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Background: Cone beam computed tomography (CBCT) is widely used in many medical fields. However, conventional CBCT circular scans suffer from cone beam (CB) artifacts that limit the quality and reliability of the reconstructed images due to incomplete data. Purpose: Saddle trajectories in theory might be able to improve the CBCT image quality by providing a larger region with complete data. Therefore, we investigated the feasibility and performance of saddle trajectory CBCT scans and compared them to circular trajectory scans. Methods: We performed circular and saddle trajectory scans using a novel robotic CBCT scanner (Mobile ImagingRing (IRm); medPhoton, Salzburg, Austria). For the saddle trajectory, the gantry executed yaw motion up to ±10∘$\pm 10^{\circ }$ using motorized wheels driving on the floor. An infrared (IR) tracking device with reflective markers was used for online geometric calibration correction (mainly floor unevenness). All images were reconstructed using penalized least‐squares minimization with the conjugate gradient algorithm from RTK with 0.5×0.5×0.5mm3$0.5 \times 0.5\times 0.5 \text{ mm}^3$ voxel size. A disk phantom and an Alderson phantom were scanned to assess the image quality. Results were correlated with the local incompleteness value represented by tan(ψ)$\tan (\psi)$, which was calculated at each voxel as a function of the source trajectory and the voxel's 3D coordinates. We assessed the magnitude of CB artifacts using the full width half maximum (FWHM) of each disk profile in the axial center of the reconstructed images. Spatial resolution was also quantified by the modulation transfer function at 10% (MTF10). Results: When using the saddle trajectory, the region without CB artifacts was increased from 43 to 190 mm in the SI direction compared to the circular trajectory. This region coincided with low values for tan(ψ)$\tan (\psi)$. When tan(ψ)$\tan (\psi)$ was larger than 0.02, we found there was a linear relationship between the FWHM and tan(ψ)$\tan (\psi)$. For the saddle, IR tracking allowed the increase of MTF10 from 0.37 to 0.98 lp/mm. Conclusions: We achieved saddle trajectory CBCT scans with a novel CBCT system combined with IR tracking. The results show that the saddle trajectory provides a larger region with reliable reconstruction compared to the circular trajectory. The proposed method can be used to evaluate other non‐circular trajectories. [ABSTRACT FROM AUTHOR]

Background: The treatment of moving tumor entities is expected to have superior clinical outcomes, using image‐guided adaptive intensity‐modulated proton therapy (IMPT). Purpose: For 21 lung cancer patients, IMPT dose calculations were performed on scatter‐corrected 4D cone beam CTs (4DCBCTcor) to evaluate their potential for triggering treatment adaptation. Additional dose calculations were performed on corresponding planning 4DCTs and day‐of‐treatment 4D virtual CTs (4DvCTs). Methods: A 4DCBCT correction workflow, previously validated on a phantom, generates 4DvCT (CT‐to‐CBCT deformable registration) and 4DCBCTcor images (projection‐based correction using 4DvCT as a prior) with 10 phase bins, using day‐of‐treatment free‐breathing CBCT projections and planning 4DCT images as input. Using a research planning system, robust IMPT plans administering eight fractions of 7.5 Gy were created on a free‐breathing planning CT (pCT) contoured by a physician. The internal target volume (ITV) was overridden with muscle tissue. Robustness settings for range and setup uncertainties were 3% and 6 mm, and a Monte Carlo dose engine was used. On every phase of planning 4DCT, day‐of‐treatment 4DvCT, and 4DCBCTcor, the dose was recalculated. For evaluation, image analysis as well as dose analysis were performed using mean error (ME) and mean absolute error (MAE) analysis, dose–volume histogram (DVH) parameters, and 2%/2‐mm gamma pass rate analysis. Action levels (1.6% ITV D98 and 90% gamma pass rate) based on our previous phantom validation study were set to determine which patients had a loss of dosimetric coverage. Results: Quality enhancements of 4DvCT and 4DCBCTcor over 4DCBCT were observed. ITV D98% and bronchi D2% had its largest agreement for 4DCBCTcor–4DvCT, and the largest gamma pass rates (>94%, median 98%) were found for 4DCBCTcor–4DvCT. Deviations were larger and gamma pass rates were smaller for 4DvCT–4DCT and 4DCBCTcor–4DCT. For five patients, deviations were larger than the action levels, suggesting substantial anatomical changes between pCT and CBCT projections acquisition. Conclusions: This retrospective study shows the feasibility of daily proton dose calculation on 4DCBCTcor for lung tumor patients. The applied method is of clinical interest as it generates up‐to‐date in‐room images, accounting for breathing motion and anatomical changes. This information could be used to trigger replanning. [ABSTRACT FROM AUTHOR]

In modern radiotherapy (RT), especially for stereotactic radiotherapy or stereotactic radiosurgery treatments, image guidance is essential. Recently, the ExacTrac Dynamic (EXTD) system, a new combined surface‐guided RT and image‐guided RT (IGRT) system for patient positioning, monitoring, and tumor targeting, was introduced in clinical practice. The purpose of this study was to provide more information about the geometric accuracy of EXTD and its workflow in a clinical environment. The surface optical/thermal‐ and the stereoscopic X‐ray imaging positioning systems of EXTD was evaluated and compared to cone‐beam computed tomography (CBCT). Additionally, the congruence with the radiation isocenter was tested. A Winston Lutz test was executed several times over 1 year, and repeated end‐to‐end positioning tests were performed. The magnitude of the displacements between all systems, CBCT, stereoscopic X‐ray, optical‐surface imaging, and MV portal imaging was within the submillimeter range, suggesting that the image guidance provided by EXTD is accurate at any couch angle. Additionally, results from the evaluation of 14 patients with intracranial tumors treated with open‐face masks are reported, and limited differences with a maximum of 0.02 mm between optical/thermal‐ and stereoscopic X‐ray imaging were found. As the optical/thermal positioning system showed a comparable accuracy to other IGRT systems, and due to its constant monitoring capability, it can be an efficient tool for detecting intra‐fractional motion and for real‐time tracking of the surface position during RT. [ABSTRACT FROM AUTHOR]

Proton therapy treatment for lungs remains challenging as images enabling the detection of inter- and intra-fractional motion, which could be used for proton dose adaptation, are not readily available. 4D computed tomography (4DCT) provides high image quality but is rarely available in-room, while in-room 4D cone beam computed tomography (4DCBCT) suffers from image quality limitations stemming mostly from scatter detection. This study investigated the feasibility of using virtual 4D computed tomography (4DvCT) as a prior for a phase-per-phase scatter correction algorithm yielding a 4D scatter corrected cone beam computed tomography image (4DCBCTcor), which can be used for proton dose calculation. 4DCT and 4DCBCT scans of a porcine lung phantom, which generated reproducible ventilation, were acquired with matching breathing patterns. Diffeomorphic Morphons, a deformable image registration algorithm, was used to register the mid-position 4DCT to the mid-position 4DCBCT and yield a 4DvCT. The 4DCBCT was reconstructed using motion-aware reconstruction based on spatial and temporal regularization (MA-ROOSTER). Successively for each phase, digitally reconstructed radiographs of the 4DvCT, simulated without scatter, were exploited to correct scatter in the corresponding CBCT projections. The 4DCBCTcor was then reconstructed with MA-ROOSTER using the corrected CBCT projections and the same settings and deformation vector fields as those already used for reconstructing the 4DCBCT. The 4DCBCTcor and the 4DvCT were evaluated phase-by-phase, performing proton dose calculations and comparison to those of a ground truth 4DCT by means of dose-volume-histograms (DVH) and gamma pass-rates (PR). For accumulated doses, DVH parameters deviated by at most 1.7% in the 4DvCT and 2.0% in the 4DCBCTcor case. The gamma PR for a (2%, 2 mm) criterion with 10% threshold were at least 93.2% (4DvCT) and 94.2% (4DCBCTcor), respectively. The 4DCBCTcor technique enabled accurate proton dose calculation, which indicates the potential for applicability to clinical 4DCBCT scans. [ABSTRACT FROM AUTHOR]

Purpose: The implementation of volumetric in‐room imaging for online adaptive radiotherapy makes extensive testing of this image data for treatment planning necessary. Especially for proton beams the higher sensitivity to stopping power properties of the tissue results in more stringent requirements. Current approaches mainly focus on recalculation of the plans on the new image data, lacking experimental verification, and ignoring the impact on the plan re‐optimization process. The aim of this study was to use gel and film dosimetry coupled with a three‐dimensional (3D) printed head phantom (based on the planning CT of the patient) for 3D range verification of intensity‐corrected cone beam computed tomography (CBCT) image data for adaptive proton therapy. Methods: Single field uniform dose pencil beam scanning proton plans were optimized for three different patients on the patients' planning CT (planCT) and the patients' intensity‐corrected CBCT (scCBCT) for the same target volume using the same optimization constraints. The CBCTs were corrected on projection level using the planCT as a prior. The dose optimized on planCT and recalculated on scCBCT was compared in terms of proton range differences (80% distal fall‐off, recalculation). Moreover, the dose distribution resulting from recalculation of the scCBCT‐optimized plan on the planCT and the original planCT dose distribution were compared (simulation). Finally, the two plans of each patient were irradiated on the corresponding patient‐specific 3D printed head phantom using gel dosimetry inserts for one patient and film dosimetry for all three patients. Range differences were extracted from the measured dose distributions. The measured and the simulated range differences were corrected for range differences originating from the initial plans and evaluated. Results: The simulation approach showed high agreement with the standard recalculation approach. The median values of the range differences of these two methods agreed within 0.1 mm and the interquartile ranges (IQRs) within 0.3 mm for all three patients. The range differences of the film measurement were accurately matching with the simulation approach in the film plane. The median values of these range differences deviated less than 0.1 mm and the IQRs less than 0.4 mm. For the full 3D evaluation of the gel range differences, the median value and IQR matched those of the simulation approach within 0.7 and 0.5 mm, respectively. scCBCT‐ and planCT‐based dose distributions were found to have a range agreement better than 3 mm (median and IQR) for all considered scenarios (recalculation, simulation, and measurement). Conclusions: The results of this initial study indicate that an online adaptive proton workflow based on scatter‐corrected CBCT image data for head irradiations is feasible. The novel presented measurement‐ and simulation‐based method was shown to be equivalent to the standard literature recalculation approach. Additionally, it has the capability to catch effects of image differences on the treatment plan optimization. This makes the measurement‐based approach particularly interesting for quality assurance of CBCT‐based online adaptive proton therapy. The observed uncertainties could be kept within those of the registration and positioning. The proposed validation could also be applied for other alternative in‐room images, e.g. for MR‐based pseudoCTs. [ABSTRACT FROM AUTHOR]

In presence of inter-fractional anatomical changes, clinical benefits are anticipated from image-guided adaptive radiotherapy. Nowadays, cone-beam CT (CBCT) imaging is mostly utilized during pre-treatment imaging for position verification. Due to various artifacts, image quality is typically not sufficient for photon or proton dose calculation, thus demanding accurate CBCT correction, as potentially provided by deep learning techniques. This work aimed at investigating the feasibility of utilizing a cycle-consistent generative adversarial network (cycleGAN) for prostate CBCT correction using unpaired training. Thirty-three patients were included. The network was trained to translate uncorrected, original CBCT images (CBCTorg) into planning CT equivalent images (CBCTcycleGAN). HU accuracy was determined by comparison to a previously validated CBCT correction technique (CBCTcor). Dosimetric accuracy was inferred for volumetric-modulated arc photon therapy (VMAT) and opposing single-field uniform dose (OSFUD) proton plans, optimized on CBCTcor and recalculated on CBCTcycleGAN. Single-sided SFUD proton plans were utilized to assess proton range accuracy. The mean HU error of CBCTcycleGAN with respect to CBCTcor decreased from 24 HU for CBCTorg to −6 HU. Dose calculation accuracy was high for VMAT, with average pass-rates of 100%/89% for a 2%/1% dose difference criterion. For proton OSFUD plans, the average pass-rate for a 2% dose difference criterion was 80%. Using a (2%, 2 mm) gamma criterion, the pass-rate was 96%. 93% of all analyzed SFUD profiles had a range agreement better than 3 mm. CBCT correction time was reduced from 6–10 min for CBCTcor to 10 s for CBCTcycleGAN. Our study demonstrated the feasibility of utilizing a cycleGAN for CBCT correction, achieving high dose calculation accuracy for VMAT. For proton therapy, further improvements may be required. Due to unpaired training, the approach does not rely on anatomically consistent training data or potentially inaccurate deformable image registration. The substantial speed-up for CBCT correction renders the method particularly interesting for adaptive radiotherapy. [ABSTRACT FROM AUTHOR]

Purpose: To demonstrate a proof‐of‐concept for fast cone‐beam CT (CBCT) intensity correction in projection space by the use of deep learning. Methods: The CBCT scans and corresponding projections were acquired from 30 prostate cancer patients. Reference shading correction was performed using a validated method (CBCTcor), which estimates scatter and other low‐frequency deviations in the measured CBCT projections on the basis of a prior CT image obtained from warping the planning CT to the CBCT. A convolutional neural network (ScatterNet) was designed, consisting of an attenuation conversion stage followed by a shading correction stage using a UNet‐like architecture. The combined network was trained in 2D, utilizing pairs of measured and corrected projections of the reference method, in order to perform shading correction in projection space before reconstruction. The number of patients used for training, testing, and evaluation was 15, 7, and 8, respectively. The reconstructed CBCTScatterNet was compared to CBCTcor in terms of mean and absolute errors (ME and MAE) for the eight evaluation patients (not included in the network training). Volumetric modulated arc photon therapy (VMAT) and intensity‐modulated proton therapy (IMPT) plans were generated on CBCTcor. Dose was recalculated on CBCTScatterNet to evaluate its dosimetric accuracy. Single‐field uniform dose proton plans were utilized for proton range comparison of CBCTScatterNet and CBCTcor. Results: The CBCTScatterNet showed no cupping artifacts and a considerably smaller MAE and ME with respect to CBCTcor than the uncorrected CBCT (on average 144 Hounsfield units (HU) vs 46 HU for MAE and 138 HU vs −3 HU for ME). The pass‐rates using a 2% dose‐difference criterion at 50% dose cut‐off, were close to 100% for the VMAT plans of all patients when comparing CBCTScatterNet to CBCTcor. For IMPT plans pass‐rates were clearly lower, ranging from 15% to 81%. Proton range differences of up to 5 mm occurred. Conclusions: Using a deep convolutional neural network for CBCT intensity correction was shown to be feasible in the pelvic region for the first time. Dose calculation accuracy on CBCTScatterNet was high for VMAT, but unsatisfactory for IMPT. With respect to the reference technique (CBCTcor), the neural network enabled a considerable increase in speed for intensity correction and might eventually allow for on‐the‐fly shading correction during CBCT acquisition. [ABSTRACT FROM AUTHOR]

Purpose: This work aims at investigating intensity corrected cone-beam x-ray computed tomography (CBCT) images for accurate dose calculation in adaptive intensity modulated proton therapy (IMPT) for prostate and head and neck (H&N) cancer. A deformable image registration (DIR)-based method and a scatter correction approach using the image data obtained from DIR as prior are characterized and compared on the basis of the same clinical patient cohort for the first time. Methods: Planning CT (pCT) and daily CBCT data (reconstructed images and measured projections) of four H&N and four prostate cancer patients have been considered in this study. A previously validated Morphons algorithm was used for DIR of the planning CT to the current CBCT image, yielding a so-called virtual CT (vCT). For the first time, this approach was translated from H&N to prostate cancer cases in the scope of proton therapy. The warped pCT images were also used as prior for scatter correction of the CBCT projections for both tumor sites. Single field uniform dose and IMPT (only for H&N cases) treatment plans have been generated with a research version of a commercial planning system. Dose calculations on vCT and scatter corrected CBCT (CBCTcor) were compared by means of the proton range and a gamma-index analysis. For the H&N cases, an additional diagnostic replanning CT (rpCT) acquired within three days of the CBCT served as additional reference. For the prostate patients, a comprehensive contour comparison of CBCT and vCT, using a trained physician's delineation, was performed. Results: A high agreement of vCT and CBCTcor was found in terms of the proton range and gamma-index analysis. For all patients and indications between 95% and 100% of the proton dose profiles in beam's eye view showed a range agreement of better than 3 mm. The pass rate in a (2%,2 mm) gamma-comparison was between 96% and 100%. For H&N patients, an equivalent agreement of vCT and CBCTcor to the reference rpCT was observed. However, for the prostate cases, an insufficient accuracy of the vCT contours retrieved from DIR was found, while the CBCTcor contours showed very high agreement to the contours delineated on the raw CBCT. Conclusions: For H&N patients, no considerable differences of vCT and CBCTcor were found. For prostate cases, despite the high dosimetric agreement, the DIR yields incorrect contours, probably due to the more pronounced anatomical changes in the abdomen and the reduced soft-tissue contrast in the CBCT. Using the vCT as prior, these inaccuracies can be overcome and images suitable for accurate delineation and dose calculation in CBCT-based adaptive IMPT can be retrieved from scatter correction of the CBCT projections. [ABSTRACT FROM AUTHOR]

Background and purpose Our aim was to evaluate the feasibility and potential advantages of dose guided patient positioning based on dose recalculation on scatter corrected cone beam computed tomography (CBCT) image data. Material and methods A scatter correction approach has been employed to enable dose calculations on CBCT images. A recently proposed tool for interactive multicriterial dose-guided patient positioning which uses interpolation between pre-calculated sample doses has been utilized. The workflow was retrospectively evaluated for two head and neck patients with a total of 39 CBCTs. Dose–volume histogram (DVH) parameters were compared to rigid image registration based isocenter corrections (clinical scenario). Results The accuracy of the dose interpolation was found sufficient, facilitating the implementation of dose guided patient positioning. Compared to the clinical scenario, the mean dose to the parotid glands could be improved for 2 out of 5 fractions for the first patient while other parameters were preserved. For the second patient, the mean coverage over all fractions of the high dose PTV could be improved by 4%. For this patient, coverage improvements had to be traded against organ at risk (OAR) doses within their clinical tolerance limits. Conclusions Dose guided patient positioning using in-room CBCT data is feasible and offers increased control over target coverage and doses to OARs. [ABSTRACT FROM AUTHOR]