Four-Dimensional Imaging of Respiratory Motion in the Radiotherapy Treatment Room Using a Gantry Mounted Flat Panel Imaging Device

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Imaging respiratory induced tumor motion in the radiation therapy treatment room could eliminate the necessity for large motion encompassing margins that result in excessive irradiation of healthy tissues. Currently available image guidance technologies are ill-suited for this task. Two-dimensional fluoroscopic images are acquired with sufficient speed to image respiratory motion. However, volume information is not present, and soft tissue structures are often not visible because a large volume is projected onto a single plane. Currently available volumetric imaging modalities are not acquired with sufficient speed to capture full motion trajectory information. Four-dimensional cone-beam computed tomography (4D CBCT) using a gantry mounted 2D flat panel imaging device has been proposed but has been limited by high doses, long scan times and severe under-sampling artifacts. The focus of the work completed in this thesis was to find ways to improve 4D imaging using a gantry mounted 2D kV imaging system. Specifically, the goals were to investigate methods for minimizing imaging dose and scan time while achieving consistent, controllable, high quality 4D images.

First, we introduced four-dimensional digital tomosynthesis (4D DTS) and characterized its potential for 3D motion analysis using a motion phantom. The motion phantom was programmed to exhibit motion profiles with various known amplitudes in all three dimensions and scanned using a 2D kV imaging system mounted on a linear accelerator. Two arcs of projection data centered about the anterior-posterior and lateral axes were used to reconstruct phase resolved DTS coronal and sagittal images. Respiratory signals were obtained by analyzing projection data, and these signals were used to derive phases for each of the projection images. Projection images were sorted according to phase, and DTS phase images were reconstructed for each phase bin. 4D DTS target location accuracies for peak inhalation and peak exhalation in all three dimensions were limited only by the 0.5 mm pixel resolution for all DTS scan angles. The average localization errors for all phases of an assymetric motion profile with a 2 cm peak-to-peak amplitude were 0.68, 0.67 and 1.85 mm for 60 o 4D DTS, 360 o CBCT and 4DCT, respectively. Motion artifacts for 4D DTS were found to be substantially less than those seen in 4DCT, which is the current clinical standard in 4D imaging.

We then developed a comprehensive framework for relating patient respiratory parameters with acquisition and reconstruction parameters for slow gantry rotation 4D DTS and 4D CBCT imaging. This framework was validated and optimized with phantom and lung patient studies. The framework facilitates calculation of optimal frame rates and gantry rotation speeds based on patient specific respiratory parameters and required temporal resolution (task dependent). We also conducted lung patient studies to investigate required scan angles for 4D DTS and achievable dose and scan times for 4D DTS and 4D CBCT using the optimized framework. This explicit and comprehensive framework of relationships allowed us to demonstrate that under-sampling artifacts can be controlled, and 4D CBCT images can be acquired using lower doses than previously reported. We reconstructed 4D CBCT images of three patients with accumulated doses of 4.8 to 5.7 cGy. These doses are three times less than the doses used for the only previously reported 4D CBCT investigation that did not report images characterized by severe under-sampling artifacts.

We found that scan times for 200 o 4D CBCT imaging using acquisition sequences optimized for reduction of imaging dose and under-sampling artifacts were necessarily between 4 and 7 minutes (depending on patient respiration). The results from lung patient studies concluded that scan times could be reduced using 4D DTS. Patient 4D DTS studies demonstrated that tumor visibility for the lung patients we studied could be achieved using 30 o scan angles for coronal views. Scan times for those cases were between 41 and 50 seconds. Additional dose reductions were also demonstrated. Image doses were between 1.56 and 2.13 cGy. These doses are well below doses for standard CBCT scans. The techniques developed and reported in this thesis demonstrate how respiratory motion can be imaged in the radiotherapy treatment room using clinically feasible imaging doses and scan times.





Maurer, Jacqueline (2010). Four-Dimensional Imaging of Respiratory Motion in the Radiotherapy Treatment Room Using a Gantry Mounted Flat Panel Imaging Device. Dissertation, Duke University. Retrieved from


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