Optimization of Image Guided Radiation Therapy for Lung Cancer Using Limited-angle Projections
The developments of highly conformal and precise radiation therapy techniques promote the necessity of more accurate treatment target localization and tracking. On-board imaging techniques, especially the x-ray based techniques, have found a great popularity nowadays for on-board target localization and tracking. With an objective to improve the accuracy of on-board imaging for lung cancer patients, the dissertation work focuses on the investigations of using limited-angle on-board x-ray projections for image guidance. The limited-angle acquisition enables scan time and imaging dose reduction and improves the mechanical clearance of imaging.
First of all, the dissertation developed a phase-matched digital tomosynthesis (DTS) technique using limited-angle (<=30 deg) projections for lung tumor localization. This technique acquires the same traditional motion-blurred on-board DTS image as the 3D-DTS technique, but uses the planning 4D computed tomography (CT) to synthesize a phase-matched reference DTS to register with the on-board DTS for tumor localization. Of the 324 different scenarios simulated using the extended cardiac torso (XCAT) digital phantom, the phase-matched DTS technique localizes the 3D target position with an localization error of 1.07 mm (± 0.57 mm) (average ± standard deviation (S.D.)). Similarly, for the total 60 scenarios evaluated using the computerized imaging reference system (CIRS) 008A physical phantom, the phase-matched DTS technique localizes the 3D target position with an average localization error of 1.24 mm (± 0.87 mm). In addition to the phantom studies, preliminary clinical cases were also studied using imaging data from three lung cancer patients. Using the localization results of 4D cone beam computed tomography (CBCT) as `gold-standard', the phase-matched DTS techniques localized the tumor to an average localization error of 1.5 mm (± 0.5 mm).
The phantom and patient study results show that the phase-matched DTS technique substantially improved the accuracy of moving lung target localization, as compared to the 3D-DTS technique. The phase-matched DTS technique can provide accurate lung target localizations like 4D-DTS, but with much reduced imaging dose and scan time. The phase-matched DTS technique is also found more robust, being minimally affected by variations of respiratory cycle lengths, fractions of respiration cycle contained within the DTS scan and the scan directions, which potentially enables quasi-instantaneous (within a sub-breathing cycle) moving target verification during radiation therapy, preferably arc therapy.
Though the phase-matched DTS technique can provide accurate target localization under normal scenarios, its accuracy is limited when the patient on-board breathing experiences large variations in motion amplitudes. In addition, the limited-angle based acquisition leads to severe structural distortions in DTS images reconstructed by the current clinical gold-standard Feldkamp-Davis-Kress (FDK) reconstruction algorithm, which prohibit accurate target deformation tracking, delineation and dose calculation.
To solve the above issues, the dissertation further developed a prior knowledge based image estimation technique to fundamentally change the landscape of limited-angle based imaging. The developed motion modeling and free-form deformation (MM-FD) method estimates high quality on-board 4D-CBCT images through applying deformation field maps to existing prior planning 4D-CT images. The deformation field maps are solved using two steps: first, a principal component analysis based motion model is built using the planning 4D-CT (motion modeling). The deformation field map is constructed as an optimized linear combination of the extracted motion modes. Second, with the coarse deformation field maps obtained from motion modeling, a further fine-tuning process called free-form deformation is applied to further correct the residual errors from motion modeling. Using the XCAT phantom, a lung patient with a 30 mm diameter tumor was simulated to have various anatomical and respirational variations from the planning 4D-CT to on-board 4D-CBCTs, including respiration amplitude variations, tumor size variations, tumor average position variations, and phase shift between tumor and body respiratory cycles. The tumors were contoured in both the estimated and the `ground-truth' on-board 4D-CBCTs for comparison. 3D volume percentage error (VPE) and center-of-mass error (COME) were calculated to evaluate the estimation accuracy of the MM-FD technique. For all simulated patient scenarios, the average (± S.D.) VPE / COME of the tumor in the prior image without image estimation was 136.11% (± 42.76%) / 15.5 mm (± 3.9 mm). Using orthogonal-view 30 deg scan angle, the average VPE/COME of the tumors in the MM-FD estimated on-board images was substantially reduced to 5.22% (± 2.12%) / 0.5 mm (± 0.4 mm).
In addition to XCAT simulation, CIRS phantom measurements and actual patient studies were also performed. For these clinical studies, we used the normalized cross-correlation (NCC) as a new similarity metric and developed an updated MMFD-NCC method, to improve the robustness of the image estimation technique to the intensity mismatches between CT and CBCT imaging systems. Using 4D-CBCT reconstructed from fully-sampled on-board projections as `gold-standard', for the CIRS phantom study, the average (± S.D.) VPE / COME of the tumor in the prior image and the tumors in the MMFD-NCC estimated images was 257.1% (± 60.2%) / 10.1 mm (± 4.5 mm) and 7.7% (± 1.2%) / 1.2 mm (± 0.2mm), respectively. For three patient cases, the average (± S.D.) VPE / COME of tumors in the prior images and tumors in the MMFD-NCC estimated images was 55.6% (± 45.9%) / 3.8 mm (± 1.9 mm) and 9.6% (± 6.1%) / 1.1 mm (± 0.5 mm), respectively. With the combined benefits of motion modeling and free-form deformation, the MMFD-NCC method has achieved highly accurate image estimation under different scenarios.
Another potential benefit of on-board 4D-CBCT imaging is the on-board dose calculation and verification. Since the MMFD-NCC estimates the on-board 4D-CBCT through deforming prior 4D-CT images, the 4D-CBCT inherently has the same image quality and Hounsfield unit (HU) accuracy as 4D-CT and therefore can potentially improve the accuracy of on-board dose verification. Both XCAT and CIRS phantom studies were performed for the dosimetric study. Various inter-fractional variations featuring patient motion pattern change, tumor size change and tumor average position change were simulated from planning CT to on-board images. The doses calculated on the on-board CBCTs estimated by MMFD-NCC (MMFD-NCC doses) were compared to the doses calculated on the `gold-standard' on-board images (gold-standard doses). The absolute deviations of minimum dose (DDmin), maximum dose (DDmax), mean dose (DDmean) and prescription dose coverage (DV100%) of the planning target volume (PTV) were evaluated. In addition, 4D on-board treatment dose accumulations were performed using 4D-CBCT images estimated by MMFD-NCC in the CIRS phantom study. The accumulated doses were compared to those measured using optically stimulated luminescence (OSL) detectors and radiochromic films.
The MMFD-NCC doses matched very well with the gold-standard doses. For the XCAT phantom study, the average (± S.D.) DDmin, DDmax, DDmean and DV100% (values normalized by the prescription dose or the total PTV volume) between the MMFD-NCC PTV doses and the gold-standard PTV doses were 0.3% (± 0.2%), 0.9% (± 0.6%), 0.6% (± 0.4%) and 1.0% (± 0.8%), respectively. Similarly, for the CIRS phantom study, the corresponding values between the MMFD-NCC PTV doses and the gold-standard PTV doses were 0.4% (± 0.8%), 0.8% (± 1.0%), 0.5% (± 0.4%) and 0.8% (± 0.8%), respectively. For the 4D dose accumulation study, the average (± S.D.) absolute dose deviation (normalized by local doses) between the accumulated doses and the OSL measured doses was 3.0% (± 2.4%). The average gamma index (3%/3mm) between the accumulated doses and the radiochromic film measured doses was 96.1%. The MMFD-NCC estimated 4D-CBCT enables accurate on-board dose calculation and accumulation for lung radiation therapy under different scenarios. It can potentially be valuable for treatment quality assessment and adaptive radiation therapy.
However, a major limitation of the estimated 4D-CBCTs above is that they can only capture inter-fractional patient variations as they were acquired prior to each treatment. The intra-treatment patient variations cannot be captured, which can also affect the treatment accuracy. In light of this issue, an aggregated kilo-voltage (kV) and mega-voltage (MV) imaging scheme was developed to enable intra-treatment imaging. Through using the simultaneously acquired kV and MV projections during the treatment, the MMFD-NCC method enabled 4D-CBCT estimation using combined kV and MV projections.
For all XCAT-simulated patient scenarios, the average (± S.D.) VPE / COME of the tumor in the prior image and tumors in the MMFD-NCC estimated images (using kV + open field MV) was 136.11% (± 42.76%) / 15.5 mm (± 3.9 mm) and 4.5% (± 1.9%) / 0.3 mm (± 0.4 mm), respectively. In contrast, the MMFD-NCC estimation using kV + beam's eye view (BEV) MV projections yielded results of 4.3% (± 1.5%) / 0.3 mm (± 0.3 mm). The kV + BEV MV aggregation can estimate the target as accurately as the kV + open field MV aggregation. The impact of this study is threefold: 1. the kV and MV projections can be acquired at the same time. The imaging time will be cut to half as compared to the cases which use kV projections only. 2. The kV and MV aggregation enables intra-treatment imaging and target tracking, since the MV projections can be the side products of the treatment beams (BEV MV). 3. As the BEV MV projections originate from the treatment beams, there will be no extra MV imaging dose to the patient.
The above introduced 4D-CBCT estimation techniques were all based on limited-angle acquisition. Though limited-angle acquisition enables substantial scan time and dose reduction as compared to the full-angle scan, it is still not real-time and cannot provide `cine' imaging, which refers to the instantaneous imaging with negligible scan time and imaging dose. Cine imaging is important in image guided radiation therapy practice, considering the respirational variations may occur quickly and frequently during the treatment. For instance, the patient may experience a breathing baseline shift after every respiratory cycle. The limited-angle 4D-CBCT approach still requires a scan time of multiple respiratory cycles, which will not be able to capture the baseline shift in a timely manner.
In light of this issue, based on the previously developed MMFD-NCC method, an AI-FD-NCC method was further developed to enable quasi-cine CBCT imaging using extremely limited-angle (<=6 deg) projections. Using pre-treatment 4D-CBCTs acquired just before the treatment as prior information, AI-FD-NCC enforces an additional prior adaptive constraint to estimate high quality `quasi-cine' CBCT images. Two on-board patient scenarios: tumor baseline shift and continuous motion amplitude change were simulated through the XCAT phantom. Using orthogonal-view 6 deg projections, for the baseline shift scenario, the average (± S.D.) VPE / COME of the tumors in the AI-FD-NCC estimated images was 1.3% (± 0.5%) / 0.4 mm (± 0.1 mm). For the amplitude variation scenario, the average (± S.D.) VPE / COME of the tumors in the AI-FD-NCC estimated images was 1.9% (± 1.1%) / 0.5 mm (± 0.2 mm). The impact of this study is three-fold: first, the quasi-cine CBCT technique enables actual real-time volumetric tracking of tumor and normal tissues. Second, the method enables real-time tumor and normal tissues dose calculation and accumulation. Third, the high-quality volumetric images obtained can potentially be used for real-time adaptive radiation therapy.
In summary, the dissertation work uses limited-angle on-board x-ray projections to reconstruct/estimate volumetric images for lung tumor localization, delineation and dose calculation. Limited-angle acquisition reduces imaging dose, scan time and improves imaging mechanical clearance. Using limited-angle projections enables continuous, sub respiratory-cycle tumor localization, as validated in the phase-matched DTS study. The combination of prior information, motion modeling, free-form deformation and limited-angle on-board projections enables high-quality on-board 4D-CBCT estimation, as validated by the MM-FD / MMFD-NCC techniques. The high-quality 4D-CBCT not only can be applied for accurate target localization and delineation, but also can be used for accurate treatment dose verification, as validated in the dosimetric study. Through aggregating the kV and MV projections for image estimation, intra-treatment 4D-CBCT imaging was also proposed and validated for its feasibility. At last, the introduction of more accurate prior information and additional adaptive prior knowledge constraints also enables quasi-cine CBCT imaging using extremely-limited angle projections. The dissertation work contributes to lung on-board imaging in many aspects with various approaches, which can be beneficial to the future lung image guided radiation therapy practice.
Image Guided Radiation Therapy
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