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    Cone Beam CT Guided Radiotherapy: Jan-Jakob Sonke

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    Cone Beam CT Guided Radiotherapy: Jan-Jakob Sonke

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    85 views64 pages

    Cone Beam CT Guided Radiotherapy: Jan-Jakob Sonke

    Uploaded by

    babba241276

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    Cone Beam CT guided Radiotherapy

    Jan-Jakob Sonke

    Acknowledgements
    NKI-AVL: Marcel van Herk, Jose Belderbos, Suzanne van Beek, Anja Betgen, Josien de Bois, ~Rianne de Jong, Michel Frenay, Danny Minkema, Tonnis Nuver, Jasper Nijkamp, Floris Pos, Monique Smitsmans, Simon van Kramen, Jochem Wolthaus, Lambert Zijp, Peter Remeijer, Coen Rasch and Joos Lebesque PMH, Toronto David Jaffray Doug Moseley Jeffrey Siewerdsen Beaumont Hospital Di Yan Alvaro Martinez
    Elekta Synergy Research Group

    Contents
    Introduction CBCT Acquisition & Reconstruction CBCT image quality Clinical Implementation & Protocols

    CT Acquisition
    Conventional CT - Fan beam - 1D detector - 1 rotation = 1 slice Cone-beam CT - Cone beam - 2D detector - 1 rotation = volume (many slices)

    kV image guidance: not a new idea !

    First isocentric Co-60 machine in Netherlands at NKI (1960)

    First Prototype CBCT Guided Linac

    6.5 cm

    D. Jaffray et al. Int J. Radiat. Oncol. Biol. Phys. 2002

    Available Cone Beam Systems

    Elekta Synergy

    Siemens Artiste

    Varian Trilogy C-arms

    Bench Top

    Acquisition and Reconstruction

    Elekta Synergy Research system at NKI

    Frame Rate: 5.4 fps; Acquisition Time: 1 - 2 min

    Cone beam reconstruction

    V ( x, y, z ) = W2 ( (W1 p( , a ( x, y, z , ), b( x, y, z , ) )) g (a ) ) d
    0

    dimx * dimy * dimz * Nproj computations: 5 * 109 for 2563

    Imaging Field of View

    Field of View
    180 + fan-angle

    Central detector position

    Field of View: Offset Detector

    Partially displaced detector position

    Offset Detector

    Partially displaced detector position

    Offset Detector

    Panel Position Central Partially displaced Fully displaced

    FOV 25 cm 40 cm 50 cm

    Partially displaced detector position

    Geometric Calibration and QA

    Geometry: Flex calibration


    0.5 0.4 0.3 0.2 0.1 0 -0.1 -0.2 -200 XG (AB) YG (GT) -150 -100 -50 0 50 angle [ ] 100 150 200

    Calculate center of ball bearing for all gantry angles Generate Lookup table for U & V displacements Lookup table includes Set-up error BB

    displacement [cm]

    Geometry: kV to MV Isoc Calibration

    Gantry& Collimator Angle:

    -180, -90, 0, 90, 180

    Determine COG field edge & BB Calculate mean setup error

    QA Phantom

    QA Geometrical Accuracy
    Planning CT CBCT CT

    Match 3D

    same ?

    Match 2x 2D

    DRR

    EPI

    3D Imaging Performance and Artifacts

    Sources of cupping and streaks


    Missing data (truncation)
    Detector field of view 25 cm

    Scattered radiation
    Extra signal not from local anatomy Adds noise !

    Beam hardening
    Attenuation of patient smaller than expected

    Ghosting
    High exposure signal gives residual extra signal later

    Scatter & Imaging Geometry

    Cone Beam CT

    Fan Beam CT

    Scatter-to-primary ratio (SPR) in excess of 300% occur in lateral pelvic projection data occur for CBCT geometry

    Strategies for Scatter Management


    Select Minimize FOVCC to minimize SPR Optimize Air gap 0.5 0.6 m Compensators (e.g. BowTie filters) Reject Anti-scatter grid Siewerdsen et al. Med.Phys. Dec2004 Correct Scatter correction algorithm

    Courtesy Jaffrey Siewerdsen

    Shading

    Scatter correction algorithm

    Without correction
    Assumption: scatter uniform and proportional to average image intensity where there is patient in the beam

    With correction

    Boellaard et al. Two-dimensional exit dosimetry using a liquidfilled electronic portal imaging device and a convolution model Radiother. Oncol. 44 149-157, 1997

    CBCT versus Fan Beam CT


    FBCT CBCT CBCT

    FBCT

    Motion

    Moving Gas

    Smitsmans et al. Med Phys. 2005

    Image quality
    Diet, given by a dietician based on the patients own insight, starting 7 days before treatment

    Mild laxatives: Magnesium-oxide tablets (1 gram) 2 nights before CT scan and during treatments No scans/treatments before 10 am

    CBCT

    Moving structures are blurred over their trajectory

    4D CBCT

    Retrospective sorting of the projections before reconstruction yields 4D data

    3D versus 4D CBCT

    4D Data set 8 x 84 projections

    3D Data set 670 projections

    The Amsterdam Shroud (Lambert Zijp)

    CC position

    X-ray image #
    Breathing Signal automatically extracted from projection data

    Clinical Implementation

    Clinical Implementation CBCT @ NKI-AvL


    First clinical images on July 9th, 2003 Special team of 4 radiotherapy technicians Normal patient program during the morning Patients with extra CBCT in the afternoon Close cooperation with the physicists

    Clinical Implementation CBCT @ NKI-AvL


    8 months of validation and improvement of image quality (waiting for CE marking for intervention):
    Over 150 scans made to compare with EPID: prostate, head & neck, lung, bladder, sarcoma, stomach and breast patient Different scan protocols were tested Position of the detector Variation in kV and mA Variation in number of frames, by reducing gantry rotation speed

    Current situation @ NKI - AvL


    Patient set-up is monitored with CBCT for most of our patient groups, using a decision protocol based on bony anatomy match Radiotherapy technicians perform the acquisition, registration and evaluation (bony anatomy) Soft-tissue registrations performed by dedicated radiotherapy technicians in close cooperation with physicists and physicians

    Current situation (AvL)


    June 2006 We have acquired:
    > 6500 CBCT scans On 3 Synergy systems > 700 patients

    Archiving

    Scenario I
    Online Protocol 30 scans per day per machine Storing projections at high resolution (1024^2) 650 * 2 MB per image Storing high resolution scans (0.5 mm voxel size) 256 625 MB per scan ~225 GB per machine per week

    Scenario II
    Offline Protocol 10 scans per day per machine Storing projections at medium resolution (1024^2) 650 * 0.5 MB per image Storing medium resolution scans (1 mm voxel size) 32 MB per scan ~17 GB per machine per week

    Scenario III
    Offline Protocol 10 scans per day per machine Storing no projections Storing medium resolution scans (1 mm voxel size) 32 MB per scan ~1.5 GB per machine per week

    Set-up Error Bony Anatomy Registration

    Image analysis: comparison with reference image


    reference localization

    Reference image (planning CT)

    Localization image (cone beam CT)

    Mixed image (not matched)

    Automatic matching on region of interest built-in in Synergy system


    reference localization reference localization

    Tumor in top of neck


    Required table shift: (-3.2, -1.5, -0.6) mm

    Tumor in lower part of neck


    Required table shift: (+1.5, -3.2, -6.1) mm

    By zooming in on a region of interest, any target can be accurately localized even if the anatomy changes shape

    Matching cone beam to planning CT on bone is highly accurate example for lung treatment series - 10 days matched

    Vertebrae are perfectly still

    Estimated match accuracy << 1 mm SD, much better as EPID for lung

    Can cone beam CT replace EPID ?


    As CBCT acquisition is slower but alignment is faster Cone beam CT is matched more accurately Imaging dose is similar or lower

    Cone beam CT can safely replace EPID for bony anatomy setup corrections We replaced EPID with cone beam CT The collected data is used to develop soft tissue protocols

    Adaptive Radiation Therapy (ART)

    Principle
    Adaptive Radiation Therapy (ART *) uses imaging information of the first few treatment fractions to re-optimize the treatment plan reduction systematic error reduction treatment margins reduction dose to the rectal wall reduction of rectal toxicity **
    * Yan et al., IJROBP 50 (2001) ** Peeters et al., IJROBP jan. (2006)

    ART treatment scheme

    Conventional plan, 10 mm

    Average prostate & rectum adaptive plan, 7 mm**

    CBCT first 6 days

    weekly monitoring treatment

    ** unpublished data: Tonnis Nuver (NKI/AVL)

    Average prostate
    Grey-value registration
    TAP / TCC / TLR / RAP / RCC / RLR

    ** Smitsmans et al., IJROBP 60 (2004)

    Automatic prostate localization in CBCT (30 s)

    Cone beam CT 10 CBCT scans: automatic bone match

    Planning CT contours placed automatically

    10 CBCT scans: automatic prostate match help line (GTV+3.6 mm)


    Smitsmans et al., IJROBP 2004, 2005

    Monitoring the treatment


    Visual assessment if the prostate + SV were inside average prostate + 7 mm (PTV volume ART plan)

    Variability of 4D CT Patient Models

    Repeat 4D cone beam CT

    Shows respiration, tumor shrinkage and baseline position variation

    Base line shifts

    Tumor motion is very similar but occurs at very different places. Verification is essential for accurate treatment

    Local Rigid Body Registration

    Visual Validation

    Multiple Targets

    Misalignment of the primary target

    Multiple Targets

    Correcting alignment of the primary target

    Multiple Targets

    Correct alignment of primary target might misalign the nodes

    Conclusions
    Organ motion limits accuracy of radiotherapy Cone-beam CT provides soft tissue contrast, is efficient and does not require moving or touching the patient (4D) CBCT provides a wealth of information (and a huge amount of data!) Dose needed for CBCT scan is considerably smaller than for standard EPID localization fields Image quality sufficient for image guidance

    Conclusions
    Several soft-tissue and bony anatomy based protocols in routine clinical use Substantial investment and support of vendors required to enable advanced image guided protocols Image Guidance is potentially dangerous. Do not underestimate the residual uncertainties!

    Delineation variation: CT versus CT + PET

    CT (T2N2) SD 7.5 mm Steenbakkers et al Radiother Oncol. 2005

    CT + PET (T2N1) SD 3.5 mm

    The beams will be pointed to the target the physician draws !

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