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Title: The effect of irregular breathing patterns on internal target volumes in four-dimensional CT and cone-beam CT images in the context of stereotactic lung radiotherapy

Abstract

Purpose: Stereotactic lung radiotherapy is complicated by tumor motion from patient respiration. Four-dimensional CT (4DCT) imaging is a motion compensation method used in treatment planning to generate a maximum intensity projection (MIP) internal target volume (ITV). Image guided radiotherapy during treatment may involve acquiring a volumetric cone-beam CT (CBCT) image and visually aligning the tumor to the planning 4DCT MIP ITV contour. Moving targets imaged with CBCT can appear blurred and currently there are no studies reporting on the effect that irregular breathing patterns have on CBCT volumes and their alignment to 4DCT MIP ITV contours. The objective of this work was therefore to image a phantom moving with irregular breathing patterns to determine whether any configurations resulted in errors in volume contouring or alignment. Methods: A Perspex thorax phantom was used to simulate a patient. Three wooden 'lung' inserts with embedded Perspex 'lesions' were moved up to 4 cm with computer-generated motion patterns, and up to 1 cm with patient-specific breathing patterns. The phantom was imaged on 4DCT and CBCT with the same acquisition settings used for stereotactic lung patients in the clinic and the volumes on all phantom images were contoured. This project assessed the volumes for qualitativemore » and quantitative changes including volume, length of the volume, and errors in alignment between CBCT volumes and 4DCT MIP ITV contours. Results: When motion was introduced 4DCT and CBCT volumes were reduced by up to 20% and 30% and shortened by up to 7 and 11 mm, respectively, indicating that volume was being under-represented at the extremes of motion. Banding artifacts were present in 4DCT MIP images, while CBCT volumes were largely reduced in contrast. When variable amplitudes from patient traces were used and CBCT ITVs were compared to 4DCT MIP ITVs there was a distinct trend in reduced ITV with increasing amplitude that was not seen when compared to true ITVs. Breathing patterns with a rest period following expiration resulted in well-defined superior edges and were better aligned using an edge-to-edge alignment technique. In most cases, sinusoidal motion patterns resulted in the closest agreements to true values and the smallest misalignments. Conclusions: Strategies are needed to compensate for volume losses at the extremes of motion for both 4DCT MIP and CBCT images for larger and varied amplitudes, and for patterns with rest periods following expiration. Lesions moving greater than 2 cm would warrant larger treatment margins added to the 4DCT MIP ITV to account for the volume being under-represented at the extremes of motion. Lesions moving with a rest period following expiration would be better aligned using an edge-to-edge alignment technique. Sinusoidal patterns represented the ideal clinical scenario, reinforcing the importance of investigating clinically relevant motions and their effects on 4DCT MIP and CBCT volumes. Since most patients do not breathe sinusoidally this may lead to misinterpretation of previous studies using only sinusoidal motion.« less

Authors:
 [1]; ;  [2]; ;  [3]; ;  [4]; ; ;  [5]
  1. Department of Physical Sciences, Peter MacCallum Cancer Centre, East Melbourne 3002, Australia and Department of Applied Sciences, RMIT University, Melbourne 3001 (Australia)
  2. Department of Physical Sciences, Peter MacCallum Cancer Centre, East Melbourne 3002 (Australia)
  3. Department of Applied Sciences, RMIT University, Melbourne 3001 (Australia)
  4. Department of Radiation Therapy, Peter MacCallum Cancer Centre, East Melbourne 3002 (Australia)
  5. Department of Radiation Oncology, Peter MacCallum Cancer Centre, East Melbourne 3002 (Australia)
Publication Date:
OSTI Identifier:
22130528
Resource Type:
Journal Article
Resource Relation:
Journal Name: Medical Physics; Journal Volume: 40; Journal Issue: 2; Other Information: (c) 2013 American Association of Physicists in Medicine; Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; 60 APPLIED LIFE SCIENCES; CAT SCANNING; COMPARATIVE EVALUATIONS; FOUR-DIMENSIONAL CALCULATIONS; IMAGE PROCESSING; IMAGES; LUNGS; PATIENTS; PERSPEX; PHANTOMS; RADIOTHERAPY; RESPIRATION

Citation Formats

Clements, N., Kron, T., Roxby, P., Franich, R., Dunn, L., Aarons, Y., Chesson, B., Siva, S., Duplan, D., and Ball, D. The effect of irregular breathing patterns on internal target volumes in four-dimensional CT and cone-beam CT images in the context of stereotactic lung radiotherapy. United States: N. p., 2013. Web. doi:10.1118/1.4773310.
Clements, N., Kron, T., Roxby, P., Franich, R., Dunn, L., Aarons, Y., Chesson, B., Siva, S., Duplan, D., & Ball, D. The effect of irregular breathing patterns on internal target volumes in four-dimensional CT and cone-beam CT images in the context of stereotactic lung radiotherapy. United States. doi:10.1118/1.4773310.
Clements, N., Kron, T., Roxby, P., Franich, R., Dunn, L., Aarons, Y., Chesson, B., Siva, S., Duplan, D., and Ball, D. 2013. "The effect of irregular breathing patterns on internal target volumes in four-dimensional CT and cone-beam CT images in the context of stereotactic lung radiotherapy". United States. doi:10.1118/1.4773310.
@article{osti_22130528,
title = {The effect of irregular breathing patterns on internal target volumes in four-dimensional CT and cone-beam CT images in the context of stereotactic lung radiotherapy},
author = {Clements, N. and Kron, T. and Roxby, P. and Franich, R. and Dunn, L. and Aarons, Y. and Chesson, B. and Siva, S. and Duplan, D. and Ball, D.},
abstractNote = {Purpose: Stereotactic lung radiotherapy is complicated by tumor motion from patient respiration. Four-dimensional CT (4DCT) imaging is a motion compensation method used in treatment planning to generate a maximum intensity projection (MIP) internal target volume (ITV). Image guided radiotherapy during treatment may involve acquiring a volumetric cone-beam CT (CBCT) image and visually aligning the tumor to the planning 4DCT MIP ITV contour. Moving targets imaged with CBCT can appear blurred and currently there are no studies reporting on the effect that irregular breathing patterns have on CBCT volumes and their alignment to 4DCT MIP ITV contours. The objective of this work was therefore to image a phantom moving with irregular breathing patterns to determine whether any configurations resulted in errors in volume contouring or alignment. Methods: A Perspex thorax phantom was used to simulate a patient. Three wooden 'lung' inserts with embedded Perspex 'lesions' were moved up to 4 cm with computer-generated motion patterns, and up to 1 cm with patient-specific breathing patterns. The phantom was imaged on 4DCT and CBCT with the same acquisition settings used for stereotactic lung patients in the clinic and the volumes on all phantom images were contoured. This project assessed the volumes for qualitative and quantitative changes including volume, length of the volume, and errors in alignment between CBCT volumes and 4DCT MIP ITV contours. Results: When motion was introduced 4DCT and CBCT volumes were reduced by up to 20% and 30% and shortened by up to 7 and 11 mm, respectively, indicating that volume was being under-represented at the extremes of motion. Banding artifacts were present in 4DCT MIP images, while CBCT volumes were largely reduced in contrast. When variable amplitudes from patient traces were used and CBCT ITVs were compared to 4DCT MIP ITVs there was a distinct trend in reduced ITV with increasing amplitude that was not seen when compared to true ITVs. Breathing patterns with a rest period following expiration resulted in well-defined superior edges and were better aligned using an edge-to-edge alignment technique. In most cases, sinusoidal motion patterns resulted in the closest agreements to true values and the smallest misalignments. Conclusions: Strategies are needed to compensate for volume losses at the extremes of motion for both 4DCT MIP and CBCT images for larger and varied amplitudes, and for patterns with rest periods following expiration. Lesions moving greater than 2 cm would warrant larger treatment margins added to the 4DCT MIP ITV to account for the volume being under-represented at the extremes of motion. Lesions moving with a rest period following expiration would be better aligned using an edge-to-edge alignment technique. Sinusoidal patterns represented the ideal clinical scenario, reinforcing the importance of investigating clinically relevant motions and their effects on 4DCT MIP and CBCT volumes. Since most patients do not breathe sinusoidally this may lead to misinterpretation of previous studies using only sinusoidal motion.},
doi = {10.1118/1.4773310},
journal = {Medical Physics},
number = 2,
volume = 40,
place = {United States},
year = 2013,
month = 2
}
  • Purpose: In this study, we investigate a technique of matching internal target volumes (ITVs) in four-dimensional (4D) simulation computed tomography (CT) to the composite target volume in free-breathing on-board cone-beam (CB) CT. The technique is illustrated by using both phantom and patient cases. Methods and Materials: A dynamic phantom with a target ball simulating respiratory motion with various amplitude and cycle times was used to verify localization accuracy. The dynamic phantom was scanned using simulation CT with a phase-based retrospective sorting technique. The ITV was then determined based on 10 sets of sorted images. The size and epicenter of themore » ITV identified from 4D simulation CT images and the composite target volume identified from on-board CBCT images were compared to assess localization accuracy. Similarly, for two clinical cases of patients with lung cancer, ITVs defined from 4D simulation CT images and CBCT images were compared. Results: For the phantom, localization accuracy between the ITV in 4D simulation CT and the composite target volume in CBCT was within 1 mm, and ITV was within 8.7%. For patient cases, ITVs on simulation CT and CBCT were within 8.0%. Conclusion: This study shows that CBCT is a useful tool to localize ITV for targets affected by respiratory motion. Verification of the ITV from 4D simulation CT using on-board free-breathing CBCT is feasible for the target localization of lung tumors.« less
  • Purpose: To investigate whether the three-dimensional cone-beam CT (CBCT) is clinically equivalent to the four-dimensional computed tomography (4DCT) maximum intensity projection (MIP) reconstructed images for internal target volume (ITV) localization in image-guided lung stereotactic radiotherapy.Methods: A ball-shaped polystyrene phantom with built-in cube, sphere, and cone of known volumes was attached to a motor-driven platform, which simulates a sinusoidal movement with changeable motion amplitude and frequency. Target motion was simulated in the patient in a superior-inferior (S-I) direction with three motion periods and 2 cm peak-to-peak amplitudes. The Varian onboard Exact-Arms kV CBCT system and the GE LightSpeed four-slice CT integratedmore » with the respiratory-position-management 4DCT scanner were used to scan the moving phantom. MIP images were generated from the 4DCT images. The clinical equivalence of the two sets of images was evaluated by comparing the extreme locations of the moving objects along the motion direction, the centroid position of the ITV, and the ITV volumes that were contoured automatically by Velocity or calculated with an imaging gradient method. The authors compared the ITV volumes determined by the above methods with those theoretically predicted by taking into account the physical object dimensions and the motion amplitudes. The extreme locations were determined by the gradient method along the S-I axis through the center of the object. The centroid positions were determined by autocenter functions. The effect of motion period on the volume sizes was also studied.Results: It was found that the extreme locations of the objects determined from the two image modalities agreed with each other satisfactorily. They were not affected by the motion period. The average difference between the two modalities in the extreme locations was 0.68% for the cube, 1.35% for the sphere, and 0.5% for the cone, respectively. The maximum difference in the centroid position of the cylinder, sphere, and cone was less than 1.4 mm between the two modalities for all motion periods studied. For the ITV volume evaluation, the authors found that both MIP-based and CBCT-based ITVs increased with increases of motion period. Furthermore, the MIP-based ITV volumes were generally larger than those determined from the CBCT images, with the difference in autocontoured volumes being 2.57%, 1.66%, and 1.82% for the sphere, cylinder, and cone, respectively, while these differences increased to 9.57%, 3.52%, 8.71% for the above objects when the gradient method was used. The authors found that the autocontour method was accurate enough to predict the actual ITV values with the absolute differences less than 2.4% comparing to the theoretically predicted values.Conclusions: The extreme location and the centroid position of the objects agree with each other between the two image modalities when the breathing motion is sinusoidal. Although the ITV volumes delineated from both image modalities changed with the motion period, the differences in ITV between the two modalities were minimal when an optimized window level was used. The authors’ results suggest that CBCT and MIP images are equivalent in determining an ITV's position in the conditions studied. The CBCT is adequate in providing imaging-guidance for lung cancer treatment.« less
  • Purpose: To quantify the localization accuracy and intrafraction stability of lung cancer patients treated with frameless, four-dimensional (4D) cone beam computed tomography (CBCT)-guided stereotactic body radiotherapy (SBRT) and to calculate and validate planning target volume (PTV) margins to account for the residual geometric uncertainties. Materials and Methods: Sixty-five patients with small peripheral lung tumors were treated with SBRT without a body frame to 54 Gy in three fractions. For each fraction, three 4D-CBCT scans were acquired: before treatment to measure and correct the time-weighted mean tumor position, after correction to validate the correction applied, and after treatment to estimate themore » intrafraction stability. Patient-specific PTV margins were computed and subsequently validated using Monte Carlo error simulations. Results: Systematic tumor localization inaccuracies (1 SD) were 0.8, 0.8, and 0.9 mm for the left-right, craniocaudal, and anteroposterior direction, respectively. Random localization inaccuracies were 1.1, 1.1, and 1.4 mm. Baseline variations were 1.8, 2.9, and 3.0 mm (systematic) and 1.1, 1.5, and 2.0 mm (random), indicating the importance of image guidance. Intrafraction stability of the target was 1.2, 1.2, and 1.8 mm (systematic) and 1.3, 1.5, and 1.8 mm (random). Monte Carlo error simulations showed that patient-specific PTV margins (5.8-10.5 mm) were adequate for 94% of the evaluated cases (2-28 mm peak-to-peak breathing amplitude). Conclusions: Frameless SBRT can be safely administered using 4D-CBCT guidance. Even with considerable breathing motion, the PTV margins can safely be kept small, allowing patients with larger tumors to benefit from the advantages of SBRT. In case bony anatomy would be used as a surrogate for tumor position, considerably larger PTV margins would be required.« less
  • Purpose: The purpose of this study was to evaluate the interfractional and intrafractional motion of liver tumors in stereotactic body radiation therapy (SBRT), based on four-dimensional cone-beam computed tomography using fiducial markers. (4D-CBCT). Methods: Seven patients with liver tumors were treated by SBRT with abdominal compression (AC) in five fractions with image guidance based on 4D-CBCT. The 4D-CBCT studies were performed to determine the individualized internal margin for the planning simulation. The interfractional and intrafractional changes of liver tumor motion for all patients was measured, based on the planning simulation 4D-CBCT, pre-SBRT 4D-CBCT, and post-SBRT 4D-CBCT. The interfractional motion changemore » was calculated from the difference in liver tumor amplitude on pre-SBRT 4D-CBCT relative to that of the planning simulation 4D-CBCT for each fraction. The intrafractional motion change was calculated from the difference between the liver tumor amplitudes of the pre- and post-SBRT 4D-CBCT for each fraction. Significant interfractional and intrafractional changes in liver tumor motion were defined as a change ≥3 mm. Statistical analysis was performed using the Pearson correlation. Results: The values of the mean amplitude of liver tumor, as indicated by planning simulation 4D-CBCT, were 1.6 ± 0.8 mm, 1.6 ± 0.9 mm, and 4.9 ± 2.2 mm in the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) directions, respectively. Pearson correlation coefficients between the liver tumor amplitudes, based on planning simulation 4D-CBCT, and pre-SBRT 4D-CBCT during fraction treatment in the LR, AP, and SI directions were 0.6, 0.7, and 0.8, respectively. Interfractional and intrafractional motion changes of ≥3 mm occurred in 23% and 3% of treatment fractions, respectively. Conclusion: The interfractional and intrafractional changes of liver tumor motion were small in most patients who received liver SBRT with AC. In addition, planning simulation 4D-CBCT was useful for representing liver tumor movement in patients undergoing SBRT. This work was supported by JSPS KAKENHI Grant Number 26861004.« less
  • Purposes: To quantitatively compare two-dimensional (2D) orthogonal kV with three-dimensional (3D) cone-beam CT (CBCT) for target localization; and to assess intrafraction motion with kV images in patients undergoing stereotactic body radiotherapy (SBRT). Methods and Materials: A total of 50 patients with 58 lesions received 178 fractions of SBRT. After clinical setup using in-room lasers and skin/cradle marks placed at simulation, patients were imaged and repositioned according to orthogonal kV/MV registration of bony landmarks to digitally reconstructed radiographs from the planning CT. A subsequent CBCT was registered to the planning CT using soft tissue information, and the resultant 'residual error' wasmore » measured and corrected before treatment. Posttreatment 2D kV and/or 3D CBCT images were compared with pretreatment images to determine any intrafractional position changes. Absolute averages, statistical means, standard deviations, and root mean square (RMS) values of observed setup error were calculated. Results: After initial setup to external marks with laser guidance, 2D kV images revealed vector mean setup deviations of 0.67 cm (RMS). Cone-beam CT detected residual setup deviations of 0.41 cm (RMS). Posttreatment imaging demonstrated intrafractional variations of 0.15 cm (RMS). The individual shifts in three standard orthogonal planes showed no obvious directional biases. Conclusions: After localization based on superficial markings in patients undergoing SBRT, orthogonal kV imaging detects setup variations of approximately 3 to 4 mm in each direction. Cone-beam CT detects residual setup variations of approximately 2 to 3 mm.« less