A method for the reconstruction of four-dimensional synchronized CT scans acquired during free breathing

Breathing motion is a significant source of error in radiotherapy treatment planning for the thorax and upper abdomen. Accounting for breathing motion has a profound effect on the size of conformal radiation portals employed in these sites. Breathing motion also causes artifacts and distortions in treatment planning computed tomography (CT) scans acquired during free breathing and also causes a breakdown of the assumption of the superposition of radiation portals in intensity-modulated radiation therapy, possibly leading to significant dose delivery errors. Proposed voluntary and involuntary breath-hold techniques have the potential for reducing or eliminating the effects of breathing motion, however, they are limited in practice, by the fact that many lung cancer patients cannot tolerate holding their breath. We present an alternative solution to accounting for breathing motion in radiotherapy treatment planning, where multislice CT scans are collected simultaneously with digital spirometry over many free breathing cycles to create a four-dimensional (4-D) image set, where tidal lung volume is the additional dimension. An analysis of this 4-D data leads to methods for digital-spirometry, based elimination or accounting of breathing motion artifacts in radiotherapy treatment planning for free breathing patients. The 4-D image set is generated by sorting free-breathing multislice CT scans according to user-defined tidal-volume bins. A multislice CT scanner is operated in the ciné mode, acquiring 15 scans per couch position, while the patient undergoes simultaneous digital-spirometry measurements. The spirometry is used to retrospectively sort the CT scans by their correlated tidal lung volume within the patient's normal breathing cycle. This method has been prototyped using data from three lung cancer patients. The actual tidal lung volumes agreed with the specified bin volumes within standard deviations ranging between 22 and 33 cm3. An analysis of sagittal and coronal images demonstrated relatively small (<1 cm) motion artifacts along the diaphragm, even for tidal volumes where the rate of breathing motion is greatest. While still under development, this technology has the potential for revolutionizing the radiotherapy treatment planning for the thorax and upper abdomen.     

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.     

Reduction of motion blurring artifacts using respiratory gated CT in sinogram space: a quantitative evaluation

Techniques have been developed for reducing motion blurring artifacts by using respiratory gated computed tomography (CT) in sinogram space and quantitatively evaluating the artifact reduction. A synthetic sinogram was built from multiple scans intercepting a respiratory gating window. A gated CT image was then reconstructed using the filtered back-projection algorithm. Wedge phantoms, developed for quantifying the motion artifact reduction, were scanned while being moved using a computer-controlled linear stage. The resulting artifacts appeared between the high and low density regions as an apparent feature with a Hounsfield value that was the average of the two regions. A CT profile through these regions was fit using two error functions, each modeling the partial-volume averaging characteristics for the unmoving phantom. The motion artifact was quantified by determining the apparent distance between the two functions. The blurring artifact had a linear relationship with both the speed and the tangent of the wedge angles. When gating was employed, the blurring artifact was reduced systematically at the air-phantom interface. The gated image of phantoms moving at 20 mm/s showed similar blurring artifacts as the nongated image of phantoms moving at 10 mm/s. Nine patients were also scanned using the synchronized respiratory motion technique. Image artifacts were evaluated in the diaphragm, where high contrast interfaces intercepted the imaging plane. For patients, this respiratory gating technique reduced the blurring artifacts by 9%-41% at the lung-diaphragm interface.     

Iterative sorting for four-dimensional CT images based on internal anatomy motion

Current four-dimensional (4D) computed tomography (CT) imaging techniques using multislice CT scanners require retrospective sorting of the reconstructed two-dimensional (2D) CT images. Most existing sorting methods depend on externally monitored breathing signals recorded by extra instruments. External signals may not always accurately capture the breathing status and may lead to severe discontinuity artifacts in the sorted CT volumes. This article describes a method to find the temporal correspondences for the free-breathing multislice CT images acquired at different table positions based on internal anatomy movement. The algorithm iteratively sorts the CT images using estimated internal motion indices. It starts from two imperfect reference volumes obtained from the unsorted CT images; then, in each iteration, thorax motion is estimated from the reference volumes and the free-breathing CT images. Based on the estimated motion, the breathing indices as well as the reference volumes are refined and fed into the next iteration. The algorithm terminates when two successive iterations attain the same sorted reference volumes. In three out of five patient studies, our method attained comparable image quality with that using external breathing signals. For the other two patient studies, where the external signals poorly reflected the internal motion, the proposed method significantly improved the sorted 4D CT volumes, albeit with greater computation time.     

Fusion of respiration-correlated PET and CT scans: correlated lung tumour motion in anatomical and functional scans

Lower lobe lung tumours in particular can move up to 2 cm in the cranio-caudal direction during the respiration cycle. This breathing motion causes image artefacts in conventional free-breathing computed tomography (CT) and positron emission tomography (PET) scanning, rendering delineation of structures for radiotherapy inaccurate. The purpose of this study was to develop a method for four-dimensional (4D) respiration-correlated (RC) acquisition of both CT and PET scans and to develop a framework to fuse these modalities. The breathing signal was acquired using a thermometer in the breathing airflow of the patient. Using this breathing signal, the acquired CT and PET data were grouped to the corresponding respiratory phases, thereby obtaining 4D CT and PET scans. Tumour motion curves were assessed in both image modalities. From these tumour motion curves, the deviation with respect to the mean tumour position was calculated for each phase. The absolute position of the centre of the tumour, relative to the bony anatomy, in the RCCT and gated PET scans was determined. This 4D acquisition and 4D fusion methodology was performed for five patients with lower lobe tumours. The peak-to-peak amplitude range in this sample group was 1-2 cm. The 3D tumour motion curve differed less than 1 mm between PET and CT for all phases. The mean difference in amplitude was less than 1 mm. The position of the centre of the tumour (relative to the bony anatomy) in the RCCT and gated PET scan was similar (difference <1 mm) when no atelectasis was present. Based on these results, we conclude that the method described in this study allows for accurate quantification of tumour motion in CT and PET scans and yields accurate respiration-correlated 4D anatomical and functional information on the tumour region.     

Validation of target volume and position in respiratory gated CT planning and treatment

The capability of a commercial respiratory gating system based on video tracking of reflective markers to reduce motion-induced CT planning and treatment errors was evaluated. Spherical plastic shells (2.8-82 cm3), simulating the gross target volume (GTV), were placed in a water-filled body phantom that was moved sinusoidally along the longitudinal axis of the CT scanner and the accelerator for +/- 1 cm at 15-30 cycle/min. During gated CT imaging, the x-ray exposure was initiated by the gating system shortly before the end of expiration (so that the imaging time would be centered at the end of expiration); it was terminated by the scanner after completion of each slice. In nongated CT images, the target appeared distorted and often broken up. GTVs volume errors ranged 16%-110% in axial scans, and 7%-36% in spiral scans. In gated CT images, the spheres appeared 3 and 5 mm longer than their actual diameters (volume errors 2%-16%), at the respective respiration rates of 15 and 20 cycles/min. At 30 cycles/min the target appeared 1 cm longer, and volume error ranged 25%-53%. During treatment, gating kept the beam on for a duration equal to the CT acquisition time of 1 s/slice. The difference in positional errors between gated CT and portal films was 1 mm, regardless the size of residual motion errors. Because of the potential of suboptimal placement of the gating window between CT imaging and treatment, an extra 1.5-2.5 mm safety margin can be added regardless of the size of residual motion error. For respiratory rates > or = 30 cycles/min, the effectiveness of gating is limited by large residual motion in the 1 s CT acquisition time.     

Dosimetric impact of motion in free-breathing and gated lung radiotherapy: a 4D Monte Carlo study of intrafraction and interfraction effects

The purpose of this study was to investigate if interfraction and intrafraction motion in free-breathing and gated lung IMRT can lead to systematic dose differences between 3DCT and 4DCT. Dosimetric effects were studied considering the breathing pattern of three patients monitored during the course of their treatment and an in-house developed 4D Monte Carlo framework. Imaging data were taken in free-breathing and in cine mode for both 3D and 4D acquisition. Treatment planning for IMRT delivery was done based on the free-breathing data with the CORVUS (North American Scientific, Chatsworth, CA) planning system. The dose distributions as a function of phase in the breathing cycle were combined using deformable image registration. The study focused on (a) assessing the accuracy of the CORVUS pencil beam algorithm with Monte Carlo dose calculation in the lung, (b) evaluating the dosimetric effect of motion on the individual breathing phases of the respiratory cycle, and (c) assessing intrafraction and interfraction motion effects during free-breathing or gated radiotherapy. The comparison between (a) the planning system and the Monte Carlo system shows that the pencil beam algorithm underestimates the dose in low-density regions, such as lung tissue, and overestimates the dose in high-density regions, such as bone, by 5% or more of the prescribed dose (corresponding to approximately 3-5 Gy for the cases considered). For the patients studied this could have a significant impact on the dose volume histograms for the target structures depending on the margin added to the clinical target volume (CTV) to produce either the planning target (PTV) or internal target volume (ITV). The dose differences between (b) phases in the breathing cycle and the free-breathing case were shown to be negligible for all phases except for the inhale phase, where an underdosage of the tumor by as much as 9.3 Gy relative to the free-breathing was observed. The large difference was due to breathing-induced motion/deformation affecting the soft/lung tissue density and motion of the bone structures (such as the rib cage) in and out of the beam. Intrafraction and interfraction dosimetric differences between (c) free-breathing and gated delivery were found to be small. However, more significant dosimetric differences, of the order of 3%-5%, were observed between the dose calculations based on static CT (3DCT) and the ones based on time-resolved CT (4DCT). These differences are a consequence of the larger contribution of the inhale phase in the 3DCT data than in the 4DCT.     

The effects of tumor motion on planning and delivery of respiratory-gated IMRT

The purpose of this study is to investigate the effects of object motion on the planning and delivery of IMRT. Two phantoms containing objects were imaged using CT under a variety of motion conditions. The effects of object motion on axial CT acquisition with and without gating were assessed qualitatively and quantitatively. Measurements of effective slice width and position for the CT scans were made. Mutual information image fusion was adapted for use as a quantitative measure of object deformation in CT images. IMRT plans were generated on the CT scans of the moving and gated object images. These plans were delivered with motion, with and without gating, and the delivery error between the moving deliveries and a nonmoving delivery was assessed using a scalable vector-based index. Motion during CT acquisition produces motion artifact, object deformation, and object mispositioning, which can be substantially reduced with gating. Objects that vary in cross section in the direction of motion exhibit the most deformation in CT images. Mutual information provides a useful quantitative estimate of object deformation. The delivery of IMRT in the presence of target motion significantly alters the delivered dose distribution in relation to the planned distribution. The utilization of gating for IMRT treatment, including imaging, planning, and delivery, significantly reduces the errors introduced by object motion.     

Four-dimensional computed tomography: image formation and clinical protocol

Respiratory motion can introduce significant errors in radiotherapy. Conventional CT scans as commonly used for treatment planning can include severe motion artifacts that result from interplay effects between the advancing scan plane and object motion. To explicitly include organ/target motion in treatment planning and delivery, time-resolved CT data acquisition (4D Computed Tomography) is needed. 4DCT can be accomplished by oversampled CT data acquisition at each slice. During several CT tube rotations projection data are collected in axial cine mode for the duration of the patient's respiratory cycle (plus the time needed for a full CT gantry rotation). Multiple images are then reconstructed per slice that are evenly distributed over the acquisition time. Each of these images represents a different anatomical state during a respiratory cycle. After data acquisition at one couch position is completed, x rays are turned off and the couch advances to begin data acquisition again until full coverage of the scan length has been obtained. Concurrent to CT data acquisition the patient's abdominal surface motion is recorded in precise temporal correlation. To obtain CT volumes at different respiratory states, reconstructed images are sorted into different spatio-temporally coherent volumes based on respiratory phase as obtained from the patient's surface motion. During binning, phase tolerances are chosen to obtain complete volumetric information since images at different couch positions are reconstructed at different respiratory phases. We describe 4DCT image formation and associated experiments that characterize the properties of 4DCT. Residual motion artifacts remain due to partial projection effects. Temporal coherence within resorted 4DCT volumes is dominated by the number of reconstructed images per slice. The more images are reconstructed, the smaller phase tolerances can be for retrospective sorting. From phantom studies a precision of about 2.5 mm for quasiregular motion and typical respiratory periods could be concluded. A protocol for 4DCT scanning was evaluated and clinically implemented at the MGH. Patient data are presented to elucidate how additional patient specific parameters can impact 4DCT imaging.     

Acquiring 4D thoracic CT scans using a multislice helical method

Respiratory motion degrades anatomic position reproducibility during imaging, necessitates larger margins during radiotherapy planning and causes errors during radiation delivery. Computed tomography (CT) scans acquired synchronously with the respiratory signal can be used to reconstruct 4D CT scans, which can be employed for 4D treatment planning to explicitly account for respiratory motion. The aim of this research was to develop, test and clinically implement a method to acquire 4D thoracic CT scans using a multislice helical method. A commercial position-monitoring system used for respiratory-gated radiotherapy was interfaced with a third generation multislice scanner. 4D cardiac reconstruction methods were modified to allow 4D thoracic CT acquisition. The technique was tested on a phantom under different conditions: stationary, periodic motion and non-periodic motion. 4D CT was also implemented for a lung cancer patient with audio-visual breathing coaching. For all cases, 4D CT images were successfully acquired from eight discrete breathing phases, however, some limitations of the system in terms of respiration reproducibility and breathing period relative to scanner settings were evident. Lung mass for the 4D CT patient scan was reproducible to within 2.1% over the eight phases, though the lung volume changed by 20% between end inspiration and end expiration (870 cm3). 4D CT can be used for 4D radiotherapy, respiration-gated radiotherapy, 'slow' CT acquisition and tumour motion studies.     

Prospective respiratory-gated micro-CT of free breathing rodents

Microcomputed tomography (Micro-CT) has the potential to noninvasively image the structure of organs in rodent models with high spatial resolution and relatively short image acquisition times. However, motion artifacts associated with the normal respiratory motion of the animal may arise when imaging the abdomen or thorax. To reduce these artifacts and the accompanying loss of spatial resolution, we propose a prospective respiratory gating technique for use with anaesthetized, free-breathing rodents. A custom-made bed with an embedded pressure chamber was connected to a pressure transducer. Anaesthetized animals were placed in the prone position on the bed with their abdomens located over the chamber. During inspiration, the motion of the diaphragm caused an increase in the chamber pressure, which was converted into a voltage signal by the transducer. An output voltage was used to trigger image acquisition at any desired time point in the respiratory cycle. Digital radiographic images were acquired of anaesthetized, free-breathing rats with a digital radiographic system to correlate the respiratory wave form with respiration-induced organ motion. The respiratory wave form was monitored and recorded simultaneously with the x-ray radiation pulses, and an imaging window was defined, beginning at end expiration. Phantom experiments were performed to verify that the respiratory gating apparatus was triggering the micro-CT system. Attached to the distensible phantom were 100 microm diameter copper wires and the measured full width at half maximum was used to assess differences in image quality between respiratory-gated and ungated imaging protocols. This experiment allowed us to quantify the improvement in the spatial resolution, and the reduction of motion artifacts caused by moving structures, in the images resulting from respiratory-gated image acquisitions. The measured wire diameters were 0.135 mm for the stationary phantom image, 0.137 mm for the image gated at end deflation, 0.213 mm for the image gated at peak inflation, and 0.406 mm for the ungated image. Micro-CT images of anaesthetized, free-breathing rats were acquired with a General Electric Healthcare eXplore RS in vivo micro-CT system. Images of the thorax were acquired using the respiratory cycle-based trigger for the respiratory-gated mode. Respiratory gated-images were acquired at inspiration and end expiration, during a period of minimal respiration-induced organ motion. Gated images were acquired with a nominal isotropic voxel spacing of 44 microm in 20-25 min (80 kVp, 113 mAs, 300 ms imaging window per projection). The equivalent ungated acquisitions were 11 min in length. We observed improved definition of the diaphragm boundary and increased conspicuity of small structures within the lungs in the gated images, when compared to the ungated acquisitions. In this work, we have characterized the externally monitored respiratory wave form of free-breathing, anaesthetized rats and correlated the respiration-induced organ motion to the respiratory cycle. We have shown that the respiratory pressure wave form is an excellent surrogate for the radiographic organ motion. This information facilitates the definition of an imaging window at any phase of the breathing cycle. This approach for prospectively gated micro-CT can provide high quality images of anaesthetized free-breathing rodents.     

Optimization of multi-slice helical respiration-correlated CT: the effects of table speed and rotation time

While respiration-correlated CT is gaining acceptance in clinical radiotherapy, the effect of scanning parameters on the image quality has yet to be addressed. The intent of this study was to characterize the effects of gantry rotation and table speed on various image quality characteristics in multi-slice, helical, retrospectively-gated CT images. Images of stationary and moving phantoms were obtained in helical mode on a 20-slice CT scanner. Motion was generated by a computer-controlled platform capable of moving simultaneously in two dimensions. Motion was monitored using a pressure gauge inserted inside an adjustable belt. Selected scans were retrospectively gated into ten phases based on the monitored motion. Gantry rotation speeds of 0.5 s and 1.0 s were evaluated with pitches ranging from 0.1 to 0.45. Several parameters, including calculated object volumes, trajectory (movement from peak to trough), deformation (actual volume divided by volume created with the maximum diameter of contoured object) and z-axis resolution, were used to characterize image quality. These studies indicate that for objects in the peak phase of a movement pattern that simulates breathing, retrospectively gated scans using fast gantry rotation speeds produce volume, trajectory, deformation and z-axis resolution results comparable with those of a stationary object.     

Reconstruction of a time-averaged midposition CT scan for radiotherapy planning of lung cancer patients using deformable registration

PURPOSE: lower lobe lung tumors move with amplitudes of up to 2 cm due to respiration. To reduce respiration imaging artifacts in planning CT scans, 4D imaging techniques are used. Currently, we use a single (midventilation) frame of the 4D data set for clinical delineation of structures and radiotherapy planning. A single frame, however, often contains artifacts due to breathing irregularities, and is noisier than a conventional CT scan since the exposure per frame is lower. Moreover, the tumor may be displaced from the mean tumor position due to hysteresis. The aim of this work is to develop a framework for the acquisition of a good quality scan representing all scanned anatomy in the mean position by averaging transformed (deformed) CT frames, i.e., canceling out motion. A nonrigid registration method is necessary since motion varies over the lung. METHODS AND MATERIALS: 4D and inspiration breath-hold (BH) CT scans were acquired for 13 patients. An iterative multiscale motion estimation technique was applied to the 4D CT scan, similar to optical flow but using image phase (gray-value transitions from bright to dark and vice versa) instead. From the (4D) deformation vector field (DVF) derived, the local mean position in the respiratory cycle was computed and the 4D DVF was modified to deform all structures of the original 4D CT scan to this mean position. A 3D midposition (MidP) CT scan was then obtained by (arithmetic or median) averaging of the deformed 4D CT scan. Image registration accuracy, tumor shape deviation with respect to the BH CT scan, and noise were determined to evaluate the image fidelity of the MidP CT scan and the performance of the technique. RESULTS: Accuracy of the used deformable image registration method was comparable to established automated locally rigid registration and to manual landmark registration (average difference to both methods < 0.5 mm for all directions) for the tumor region. From visual assessment, the registration was good for the clearly visible features (e.g., tumor and diaphragm). The shape of the tumor, with respect to that of the BH CT scan, was better represented by the MidP reconstructions than any of the 4D CT frames (including MidV; reduction of "shape differences" was 66%). The MidP scans contained about one-third the noise of individual 4D CT scan frames. CONCLUSIONS: We implemented an accurate method to estimate the motion of structures in a 4D CT scan. Subsequently, a novel method to create a midposition CT scan (time-weighted average of the anatomy) for treatment planning with reduced noise and artifacts was introduced. Tumor shape and position in the MidP CT scan represents that of the BH CT scan better than MidV CT scan and, therefore, was found to be appropriate for treatment planning.     

Optimization of a retrospective technique for respiratory-gated high speed micro-CT of free-breathing rodents

The objective of this study was to develop a technique for dynamic respiratory imaging using retrospectively gated high-speed micro-CT imaging of free-breathing mice. Free-breathing C57Bl6 mice were scanned using a dynamic micro-CT scanner, comprising a flat-panel detector mounted on a slip-ring gantry. Projection images were acquired over ten complete gantry rotations in 50 s, while monitoring the respiratory motion in synchrony with projection-image acquisition. Projection images belonging to a selected respiratory phase were retrospectively identified and used for 3D reconstruction. The effect of using fewer gantry rotations--which influences both image quality and the ability to quantify respiratory function--was evaluated. Images reconstructed using unique projections from six or more gantry rotations produced acceptable images for quantitative analysis of lung volume, CT density, functional residual capacity and tidal volume. The functional residual capacity (0.15 +/- 0.03 mL) and tidal volumes (0.08 +/- 0.03 mL) measured in this study agree with previously reported measurements made using prospectively gated micro-CT and at higher resolution (150 microm versus 90 microm voxel spacing). Retrospectively gated micro-CT imaging of free-breathing mice enables quantitative dynamic measurement of morphological and functional parameters in the mouse models of respiratory disease, with scan times as short as 30 s, based on the acquisition of projection images over six gantry rotations.     

Automatic segmentation of phase-correlated CT scans through nonrigid image registration using geometrically regularized free-form deformation

Conventional radiotherapy is planned using free-breathing computed tomography (CT), ignoring the motion and deformation of the anatomy from respiration. New breath-hold-synchronized, gated, and four-dimensional (4D) CT acquisition strategies are enabling radiotherapy planning utilizing a set of CT scans belonging to different phases of the breathing cycle. Such 4D treatment planning relies on the availability of tumor and organ contours in all phases. The current practice of manual segmentation is impractical for 4D CT, because it is time consuming and tedious. A viable solution is registration-based segmentation, through which contours provided by an expert for a particular phase are propagated to all other phases while accounting for phase-to-phase motion and anatomical deformation. Deformable image registration is central to this task, and a free-form deformation-based nonrigid image registration algorithm will be presented. Compared with the original algorithm, this version uses novel, computationally simpler geometric constraints to preserve the topology of the dense control-point grid used to represent free-form deformation and prevent tissue fold-over. Using mean squared difference as an image similarity criterion, the inhale phase is registered to the exhale phase of lung CT scans of five patients and of characteristically low-contrast abdominal CT scans of four patients. In addition, using expert contours for the inhale phase, the corresponding contours were automatically generated for the exhale phase. The accuracy of the segmentation (and hence deformable image registration) was judged by comparing automatically segmented contours with expert contours traced directly in the exhale phase scan using three metrics: volume overlap index, root mean square distance, and Hausdorff distance. The accuracy of the segmentation (in terms of radial distance mismatch) was approximately 2 mm in the thorax and 3 mm in the abdomen, which compares favorably to the accuracies reported elsewhere. Unlike most prior work, segmentation of the tumor is also presented. The clinical implementation of 4D treatment planning is critically dependent on automatic segmentation, for which is offered one of the most accurate algorithms yet presented.     

Streaking artifacts reduction in four-dimensional cone-beam computed tomography

Cone-beam computed tomography (CBCT) using an "on-board" x-ray imaging device integrated into a radiation therapy system has recently been made available for patient positioning, target localization, and adaptive treatment planning. One of the challenges for gantry mounted image-guided radiation therapy (IGRT) systems is the slow acquisition of projections for cone-beam CT (CBCT), which makes them sensitive to any patient motion during the scans. Aiming at motion artifact reduction, four-dimensional CBCT (4D CBCT) techniques have been introduced, where a surrogate for the target's motion profile is utilized to sort the cone-beam data by respiratory phase. However, due to the limited gantry rotation speed and limited readout speed of the on-board imager, fewer than 100 projections are available for the image reconstruction at each respiratory phase. Thus, severe undersampling streaking artifacts plague 4D CBCT images. In this paper, the authors propose a simple scheme to significantly reduce the streaking artifacts. In this method, a prior image is first reconstructed using all available projections without gating, in which static structures are well reconstructed while moving objects are blurred. The undersampling streaking artifacts from static structures are estimated from this prior image volume and then can be removed from the phase images using gated reconstruction. The proposed method was validated using numerical simulations, experimental phantom data, and patient data. The fidelity of stationary and moving objects is maintained, while large gains in streak artifact reduction are observed. Using this technique one can reconstruct 4D CBCT datasets using no more projections than are acquired in a 60 s scan. At the same time, a temporal gating window as narrow as 100 ms was utilized. Compared to the conventional 4D CBCT reconstruction, streaking artifacts were reduced by 60% to 70%.     

Respiratory correlated cone beam CT

A cone beam computed tomography (CBCT) scanner integrated with a linear accelerator is a powerful tool for image guided radiotherapy. Respiratory motion, however, induces artifacts in CBCT, while the respiratory correlated procedures, developed to reduce motion artifacts in axial and helical CT are not suitable for such CBCT scanners. We have developed an alternative respiratory correlated procedure for CBCT and evaluated its performance. This respiratory correlated CBCT procedure consists of retrospective sorting in projection space, yielding subsets of projections that each corresponds to a certain breathing phase. Subsequently, these subsets are reconstructed into a four-dimensional (4D) CBCT dataset. The breathing signal, required for respiratory correlation, was directly extracted from the 2D projection data, removing the need for an additional respiratory monitor system. Due to the reduced number of projections per phase, the contrast-to-noise ratio in a 4D scan reduced by a factor 2.6-3.7 compared to a 3D scan based on all projections. Projection data of a spherical phantom moving with a 3 and 5 s period with and without simulated breathing irregularities were acquired and reconstructed into 3D and 4D CBCT datasets. The positional deviations of the phantoms center of gravity between 4D CBCT and fluoroscopy were small: 0.13 +/- 0.09 mm for the regular motion and 0.39 +/- 0.24 mm for the irregular motion. Motion artifacts, clearly present in the 3D CBCT datasets, were substantially reduced in the 4D datasets, even in the presence of breathing irregularities, such that the shape of the moving structures could be identified more accurately. Moreover, the 4D CBCT dataset provided information on the 3D trajectory of the moving structures, absent in the 3D data. Considerable breathing irregularities, however, substantially reduces the image quality. Data presented for three different lung cancer patients were in line with the results obtained from the phantom study. In conclusion, we have successfully implemented a respiratory correlated CBCT procedure yielding a 4D dataset. With respiratory correlated CBCT on a linear accelerator, the mean position, trajectory, and shape of a moving tumor can be verified just prior to treatment. Such verification reduces respiration induced geometrical uncertainties, enabling safe delivery of 4D radiotherapy such as gated radiotherapy with small margins.     

Geometrical differences in target volumes between slow CT and 4D CT imaging in stereotactic body radiotherapy for lung tumors in the upper and middle lobe

Since stereotactic body radiotherapy (SBRT) was started for patients with lung tumor in 1998 in our institution, x-ray fluoroscopic examination and slow computed tomography (CT) scan with a rotation time of 4 s have been routinely applied to determine target volumes. When lung tumor motion observed with x-ray fluoroscopy is larger than 8 mm, diaphragm control (DC) is used to reduce tumor motion during respiration. After the installation of a four-dimensional (4D) CT scanner in 2006, 4D CT images have been supplementarily acquired to determine target volumes. It was found that target volumes based on slow CT images were substantially different from those on 4D CT images, even for patients with lung tumor motion no larger than 8 mm. Although slow CT scan might be expected to fare well for lung tumors with motion range of 8 mm or less, the potential limitations of slow CT scan are unknown. The purpose of this study was to evaluate the geometrical differences in target volumes between slow CT and 4D CT imaging for lung tumors with motion range no larger than 8 mm in the upper and middle lobe. Of the patients who underwent SBR between October 2006 and April 2008, 32 patients who had lung tumor with motion range no larger than 8 mm and did not need to use DC were enrolled in this study. Slow CT and 4D CT images were acquired under free breathing for each patient. Target volumes were manually delineated on slow CT images (TV(slow CT)). Gross tumor volumes were also delineated on each of the 4D CT volumes and their union (TV(4D CT)) was constructed. Volumetric and statistical analyses were performed for each patient. The mean +/- standard deviation (S.D.) of TV(slow CT)/TV(4D CT) was 0.75 +/- 0.17 (range, 0.38-1.10). The difference between sizes of TV(slow CT) and TV(4D CT) was not statistically significant (P = 0.096). A mean of 8% volume of TV(slow CT) was not encompassed in TV(4D CT) (mean +/- S.D. = 0.92 +/- 0.07). The patients were separated into two groups to test whether the quality of target delineation on slow CT scans depends on respiratory periods below or above the CT rotation time of 4 s. No significant difference was observed between these groups (P = 0.229). Even lung tumors with motion range no larger than 8 mm might not be accurately depicted on slow CT images. When only a single slow CT scan was used for lung tumors with motion range of 8 mm or less, 95% confidence values for additional margins for TV(slow CT) to encompass TV(4D CT) were 4.0, 5.4, 4.9, 5.1, 1.8, and 1.7 mm for lateral, medial, ventral, dorsal, cranial, and caudal directions, respectively.     

The susceptibility of IMRT dose distributions to intrafraction organ motion: an investigation into smoothing filters derived from four dimensional computed tomography data

This study investigated the sensitivity of static planning of intensity-modulated beams (IMBs) to intrafraction deformable organ motion and assessed whether smoothing of the IMBs at the treatment-planning stage can reduce this sensitivity. The study was performed with a 4D computed tomography (CT) data set for an IMRT treatment of a patient with liver cancer. Fluence profiles obtained from inverse-planning calculations on a standard reference CT scan were redelivered on a CT scan from the 4D data set at a different part of the breathing cycle. The use of a nonrigid registration model on the 4D data set additionally enabled detailed analysis of the overall intrafraction motion effects on the IMRT delivery during free breathing. Smoothing filters were then applied to the beam profiles within the optimization process to investigate whether this could reduce the sensitivity of IMBs to intrafraction organ motion. In addition, optimal fluence profiles from calculations on each individual phase of the breathing cycle were averaged to mimic the convolution of a static dose distribution with a motion probability kernel and assess its usefulness. Results from nonrigid registrations of the CT scan data showed a maximum liver motion of 7 mm in superior-inferior direction for this patient. Dose-volume histogram (DVH) comparison indicated a systematic shift when planning treatment on a motion-frozen, standard CT scan but delivering over a full breathing cycle. The ratio of the dose to 50% of the normal liver to 50% of the planning target volume (PTV) changed up to 28% between different phases. Smoothing beam profiles with a median-window filter did not overcome the substantial shift in dose due to a difference in breathing phase between planning and delivery of treatment. Averaging of optimal beam profiles at different phases of the breathing cycle mainly resulted in an increase in dose to the organs at risk (OAR) and did not seem beneficial to compensate for organ motion compared with using a large margin. Additionally, the results emphasized the need for 4D CT scans when aiming to reduce the internal margin (IM). Using only a single planning scan introduces a systematic shift in the dose distribution during delivery. Smoothing beam profiles either based on a single scan or over the different breathing phases was not beneficial for reducing this shift.     

Tracking lung tissue motion and expansion/compression with inverse consistent image registration and spirometry

Breathing motion is one of the major limiting factors for reducing dose and irradiation of normal tissue for conventional conformal radiotherapy. This paper describes a relationship between tracking lung motion using spirometry data and image registration of consecutive CT image volumes collected from a multislice CT scanner over multiple breathing periods. Temporal CT sequences from 5 individuals were analyzed in this study. The couch was moved from 11 to 14 different positions to image the entire lung. At each couch position, 15 image volumes were collected over approximately 3 breathing periods. It is assumed that the expansion and contraction of lung tissue can be modeled as an elastic material. Furthermore, it is assumed that the deformation of the lung is small over one-fifth of a breathing period and therefore the motion of the lung can be adequately modeled using a small deformation linear elastic model. The small deformation inverse consistent linear elastic image registration algorithm is therefore well suited for this problem and was used to register consecutive image scans. The pointwise expansion and compression of lung tissue was measured by computing the Jacobian of the transformations used to register the images. The logarithm of the Jacobian was computed so that expansion and compression of the lung were scaled equally. The log-Jacobian was computed at each voxel in the volume to produce a map of the local expansion and compression of the lung during the breathing period. These log-Jacobian images demonstrate that the lung does not expand uniformly during the breathing period, but rather expands and contracts locally at different rates during inhalation and exhalation. The log-Jacobian numbers were averaged over a cross section of the lung to produce an estimate of the average expansion or compression from one time point to the next and compared to the air flow rate measured by spirometry. In four out of five individuals, the average log-Jacobian value and the air flow rate correlated well (R2 = 0.858 on average for the entire lung). The correlation for the fifth individual was not as good (R2 = 0.377 on average for the entire lung) and can be explained by the small variation in tidal volume for this individual. The correlation of the average log-Jacobian value and the air flow rate for images near the diaphragm correlated well in all five individuals (R2 = 0.943 on average). These preliminary results indicate a strong correlation between the expansion/compression of the lung measured by image registration and the air flow rate measured by spirometry. Predicting the location, motion, and compression/expansion of the tumor and normal tissue using image registration and spirometry could have many important benefits for radiotherapy treatment. These benefits include reducing radiation dose to normal tissue, maximizing dose to the tumor, improving patient care, reducing treatment cost, and increasing patient throughput.