The First Implementation of Respiratory Triggered 4DCBCT on a Linear Accelerator

Four Dimensional Cone Beam Computed Tomography (4DCBCT) is an image guidance strategy used for patient positioning in radiotherapy. In conventional implementations of 4DCBCT, a constant gantry speed and a constant projection pulse rate are used. Unfortunately, this leads to higher imaging doses than are necessary because a large number of redundant projections are acquired. In theoretical studies, we have previously demonstrated that by suppressing redundant projections the imaging dose can be reduced by 40-50% for a majority of patients with little reduction in image quality. The aim of this study was to experimentally realise the projection suppression technique, which we have called Respiratory Triggered 4DCBCT (RT-4DCBCT). A real-time control system was developed that takes the respiratory signal as input and computes whether to acquire, or suppress, the next projection trigger during 4DCBCT acquisition. The CIRS dynamic thorax phantom was programmed with a 2cm peak-to-peak motion and periods ranging from 2 to 8 seconds. Image quality was assessed by computing the edge response width of a 3cm imaging insert placed in the phantom as well as the signal to noise ratio of the phantoms tissue and the contrast to noise ratio between the phantoms lung and tissue. The standard deviation in the Superior-Inferior direction of the 3cm imaging insert was used to assess intra-phase bin displacement variations with a higher standard deviation implying more motion blur. The 4DCBCT imaging dose was reduced by 8.6%, 41%, 54%, 70% and 77% for patients with 2, 3, 4, 6 and 8 second breathing periods respectively when compared to conventional 4DCBCT. The standard deviation of the intra-phase bin displacement variation of the 3cm imaging insert was reduced by between 13% and 43% indicating a more consistent position for the projections within respiratory phases. For the 4 second breathing period, the edge response width was reduced by 39% (0.8mm) with only a 6-7% decrease in the signal to noise and contrast to noise ratios. RT-4DCBCT has been experimentally realised and reduced to practice on a linear accelerator with a measurable imaging dose reductions over conventional 4DCBCT and little degradation in image quality