Peter Munro

Four‐dimensional cone‐beam computed tomography using an on‐board imager

On-board cone-beam computed tomography (CBCT) has recently become available to provide volumetric information of a patient in the treatment position, and holds promises for improved target localization and irradiation dose verification. The design of currently available on-board CBCT, however, is far from optimal. Its quality is adversely influenced by many factors, such as scatter, beam hardening, and intra-scanning organ motion. In this work we quantitatively study the influence of organ motion on CBCT imaging and investigate a strategy to acquire high quality phase-resolved [four-dimensional (4D)] CBCT images based on phase binning of the CBCT projection data. An efficient and robust method for binning CBCT data according to the patients respiratory phase derived in the projection space was developed. The phase-binned projections were reconstructed using the conventional Feldkamp algorithm to yield 4D CBCT images. Both phantom and patient studies were carried out to validate the technique and to optimize the 4D CBCT data acquisition protocol. Several factors that are important to the clinical implementation of the technique, such as the image quality, scanning time, number of projections, and radiation dose, were analyzed for various scanning schemes. The general references drawn from this study are: (i) reliable phase binning of CBCT projections is accomplishable with the aid of external or internal marker and simple analysis of its trace in the projection space, and (ii) artifact-free 4D CBCT images can be obtained without increasing the patient radiation dose as compared to the current 3D CBCT scan.

A quality assurance program for the on-board imager ®

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

Four‐dimensional cone beam CT with adaptive gantry rotation and adaptive data sampling

We have developed a new four-dimensional cone beam CT (4D-CBCT) on a Varian image-guided radiation therapy system, which has radiation therapy treatment and cone beam CT imaging capabilities. We adapted the speed of gantry rotation time of the CBCT to the average breath cycle of the patient to maintain the same level of image quality and adjusted the data sampling frequency to keep a similar level of radiation exposure to the patient. Our design utilized the real-time positioning and monitoring system to record the respiratory signal of the patient during the acquisition of the CBCT data. We used the full-fan bowtie filter during data acquisition, acquired the projection data over 200 deg of gantry rotation, and reconstructed the images with a half-scan cone beam reconstruction. The scan time for a 200-deg gantry rotation per patient ranged from 3.3 to 6.6 min for the average breath cycle of 3-6 s. The radiation dose of the 4D-CBCT was about 1-2 times the radiation dose of the 4D-CT on a multislice CT scanner. We evaluated the 4D-CBCT in scanning, data processing and image quality with phantom studies. We demonstrated the clinical applicability of the 4D-CBCT and compared the 4D-CBCT and the 4D-CT scans in four patient studies. The contrast-to-noise ratio of the 4D-CT was 2.8-3.5 times of the contrast-to-noise ratio of the 4D-CBCT in the four patient studies.

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

PURPOSE To develop an image receptor capable of forming high-quality megavoltage CT images using modest radiation doses. METHODS AND MATERIALS A flat-panel imaging system consisting of a conventional flat-panel sensor attached to a thick CsI scintillator has been fabricated. The scintillator consists of individual CsI crystals 8 mm thick by 0.38 mm x 0.38-mm pitch. Five sides of each crystal are coated with a reflecting powder/epoxy mixture, and the sixth side is in contact with the flat-panel sensor. A timing interface coordinates acquisition by the imaging system and pulsing of the linear accelerator. With this interface, as little as one accelerator pulse (0.023 cGy at the isocenter) can be used to form projection images. Different CT phantoms irradiated by a 6-MV X-ray beam have been imaged to evaluate the performance of the imaging system. The phantoms have been mounted on a rotating stage and rotated while 360 projection images are acquired in 48 s. These projections have been reconstructed using the Feldkamp cone-beam CT reconstruction algorithm. RESULTS AND DISCUSSION Using an irradiation of 16 cGy (360 projections x 0.046 cGy/projection), the contrast resolution is approximately 1% for large objects. High-contrast structures as small as 1.2 mm are clearly visible. The reconstructed CT values are linear (R(2) = 0.98) for electron densities between 0.001 and 2.16 g/cm(3), and the reconstruction time for a 512 x 512 x 512 data set is 6 min. Images of an anthropomorphic phantom show that soft-tissue structures such as the heart, lung, kidneys, and liver are visible in the reconstructed images (16 cGy, 5-mm-thick slices). CONCLUSIONS The acquisition of megavoltage CT images with soft-tissue contrast is possible with irradiations as small as 16 cGy.

Multiple-gain-ranging readout method to extend the dynamic range of amorphous silicon flat-panel imagers

The dynamic range of many flat panel imaging systems are fundamentally limited by the dynamic range of the charge amplifier and readout signal processing. We developed two new flat panel readout methods that achieve extended dynamic range by changing the read out charge amplifier feedback capacitance dynamically and on a real-time basis. In one method, the feedback capacitor is selected automatically by a level sensing circuit, pixel-by-pixel, based on its exposure level. Alternatively, capacitor selection is driven externally, such that each pixel is read out two (or more) times, each time with increased feedback capacitance. Both methods allow the acquisition of X-ray image data with a dynamic range approaching the fundamental limits of flat panel pixels. Data with an equivalent bit depth of better than 16 bits are made available for further image processing. Successful implementation of these methods requires careful matching of selectable capacitor values and switching thresholds, with the imager noise and sensitivity characteristics, to insure X-ray quantum limited operation over the whole extended dynamic range. Successful implementation also depends on the use of new calibration methods and image reconstruction algorithms, to insure artifact free rebuilding of linear image data by the downstream image processing systems. The multiple gain ranging flat panel readout method extends the utility of flat panel imagers and paves the way to new flat panel applications, such as cone beam CT. We believe that this method will provide a valuable extension to the clinical application of flat panel imagers.

Radiation exposure to patients from image guidance procedures and techniques to reduce the imaging dose

PURPOSE To compare imaging doses from MV images, kV radiographs, and kV-CBCT and describe methods to reduce the dose to patients organs using existing on-board imaging devices. METHOD AND MATERIALS Monte Carlo techniques were used to simulate kV X-ray sources. The kV image doses to a variety of patient anatomies were calculated by using the simulated realistic sources to deposit dose in patient CT images. For MV imaging, the doses for the same patients were calculated using a commercial treatment planning system. RESULTS Portal imaging results in the largest dose to anatomic structures, followed by Varian OBI CBCT, Varian TrueBeam CBCT and then kV radiographs. The imaging doses for the 50% volume from the DVHs, D50, to the eyes for representative head images are 4.3-4.8cGy; 0.05-0.06cGy; 0.04-0.05cGy; and, 0.12cGy; D50 to the bladder for representative pelvis images are 3.3cGy; 1.6cGy; 1.0cGy; and, 0.07cGy; while D50 to the heart for representative thorax images are 3.5cGy; 0.42cGy; 0.2cGy; and, 0.07cGy; when using portal imaging, OBI kV-CBCT scans, TrueBeam kV-CBCT scans and kV radiographs, respectively. The orientation of the kV beam can affect organ dose. For example, D50 to the eyes can be reduced from 0.12cGy using AP and right lateral radiographs to 0.008-0.017cGy when using PA and right lateral radiographs. In addition, organ exposures can be further reduced to 15-70% of their original values with the use of a full-fan, bow-tie filter for kV radiographs. In contrast, organ doses increase by a factor of ∼2-4 if bow-tie filters are not used during kV-CBCT acquisitions. CONCLUSION Current on-board kV imaging devices result in much lower imaging doses compared to MV imagers even taking into account of higher bone dose from kV X-rays. And a variety of approaches are available to significantly reduce the image doses.

Reducing radiation exposure to patients from kV-CBCT imaging

BACKGROUND AND PURPOSE This study explores methods to reduce dose due to kV-CBCT imaging for patients undergoing radiation therapy. MATERIAL AND METHODS Doses resulting from kV-CBCT scans were calculated using Monte Carlo techniques and were analyzed using dose-volume histograms. Patients were modeled as were CBCT acquisitions using both 360° and 200° gantry rotations. The effects of using the half fan bow-tie and the full fan bow-tie filters were examined. RESULTS Doses for OBI 1.3 are 15 times (head), 5 times (thorax) and 2 times (Pelvis) larger than the current OBI 1.4. When using 200° scans, the doses to eyes and cord are 0.2 (or 0.65) cGy and 0.35 (or 0.2) cGy when rotating the X-ray source underneath (or above) the patient, respectively. The 360° Pelvis scan dose is 1-2 cGy. The rectum dose is 1.1 (or 2.8) cGy when rotating the source above (or below) the patient with the 200° Pelvis scan. The dose increases up to two times as the patient size decreases. CONCLUSIONS The dose can be minimized by reducing the scan length, the exposure settings, by selecting the gantry rotation angles, and by using the full fan bow-tie whenever possible.

Dosimetric verification of IMAT delivery with a conventional EPID system and a commercial portal dose image prediction tool.

PURPOSE The electronic portal imaging device (EPID) is a system for checking the patient setup; as a result of its integration with the linear accelerator and software customized for dosimetry, it is increasingly used for verification of the delivery of fixed-field intensity-modulated radiation therapy (IMRT). In order to extend such an approach to intensity-modulated arc therapy (IMAT), the combined use of an EPID system and a portal dose image prediction (PDIP) tool has been investigated. METHODS The dosimetric behavior of an EPID system, mechanically reinforced to maintain its positional stability during the accelerator gantry rotation, has been studied to assess its ability to measure portal dose distributions for IMAT treatment beams. In addition, the PDIP tool of a commercial treatment planning system, commonly used for static IMRT dosimetry, has been validated for simulating the PDIs of IMAT treatment fields. The method has been applied to the delivery verification of 23 treatment fields that were measured in their dual mode of IMRT and IMAT modalities. RESULTS The EPID system has proved to be appropriate for measuring the PDIs of IMAT fields; additionally the PDIP tool was able to simulate these accurately. The results are quite similar to those obtained for static IMRT treatment verification, although it was necessary to investigate the dependence of the EPID signal and of the accelerator monitor chamber response on variable dose rate. CONCLUSIONS Our initial tests indicate that the EPID system, together with the PDIP tool, is a suitable device for the verification of IMAT plan delivery; however, additional tests are necessary to confirm these results.

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 (4.2-13.9MU 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 13MU (corresponding to a maximum absorbed dose of about 12cGy 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.

Evaluation of IsoCal geometric calibration system for Varian linacs equipped with on-board imager and electronic portal imaging device imaging systems

The purpose of this study is to evaluate the accuracy and reproducibility of the IsoCal geometric calibration system for kilovoltage (kV) and megavoltage (MV) imagers on Varian C‐series linear accelerators (linacs). IsoCal calibration starts by imaging a phantom and collimator plate using MV images with different collimator angles, as well as MV and kV images at different gantry angles. The software then identifies objects on the collimator plate and in the phantom to determine the location of the treatment isocenter and its relation to the MV and kV imager centers. It calculates offsets between the positions of the imaging panels and the treatment isocenter as a function of gantry angle and writes a correction file that can be applied to MV and kV systems to correct for those offsets in the position of the panels. We performed IsoCal calibration three times on each of five Varian C‐series linacs, each time with an independent setup. We then compared the IsoCal calibrations with a simplified Winston‐Lutz (WL)‐based system and with a Varian cubic phantom (VC)‐based system. The maximum IsoCal corrections ranged from 0.7 mm to 1.5 mm for MV and 0.9 mm to 1.8 mm for kV imagers across the five linacs. The variations in the three calibrations for each linac were less than 0.2 mm. Without IsoCal correction, the WL results showed discrepancies between the treatment isocenter and the imager center of 0.9 mm to 1.6 mm (for the MV imager) and 0.5 mm to 1.1 mm (for the kV imager); with IsoCal corrections applied, the differences were reduced to 0.2 mm to 0.6 mm (MV) and 0.3 mm to 0.6 mm (kV) across the five linacs. The VC system was not as precise as the WL system, but showed similar results, with discrepancies of less than 1.0 mm when the IsoCal corrections were applied. We conclude that IsoCal is an accurate and consistent method for calibration and periodic quality assurance of MV and kV imaging systems. PACS numbers: 87.55.Qr, 87.56.Fc