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

Set-up error validation with EPID images: Measurements vs Egs_cbct simulation

Aim

In this study, the egs_cbct code's ability to replicate an electronic portal imaging device (EPID) is explored.

Background

We have investigated head and neck (H&N) setup verification on an Elekta Precise linear accelerator. It is equipped with an electronic portal imaging device (EPID) that can capture a set of projection images over different gantry angles.

Methods and materials

Cone-beam computed tomography (CBCT) images were reconstructed from projection images of two different setup scenarios. Projections of an Anthropomorphic Rando head phantom were also simulated by using the egs_cbct Monte Carlo code for comparison with the measured projections.Afterwards, CBCT images were reconstructed from this data. Image quality was evaluated against a metric defined as the image acquisition interval (IAI). It determines the number of projection images to be used for CBCT image reconstruction.

Results

From this results it was established that phantom shifts could be determined within 2 mm and rotations within one degree accuracy using only 20 projection images (IAI = 10 degrees). Similar results were obtained with the simulated data.

Conclusion

In this study it is demonstrated that a head and neck setup can be verified using substantially fewer projection images. Bony landmarks and air cavities could still be observed in the reconstructed Rando head phantom. The egs_cbct code can be used as a tool to investigate setup errors without tedious measurements with an EPID system.

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.

Investigation of the mechanical performance of Siemens linacs components during arc: gantry, MLC, and electronic portal imaging device

Background

In radiotherapy treatments, it is crucial to monitor the performance of linac components including gantry, collimation system, and electronic portal imaging device (EPID) during arc deliveries. In this study, a simple EPID-based measurement method is suggested in conjunction with an algorithm to investigate the stability of these systems at various gantry angles with the aim of evaluating machine-related errors in treatments.

Methods

The EPID sag, gantry sag, changes in source-to-detector distance (SDD), EPID and collimator skewness, EPID tilt, and the sag in leaf bank assembly due to linac rotation were separately investigated by acquisition of 37 EPID images of a simple phantom with five ball bearings at various gantry angles. A fast and robust software package was developed for automated analysis of image data. Three Siemens linacs were investigated.

Results

The average EPID sag was within 1 mm for all tested linacs. Two machines showed >1 mm gantry sag. Changes in the SDD values were within 7.5 mm. EPID skewness and tilt values were <1° in all machines. The maximum sag in leaf bank assembly was <1 mm.

Conclusion

The method and software developed in this study provide a simple tool for effective investigation of the behavior of Siemens linac components with gantry rotation. Such a comprehensive study has been performed for the first time on Siemens machines.

Detection of prostate calcification with megavoltage helical CT

RATIONALE AND OBJECTIVES

Prostate calcification is a noninvasive landmark for daily positioning of image-guided radiation therapy. However, detectability of prostate calcification with megavoltage helical computed tomography (MVCT) has not been evaluated. The purpose of this study was to evaluate the detectability of prostate calcification and to investigate how to predict detectability of calcification with MVCT.

MATERIALS AND METHODS

Thirty patients with prostate cancer who were scheduled for helical tomotherapy were included in this study. The detectability of prostate calcification on MVCT was evaluated by comparing against kilovoltage multidetector-row CT (KVCT) as the standard of reference. Maximum signal intensity (SImax), area (A) of calcification, and the product of both (SImax·A) were compared between undetectable and detectable calcifications. Then, the threshold values of SImax, A, and SImax·A were decided to achieve 100% sensitivity on MVCT.

RESULTS

KVCT identified 49 calcifications in 28 of 30 patients. MVCT detected 19 (39%) of 49 calcifications in 15 (50%) of 30 patients. The minimum threshold values of SImax, A, and SImax·A to detect prostate calcifications were 953 HU, 20.98 mm(2), and 7784 HU mm(2), respectively. Using the threshold values of SImax, A, and SImax·A, 20% (10/49), 18% (9/49), and 35% (17/49) of calcifications were in the detection range, respectively.

CONCLUSIONS

MVCT can depict about one-third of prostate calcifications detectable on KVCT. The product of maximum signal intensity and area of calcification is the most distinguishable index for predicting patients showing prostate calcifications on MVCT.

Evaluation of the effect of respiratory and anatomical variables on a Fourier technique for markerless, self-sorted 4D-CBCT

A novel technique based on Fourier transform theory has been developed that directly extracts respiratory information from projections without the use of external surrogates. While the feasibility has been demonstrated with three patients, a more extensive validation is necessary. Therefore, the purpose of this work is to investigate the effects of a variety of respiratory and anatomical scenarios on the performance of the technique with the 4D digital extended cardiac torso phantom. FT-phase and FT-magnitude methods were each applied to identify peak-inspiration projections and quantitatively compared to the gold standard of visual identification. Both methods proved to be robust across the studied scenarios with average differences in respiratory phase <10% and percentage of projections assigned within 10% of the gold standard >90%, when incorporating minor modifications to region-of-interest (ROI) selection and/or low-frequency location for select cases of DA and lung percentage in the field of view of the projection. Nevertheless, in the instance where one method initially faltered, the other method prevailed and successfully identified peak-inspiration projections. This is promising because it suggests that the two methods provide complementary information to each other. To ensure appropriate clinical adaptation of markerless, self-sorted four-dimensional cone-beam CT (4D-CBCT), perhaps an optimal integration of the two methods can be developed.

Investigation of gated cone-beam CT to reduce respiratory motion blurring

PURPOSE

Methods of reducing respiratory motion blurring in cone-beam CT (CBCT) have been limited to lung where soft tissue contrast is large. Respiration-correlated cone-beam CT uses slow continuous gantry rotation but image quality is limited by uneven projection spacing. This study investigates the efficacy of a novel gated CBCT technique.

METHODS

In gated CBCT, the linac is programmed such that gantry rotation and kV image acquisition occur within a gate around end expiration and are triggered by an external respiratory monitor. Standard CBCT and gated CBCT scans are performed in 22 patients (11 thoracic, 11 abdominal) and a respiration-correlated CT (RCCT) scan, acquired on a standard CT scanner, from the same day serves as a criterion standard. Image quality is compared by calculating contrast-to-noise ratios (CNR) for tumors in lung, gastroesophageal junction (GEJ) tissue, and pancreas tissue, relative to surrounding background tissue. Congruence between the object in the CBCT images and that in the RCCT is measured by calculating the optimized normalized cross-correlation (NCC) following CBCT-to-RCCT rigid registrations.

RESULTS

Gated CBCT results in reduced motion artifacts relative to standard CBCT, with better visualization of tumors in lung, and of abdominal organs including GEJ, pancreas, and organs at risk. CNR of lung tumors is larger in gated CBCT in 6 of 11 cases relative to standard CBCT. A paired two-tailed t-test of lung patient mean CNR shows no statistical significance (p = 0.133). In 4 of 5 cases where CNR is not increased, lung tumor motion observed in RCCT is small (range 1.3-5.2 mm). CNR is increased and becomes statistically significant for 6 out of 7 lung patients with > 5 mm tumor motion (p = 0.044). CNR is larger in gated CBCT in 5 of 7 GEJ cases and 3 of 4 pancreas cases (p = 0.082 and 0.192). Gated CBCT yields improvement with lower NCC relative to standard CBCT in 10 of 11, 7 of 7, and 3 of 4 patients for lung, GEJ, and pancreas images, respectively (p = 0.0014, 0.0030, 0.165).

CONCLUSIONS

Gated CBCT reduces image blurring caused by respiratory motion. The gated gantry rotation yields uniformly and closely spaced projections resulting in improved reconstructed image quality. The technique is shown to be applicable to abdominal sites, where image contrast of soft tissues is low.

A novel technique for markerless, self-sorted 4D-CBCT: feasibility study

PURPOSE

Four-dimensional CBCT (4D-CBCT) imaging in the treatment room can provide verification of moving targets, facilitating the potential for margin reduction and consequent dose escalation. Reconstruction of 4D-CBCT images requires correlation of respiratory phase with projection acquisition, which is often achieved with external surrogate measures of respiration. However, external measures may not be a direct representation of the motion of the internal anatomy and it is therefore the aim of this work to develop a novel technique for markerless, self-sorted 4D-CBCT reconstruction.

METHODS

A novel 4D-CBCT reconstruction technique based on the principles of Fourier transform (FT) theory was investigated for markerless extraction of respiratory phase directly from projection data. In this FT technique, both phase information (FT-phase) and magnitude information (FT-magnitude) were separately implemented in order to discern projections corresponding to peak inspiration, which then facilitated the proceeding sort and bin processes involved in retrospective 4D image reconstruction. In order to quantitatively evaluate the accuracy of the Fourier methods, peak-inspiration projections identified each by FT-phase and FT-magnitude were compared to those manually identified by visual tracking of structures. The average phase difference as assigned by each method vs the manual technique was calculated per projection dataset. The percentage of projections that were assigned within 10% phase of each other was also computed. Both Fourier methods were tested on two phantom datasets, programmed to exhibit sinusoidal respiratory cycles of 2.0 cm in amplitude with respiratory cycle lengths of 3 and 6 s, respectively. Additionally, three sets of patient projections were studied. All of the data were previously acquired at slow-gantry speeds ranging between 0.6°/s and 0.7°/s over a 200° rotation. Ten phase bins with 10% phase windows were selected for 4D-CBCT reconstruction of one phantom and one patient case for visual and quantitative comparison. Line profiles were plotted for the 0% and 50% phase images as reconstructed by the manual technique and each of the Fourier methods.

RESULTS

As compared with the manual technique, the FT-phase method resulted in average phase differences of 1.8% for the phantom with the 3 s respiratory cycle, 3.9% for the phantom with the 6 s respiratory cycle, 2.9% for patient 1, 5.0% for patient 2, and 3.8% for patient 3. For the FT-magnitude method, these numbers were 2.1%, 4.0%, 2.9%, 5.3%, and 3.5%, respectively. The percentage of projections that were assigned within 10% phase by the FT-phase method as compared to the manual technique for the five datasets were 100.0%, 100.0%, 97.6%, 93.4%, and 94.1%, respectively, whereas for the FT-magnitude method these percentages were 98.1%, 92.3%, 98.7%, 87.3%, and 95.7%. Reconstructed 4D phase images for both the phantom and patient case were visually and quantitatively equivalent between each of the Fourier methods vs the manual technique.

CONCLUSIONS

A novel technique employing the basics of Fourier transform theory was investigated and demonstrated to be feasible in achieving markerless, self-sorted 4D-CBCT reconstruction.

Extracting respiratory signals from thoracic cone beam CT projections

The patient respiratory signal associated with the cone beam CT (CBCT) projections is important for lung cancer radiotherapy. In contrast to monitoring an external surrogate of respiration, such a signal can be extracted directly from the CBCT projections. In this paper, we propose a novel local principal component analysis (LPCA) method to extract the respiratory signal by distinguishing the respiration motion-induced content change from the gantry rotation-induced content change in the CBCT projections. The LPCA method is evaluated by comparing with three state-of-the-art projection-based methods, namely the Amsterdam Shroud method, the intensity analysis method and the Fourier-transform-based phase analysis method. The clinical CBCT projection data of eight patients, acquired under various clinical scenarios, were used to investigate the performance of each method. We found that the proposed LPCA method has demonstrated the best overall performance for cases tested and thus is a promising technique for extracting a respiratory signal. We also identified the applicability of each existing method.

Detection and correction for EPID and gantry sag during arc delivery using cine EPID imaging

PURPOSE

Electronic portal imaging devices (EPIDs) have been studied and used for pretreatment and in-vivo dosimetry applications for many years. The application of EPIDs for dosimetry in arc treatments requires accurate characterization of the mechanical sag of the EPID and gantry during rotation. Several studies have investigated the effects of gravity on the sag of these systems but each have limitations. In this study, an easy experiment setup and accurate algorithm have been introduced to characterize and correct for the effect of EPID and gantry sag during arc delivery.

METHODS

Three metallic ball bearings were used as markers in the beam: two of them fixed to the gantry head and the third positioned at the isocenter. EPID images were acquired during a 360° gantry rotation in cine imaging mode. The markers were tracked in EPID images and a robust in-house developed MATLAB code was used to analyse the images and find the EPID sag in three directions as well as the EPID + gantry sag by comparison to the reference gantry zero image. The algorithm results were then tested against independent methods. The method was applied to compare the effect in clockwise and counter clockwise gantry rotations and different source-to-detector distances (SDDs). The results were monitored for one linear accelerator over a course of 15 months and six other linear-accelerators from two treatment centers were also investigated using this method. The generalized shift patterns were derived from the data and used in an image registration algorithm to correct for the effect of the mechanical sag in the system. The Gamma evaluation (3%, 3 mm) technique was used to investigate the improvement in alignment of cine EPID images of a fixed field, by comparing both individual images and the sum of images in a series with the reference gantry zero image.

RESULTS

The mechanical sag during gantry rotation was dependent on the gantry angle and was larger in the in-plane direction, although the patterns were not identical for various linear-accelerators. The reproducibility of measurements was within 0.2 mm over a period of 15 months. The direction of gantry rotation and SDD did not affect the results by more than 0.3 mm. Results of independent tests agreed with the algorithm within the accuracy of the measurement tools. When comparing summed images, the percentage of points with Gamma index <1 increased from 85.4% to 94.1% after correcting for the EPID sag, and to 99.3% after correction for gantry + EPID sag.

CONCLUSIONS

The measurement method and algorithms introduced in this study use cine-images, are highly accurate, simple, fast, and reproducible. It tests all gantry angles and provides a suitable automatic analysis and correction tool to improve EPID dosimetry and perform comprehensive linac QA for arc treatments.

Potential underestimation of the internal target volume (ITV) from free-breathing CBCT

PURPOSE

Localization prior to delivery of SBRT to free-breathing patients is performed by aligning the planning internal target volume (ITV) from 4DCT with an on-board free-breathing cone-beam CT (FB-CBCT) image. The FB-CBCT image is assumed to also generate an ITV that captures the full range of motion, due to the acquisition spanning multiple respiratory cycles. However, the ITV could potentially be underestimated when the ratio of time spent in inspiration versus time spent in expiration (I/E ratio) deviates from unity. Therefore, the aim of this study was to investigate the effect of variable I/E ratios on the FB ITV generated from a FB-CBCT scan.

METHODS

This study employed both phantom and patient imaging data. For the phantom study, five periodic respiratory cycles were simulated with different I/E ratios. Six patient respiratory cycles with variable I/E ratios were also selected. All profiles were then programmed into a motion phantom for imaging and modified to exhibit three peak-to-peak motion amplitudes (0.5, 1.0, and 2.0 cm). Each profile was imaged using two spherical targets with 1.0 and 3.0 cm diameters. 2D projections were acquired with full gantry rotation of a kiloVoltage (kV) imager mounted onto the gantry of a modem linear accelerator. CBCT images were reconstructed from 2D projections using a standard filtered back-projection reconstruction algorithm. Quantitative analyses for the phantom study included computing the change in contrast along the direction of target motion as well as determining the area (which is proportional to the target volume) inside of the contour extracted using a Canny edge detector. For the patient study, projection data that were previously acquired under an investigational 4D CBCT slow-gantry imaging protocol were used to generate both FB-CBCT and 4D CBCT images. Volumes were then manually contoured from both datasets (using the same window and level) for quantitative comparison.

RESULTS

The phantom study indicated a reduction in contrast at the inferior edge of the ITV (corresponding to inspiration) as the ratio decreased, for both simulated and patient respiratory cycles. For the simulated phantom respiratory cycles, the contrast reduction of the smallest I/E ratio was 27.6% for the largest target with the smallest amplitude and 89.7% for the smallest target with the largest amplitude. For patient respiratory cycles, these numbers were 22.3% and 94.0%, respectively. The extracted area from inside of the target contours showed a decreasing trend as the I/E ratio decreased. In the patient study, the FB-CBCT ITVs of both lung tumors studied were underestimated when compared with their corresponding 4D CBCT ITV. The underestimations found were 40.1% for the smaller tumor and 24.2% for the larger tumor.

CONCLUSIONS

The ITV may be underestimated in a FB-CBCT image when a patient's respiratory pattern is characterized by a disparate length of time spent in inspiration versus expiration. Missing the full target motion information during on-board verification imaging may result in localization errors.

Individualized margins for prostate patients using a wireless localization and tracking system

This study investigates the dosimetric benefits of designing patient-specific margins for prostate cancer patients based on 4D localization and tracking. Ten prostate patients, each implanted with three radiofrequency transponders, were localized and tracked for 40 fractions. "Conventional margin" (CM) planning target volumes (PTV) and PTVs resulting from uniform margins of 5 mm (5M) and 7 mm (7M) were explored. Through retrospective review of each patient's tracking data, an individualized margin (IM) design for each patient was determined. IMRT treatment plans with identical constraints were generated for all four margin strategies and compared. The IM plans generally created the smallest PTV volumes. For similar PTV coverage, the IM plans had a lower mean bladder (rectal) dose by an average of 3.9% (2.5%), 8.5% (5.7%) and 16.2 % (9.8%) compared to 5M, 7M and CM plans, respectively. The IM plan had the lowest gEUD value of 23.8 Gy for bladder, compared to 35.1, 28.4 and 25.7, for CM, 7M and 5M, respectively. Likewise, the IM plan had the lowest NTCP value for rectum of 0.04, compared to 0.07, 0.06 and 0.05 for CM, 7M and 5M, respectively. Individualized margins can lead to significantly reduced PTV volumes and critical structure doses, while still ensuring a minimum delivered CTV dose equal to 95% of the prescribed dose.

Dosimetry challenges for implementing emerging technologies

During the last 10 years, radiation therapy technologies have gone through major changes, mainly related introduction of sophisticated delivery and imaging techniques to improve the target localization accuracy and dose conformity. While implementation of these emerging technologies such as image-guided SRS/SBRT, IMRT/IMAT, IGRT, 4D motion management, and special delivery technologies showed substantial clinical gains for patient care, many other factors, such as training/quality, efficiency/efficacy, and cost/effectiveness etc. remain to be challenging. This talk will address technical challenges for dosimetry verification of implementing these emerging technologies in radiation therapy.

Evaluation of respiration-correlated digital tomosynthesis in lung

Digital tomosynthesis (DTS) with a linear accelerator-mounted imaging system provides a means of reconstructing tomographic images from radiographic projections over a limited gantry arc, thus requiring only a few seconds to acquire. Its application in the thorax, however, often results in blurred images from respiration-induced motion. This work evaluates the feasibility of respiration-correlated (RC) DTS for soft-tissue visualization and patient positioning. Image data acquired with a gantry-mounted kilovoltage imaging system while recording respiration were retrospectively analyzed from patients receiving radiotherapy for non-small-cell lung carcinoma. Projection images spanning an approximately 30 degrees gantry arc were sorted into four respiration phase bins prior to DTS reconstruction, which uses a backprojection, followed by a procedure to suppress structures above and below the reconstruction plane of interest. The DTS images were reconstructed in planes at different depths through the patient and normal to a user-selected angle close to the center of the arc. The localization accuracy of RC-DTS was assessed via a comparison with CBCT. Evaluation of RC-DTS in eight tumors shows visible reduction in image blur caused by the respiratory motion. It also allows the visualization of tumor motion extent. The best image quality is achieved at the end-exhalation phase of the respiratory motion. Comparison of RC-DTS with respiration-correlated cone-beam CT in determining tumor position, motion extent and displacement between treatment sessions shows agreement in most cases within 2-3 mm, comparable in magnitude to the intraobserver repeatability of the measurement. These results suggest the method's applicability for soft-tissue image guidance in lung, but must be confirmed with further studies in larger numbers of patients.

High-DQE EPIDs based on thick, segmented BGO and CsI:Tl scintillators: performance evaluation at extremely low dose

PURPOSE

Electronic portal imaging devices (EPIDs) based on active matrix, flat-panel imagers (AMFPIs) have become the gold standard for portal imaging and are currently being investigated for megavoltage cone-beam computed tomography (CBCT) and cone-beam digital tomosynthesis (CBDT). However, the practical realization of such volumetric imaging techniques is constrained by the relatively low detective quantum efficiency (DQE) of AMFPI-based EPIDs at radiotherapy energies, approximately 1% at 6 MV. In order to significantly improve DQE, the authors are investigating thick, segmented scintillators, consisting of 2D matrices of scintillating crystals separated by septal walls.

METHODS

A newly constructed segmented BGO scintillator (11.3 mm thick) and three segmented CsI:Tl scintillators (11.4, 25.6, and 40.0 mm thick) were evaluated using a 6 MV photon beam. X-ray sensitivity, modulation transfer function, noise power spectrum, DQE, and phantom images were obtained using prototype EPIDs based on the four scintillators.

RESULTS

The BGO and CsI:Tl prototypes were found to exhibit improvement in DQE ranging from approximately 12 to 25 times that of a conventional AMFPI-based EPID at zero spatial frequency. All four prototype EPIDs provide significantly improved contrast resolution at extremely low doses, extending down to a single beam pulse. In particular, the BGO prototype provides contrast resolution comparable to that of the conventional EPID, but at 20 times less dose, with spatial resolution sufficient for identifying the boundaries of low-contrast objects. For this prototype, however, the BGO scintillator exhibited an undesirable radiation-induced variation in x-ray sensitivity.

CONCLUSIONS

Prototype EPIDs based on thick, segmented BGO and CsI:T1 scintillators provide significantly improved portal imaging performance at extremely low dose (i.e., down to 1 beam pulse corresponding to approximately 0.022 cGy), creating the possibility of soft-tissue visualization using MV CBCT and CBDT at clinically practical dose.

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.

The effect of a limited number of projections and reconstruction algorithms on the image quality of megavoltage digital tomosynthesis

In order to investigate the effect of the number of projections on digital tomosynthesis image quality, images were acquired over a 40 degree arc and sampled into sets of 2 to 41 projections used as input to three different reconstruction algorithms: the shift‐and‐add, the Feldkamp‐Davis‐Kress filtered back projection algorithms, and the simultaneous algebraic reconstruction technique. The variation of several image characteristics, such as in‐plane resolution, contrast to noise ratio, artifact spread, volumetric accuracy, and dose, are investigated based on the reconstruction algorithms used and also the number of projections used as source data. The results suggest that only 11 projections are required since the various parameters checked do not improve much past that number. As a reconstruction algorithm, SART did best but took much longer to reconstruct images. Thus, if reconstruction time is a determining factor, filtered back‐projection looks like a better compromise.

PACS number: 87.57.C‐, 87.57.nf, 87.57.Q‐, 87.59.‐e

The adaptation of megavoltage cone beam CT for use in standard radiotherapy treatment planning

Potential areas where megavoltage computed tomography (MVCT) could be used are second- and third-phase treatment planning in 3D conformal radiotherapy and IMRT, adaptive radiation therapy, single fraction palliative treatment and for the treatment of patients with metal prostheses. A feasibility study was done on using MV cone beam CT (CBCT) images generated by proprietary 3D reconstruction software based on the FDK algorithm for megavoltage treatment planning. The reconstructed images were converted to a DICOM file set. The pixel values of megavoltage cone beam computed tomography (MV CBCT) were rescaled to those of kV CT for use with a treatment planning system. A calibration phantom was designed and developed for verification of geometric accuracy and CT number calibration. The distance measured between two marker points on the CBCT image and the physical dimension on the phantom were in good agreement. Point dose verification for a 10 cm x 10 cm beam at a gantry angle of 0 degrees and SAD of 100 cm were performed for a 6 MV beam for both kV and MV CBCT images. The point doses were found to vary between +/-6.1% of the dose calculated from the kV CT image. The isodose curves for 6 MV for both kV CT and MV CBCT images were within 2% and 3 mm distance-to-agreement. A plan with three beams was performed on MV CBCT, simulating a treatment plan for cancer of the pituitary. The distribution obtained was compared with those corresponding to that obtained using the kV CT. This study has shown that treatment planning with MV cone beam CT images is feasible.

Correction of megavoltage cone-beam CT images of the pelvic region based on phantom measurements for dose calculation purposes

Megavoltage cone‐beam CT (MVCBCT) is an imaging technology that provides a 3D representation of the patient in treatment position. Because it is a form of x‐ray tomography, MVCBCT images give information about the attenuation coefficients of the imaged tissues, and thus could be used for dose calculation. However, the cupping and missing data artifacts seen on MVCBCT images can cause inaccuracies in dose calculations. To eliminate these inaccuracies, a correction method specific to pelvis imaging and based on phantom measurements has been devised. Pelvis‐shaped water phantoms of three different sizes were designed and imaged with MVCBCT. Three sets of correction factors were created from the artifacts observed in these MVCBCT images by dividing the measured CT number by the predefined CT number for water. Linear interpolation is performed between the sets of correction factors to take into account the varying size of different patients. To compensate for the missing anatomy due to the limited field of view of the MVCBCT system, the MVCBCT image is complemented with the kilovoltage CT (kVCT) image acquired for treatment planning. When the correction method is applied to an anthropomorphic pelvis phantom, the standard deviation between dose calculations performed with kVCT and MVCBCT images is 0.6%, with 98% of the dose points agreeing within ±3%. With uncorrected MVCBCT images this percentage falls to 75%. An example of dose calculation performed with a corrected clinical MVCBCT image of a prostate cancer patient shows that changes in anatomy of normal tissues result in variation of the dose distribution received by these tissues. This correction method enables MVCBCT images to be used for the verification of the daily dose distribution for patients treated in the pelvis region.

PACS numbers: 87.57.Q‐ Computed tomography, 87.57.cp Artifacts and distortion

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.

Clinical assessment and characterization of a dual tube kilovoltage X-ray localization system in the radiotherapy treatment room

INTRODUCTION

Although flat-panel based X-ray imaging has been well tested in diagnostic radiology, its use as an image-guided-radiotherapy (IGRT) system in a treatment room is new and requires systematic assessment.

MATERIALS AND METHODS

BrainLab Novalis IGRT system was used for this study. It consists of two floor mounted kV X-ray tubes projecting obliquely into two flat-panel detectors mounted on the ceiling. The system automatically fuses the 2D localization images with 3D simulation CT image to provide positioning guidance. The following characteristics of the system were studied: (1) Coincidence of the isocenters between the IGRT and Linac; (2) Image quality; (3) Exposure; (4) Linearity, uniformity and repeatability.

RESULTS

(1) Localization accuracy and coincidence of the isocenters between the IGRT and Linac was better than 1-mm. (2) The spatial resolution was quantified using the relative modulation-transfer-function with f50=0.7-0.9 lp/mm. The variation of contrast-noise-ratio with technical settings was measured. (3) The maximal exposure of an image was less than 95 mR. An empirical relation between the exposure and the X-ray technical setting was derived. (4) The linearity, uniformity and repeatability of the system generally meet the requirements.

CONCLUSION

The system can be safely and reliably used as a target localization device.

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.

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

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

Lag correction model and ghosting analysis for an indirect-conversion flat-panel imager

Cone‐beam digital tomosynthesis (CBDT) is a new approach that was recently proposed for rapid tomographic imaging of soft‐tissue targets in the radiotherapy treatment room. One of the potential problems in implementing CBDT using, for example, megavoltage (MV) X rays is the possibility of artifacts caused by image lag and ghosting of the X‐ray detector used. In the present work, we developed a model to correct for image lag with indirect‐conversion flat‐panel imagers (FPIs) used for MV‐CBDT. This model is based on measurement and analysis of image lag in an indirect‐conversion FPI irradiated with a 6‐MV X‐ray beam. Our results demonstrated that image lag is amenable to correction. In addition, we measured the ghosting effect for an indirect‐conversion FPI and found it to be insignificant.

PACS numbers: 87.53.Oq, 87.57.Ce

Observation of interfractional variations in lung tumor position using respiratory gated and ungated megavoltage cone-beam computed tomography

PURPOSE

To evaluate the use of megavoltage cone-beam computed tomography (MV CBCT) to measure interfractional variation in lung tumor position.

METHODS AND MATERIALS

Eight non-small-cell lung cancer patients participated in the study, 4 with respiratory gating and 4 without. All patients underwent MV CBCT scanning at weekly intervals. Contoured planning CT and MV CBCT images were spatially registered based on vertebral anatomy, and displacements of the tumor centroid determined. Setup error was assessed by comparing weekly portal orthogonal radiographs with digitally reconstructed radiographs generated from planning CT images. Hypothesis testing was performed to test the statistical significance of the volume difference, centroid displacement, and setup uncertainty.

RESULTS

The vertebral bodies and soft tissue portions of tumor within lung were visible on the MV CBCT scans. Statistically significant systematic volume decrease over the course of treatment was observed for 1 patient. The average centroid displacement between simulation CT and MV CBCT scans were 2.5 mm, -2.0 mm, and -1.5 mm with standard deviations of 2.7 mm, 2.7 mm, and 2.6 mm in the right-left, anterior-posterior and superior-inferior directions. The mean setup errors were smaller than the centroid shifts, while the standard deviations were comparable. In most cases, the gross tumor volume (GTV) defined on the MV CBCT was located on average at least 5 mm inside a 10 mm expansion of the GTV defined on the planning CT scan.

CONCLUSIONS

The MV CBCT technique can be used to image lung tumors and may prove valuable for image-guided radiotherapy. Our conclusions must be verified in view of the small patient number.

Patient dose considerations for routine megavoltage cone-beam CT imaging

Megavoltage cone-beam CT (MVCBCT), the recent addition to the family of in-room CT imaging systems for image-guided radiation therapy (IGRT), uses a conventional treatment unit equipped with a flat panel detector to obtain a three-dimensional representation of the patient in treatment position. MVCBCT has been used for more than two years in our clinic for anatomy verification and to improve patient alignment prior to dose delivery. The objective of this research is to evaluate the image acquisition dose delivered to patients for MVCBCT and to develop a simple method to reduce the additional dose resulting from routine MVCBCT imaging. Conventional CT scans of phantoms and patients were imported into a commercial treatment planning system (TPS: Phillips, Pinnacle) and an arc treatment mimicking the MVCBCT acquisition process was generated to compute the delivered acquisition dose. To validate the dose obtained from the TPS, a simple water-equivalent cylindrical phantom with spaces for MOSFETs and an ion chamber was used to measure the MVCBCT image acquisition dose. Absolute dose distributions were obtained by simulating MVCBCTs of 9 and 5 monitor units (MU) on pelvis and head and neck patients, respectively. A compensation factor was introduced to generate composite plans of treatment and MVCBCT imaging dose. The article provides a simple equation to compute the compensation factor. The developed imaging compensation method was tested on routinely used clinical plans for prostate and head and neck patients. The quantitative comparison between the calculated dose by the TPS and measurement points on the cylindrical phantom were all within 3%. The dose percentage difference for the ion chamber placed in the center of the phantom was only 0.2%. For a typical MVCBCT, the dose delivered to patients forms a small anterior-posterior gradient ranging from 0.6 to 1.2 cGy per MVCBCT MU. MVCBCT acquisitions in the pelvis and head and neck areas deliver slightly more dose than current portal imaging but render soft tissue information for positioning. Overall, the additional dose from daily 9 MU MVCBCTs of prostate patients is small compared to the treatment dose (<4%). Dose-volume histograms of compensated plans for pelvis and head and neck patients imaged daily with MVCBCT showed no additional dose to the target and small increases at low doses. The results indicate that the dose delivered for MVCBCT imaging can be precisely calculated in the TPS and therefore included in the treatment plan. This allows simple plan compensations, such as slightly reducing the treatment dose, to minimize the total dose received by critical structures from daily positioning with MVCBCT. The proposed compensation factor reduces the number of MU per treatment beam per fraction. Both the number of fractions and the beam arrangement are kept unchanged. Reducing the imaging volume in the cranio-caudal direction can further reduce the dose delivered for MVCBCT. This is a useful feature to eliminate the imaging dose to the eyes or to focus on a specific region of interest for alignment.

Cone-beam CT based image-guidance for extracranial stereotactic radiotherapy of intrapulmonary tumors

Cone-beam CT (CB-CT) based image-guidance was evaluated for extracranial stereotactic radiotherapy of intrapulmonary tumors. A total of 21 patients (25 lesions: prim. NSCLC n = 6; pulmonary metastases n = 19) were treated with stereotactic radiotherapy (1 to 8 fractions). Prior to every fraction a CB-CT was acquired in treatment position, errors between planned and actual tumor position were measured and corrected. Intra- and inter-observer variability of manual evaluation of tumor position error was investigated and this manual method was compared with automatic image registration. Based on CB-CTs from 66 fractions the discrepancy (3-D vector) between planned and actual tumor position was 7.7 mm +/-1.3 mm. Tumor position error relative to the bony anatomy was 5.3 mm +/-1.2 mm, the correlation between bony anatomy and tumor position was poor. Intra-observer and inter-observer variability of manual evaluation of tumor position error was 0.9 mm +/-0.8 mm and 2.3 mm +/-1.1 mm, respectively. Automatic image registration showed highly reproducible results (<1 mm). However, compared with manual registration a systematic error was found in direction of predominant tumor breathing motion (2.5 mm vs 1.4 mm). Image-guidance using CB-CT was validated for high precision radiotherapy of intrapulmonary tumors. It was shown that both the planning reference and the verification image study have to consider tumor breathing motion.

Intra-fractional uncertainties in cone-beam CT based image-guided radiotherapy (IGRT) of pulmonary tumors

PURPOSE

Intra-fractional variability of tumor position and breathing motion was evaluated in cone-beam CT (CB-CT) based image-guided radiotherapy (IGRT) of pulmonary tumors.

MATERIALS AND METHODS

Twenty-four patients (27 lesions: prim. NSCLC n=6; metastases n=21) were treated with stereotactic body radiotherapy (SBRT) (one to eight fractions). Prior to every treatment fraction (n=66) and immediately after treatment a CB-CT was acquired. Patient motion, absolute drift and drift of the tumor relative to the bony anatomy were measured. Tumor motion was investigated based on the density distribution in the CB-CT.

RESULTS

Absolute intra-fractional drift (3D vector) of the tumor position was 2.8 mm+/-1.6 mm (mean +/- SD), maximum 7.2 mm. Poor correlation between patient motion and absolute tumor drift was observed. Changes of the tumor position due to patient motion and due to drifts independently from the bony anatomy were of similar magnitude with 2.1 mm +/- 1.4 mm and 2.3 mm +/- 1.6 mm, respectively. No systematic increase or decrease of breathing motion was seen. The intra-fractional change of breathing motion was more than 2 mm and 3 mm in 39% and 16%, respectively.

CONCLUSION

Intra-fractional tumor position and breathing motion were stable. In IGRT of pulmonary tumors we suggest an ITV-to-PTV margin of 5 mm to compensate intra-fractional changes.

Extracranial chordoma: Outcome in patients treated with function-preserving surgery followed by spot-scanning proton beam irradiation

PURPOSE

To evaluate the use of postoperative proton therapy (PT) in extracranial chordoma.

PATIENTS AND METHODS

Twenty-six patients were treated. Gross total resection was achieved in 18 patients. Nine patients had cervical, 2 had thoracic, 8 had lumbar, and 7 had sacro-coccygeal chordomas. Thirteen patients had implants. PT was administered after function-preserving surgery, using a gantry and spot scanning, without or with intensity modulation (IMPT; 6 patients), and/or photon-based radiotherapy (RT, 6 patients). Median total dose was 72 cobalt Gray equivalent (CGE; range, 59.4-74.4), with means of 70.5 and 73.2 CGE for patients with and without implants. Median follow-up time was 35 months (range, 13-73 months). Adverse events were scored using the Common Terminology Criteria for Adverse Events grading system (version 3.0).

RESULTS

At 3 years, actuarial overall survival (OS) and progression-free survival (PFS) rates were 84% and 77%, respectively. One patient each died of local failure (LF), distant failure (DF), suicide, and secondary tumor. We observed 5 LFs and 3 DFs; 3-year LF-free and DF-free survival rates were 86%. We observed four radiation-induced late adverse events (Grade 2 sensory neuropathy; Grade 3 subcutaneous necrosis, and osteonecrosis; and Grade 5 secondary cancer). In univariate analysis, implants were associated with LF (p = 0.034). Gross residual tumor above 30 mL was negatively associated with OS (p = 0.013) and PFS (p = 0.025).

CONCLUSIONS

Postoperative PT for extracranial chordomas delivered with spot scanning offers high local control rates. Toxicity was acceptable. Implants were significantly associated with LF. Residual tumor above 30 mL impacted negatively on OS and PFS.

Monte Carlo feasibility study of orthogonal bremsstrahlung beams for improved radiation therapy imaging

The basic characteristics of orthogonal bremsstrahlung beams are studied and the feasibility of improved contrast imaging with such a beam is evaluated. In the context of this work, orthogonal bremsstrahlung beams represent the component of the bremsstrahlung distribution perpendicular to the electron beam impinging on an accelerator target. The BEAMnrc Monte Carlo code was used to study target characteristics, energy spectra and relative fluences of orthogonal beams to optimize target design. The reliability of the simulations was verified by comparing our results with benchmark experiments. Using the results of the Monte Carlo optimization, the targets with various materials and a collimator were designed and built. The primary pencil electron beam from the research port of a Varian Clinac-18 accelerator striking on Al, Pb and C targets was used to create orthogonal beams. For these beams, diagnostic image contrast was tested by placing simple Lucite objects in the path of the beams and comparing image contrast obtained in the orthogonal direction to the one obtained in the forward direction. The simulations for various target materials and various primary electron energies showed that a width of 80% of the continuous-slowing-down approximation range (RCSDA) is sufficient to remove electron contamination in the orthogonal direction. The photon fluence of the orthogonal beam for high Z targets is larger compared to low Z targets, i.e. by a factor of 20 for W compared to Be. For a 6 MeV electron beam, the mean energy for low Z targets is calculated to be 320 keV for Al and 150 keV for Be, and for a high Z target like Pb to be 980 keV. For irradiation times of 1.2 s in an electron mode of the linac, the contrast of diagnostic images created with orthogonal beams from the Al target is superior to that in the forward direction. The image contrast and the beam profile of the bremsstrahlung beams were also studied. Both the Monte Carlo study and experiment showed an improvement of the contrast for lower Z target materials. This study confirms the feasibility, both in terms of intensity and image contrast, of orthogonal bremsstrahlung beams for radiation therapy imaging.

Megavoltage cone-beam CT: system description and clinical applications

In this article, we describe a clinical mega-voltage cone-beam computed tomography (MV CBCT) system, present the image acquisition and patient setup procedure, discuss the positioning accuracy and image quality, and illustrate its potential use for image-guided radiation therapy (IGRT) through selected clinical examples. The MV CBCT system consists of a standard linear accelerator equipped with an amorphous-silicon flat panel electronic portal-imaging device adapted for mega-electron volt (MeV) photons. An integrated computer workspace provides automated acquisition of projection images, image reconstruction, CT to CBCT image registration, and couch shift calculation. The system demonstrates submillimeter localization precision and sufficient soft-tissue resolution to visualize structures such as the prostate. In our clinic, we have used the MV CBCT system to detect nonrigid spinal cord distortions, monitor tumor growth and shrinkage, and locate and position stationary tumors in the lung. MV CBCT has also greatly improved the delineation of structures in CT images that suffer from metal artifacts. MV CBCT has undergone significant development in the last few years. Current image quality has already proven sufficient for many IGRT applications. Moreover, we expect the range of clinical applications for MV CBCT to grow as imaging technology continues to improve.

Localization: conventional and CT simulation

Recent developments in imaging and computer power have led to the ability to acquire large three dimensional data sets for target localization and complex treatment planning for radiation therapy. Conventional simulation implies the use of a machine capable of the same mechanical movements as treatment units. Images obtained from these machines are essentially two dimensional with the facility to acquire a limited number of axial slices to provide patient contours and tissue density information. The recent implementation of cone beam imaging on simulators has transformed them into three dimensional imaging devices able to produce the data required for complex treatment planning. The introduction of computed axial tomography (CT) in the 1970s was a step-change in imaging and its potential use in radiotherapy was quickly realised. However, it remained a predominantly diagnostic tool until modifications were introduced to meet the needs of radiotherapy and software was developed to perform the simulation function. The comparability of conventional and virtual simulation has been the subject of a number of studies at different disease sites. The development of different cross sectional imaging modalities such as MRI and positron emission tomography has provided additional information that can be incorporated into the simulation software by image fusion and has been shown to aid in the delineation of tumours. Challenges still remain, particularly in localizing moving structures. Fast multislice scanning protocols freeze patient and organ motion in time and space, which may lead to inaccuracy in both target delineation and the choice of margins in three dimensions. Breath holding and gated respiration techniques have been demonstrated to produce four-dimensional data sets that can be used to reduce margins or to minimize dose to normal tissue or organs at risk. Image guided radiotherapy is being developed to address the interfraction movement of both target volumes and critical normal structures. Whichever method of localization and simulation is adopted, the role of quality control is important for the overall accuracy of the patient's treatment and must be adapted to reflect the networked nature of the process.

Low-dose megavoltage cone-beam computed tomography for lung tumors using a high-efficiency image receptor

We report on the capabilities of a low-dose megavoltage cone-beam computed tomography (MV CBCT) system. The high-efficiency image receptor consists of a photodiode array coupled to a scintillator composed of individual CsI crystals. The CBCT system uses the 6 MV beam from a linear accelerator. A synchronization circuit allows us to limit the exposure to one beam pulse [0.028 monitor units (MU)] per projection image. 150-500 images (4.2-13.9 MU total) are collected during a one-minute scan and reconstructed using a filtered backprojection algorithm. Anthropomorphic and contrast phantoms are imaged and the contrast-to-noise ratio of the reconstruction is studied as a function of the number of projections and the error in the projection angles. The detector dose response is linear (R2 value 0.9989). A 2% electron density difference is discernible using 460 projection images and a total exposure of 13 MU (corresponding to a maximum absorbed dose of about 12 cGy in a patient). We present first patient images acquired with this system. Tumors in lung are clearly visible and skeletal anatomy is observed in sufficient detail to allow reproducible registration with the planning kV CT images. The MV CBCT system is shown to be capable of obtaining good quality three-dimensional reconstructions at relatively low dose and to be clinically usable for improving the accuracy of radiotherapy patient positioning.

Image-guided radiation therapy: current and future directions

Since its discovery, ionizing radiation has been a cornerstone of cancer treatment. In step with technological advances, radiation therapy has strived to increase its therapeutic ratio. With the advent of 3D and cross-sectional imaging, and the ability to modulate the radiation beam, the current age of radiation oncology was initiated, promising better tumor control rates with fewer side effects. However, these ever more precise and conformal treatments have also revealed the importance of accounting for organ and tumor motion. Efforts to understand and compensate for the uncertainties caused by movement are required to ensure accurate conformal radiation therapy. This review will explore the current and future directions of image-guided radiation therapy, whose goal is to increase the accuracy of radiotherapy.

Integrating respiratory gating into a megavoltage cone-beam CT system

We have previously described a low-dose megavoltage cone beam computed tomography (MV CBCT) system capable of producing projection image using one beam pulse. In this study, we report on its integration with respiratory gating for gated radiotherapy. The respiratory gating system tracks a reflective marker on the patient's abdomen midway between the xiphoid and umbilicus, and disables radiation delivery when the marker position is outside predefined thresholds. We investigate two strategies for acquiring gated scans. In the continuous rotation-gated acquisition, the linear accelerator (LINAC) is set to the fixed x-ray mode and the gantry makes a 5 min, 360 degree continuous rotation, during which the gating system turns the radiation beam on and off, resulting in projection images with an uneven distribution of projection angles (e.g., in 70 arcs each covering 2 degrees). In the gated rotation-continuous acquisition, the LINAC is set to the dynamic arc mode, which suspends the gantry rotation when the gating system inhibits the beam, leading to a slightly longer (6-7 min) scan time, but yielding projection images with more evenly distributed projection angles (e.g., approximately 0.8 degrees between two consecutive projection angles). We have tested both data acquisition schemes on stationary (a contrast detail and a thoracic) phantoms and protocol lung patients. For stationary phantoms, a separate motion phantom not visible in the images is used to trigger the RPM system. Frame rate is adjusted so that approximately 450 images (13 MU) are acquired for each scan and three-dimensional tomographic images reconstructed using a Feldkamp filtered backprojection algorithm. The gated rotation-continuous acquisition yield reconstructions free of breathing artifacts. The tumor in parenchymal lung and normal tissues are easily discernible and the boundary between the diaphragm and the lung sharply defined. Contrast-to-noise ratio (CNR) is not degraded relative to nongated scans of stationary phantoms. The continuous rotation-gated acquisition scan also yields tomographic images with discernible anatomic features; however, streak artifacts are observed and CNR is reduced by approximately a factor of 4. In conclusion, we have successfully developed a gated MV CBCT system to verify the patient positioning for gated radiotherapy.

Segmented crystalline scintillators: Empirical and theoretical investigation of a high quantum efficiency EPID based on an initial engineering prototype CsI(Tl) detector

Modern-day radiotherapy relies on highly sophisticated forms of image guidance in order to implement increasingly conformal treatment plans and achieve precise dose delivery. One of the most important goals of such image guidance is to delineate the clinical target volume from surrounding normal tissue during patient setup and dose delivery, thereby avoiding dependence on surrogates such as bony landmarks. In order to achieve this goal, it is necessary to integrate highly efficient imaging technology, capable of resolving soft-tissue contrast at very low doses, within the treatment setup. In this paper we report on the development of one such modality, which comprises a nonoptimized, prototype electronic portal imaging device (EPID) based on a 40 mm thick, segmented crystalline CsI(Tl) detector incorporated into an indirect-detection active matrix flat panel imager (AMFPI). The segmented detector consists of a matrix of 160 x 160 optically isolated, crystalline CsI(Tl) elements spaced at 1016 microm pitch. The detector was coupled to an indirect detection-based active matrix array having a pixel pitch of 508 microm, with each detector element registered to 2 x 2 array pixels. The performance of the prototype imager was evaluated under very low-dose radiotherapy conditions and compared to that of a conventional megavoltage AMFPI based on a Lanex Fast-B phosphor screen. Detailed quantitative measurements were performed in order to determine the x-ray sensitivity, modulation transfer function, noise power spectrum, and detective quantum efficiency (DQE). In addition, images of a contrast-detail phantom and an anthropomorphic head phantom were also acquired. The prototype imager exhibited approximately 22 times higher zero-frequency DQE (approximately 22%) compared to that of the conventional AMFPI (approximately 1%). The measured zero-frequency DQE was found to be lower than theoretical upper limits (approximately 27%) calculated from Monte Carlo simulations, which were based solely on the x-ray energy absorbed in the detector-indicating the presence of optical Swank noise. Moreover, due to the nonoptimized nature of this prototype, the spatial resolution was observed to be significantly lower than theoretical expectations. Nevertheless, due to its high quantum efficiency (approximately 55%), the prototype imager exhibited significantly higher DQE than that of the conventional AMFPI across all spatial frequencies. In addition, the frequency-dependent DQE was observed to be relatively invariant with respect to the amount of incident radiation, indicating x-ray quantum limited behavior. Images of the contrast-detail phantom and the head phantom obtained using the prototype system exhibit good visualization of relatively large, low-contrast features, and appear significantly less noisy compared to similar images from a conventional AMFPI. Finally, Monte Carlo-based theoretical calculations indicate that, with proper optimization, further, significant improvements in the DQE performance of such imagers could be achieved. It is strongly anticipated that the realization of optimized versions of such very high-DQE EPIDs would enable megavoltage projection imaging at very low doses, and tomographic imaging from a "beam's eye view" at clinically acceptable doses.

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

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

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