoA) less than ± 3 mm. The cumulative frequencies of the absolute differences between the two registration methods were calculated to assess the distributions of the setup error differences. There were significant differences (p < 0.001) in the setup errors between both registration methods. There were moderate (SI, r = 0.45) and strong positive correlation coefficients (LR, r = 0.74; AP, r = 0.72), whereas the 95% LoA (bias ± 1.96 × standard deviation of the setup error differences) were - 1.61 ± 4.29 mm (LR), - 0.41 ± 5.45 mm (SI), and 0.67 ± 4.29 mm (AP), revealing no agreements in all directions. The cumulative frequencies (%) of the cases with absolute setup error differences within 3 mm in each direction were 80.83% (LR), 81.86% (SI), and 90.71% (AP), with all directions having large proportions of > 3-mm differences. The MMI-algorithm-based automatic registration is not compatible with the bone-structure-based manual registration and should not be used alone for prostate cancer.

Imaging dose and secondary cancer risk in image-guided radiotherapy of pediatric patients

BACKGROUND

Daily image-guided radiotherapy (IGRT) can contribute to cover extended body volumes with low radiation dose. The effect of additional imaging dose on secondary cancer development is modelled for a collective of children with Morbus Hodgkin.

METHODS

Eleven radiotherapy treatment plans from pediatric patients with Hodgkin's lymphoma were retrospectively analyzed, including imaging dose from scenarios using different energies (kV/MV) and planar/cone-beam computed tomography (CBCT) techniques. In addition to assessing the effect of imaging dose on organs at risk, the excess average risk (EAR) for developing a secondary carcinoma of the lung or breast was modelled.

RESULTS

Although the variability between the patients is relatively large due to the different target volumes, the additional EAR due to imaging can be consistently determined. For daily 6MV CBCT, the EAR for developing a secondary cancer at age 50 is over 3 cases per 104 PY (patient-years) for the female breast and 0.7-0.8 per 104 PY for the lungs. This can be decreased by using only planar images (< 1 per 104 PY for the breast and 0.1 for the lungs). Similar values are achieved by daily 360° kV CBCT (0.44-0.57 per 104 PY for the breast and 0.08 per 104 PY for the lungs), which is again reduced for daily 200° kV CBCT (0.02 per 104 PY for the lungs and 0.07-0.08 per 104 PY for the breast). These values increase if an older attained age is considered (e.g., for 70 years, by a factor of four for the lungs).

CONCLUSIONS

Daily imaging can be performed with an additional secondary cancer risk of less than 1 per 104 PY if kV CBCT is applied. If MV modalities must be chosen, a similar EAR can be achieved with planar images. A further reduction in risk is possible if the imaging geometry allows for sparing of the breast by a partial rotation underneath the patient.

Image guidance doses delivered during radiotherapy: Quantification, management, and reduction: Report of the AAPM Therapy Physics Committee Task Group 180

BACKGROUND

With radiotherapy having entered the era of image guidance, or image-guided radiation therapy (IGRT), imaging procedures are routinely performed for patient positioning and target localization. The imaging dose delivered may result in excessive dose to sensitive organs and potentially increase the chance of secondary cancers and, therefore, needs to be managed.

AIMS

This task group was charged with: a) providing an overview on imaging dose, including megavoltage electronic portal imaging (MV EPI), kilovoltage digital radiography (kV DR), Tomotherapy MV-CT, megavoltage cone-beam CT (MV-CBCT) and kilovoltage cone-beam CT (kV-CBCT), and b) providing general guidelines for commissioning dose calculation methods and managing imaging dose to patients.

MATERIALS & METHODS

We briefly review the dose to radiotherapy (RT) patients resulting from different image guidance procedures and list typical organ doses resulting from MV and kV image acquisition procedures.

RESULTS

We provide recommendations for managing the imaging dose, including different methods for its calculation, and techniques for reducing it. The recommended threshold beyond which imaging dose should be considered in the treatment planning process is 5% of the therapeutic target dose.

DISCUSSION

Although the imaging dose resulting from current kV acquisition procedures is generally below this threshold, the ALARA principle should always be applied in practice. Medical physicists should make radiation oncologists aware of the imaging doses delivered to patients under their care.

CONCLUSION

Balancing ALARA with the requirement for effective target localization requires that imaging dose be managed based on the consideration of weighing risks and benefits to the patient.

Super-resolution imaging in a multiple layer EPID

A new portal imager consisting of four vertically stacked conventional electronic portal imaging device (EPID) layers has been constructed in pursuit of improved detective quantum efficiency (DQE). We hypothesize that super-resolution (SR) imaging can also be achieved in such a system by shifting each layer laterally by half a pixel relative to the layer above. Super-resolution imaging will improve resolution and contrast-to-noise ratio (CNR) in megavoltage (MV) planar and cone beam computed tomography (MV-CBCT) applications. Simulations are carried out to test this hypothesis with digital phantoms. To assess planar resolution, 2 mm long iron rods with 0.3 × 0.3 mm² square cross-section are arranged in a grid pattern at the center of a 1 cm thick solid water. For measuring CNR in MV-CBCT, a 20 cm diameter digital phantom with 8 inserts of different electron densities is used. For measuring resolution in MV-CBCT, a digital phantom featuring a bar pattern similar to the Gammex™ phantom is used. A 6 MV beam is attenuated through each phantom and detected by each of the four detector layers. Fill factor of the detector is explicitly considered. Projections are blurred with an estimated point spread function (PSF) before super-resolution reconstruction. When projections from multiple shifted layers are used in SR reconstruction, even a simple shift-add fusion can significantly improve the resolution in reconstructed images. In the reconstructed planar image, the grid pattern becomes visually clearer. In MV-CBCT, combining projections from multiple layers results in increased CNR and resolution. The inclusion of two, three and four layers increases CNR by 40%, 70% and 99%, respectively. Shifting adjacent layers by half a pixel almost doubles resolution. In comparison, using four perfectly aligned layers does not improve resolution relative to a single layer.

Influence of daily imaging on plan quality and normal tissue toxicity for prostate cancer radiotherapy

Background

Modern radiotherapy offers various possibilities for image guided verification of patient positioning. Different clinically relevant IGRT (image guided radiotherapy) scenarios were considered with regard to their influence on dosimetric plan quality and normal tissue complication probability (NTCP).

Methods

This study is based on treatment plans of 50 prostate patients. We evaluate the clinically performed IGRT and simulate the influence of different daily IGRT scenarios on plan quality. Imaging doses of planar and cone-beam-CT (CBCT) images for three different energies (6 MV, 1 MV and 121 kV) were added to the treatment plans. The plan quality of the different scenarios was assessed by a visual inspection of the dose distribution and dose-volume-histogram (DVH) and a statistical analysis of DVH criteria. In addition, an assessment of the normal tissue complication probability was performed.

Results

Daily 1MV-CBCTs result in undesirable high dose regions in the target volume. The DVH shows that the scenarios with actual imaging performed, daily kV-CBCT and daily 6MV imaging (1x CBCT, 4x planar images per week) do not differ exceedingly from the original plan; especially imaging with daily kV-CBCT has little influence to the sparing of organs at risk. In contrast, daily 1MV- CBCT entails an additional dose of up to two fraction doses. Due to the additional dose amount some DVH constraints for plan acceptability could no longer be satisfied, especially for the daily 1MV-CBCT scenario. This scenario also shows increased NTCP for the rectum.

Conclusion

Daily kV-CBCT has negligible influence on plan quality and is commendable for the clinical routine. If no kV-modality is available, a daily IGRT scenario with one CBCT per week and planar axial images on the other days should be preferred over daily MV-CBCT.

Characterization of a 2.5 MV inline portal imaging beam

A new megavoltage (MV) energy was recently introduced on Varian TrueBeam linear accelerators for imaging applications. This work describes the experimental characterization of a 2.5 MV inline portal imaging beam for commissioning, routine clinical use, and quality assurance purposes. The beam quality of the 2.5 MV beam was determined by measuring a percent depth dose, PDD, in water phantom for 10 × 10 cm2 field at source-to-surface distance 100 cm with a CC13 ion chamber, plane parallel Markus chamber, and GafChromic EBT3 film. Absolute dosimetric output calibration of the beam was performed using a traceable calibrated ionization chamber, following the AAPM Task Group 51 procedure. EBT3 film measurements were also performed to measure entrance dose. The output stability of the imaging beam was monitored for five months. Coincidence of 2.5 MV imaging beam with 6 MV therapy beam was verified with hidden-target cubic phantom. Image quality was studied using the Leeds and QC3 phantom. The depth of maximum dose, dmax, and percent dose at 10 cm depth were, respectively, 5.7 mm and 51.7% for CC13, 6.1 mm and 51.9% for Markus chamber, and 5.1 mm and 51.9% for EBT3 film. The 2.5 MV beam quality is slightly inferior to that of a 60Co teletherapy beam; however, an estimated kQ of 1.00 was used for output calibration purposes. The beam output was found to be stable to within 1% over a five-month period. The relative entrance dose as measured with EBT3 films was 63%, compared to 23% for a clinical 6 MV beam for a 10 × 10 cm2 field. Overall coincidence of the 2.5 MV imaging beam with the 6 MV clinical therapy beam was within 0.2 mm. Image quality results for two com-monly used imaging phantoms were superior for the 2.5 MV beam when compared to the conventional 6 MV beam. The results from measurements on two TrueBeam accelerators show that 2.5 MV imaging beam is slightly softer than a therapeutic 60Co beam, it provides superior image quality than a 6 MV therapy beam, and has excellent output stability. These 2.5 MV beam characterization results can serve as reference for clinics planning to commission and use this novel energy-image modality.

Low-dose 2.5 MV cone-beam computed tomography with thick CsI flat-panel imager

Most of the treatment units, both new and old models, are equipped with a megavoltage portal imager but its use for volumetric imaging is limited. This is mainly due to the poor image quality produced by the high‐energy treatment beam (>6 MV). A linac at our center is equipped with a prototype 2.5 MV imaging beam. This study evaluates the feasibility of low‐dose megavoltage cone‐beam imaging with the 2.5 MV beam and a thick cesium iodide detector, which is a high‐efficiency imager. Basic imaging properties such as spatial resolution and modulation transfer function were assessed for the 2.5 MV prototype imaging system. For image quality and imaging dose, a series of megavoltage cone‐beam scans were acquired for the head, thorax, and pelvis of an anthropomorphic phantom and were compared to kilovoltage cone‐beam and 6X megavoltage cone‐beam images. To demonstrate the advantage of MV imaging, a phantom with metallic inserts was scanned and the image quality was compared to CT and kilovoltage cone‐beam scans. With a lower energy beam and higher detector efficiency, the 2.5 MV imaging system generally yields better image quality than does the 6 MV imaging system with the conventional MV imager. In particular, with the anthropomorphic phantom studies, the contrast to noise of bone to tissue is generally improved in the 2.5 MV images compared to 6 MV. With an image quality sufficient for bony alignment, the imaging dose for 2.5 MV cone‐beam images is 2.4−3.4 MU compared to 26 MU in 6 MV cone‐beam scans for the head, thorax, and pelvis regions of the phantom. Unlike kilovoltage cone‐beam, the 2.5 MV imaging system does not suffer from high‐Z image artifacts. This can be very useful for treatment planning in cases where high‐Z prostheses are present.

PACS number(s): 87.57.Q‐

Assessment of image quality and dose calculation accuracy on kV CBCT, MV CBCT, and MV CT images for urgent palliative radiotherapy treatments

A clinical workflow was developed for urgent palliative radiotherapy treatments that integrates patient simulation, planning, quality assurance, and treatment in one 30‐minute session. This has been successfully tested and implemented clinically on a linac with MV CBCT capabilities. To make this approach available to all clinics equipped with common imaging systems, dose calculation accuracy based on treatment sites was assessed for other imaging units. We evaluated the feasibility of palliative treatment planning using on‐board imaging with respect to image quality and technical challenges. The purpose was to test multiple systems using their commercial setup, disregarding any additional in‐house development. kV CT, kV CBCT, MV CBCT, and MV CT images of water and anthropomorphic phantoms were acquired on five different imaging units (Philips MX8000 CT Scanner, and Varian TrueBeam, Elekta VersaHD, Siemens Artiste, and Accuray Tomotherapy linacs). Image quality (noise, contrast, uniformity, spatial resolution) was evaluated and compared across all machines. Using individual image value to density calibrations, dose calculation accuracies for simple treatment plans were assessed for the same phantom images. Finally, image artifacts on clinical patient images were evaluated and compared among the machines. Image contrast to visualize bony anatomy was sufficient on all machines. Despite a high noise level and low contrast, MV CT images provided the most accurate treatment plans relative to kV CT‐based planning. Spatial resolution was poorest for MV CBCT, but did not limit the visualization of small anatomical structures. A comparison of treatment plans showed that monitor units calculated based on a prescription point were within 5% difference relative to kV CT‐based plans for all machines and all studied treatment sites (brain, neck, and pelvis). Local dose differences >5% were found near the phantom edges. The gamma index for 3%/3 mm criteria was ≥95% in most cases. Best dose calculation results were obtained when the treatment isocenter was near the image isocenter for all machines. A large field of view and immediate image export to the treatment planning system were essential for a smooth workflow and were not provided on all devices. Based on this phantom study, image quality of the studied kV CBCT, MV CBCT, and MV CT on‐board imaging devices was sufficient for treatment planning in all tested cases. Treatment plans provided dose calculation accuracies within an acceptable range for simple, urgently planned palliative treatments. However, dose calculation accuracy was compromised towards the edges of an image. Feasibility for clinical implementation should be assessed separately and may be complicated by machine specific features. Image artifacts in patient images and the effect on dose calculation accuracy should be assessed in a separate, machine‐specific study.

PACS number(s): 87.55.D‐, 87.57.C‐, 87.57.Q‐

Feasibility of MV CBCT-based treatment planning for urgent radiation therapy: dosimetric accuracy of MV CBCT-based dose calculations

Unlike scheduled radiotherapy treatments, treatment planning time and resources are limited for emergency treatments. Consequently, plans are often simple 2D image‐based treatments that lag behind technical capabilities available for nonurgent radiotherapy. We have developed a novel integrated urgent workflow that uses onboard MV CBCT imaging for patient simulation to improve planning accuracy and reduce the total time for urgent treatments. This study evaluates both MV CBCT dose planning accuracy and novel urgent workflow feasibility for a variety of anatomic sites. We sought to limit local mean dose differences to less than 5% compared to conventional CT simulation. To improve dose calculation accuracy, we created separate Hounsfield unit–to–density calibration curves for regular and extended field‐of‐view (FOV) MV CBCTs. We evaluated dose calculation accuracy on phantoms and four clinical anatomical sites (brain, thorax/spine, pelvis, and extremities). Plans were created for each case and dose was calculated on both the CT and MV CBCT. All steps (simulation, planning, setup verification, QA, and dose delivery) were performed in one 30 min session using phantoms. The monitor units (MU) for each plan were compared and dose distribution agreement was evaluated using mean dose difference over the entire volume and gamma index on the central 2D axial plane. All whole‐brain dose distributions gave gamma passing rates higher than 95% for 2%/2 mm criteria, and pelvic sites ranged between 90% and 98% for 3%/3 mm criteria. However, thoracic spine treatments produced gamma passing rates as low as 47% for 3%/3 mm criteria. Our novel MV CBCT‐based dose planning and delivery approach was feasible and time‐efficient for the majority of cases. Limited MV CBCT FOV precluded workflow use for pelvic sites of larger patients and resulted in image clearance issues when tumor position was far off midline. The agreement of calculated MU on CT and MV CBCT was acceptable for all treatment sites.

PACS numbers: 87.55.D‐, 87.57.Q‐

Imaging dose from cone beam computed tomography in radiation therapy

Imaging dose in radiation therapy has traditionally been ignored due to its low magnitude and frequency in comparison to therapeutic dose used to treat patients. The advent of modern, volumetric, imaging modalities, often as an integral part of linear accelerators, has facilitated the implementation of image-guided radiation therapy (IGRT), which is often accomplished by daily imaging of patients. Daily imaging results in additional dose delivered to patient that warrants new attention be given to imaging dose. This review summarizes the imaging dose delivered to patients as the result of cone beam computed tomography (CBCT) imaging performed in radiation therapy using current methods and equipment. This review also summarizes methods to calculate the imaging dose, including the use of Monte Carlo (MC) and treatment planning systems (TPS). Peripheral dose from CBCT imaging, dose reduction methods, the use of effective dose in describing imaging dose, and the measurement of CT dose index (CTDI) in CBCT systems are also reviewed.

Optimization of the design of thick, segmented scintillators for megavoltage cone-beam CT using a novel, hybrid modeling technique

PURPOSE

Active matrix flat-panel imagers (AMFPIs) incorporating thick, segmented scintillators have demonstrated order-of-magnitude improvements in detective quantum efficiency (DQE) at radiotherapy energies compared to systems based on conventional phosphor screens. Such improved DQE values facilitate megavoltage cone-beam CT (MV CBCT) imaging at clinically practical doses. However, the MV CBCT performance of such AMFPIs is highly dependent on the design parameters of the scintillators. In this paper, optimization of the design of segmented scintillators was explored using a hybrid modeling technique which encompasses both radiation and optical effects.

METHODS

Imaging performance in terms of the contrast-to-noise ratio (CNR) and spatial resolution of various hypothetical scintillator designs was examined through a hybrid technique involving Monte Carlo simulation of radiation transport in combination with simulation of optical gain distributions and optical point spread functions. The optical simulations employed optical parameters extracted from a best fit to measurement results reported in a previous investigation of a 1.13 cm thick, 1016 μm pitch prototype BGO segmented scintillator. All hypothetical designs employed BGO material with a thickness and element-to-element pitch ranging from 0.5 to 6 cm and from 0.508 to 1.524 mm, respectively. In the CNR study, for each design, full tomographic scans of a contrast phantom incorporating various soft-tissue inserts were simulated at a total dose of 4 cGy.

RESULTS

Theoretical values for contrast, noise, and CNR were found to be in close agreement with empirical results from the BGO prototype, strongly supporting the validity of the modeling technique. CNR and spatial resolution for the various scintillator designs demonstrate complex behavior as scintillator thickness and element pitch are varied--with a clear trade-off between these two imaging metrics up to a thickness of ~3 cm. Based on these results, an optimization map indicating the regions of design that provide a balance between these metrics was obtained. The map shows that, for a given set of optical parameters, scintillator thickness and pixel pitch can be judiciously chosen to maximize performance without resorting to thicker, more costly scintillators.

CONCLUSIONS

Modeling radiation and optical effects in thick, segmented scintillators through use of a hybrid technique can provide a practical way to gain insight as to how to optimize the performance of such devices in radiotherapy imaging. Assisted by such modeling, the development of practical designs should greatly facilitate low-dose, soft tissue visualization employing MV CBCT imaging in external beam radiotherapy.

Image quality and dose distributions of three linac-based imaging modalities

BACKGROUND AND PURPOSE

Linac-based patient imaging is possible with a variety of techniques using different photon energies. The purpose of this work is to compare three imaging systems operating at 6 MV, flattening free filter (FFF) 1 MV, and 121 kV.

PATIENTS AND METHODS

The dose distributions of all pretreatment set-up images (over 1,000) were retrospectively calculated on the planning computed tomography (CT) images for all patients with prostate and head-and-neck cancer treated at our institution in 2013. We analyzed the dose distribution and the dose to organs at risk.

RESULTS

For head-and-neck cancer patients, the imaging dose from 6-MV cone beam CT (CBCT) reached maximum values at around 8 cGy. The 1-MV CBCT dose was about 63-79 % of the 6-MV CBCT dose for all organs at risk. Planar imaging reduced the imaging dose from CBCT to 30-40 % for both megavoltage modalities. The dose from the kilovoltage CBCT was 4-10 % of the 6-MV CBCT dose. For prostate cancer patients, the maximum dose from 6-MV CBCT reached 13-15 cGy, and was reduced to 66-73 % for 1 MV. Planar imaging reduces the MV CBCT dose to 10-20 %. The kV CBCT dose is 15-20 % of the 6-MV CBCT dose, slightly higher than the dose from MV axes. The dose distributions differ markedly in response to the different beam profiles and dose-depth characteristics.

A Monte Carlo investigation of low-Z target image quality generated in a linear accelerator using Varian's VirtuaLinac

PURPOSE

The focus of this work was the demonstration and validation of VirtuaLinac with clinical photon beams and to investigate the implementation of low-Z targets in a TrueBeam linear accelerator (Linac) using Monte Carlo modeling.

METHODS

VirtuaLinac, a cloud based web application utilizing Geant4 Monte Carlo code, was used to model the Linac treatment head components. Particles were propagated through the lower portion of the treatment head using BEAMnrc. Dose distributions and spectral distributions were calculated using DOSXYZnrc and BEAMdp, respectively. For validation, 6 MV flattened and flattening filter free (FFF) photon beams were generated and compared to measurement for square fields, 10 and 40 cm wide and at dmax for diagonal profiles. Two low-Z targets were investigated: a 2.35 MeV carbon target and the proposed 2.50 MeV commercial imaging target for the TrueBeam platform. A 2.35 MeV carbon target was also simulated in a 2100EX Clinac using BEAMnrc. Contrast simulations were made by scoring the dose in the phosphor layer of an IDU20 aSi detector after propagating through a 4 or 20 cm thick phantom composed of water and ICRP bone.

RESULTS

Measured and modeled depth dose curves for 6 MV flattened and FFF beams agree within 1% for 98.3% of points at depths greater than 0.85 cm. Ninety three percent or greater of points analyzed for the diagonal profiles had a gamma value less than one for the criteria of 1.5 mm and 1.5%. The two low-Z target photon spectra produced in TrueBeam are harder than that from the carbon target in the Clinac. Percent dose at depth 10 cm is greater by 3.6% and 8.9%; the fraction of photons in the diagnostic energy range (25-150 keV) is lower by 10% and 28%; and contrasts are lower by factors of 1.1 and 1.4 (4 cm thick phantom) and 1.03 and 1.4 (20 cm thick phantom), for the TrueBeam 2.35 MV/carbon and commercial imaging beams, respectively.

CONCLUSIONS

VirtuaLinac is a promising new tool for Monte Carlo modeling of novel target designs. A significant spectral difference is observed between the low-Z target beam on the Clinac platform and the proposed imaging beam line on TrueBeam, with the former providing greater diagnostic energy content.

Dosimetric properties and commissioning of cone-beam CT image beam line with a carbon target

BACKGROUND AND PURPOSE

Accurate patient positioning before radiotherapy is often verified using advanced imaging techniques such as cone-beam computed tomography (CBCT). Even for dedicated imaging beam lines, the applied dose is not necessarily negligible with respect to the treatment dose and should be considered in the treatment plan.

MATERIALS AND METHODS

This study presents measurements of the beam properties of the Siemens kView (Siemens AG, Munich, Germany) image beam line (IBL) and the commissioning in the Philips Pinnacle(3) treatment planning system (TPS; Philips, Amsterdam, Netherlands).

RESULTS

The percent depth dose curve reaches its maximum at a depth of 10 mm, with a surface dose of 44 %. The IBL operates in flattening filter-free mode, showing the characteristic dose falloff from the central axis. Stability over several days to months is within less than 2 % dose deviation or 1 mm distance-to-agreement. Modelling of the IBL beam line was performed using the Pinnacle(3) automatic modelling routine, with absolute dosimetric verification and film measurements of the fluence distribution.

CONCLUSION

After commissioning of the IBL beam model, the dose from the imaging IBL CBCT can be calculated. Even if the absolute dose deposited is small, repeated imaging doses may sum up to significant amounts and can shift the position of the dose maximum by several centimetres.

Beam quality and dose perturbation of 6 MV flattening-filter-free linac

The aim of this study is twofold: (a) determination of the spectral differences for flattening-filter-free (FFF) versus standard (STD) linac under various clinical conditions, (b) based on an extensive list of clinically important beam configurations, identification of clinical scenarios that lead to higher macroscopic dose perturbations due to the presence of high-Z material. The focus is on dose enhancement due to contrast agents including high-Z elements such as gold or gadolinium. EGSnrc was used to simulate clinical beams under various irradiation conditions: open/IMRT/spit-IMRT fields, in/out-off-field areas, different depths and field sizes. Spectra were calculated and analyzed for about 80 beams and for a total of 480 regions. Quantitative differential effects in beam quality were characterized using energy-dependent and cumulative dose perturbation metrics. Analysis of the spectral database showed that even though the general trends for both linacs (FFF/STD) were the same, there were crucial differences. In general, the relative changes between different conditions were smaller for FFF spectra. This was because of the higher component of low-energy photons of the FFF linac, which already lead to higher dose enhancement than for the STD linac (photon energies were more "uniformly" distributed for FFF spectra and henceforth their perturbation resulted in lesser relative changes). For out-of-field FFF spectra and split-IMRT fields the strongest enhancement were observed (∼25 and ∼5 respectively). Different spectral scenarios lead to different dose enhancements, however, they scale with the higher effective-Z of the materials and were directly related to the lower range of the spectra (<200 keV).

High-dose MVCT image guidance for stereotactic body radiation therapy

PURPOSE

Stereotactic body radiation therapy (SBRT) is a potent treatment for early stage primary and limited metastatic disease. Accurate tumor localization is essential to administer SBRT safely and effectively. Tomotherapy combines helical IMRT with onboard megavoltage CT (MVCT) imaging and is well suited for SBRT; however, MVCT results in reduced soft tissue contrast and increased image noise compared with kilovoltage CT. The goal of this work was to investigate the use of increased imaging doses on a clinical tomotherapy machine to improve image quality for SBRT image guidance.

METHODS

Two nonstandard, high-dose imaging modes were created on a tomotherapy machine by increasing the linear accelerator (LINAC) pulse rate from the nominal setting of 80 Hz, to 160 Hz and 300 Hz, respectively. Weighted CT dose indexes (wCTDIs) were measured for the standard, medium, and high-dose modes in a 30 cm solid water phantom using a calibrated A1SL ion chamber. Image quality was assessed from scans of a customized image quality phantom. Metrics evaluated include: contrast-to-noise ratios (CNRs), high-contrast spatial resolution, image uniformity, and percent image noise. In addition, two patients receiving SBRT were localized using high-dose MVCT scans. Raw detector data collected after each scan were used to reconstruct standard-dose images for comparison.

RESULTS

MVCT scans acquired using a pitch of 1.0 resulted in wCTDI values of 2.2, 4.7, and 8.5 cGy for the standard, medium, and high-dose modes respectively. CNR values for both low and high-contrast materials were found to increase with the square root of dose. Axial high-contrast spatial resolution was comparable for all imaging modes at 0.5 lp∕mm. Image uniformity was improved and percent noise decreased as the imaging dose increased. Similar improvements in image quality were observed in patient images, with decreases in image noise being the most notable.

CONCLUSIONS

High-dose imaging modes are made possible on a clinical tomotherapy machine by increasing the LINAC pulse rate. Increasing the imaging dose results in increased CNRs; making it easier to distinguish the boundaries of low contrast objects. The imaging dose levels observed in this work are considered acceptable at our institution for SBRT treatments delivered in 3-5 fractions.

Noise suppression in reconstruction of low-Z target megavoltage cone-beam CT images

PURPOSE

To improve the image contrast-to-noise (CNR) ratio for low-Z target megavoltage cone-beam CT (MV CBCT) using a statistical projection noise suppression algorithm based on the penalized weighted least-squares (PWLS) criterion.

METHODS

Projection images of a contrast phantom, a CatPhan(®) 600 phantom and a head phantom were acquired by a Varian 2100EX LINAC with a low-Z (Al) target and low energy x-ray beam (2.5 MeV) at a low-dose level and at a high-dose level. The projections were then processed by minimizing the PWLS objective function. The weighted least square (WLS) term models the noise of measured projection and the penalty term enforces the smoothing constraints of the projection image. The variance of projection data was chosen as the weight for the PWLS objective function and it determined the contribution of each measurement. An anisotropic quadratic form penalty that incorporates the gradient information of projection image was used to preserve edges during noise reduction. Low-Z target MV CBCT images were reconstructed by the FDK algorithm after each projection was processed by the PWLS smoothing.

RESULTS

Noise in low-Z target MV CBCT images were greatly suppressed after the PWLS projection smoothing, without noticeable sacrifice of the spatial resolution. Depending on the choice of smoothing parameter, the CNR of selected regions of interest in the PWLS processed low-dose low-Z target MV CBCT image can be higher than the corresponding high-dose image.

CONCLUSION

The CNR of low-Z target MV CBCT images was substantially improved by using PWLS projection smoothing. The PWLS projection smoothing algorithm allows the reconstruction of high contrast low-Z target MV CBCT image with a total dose of as low as 2.3 cGy.

Radiation dose and contralateral breast cancer risk associated with megavoltage cone-beam computed tomographic image verification in breast radiation therapy

PURPOSE

To measure and compare organ doses from a standard tangential breast radiation therapy treatment (50 Gy delivered in 25 fractions) and a megavoltage cone-beam computed tomography (MV-CBCT), taken for weekly image verification, and assess the risk of radiation-induced contralateral breast cancer.

METHODS AND MATERIALS

Organ doses were measured with thermoluminescent dosimeters placed strategically within a female anthropomorphic phantom. The risk of radiation-induced secondary cancer of the contralateral breast was estimated from these values using excess absolute risk and excess relative risk models.

RESULTS

The effective dose from a MV-CBCT (8-monitor units) was 35.9 ± 0.2 mSv. Weekly MV-CBCT imaging verification contributes 0.5% and 17% to the total ipsilateral and contralateral breast dose, respectively. For a woman irradiated at age 50 years, the 10-year postirradiation excess relative risk was estimated to be 0.8 and 0.9 for treatment alone and treatment plus weekly MV-CBCT imaging, respectively. The 10-year postirradiation excess absolute risk was estimated to be 4.7 and 5.6 per 10,000 women-years.

CONCLUSIONS

The increased dose and consequent radiation-induced second cancer risk as calculated by this study introduced by the imaging verification protocols utilizing MV-CBCT in breast radiation therapy must be weighed against the benefits of more accurate treatment. As additional image verification becomes more common, it is important that data be collected in regard to long-term malignancy risk.

Influence of acquisition parameters on MV-CBCT image quality

The production of high quality pretreatment images plays an increasing role in image‐guided radiotherapy (IGRT) and adaptive radiation therapy (ART). Megavoltage cone‐beam computed tomography (MV‐CBCT) is the simplest solution of all the commercially available volumetric imaging systems for localization. It also suffers the most from relatively poor contrast due to the energy range of the imaging photons. Several avenues can be investigated to improve MV‐CBCT image quality while maintaining an acceptable patient exposure: beam generation, detector technology, reconstruction parameters, and acquisition parameters. This article presents a study of the effects of the acquisition scan length and number of projections of a Siemens Artiste MV‐CBCT system on image quality within the range provided by the manufacturer. It also discusses other aspects not related to image quality one should consider when selecting an acquisition protocol. Noise and uniformity were measured on the image of a cylindrical water phantom. Spatial resolution was measured using the same phantom half filled with water to provide a sharp water/air interface to derive the modulation transfer function (MTF). Contrast‐to‐noise ratio (CNR) was measured on a pelvis‐shaped phantom with four inserts of different electron densities relative to water (1.043, 1.117, 1.513, and 0.459). Uniformity was independent of acquisition protocol. Noise decreased from 1.96% to 1.64% when the total number of projections was increased from 100 to 600 for a total exposure of 13.5 MU. The CNR showed a∓5% dependence on the number of projections and 10% dependence on the scan length. However, these variations were not statistically significant. The spatial resolution was unaffected by the arc length or the sampling rate. Acquisition parameters have little to no effect on the image quality of the MV‐CBCT system within the range of parameters available on the system. Considerations other than image quality, such as memory storage, acquisition speed, and individual projection image quality, speak in favor of the use of a coarse sampling rate on the short scan.

PACS numbers: 87.57.C‐; 87.57.nf

Image quality of an investigational imaging panel for use with the imaging beam line cone-beam CT

The purpose of this study was to measure and compare the contrast-to-noise ratio (CNR) as a function of dose for the cone-beam CT (CBCT) produced by the imaging beam line (IBL) for the standard and an investigational imaging panel. Two Siemens Artiste linear accelerators were modified at our institution such that the MV-CBCT would operate under an investigational IBL. The imaging panel from one of the machines was replaced with an investigational imaging panel. After the modification, a set of CBCT for a large and small phantom consisting of eight tissue-equivalent inserts was acquired for the standard imager and for the investigational imager with and without the standard copper plate. Ten dose settings for each phantom using the IBL in combination with the standard and investigational imaging panel were acquired. The CNR for each tissue-equivalent insert was calculated. Resolution measurements in line pairs per mm (lp/mm) of the CBCT for the various imaging panel setups were made. In addition, CBCT images of two patients that were imaged with each panel configuration were displayed for a group of physicians and therapists who were asked to identify the best and worst CBCT for each patient. This was used as a qualitative judge of practical image quality. The CNR of the muscle insert for the large phantom with 1.5 cGy at isocenter was 1.3 for the standard imager, 1.5 for the investigational imager with the copper plate, and 1.9 without the plate. Under the same conditions, the CNR of the trabecular bone insert was 5.9, 7.3, and 9.7, respectively. For the small phantom with the same dose to isocenter, the CNR for muscle was 1.7, 2.1, and 3.3, respectively. For the trabecular bone, the CNR was 8.1, 9.6, and 12.1 respectively. The resolution for 1 cGy at isocenter was 0.37 lp/mm for the standard imager, 0.32 and 0.33 for the investigational imager with and without the copper plate. The qualitative test ranked the CBCT of the investigational imager without the copper plate to be the best image, and the standard imager to be the worst. The investigational imaging panel improves image quality as compared to the standard imager for IBL CBCTs. A 1 cGy IBL CBCT, no matter which imager is used, is sufficient for bony anatomy localization. The investigational imager without the copper plate was judged clinically to produce the best IBL CBCT.

Dependence of intrafraction motion on fraction duration for pediatric patients with brain tumors

The purpose of this study was to quantify the intrafraction motion of pediatric patients with brain tumors during radiation therapy and investigate any correlation between motion, use of general anesthesia, and daily treatment duration. 100 pediatric patients with a mean age of 8.5 years (range: 1.0 to 17.8) were included in this prospective study. Forty-one patients required general anesthesia during treatment, mean age 4.8 years; 59 patients did not, mean age 11.2 years. Each patient had an intracranial tumor and was treated in the supine position with a thermoplastic facemask and headrest for immobilization. A pretreatment localization CBCT was acquired for each treatment fraction and a post-treatment CBCT was acquired every other fraction. If the magnitude of the patient's position pre-CBCT offset was ≥ 2 mm, the position was corrected. The difference between the patient's position based on the post-CBCT and the assumed position at the start of treatment (either the pre-CBCT offset if the magnitude was < 2 mm, or 0 offset due to correction) was determined and labeled intrafraction motion. Correlations between daily treatment duration and intrafraction motion were examined. There was an average of 14.2 post-CBCTs acquired per patient. The magnitude of the mean intrafraction motion was 1.2 ± 0.8 mm for patients requiring general anesthesia, and 1.5 ± 1.2 mm for those without (p < 0.001). The mean offset in each direction was less than 0.5 mm for both cohorts. There was no correlation between daily treatment duration and the magnitude of intrafraction motion. The intrafraction motion of pediatric patients undergoing external beam therapy for intracranial tumors is small, < 2 mm, and is independent of the daily treatment duration.

Comparative study of a low-Z cone-beam computed tomography system

Computed tomography images have been acquired using an experimental (low atomic number (Z) insert) megavoltage cone-beam imaging system. These images have been compared with standard megavoltage and kilovoltage imaging systems. The experimental system requires a simple modification to the 4 MeV electron beam from an Elekta Precise linac. Low-energy photons are produced in the standard medium-Z electron window and a low-Z carbon electron absorber located after the window. The carbon electron absorber produces photons as well as ensuring that all remaining electrons from the source are removed. A detector sensitive to diagnostic x-ray energies is also employed. Quantitative assessment of cone-beam computed tomography (CBCT) contrast shows that the low-Z imaging system is an order of magnitude or more superior to a standard 6 MV imaging system. CBCT data with the same contrast-to-noise ratio as a kilovoltage imaging system (0.15 cGy) can be obtained in doses of 11 and 244 cGy for the experimental and standard 6 MV systems, respectively. Whilst these doses are high for everyday imaging, qualitative images indicate that kilovoltage like images suitable for patient positioning can be acquired in radiation doses of 1-8 cGy with the experimental low-Z system.

Dosimetric consequences of rotational errors in radiation therapy of pediatric brain tumor patients

PURPOSE

To quantify the rotational offsets and estimate the dose effect of rotation on the target volume and normal tissues in children with brain tumor.

METHODS

Twenty-one pediatric patients with brain tumors were included in this study. Cone-beam CT was performed before each treatment and at the end of every other treatment. Translational offsets were corrected before the treatment. An offline analysis was performed to quantify rotational errors. The treatment plans were altered and recalculated to simulate a rotation of 2° and 4°, and the dose changes were quantified.

RESULTS

1016 CBCT datasets were analyzed for this report. The mean of the rotations were not meaningfully different from zero. 18.1% of the fractions had rotations with a magnitude ≥2°, 5.0% had rotations ≥3° and 0.9% had rotations ≥4°. For the 2° rotational simulation, the gEUD values of the PTV and critical structures changed by less than 2%. For the 4° simulation, parallel type normal structures had minor changes (<2%), but serial type normal structures and the PTV had changes of 10% and 5%, respectively.

CONCLUSIONS

The majority of rotational errors observed were less than 1°. A rotational error of 2° produced negligible changes in the gEUD to critical structures or target volumes. Rotational errors ≥4° produced undesirable results, therefore, at a minimum, errors >2° should be corrected.

Megavoltage cone beam computed tomography dose and the necessity of reoptimization for imaging dose-integrated intensity-modulated radiotherapy for prostate cancer

PURPOSE

Megavoltage cone beam computed tomography (MV-CBCT) dose can be integrated with the patient's prescription. Here, we investigated the effects of imaging dose and the necessity for additional optimization when using intensity-modulated radiotherapy (IMRT) to treat prostate cancer.

METHODS AND MATERIALS

An arc beam mimicking MV-CBCT was generated using XiO (version 4.50; Elekta, Stockholm, Sweden). The monitor units (MU) for dose calculation were determined by conforming the calculated dose to the dose measured using an ionization chamber. IMRT treatment plans of 22 patients with prostate cancer were retrospectively analyzed. Arc beams of 3, 5, 8, and 15 MU were added to the IMRT plans, and the dose covering 95% of the planning target volume (PTV) was normalized to the prescribed dose with (reoptimization) or without optimization (compensation).

RESULTS

PTV homogeneity and conformality changed negligibly with MV-CBCT integration. For critical organs, an imaging dose-dependent increase was observed for the mean rectal/bladder dose (D(mean)), and reoptimization effectively suppressed the D(mean) elevations. The bladder generalized equivalent uniform dose (gEUD) increased with imaging dose, and reoptimization suppressed the gEUD elevation when 5- to 15-MU CBCT were added, although rectal gEUD changed negligibly with any imaging dose. Whereas the dose elevation from the simple addition of the imaging dose uniformly increased rectal and bladder dose, the rectal D(mean) increase of compensation plans was due mainly to low-dose volumes. In contrast, bladder high-dose volumes were increased by integrating the CBCT dose, and reoptimization reduced them when 5- to 15-MU CBCT were added.

CONCLUSION

Reoptimization is clearly beneficial for reducing dose to critical organs, elevated by addition of high-MU CBCT, especially for the bladder. For low-MU CBCT aimed at bony structure visualization, compensation is sufficient.