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Purpose: To propose and validate a comprehensive novel metric balancing the registration accuracy and imaging dose for image-guided-radiotherapy based on real patient data. Materials and methods: With written informed consent and ethical approval, 56 patients were scanned using 6MV CBCT, 140 kV CBCT, and 100 kV CBCT on Halcyon system for three consecutive treatment fractions. Online registration was performed by various on-duty therapists under routine clinical pressure and time limitation. Offline registration was carried out by an experienced physicist without pressure. The consistency between the online and offline results was used as a surrogate of the missing ground-truth of registration accuracy, which was usually developed by introducing 'known' setup errors and rescan the phantoms, yet is ethnically not applicable to real patients. The registration differences (ΔD) between various imaging methods and observers were analyzed. The weighted CT dose index (CTDIw) for kV and MV CBCT was acquired using the PTW CTDI head phantom. The weighted-Dose-Accuracy-Product (DAPw) index was defined as DAPw =ΔD(mm) w1* CTDIw(mGy) w2, where w1 and w2 are the weighting factors of accuracy and dose respectively (w1+w2 = 1). Results: The mean and interquartile range (IQR) of ΔD decreased monotonically for MV CBCT, 100 kV CBCT, and 140 kV CBCT, supporting the registration consistency as a surrogate metric of image quality. Significant differences of ΔD were observed between the online and offline registration across three imaging methods (P<0.05). The 140 kV CBCT provides superior positioning accuracy, less dependency on observer subjectivity and time pressure of clinical workflow. Using w1=w2 = 0.5 as an example, the smallest mean, standard deviation, and IQR of DAPw were observed on the 100 kV CBCT, indicating optimal balance between dose and accuracy than the other two methods. Analysis of variance (ANOVA) showed statistically significant differences in DAPw among the different imaging methods (P<0.01, F=50.57). Conclusion: Using registration consistency as a surrogate indicator of image quality, this study proposed and validated a novel "DAPw" parameter based on real patient data, providing a purpose-specific tool for balancing setup accuracy and radiation dose in clinic. [ABSTRACT FROM AUTHOR]

Radiation therapy has the capability to conform radiation fields delivered to tumours much more accurately because of developments in therapy equipment in recent decades. This can help to reduce doses to normal tissues considerably. Successful delivery requires the patient to be in the same position on the couch as in the treatment plan. Therefore, images are taken at regular intervals, frequently at every treatment fraction and compared with images used for planning, and this is referred to as image guided radiation therapy (IGRT). If more imaging with x rays is carried out, this exposes patients to additional doses to tissues surrounding the tumour that carry a risk of inducing secondary cancers. The reductions in high dose treatment margins that can be achieved with IGRT need to be balanced against risks from greater imaging doses. ICRP Task Group 116 is preparing guidance on IGRT, and has used the ICRP mentorship programme to undertake surveys of imaging practices and to trial ways for measuring cone beam computed tomography (CBCT) doses that could be widely applied. Results from the projects are feeding into development of the report with recommendations to facilitate improvements in the application and optimisation of radiological protection in the use of imaging in radiotherapy. [ABSTRACT FROM AUTHOR]

Introduction: Image guided radiotherapy allows for particularly conformal tumour irradiation through precise patient positioning. Becoming the standard for radiotherapy, this increases imaging doses to the patient. The Halcyon 3.0 linear accelerator (Varian Medical Systems, Palo Alto, CA) requires daily imaging due to its geometry. For this reason, the accelerator is equipped with on-line kV and MV imaging. However, daily CBCT images required for irradiation apply additional radiation, which increases the dose to normal tissue and therefore can affect the patient's secondary cancer risk. In this study, actual organ doses were measured for the kV system, and a comparison of normal tissue doses for all available kV CBCT protocols was presented to demonstrate differences in imaging doses across entities and protocols. In addition, effective dose and secondary cancer risk from imaging are evaluated. Material and methods: Measurements were performed with thermoluminescent dosimeters in an anthropomorphic phantom positioned according to each entity (brain, head and neck, breast, lung, pelvis). CBCT images were obtained, using all available pre-set protocols without further adjustment of the parameters. Measured doses for each position and each protocol were then compared and secondary cancer risk of relevant and specifically radiosensitive organs was calculated. Results: It was found that imaging doses for protocols such as Pelvis and Head could be reduced by up to half using the corresponding Fast and Low Dose modes, respectively. On the other hand, larger field sizes or the Large mode yielded higher doses than their initial protocols. Image Gently was found to spare normal tissue best, however it is not suitable for certain entities due to low image quality or insufficient projection data. Discussion: By using appropriate kV-CBCT protocols, it is possible to reduce imaging doses to a significant extent and therefore spare healthy tissue. Combined with studies of image quality, the results of this study could lead to adjustments in workflow regarding the choice of protocols used in daily routine. This could prevent unnecessary radiation exposure and reduce secondary cancer risk.

Image guided radiotherapy allows for particularly conformal tumour irradiation through precise patient positioning. Becoming the standard for radiotherapy, this increases imaging doses to the patient. The Halcyon 3.0 linear accelerator (Varian Medical Systems, Palo Alto, CA) requires daily imaging due to its geometry. For this reason, the accelerator is equipped with on-line kV and MV imaging. However, daily CBCT images required for irradiation apply additional radiation, which increases the dose to normal tissue and therefore can affect the patient's secondary cancer risk. In this study, actual organ doses were measured for the kV system, and a comparison of normal tissue doses for all available kV CBCT protocols was presented to demonstrate differences in imaging doses across entities and protocols. In addition, effective dose and secondary cancer risk from imaging are evaluated. Measurements were performed with thermoluminescent dosimeters in an anthropomorphic phantom positioned according to each entity (brain, head and neck, breast, lung, pelvis). CBCT images were obtained, using all available pre-set protocols without further adjustment of the parameters. Measured doses for each position and each protocol were then compared and secondary cancer risk of relevant and specifically radiosensitive organs was calculated. It was found that imaging doses for protocols such as Pelvis and Head could be reduced by up to half using the corresponding Fast and Low Dose modes, respectively. On the other hand, larger field sizes or the Large mode yielded higher doses than their initial protocols. Image Gently was found to spare normal tissue best, however it is not suitable for certain entities due to low image quality or insufficient projection data. By using appropriate kV-CBCT protocols, it is possible to reduce imaging doses to a significant extent and therefore spare healthy tissue. Combined with studies of image quality, the results of this study could lead to adjustments in workflow regarding the choice of protocols used in daily routine. This could prevent unnecessary radiation exposure and reduce secondary cancer risk. [ABSTRACT FROM AUTHOR]

Purpose: Repeated cone-beam CT (CBCT) scans for image-guided radiotherapy (IGRT) increase the health risk of radiation-induced malignancies. Patientenrolled studies to optimize scan protocols are inadequate. We proposed a virtual clinical trial-based approach to evaluate projection-reduced low-dose CBCT for IGRT. Materials and Methods: A total of 71 patients were virtually enrolled with 26 head, 23 thorax and 22 pelvis scans. Projection numbers of full-dose CBCT scans were reduced to 1/2, 1/4, and 1/8 of the original to simulate low-dose scans. Contrast-to-noise ratio (CNR) values in fat and muscle were measured in the fulldose and low-dose images. CBCT images were registered to planning CT to derive 6-degree-of-freedom couch shifts. Registration errors were statistically analyzed with the Wilcoxon paired signed-rank test. Results: As projection numbers were reduced, CNR values descended and the magnitude of registration errors increased. The mean CNR values of full-dose and half-dose CBCT were >3.0. For full-dose and low-dose CBCT (i.e. 1/2, 1/4 and 1/8 full-dose), the mean registration errors were< ± 0.4 mm in translational directions (LAT, LNG, VRT) and ±0.2 degree in rotational directions (Pitch, Roll, Yaw); the mean magnitude of registration errors were< 1 mm in translation and< 0.5 degree in rotation. The couch shift differences between full-dose and lowdose CBCT were not statistically significant (p>0.05) in all the directions. Conclusion: The results indicate that while the impact of dose-reduction on CBCT couch shifts is not significant, the impact on CNR values is significant. Further validation on optimizing CBCT imaging dose is required. [ABSTRACT FROM AUTHOR]

Introduction: Radiochromic film (RCF) is suitable for use as a dosimeter owing to its inherently superior spatial resolution and near-water equivalence. A new model of RCF recommended for measuring imaging dose in the kV nominal energy range was recently introduced onto the market. In this study, we investigate the dependence on the beam quality of GafChromic LD-V1 film's radiation dose response. Material and methods: Pieces of LD-V1 film were irradiated to air kerma ranging from 0 to 570 mGy in X-ray photons with beam qualities of 60 kV (HVL = 1.32 mm Al), 100 kV (HVL = 2.83 mm Al), 120 kV (HVL = 5.11 mm Al), 150 kV (HVL = 6.23 mm Al), and 180 kV (HVL = 0.54 mm Cu). The net reflectance from each film was obtained from a color flatbed scanner. For each beam quality, an analytical power function was fitted to the net reflectance - air kerma relationship and tested for differences. Results: We have found that for the beam qualities investigated, the response of the Gafchromic LD-V1 film was not significantly dependent on energy, and a single calibration curve could be used. The total relative uncertainty and absolute error reached maxima of 18% and 80%, respectively for air kerma values less than 50 mGy, and remained below 10% for air kerma in the range 50 mGy to 570 mGy. Conclusions: The results of our investigation revealed that the response of Gafchromic LD-V1 film is not significantly dependent on beam quality. A minimum air kerma irradiation of 50 mGy is recommended to minimise uncertainty. [ABSTRACT FROM AUTHOR]

PurposeTo propose and validate a comprehensive novel metric balancing the registration accuracy and imaging dose for image-guided-radiotherapy based on real patient data.Materials and methodsWith written informed consent and ethical approval, 56 patients were scanned using 6MV CBCT, 140 kV CBCT, and 100 kV CBCT on Halcyon system for three consecutive treatment fractions. Online registration was performed by various on-duty therapists under routine clinical pressure and time limitation. Offline registration was carried out by an experienced physicist without pressure. The consistency between the online and offline results was used as a surrogate of the missing ground-truth of registration accuracy, which was usually developed by introducing ‘known’ setup errors and rescan the phantoms, yet is ethnically not applicable to real patients. The registration differences (ΔD) between various imaging methods and observers were analyzed. The weighted CT dose index (CTDIw) for kV and MV CBCT was acquired using the PTW CTDI head phantom. The weighted-Dose-Accuracy-Product (DAPw) index was defined as DAPw =ΔD(mm) w1* CTDIw(mGy) w2, where w1 and w2 are the weighting factors of accuracy and dose respectively (w1+w2 = 1).ResultsThe mean and interquartile range (IQR) of ΔD decreased monotonically for MV CBCT, 100 kV CBCT, and 140 kV CBCT, supporting the registration consistency as a surrogate metric of image quality. Significant differences of ΔD were observed between the online and offline registration across three imaging methods (P

Aims: We investigated imaging dose and noise under clinical scan conditions at multiple institutions using a simple and unified method, and demonstrated the need for diagnostic reference levels in image-guided radiotherapy (IGRT). Materials and Methods: Nine cone-beam and helical computed tomography (CT) scanners (Varian, Elekta, Accuray Inc., and BrainLAB) from seven institutions were investigated in this study. The weighted cone-beam dose index (CBDIw) was calculated for head and pelvic protocols using a 100 mm pencil chamber under the conditions used in actual clinical practice at each institution. Cone-beam CT image noise was evaluated using polymethylmethacrylate head and body phantoms with diameters of 16 and 32 cm, respectively. Results: For head and pelvic protocols, CBDIw values ranged from 0.94–6.59 and 1.47–20.9 mGy, respectively. Similarly, standard deviation (SD) values ranged from 9.3–34.0 and 26.9–97.4 HU, respectively. The SD values tended to increase with decreasing imaging dose (r = −0.33 and −0.61 for the head and pelvic protocols, respectively). Conclusions: Among the nine machines, the imaging dose for high imaging dose institutions was approximately 20 mGy to the pelvic phantom, and there was a 14-fold difference in dose compared with the other institutions. These results suggest the need to establish DRLs for IGRT to guide clinical decision-making.

Daily imaging is mandatory for the Halcyon and Ethos, which are the new ring-shaped radiotherapy units. This study quantified the imaging dose of the cone beam computed tomography (CBCT) system of the new ring-shaped radiotherapy units using the latest International Electrotechnical Commission (IEC) measurement approach. Furthermore, we investigated the influence of collimation width on the imaging dose and compared the imaging dose values obtained using three IEC measurement approaches. The IEC has proposed three approaches for measuring CTDI 100 : traditional, transition, and the latest measurement approach. In addition to the dose measured on the CTDI phantom, the latest IEC approach uses correction factors measured in free air for CTDI 100 measurement. The imaging dose was measured for all scanning protocols using the latest IEC approach. To investigate the influence of the collimation width on the imaging dose, the associated dose metric values were evaluated and compared using different IEC approaches to increase the collimation width (2–28 cm). Furthermore, the imaging system output stability was evaluated by repeated measurements. In the repeated measurements, the standard deviation of CTDI w value for the pelvis and head protocol was 0.05 mGy and 0.01 mGy, respectively. And the coefficient of variation was 0.21% and 0.23%, respectively. The measured CTDI w values of the clinical protocols were higher than the vendor-provided value, except for the pelvis protocol. The value of CTDI w changes little with increasing collimation width using the latest IEC approach. The traditional and transition approaches either underestimated or overestimated the value of CTDI w , as measured by the latest IEC approach, with increasing collimation width. The new ring-shaped radiotherapy units imaging system has good output stability. The CTDIw values measured for clinical scanning protocols generally exceeded the vendor-provided values. Compared with the latest IEC CTDI 100 measurement approach, the traditional and transition measurement approaches were more influenced by beam width. For wide CBCT scans, rationalizing the choice of imaging dose measurement approach is important. • Accurate quantification of the imaging dose for the Halcyon kV-CBCT imaging system. • Comparison of different CTDI measurement approaches for increasing beam width. • Integration length of 40-mm longer than collimation width is insufficient for CBCT. • Providing a clinical reference for the Ethos imaging dose. • Helping to assess the total imaging dose during radiotherapy. [ABSTRACT FROM AUTHOR]

Featured Application: The research provides data on practices in imaging employed in radiotherapy services in countries with different levels of income and development. The information will be used in deciding on recommendations to encourage optimization of radiological protection for imaging by radiotherapy facilities and in evaluating what additional dosimetry features might be included on cone beam CT facilities incorporated into radiotherapy equipment. These will be included in a publication on radiological protection aspects of imaging in radiotherapy being prepared by the International Commission on Radiological Protection (ICRP). Dramatic improvements in radiotherapy equipment have allowed radiation fields to be conformed to tumours for more accurate treatment. Successful delivery often requires imaging at every treatment fraction, a method known as image guided radiation therapy (IGRT). But increased X-ray imaging exposes patients to doses that carry risks of inducing second cancers in normal tissues. Therefore, reductions in high-dose treatment margins achieved with IGRT must be balanced against detriments from greater imaging doses. ICRP Task Group 116 has been set up to prepare guidance on radiological protection aspects of IGRT. Factors affecting the optimization of radiological protection are the modalities used, the frequency of imaging, the image acquisition parameters influencing image quality and radiation dose, and the volume of normal tissue included in the images. The Task Group has undertaken two projects: (1) a snapshot survey of radiotherapy imaging practices across six continents, which has shown that use of kV cone beam CT (CBCT) increases with Human Development Index for the country; and (2) a project looking at ways for measuring CBCT doses that could be applied more widely. The results highlight the need for raising awareness of imaging doses, and development of the dose quantities displayed on imaging equipment used in radiotherapy. [ABSTRACT FROM AUTHOR]

The purpose of this work was to evaluate the imaging dose for the Accuray Radixact ClearRT system. Low-contrast resolution and CT number consistency was evaluated as well. CTDI measurements were compared to vendor supplied values, and similar measurements were done on a Varian TrueBeam kV cone-beam CT (CBCT) and a Philips Big Bore CT scanner. In-field imaging doses were measured using various protocols in an anthropomorphic phantom, while out-of-field doses were measured 10 cm from the imaging field edge. Comparison of the CTDI and the in-field doses showed considerable disagreement when the patient anatomy size was not congruent with the size of the CTDI phantom. While that is an expected outcome, this work provides an estimate of the differences for a variety of ClearRT protocols when this situation arises. The CNR was measured for all combinations of ClearRT settings for comparisons within the system, as well as for a comparison with a CBCT and fan-beam CT system. The CNR and dose information provided in this work can be used to aid in selecting a ClearRT imaging protocol. The CT number stability was tracked over 27 months; two instances where the CT number constancy exceeded tolerance were observed after service., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier GmbH.. All rights reserved.)

• Dose to eye lenses in intracranial CyberKnife applications. • Spatial distribution of the imaging dose in CyberKnife applications. • Image degradation due to scatter radiation in CyberKnife radiosurgery. The imaging dose for intra- and extra-cranial CyberKnife radiosurgery applications was calculated and the scattered radiation reaching the digital detectors was quantified and analyzed with regard to its origin. The image guidance subsystem of the CyberKnife was modeled based on vendor-provided information. The emitted X-ray energy spectrum for 120 kV was estimated using the SpekPy software tool. Monte Carlo (MC) image acquisition simulations were performed to calculate the total, primary and scattered photon fluences reaching each detector as a function of the imaged object dimensions. MC calculations of the imaging dose were performed for intra- and extra-cranial applications assuming 120 kV and 10 mAs acquisition settings. The amount of scattered radiation reaching each detector was found to depend on the dimensions of the imaged anatomical region, contributing more than 40 % to the total photon fluence for regions more than 20 cm thick. More than 20 % of this scattered radiation originates from the contralateral imaging field. A maximum organ dose of 1.5 mGy at the nasal bones and an average dose of 0.37 mGy to the eye lenses per image pair acquisition was calculated for head applications. An entrance imaging dose of 0.4 mGy was calculated for extracranial applications. Scattered radiation reaching each detector in the skull and spine tracking applications can be reduced by acquiring the pair of radiographs sequentially instead of simultaneously. A dose of 3.7 cGy to the eye lenses is estimated assuming 100 image pair exposures required for treatment completion. [ABSTRACT FROM AUTHOR]

Background and purpose: Cone Beam Computed Tomography (CBCT) is routinely used in radiotherapy to identify the position of the target volume. The aim of this study was to determine whether the CBCT dose, when followed by the treatment, influences the therapeutic outcomes as determined by in-vitro clonogenic cell survival in a radiobiological experiment. Materials and methods: Human cell lines, four cancer and one normal, were exposed to a 6 MV photon beam, produced by a linear accelerator. For half of each sample, a prior imaging dose was delivered using the on-board CBCT. A sample size of n = 103 was used to achieve statistical power. Results: The experimental group of cell lines exposed to CBCT imaging prior to treatment exhibited a reduction in mean cancer cell survival of ~17 times (p = 0.02) greater than predicted from the average dose response and equivalent to more than 5% of the therapeutic dose, compared to 11 times greater than predicted for normal cells (n.s.). Conclusion: The greater than predicted reduction in survival resulting from the additional CBCT dose is consistent with radiation-induced bystander effects.

Using kilovoltage cone-beam computed tomography (kV-CBCT) and heavy-atom radiosensitizers in image-guided radiotherapy (IGRT) can provide numerous benefits, such as image contrast enhancement in radiation dose delivery. However, the increased use of kV-CBCT for daily imaging procedures may inevitably deposit certain amount of radiation dose to the patient, especially when nanoparticles used as radiosensitizers are involved. In this study, we use Monte Carlo simulation to evaluate the imaging dose escalation due to nanoparticle addition with varying nanoparticle material, nanoparticle concentration and photon beam energy. A phantom was used to determine the relationships between the imaging dose enhancement ratios (IDERs) and different concentrations (3–40 mg/ml) of gold (Au), platinum (Pt), iodine (I), silver (Ag) and iron oxide (Fe2O3) nanoparticles, under the delivery of 120–140 kVp photon beams from the CBCT. It is found that gold and platinum nanoparticles of 40 mg/ml concentration had the highest IDER (~1.6) under the 120 kVp photon beam. This nanoparticle addition resulted in a 0.63% increase of imaging dose based on a typical dose prescription of 200 cGy per fraction in radiotherapy, and is within the standard uncertainty of ±5% in radiation dose delivery. This study proves that the incorporation of higher concentration nanoparticles under lower photon beam energy could increase the imaging dose. The results from this study can enable us to understand more about the incorporation of heavy-atom nanoparticles in IGRT systems.

Objective . Image-guided and adaptive proton therapy rely on daily CBCT or CT imaging, which increases radiation dose and radiation-induced cancer risk. Online adaptation however also reduces setup uncertainty, and the additional risk might be compensated by reducing the setup robustness margin. This work developed a framework to investigate how much this robustness margin should be reduced to offset the secondary cancer risk from additional imaging dose and applied it to proton therapy for head-and-neck cancer. Approach . For five patients with head-and-neck cancer, voxel-wise CT and CBCT imaging doses were estimated with Monte Carlo radiation transport simulations, calibrated with air and PMMA phantom measurements. The total dose of several image-guided and adaptive treatments protocols was calculated by summing the planning CT dose, daily and weekly CBCT or CT dose, and therapy dose, robustly optimized with setup margins between 0 and 4 mm. These were compared to a reference protocol with 4 mm setup margin without daily imaging. All plans further used 3% range robustness. Organ-wise excess absolute risk (EAR) of cancer was calculated with three models to determine at which setup margin the total EAR of image-guided and adaptive treatment protocols was equal to the total EAR of the reference. Results . The difference between the simulated and measured CT and CBCT doses was within 10%. Using the Monte Carlo models, we found that a 1 mm setup margin reduction was sufficient for most patients, treatment protocols, and cancer risk models to compensate the additional risk imposed by daily and weekly imaging. For some protocols, even a smaller reduction sufficed, depending on the imaging frequency and type. The risk reduction by reducing the margin was mainly due to reducing the risk for carcinomas in the brain and, for some patients, the oral cavity. Significance . Our framework allows to compare an increased imaging dose with the reduced treatment dose from margin reductions in terms of radiation-induced cancer risk. It is extendable to different treatment sites, modalities, and imaging protocols, in clinic-specific or even patient-specific assessments., (Creative Commons Attribution license.)

Dramatic improvements in radiotherapy equipment have allowed radiation fields to be conformed to tumours for more accurate treatment. Successful delivery often requires imaging at every treatment fraction, a method known as image guided radiation therapy (IGRT). But increased X-ray imaging exposes patients to doses that carry risks of inducing second cancers in normal tissues. Therefore, reductions in high-dose treatment margins achieved with IGRT must be balanced against detriments from greater imaging doses. ICRP Task Group 116 has been set up to prepare guidance on radiological protection aspects of IGRT. Factors affecting the optimization of radiological protection are the modalities used, the frequency of imaging, the image acquisition parameters influencing image quality and radiation dose, and the volume of normal tissue included in the images. The Task Group has undertaken two projects: (1) a snapshot survey of radiotherapy imaging practices across six continents, which has shown that use of kV cone beam CT (CBCT) increases with Human Development Index for the country; and (2) a project looking at ways for measuring CBCT doses that could be applied more widely. The results highlight the need for raising awareness of imaging doses, and development of the dose quantities displayed on imaging equipment used in radiotherapy.

• Anatomical noise is the dominant source of image noise in paediatric CBCT. • CNR between fat and muscle was maintained in over 90% of cases for doses ≥1 mGy. • Increasing dose above 1 mGy does not improve image quality or registration accuracy. • Low dose paediatric CBCT protocols are recommended based on the imaging need. Cone beam CT (CBCT) is used in paediatric image-guided radiotherapy (IGRT) for patient setup and internal anatomy assessment. Adult CBCT protocols lead to excessive doses in children, increasing the risk of radiation-induced malignancies. Reducing imaging dose increases quantum noise, degrading image quality. Patient CBCTs also include 'anatomical noise' (e.g. motion artefacts), further degrading quality. We determine noise contributions in paediatric CBCT, recommending practical imaging protocols and thresholds above which increasing dose yields no improvement in image quality. Sixty CBCTs including the thorax or abdomen/pelvis from 7 paediatric patients (aged 6–13 years) were acquired at a range of doses and used to simulate lower dose scans, totalling 192 scans (0.5–12.8 mGy). Noise measured in corresponding regions of each patient and a 10-year-old phantom were compared, modelling total (including anatomical) noise, and quantum noise contributions as a function of dose. Contrast-to-noise ratio (CNR) was measured between fat/muscle. Soft tissue registration was performed on the kidneys, comparing accuracy to the highest dose scans. Quantum noise contributed <20% to total noise in all cases, suggesting anatomical noise is the largest determinant of image quality in the abdominal/pelvic region. CNR exceeded 3 in over 90% of cases ≥ 1 mGy, and 57% of cases at 0.5 mGy. Soft tissue registration was accurate for doses > 1 mGy. Anatomical noise dominates quantum noise in paediatric CBCT. Appropriate soft tissue contrast and registration accuracy can be achieved for doses as low as 1 mGy. Increasing dose above 1 mGy holds no benefit in improving image quality or registration accuracy due to the presence of anatomical noise. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to evaluate the effects of cone-beam computed tomography (CBCT) on dose distribution and normal tissue complication probability (NTCP) by constructing a comprehensive dose evaluation system for prostate intensity-modulated radiation therapy (IMRT). Methods: A system that could combine CBCT and treatment doses with MATLAB was constructed. Twenty patients treated with prostate IMRT were studied. A mean dose of 78 Gy was prescribed to the prostate region, excluding the rectal volume from the target volume, with margins of 4 mm to the dorsal side of the prostate and 7 mm to the entire circumference. CBCT and treatment doses were combined, and the dose distribution and the NTCP of the rectum and bladder were evaluated. Results: The radiation dose delivered to 2% and 98% of the target volume increased by 0.90 and 0.74 Gy on average, respectively, in the half-fan mode and on average 0.76 and 0.72 Gy, respectively, in the full-fan mode. The homogeneity index remained constant. The percent volume of the rectum and bladder irradiated at each dose increased slightly, with a maximum increase of

Objectives: This study performed dosimetry studies and secondary cancer risk assessments on using electronic portal imaging device (EPID) and cone beam computed tomography (CBCT) as image guided tools for the early lung cancer patients treated with SBRT. Methods: The imaging doses from MV-EPID and kV-CBCT of the Edge accelerator were retrospectively added to sixty-one SBRT treatment plans of early lung cancer patients. The MV-EPID imaging dose (6MV Photon beam) was calculated in Pinnacle TPS, and the kV-CBCT imaging dose was simulated and calculated by modeling of the kV energy beam in TPS using Pinnacle automatic modeling program. Three types of plans, namely PlanEPID, PlanCBCT and Planorigin, were generated with incorporating doses of EPID, CBCT and no imaging, respectively, for analysis. The effects of imaging doses on dose-volume-histogram (DVH) and plan quality were analyzed, and the excess absolute risk (EAR) of secondary cancer for ipsilateral lung was evaluated. Results: The regions that received less than 50 cGy were significantly impacted by the imaging doses, while the isodose lines greater than 1000 cGy were barely changed. The DVH values of ipsilateral lung increased the most in PlanEPID, followed by PlanCBCT. Compared to Planorigin on the average, the estimated EAR of ipsilateral lung in PlanEPID increased by 3.43%, while the corresponding EAR increase in PlanCBCT was much smaller (about 0.4%). Considering only the contribution of the imaging dose, the EAR values for the ipsilateral lung due to the MV-EPID dose in 5 years,10 years and 15 years were 1.49 cases, 2.09 cases and 2.88 cases per 104PY respectively, and those due to the kV-CBCT dose were about 9 times lower, correspondingly. Conclusions: The imaging doses produced by MV-EPID and kV-CBCT had little effects on the target dose coverage. The secondary cancer risk caused by MV-EPID dose is more than 8.5 times that of kV-CBCT. [ABSTRACT FROM AUTHOR]

Purpose: Cone beam computed tomography (CBCT) is often used for patient setup based solely on bony anatomy. The goal of this work was to evaluate whether CBCT dose can be lowered to the level of kV image pair doses when used for bony anatomy‐based IGRT without compromising positioning accuracy. Methods: An anthropomorphic phantom was CT scanned in the head, head and neck, chest, and pelvis regions and setup on the linear accelerator couch with the isocenter near the planned location. Cone beam computed tomographies were performed with the standard "full dose" protocol supplied by the linac vendor. With sequentially lowering the dose, three‐dimensional (3D) matching was performed for each without shifting the couch. The standard kV image pair protocol for each site was also used to image the phantoms. For all studies, six degrees of freedom was included in the 2D or 3D matching to the extent they could be employed. Imaging doses were determined in air at isocenter following the TG‐61 formalism. Results: Cone beam computed tomography dose was reduced by 81–98% of the standard CBCT protocol to nearly that of the standard kV image pair dose for each site. Relative to the standard CBCT shift values, translational shifts were within 0.3 and 1.6 mm for all sites, for the reduced dose CBCT and kV image pair, respectively. Rotational shifts were within 0.2 degree and 0.7 degrees for all sites, for the reduced dose CBCTs and kV image pair, respectively. Conclusion: For bony anatomy‐based image guidance, CBCT dose can be reduced to a value similar to that of a kV image pair with similar or better patient positioning accuracy than kV image pair alignment. Where rotations are important to correct, CBCT will be superior to orthogonal kV imaging without significantly increased imaging dose. This is especially important for image guidance for pediatric patient treatments. [ABSTRACT FROM AUTHOR]

Purpose: The Varian Halcyon includes an ultrafast 6 MV flattening filter free (FFF) cone-beam computed tomography (MV-CBCT). Although a kV-CBCT add-on is available, in the basic configuration MV is used for image guided radiotherapy (IGRT). We characterized the MV-CBCT imager in terms of reproducibility, linearity, field of view (FOV) dependence, detectability of soft-tissue, and the effect of metal implants. The performance of the MV-CBCT in the clinic, including resulting dose to organs, is also discussed herein.Methods: A Gammex phantom was scanned using a Halcyon MV-CBCT and a 120 kVp Siemens Definition Edge CT. Mean and standard deviation of Hounsfield Units (HUs) for different electron density relative to water (ρeW) inserts were extracted. Doses to clinical patients due to MV-CBCT are calculated within Eclipse during treatment planning.Results: A stable and near-linear HU-to-ρeW curve was obtained using the MV-CBCT. As the scan length increased from 10 to 28cm, the linearity of curve improved while the mean HUs decreased by 30%. All soft tissue inserts in the Gammex phantom were distinguishable. A crescent artifact affected HU measurements by up to 40 HUs. Soft-tissue contrast was sufficient for clinical online image-guidance in the low dose (5 MU) mode. Mean doses per fraction to organs-at-risk (OARs) were as high as 6 cGy for head and neck, 5 cGy for breast, and 4 cGy for pelvis patients. Metal rods did not affect HU values or introduce noticeable artifacts.Conclusions: Halcyon's MV-CBCT has sufficient soft tissue contrast for IGRT and lacks metal-induced artifacts. Even though the absolute HU values vary with phantom size and scanning length, the HU-to-ρeW conversions are linear and stable day-to-day. In clinical cases, highest tissue doses from MV-CBCT ranged from 2-7cGy per fraction for various treatment sites, which could be significant for some organs at risk. Dose to out-of-treatment-field organs can be limited by reducing the scan length definition during planning and using the low dose mode. The high quality imaging mode did not provide material advantages over the low dose mode. Adequate IGRT was successfully delivered to multiple tumor sites using MV-CBCT.

Using kilovoltage cone-beam computed tomography (kV-CBCT) and heavy-atom radiosensitizers in image-guided radiotherapy (IGRT) can provide numerous benefits, such as image contrast enhancement in radiation dose delivery. However, the increased use of kV-CBCT for daily imaging procedures may inevitably deposit certain amount of radiation dose to the patient, especially when nanoparticles used as radiosensitizers are involved. In this study, we use Monte Carlo simulation to evaluate the imaging dose escalation due to nanoparticle addition with varying nanoparticle material, nanoparticle concentration and photon beam energy. A phantom was used to determine the relationships between the imaging dose enhancement ratios (IDERs) and different concentrations (3–40 mg/ml) of gold (Au), platinum (Pt), iodine (I), silver (Ag) and iron oxide (Fe2O3) nanoparticles, under the delivery of 120–140 kVp photon beams from the CBCT. It is found that gold and platinum nanoparticles of 40 mg/ml concentration had the highest IDER (~1.6) under the 120 kVp photon beam. This nanoparticle addition resulted in a 0.63% increase of imaging dose based on a typical dose prescription of 200 cGy per fraction in radiotherapy, and is within the standard uncertainty of ±5% in radiation dose delivery. This study proves that the incorporation of higher concentration nanoparticles under lower photon beam energy could increase the imaging dose. The results from this study can enable us to understand more about the incorporation of heavy-atom nanoparticles in IGRT systems. [ABSTRACT FROM AUTHOR]

• The average imaging dose ranged from 0.01 cGy to 7.11 cGy, depending on the technique. • In case of implanted gold markers kV-kV planar imaging is the most optimal solution. • Without implanted gold markers kV-CBCT is the recommended technique. • Imaging dose and quality depends on type of machines from various vendors. • Imaging with 2.5 MV has superior properties compared to 6 MV. Verifying the patient position is always an essential part of the treatment process, especially in hypofractionated treatments such as accelerated partial breast irradiation (APBI). The purpose of the study was to compare five image guidance techniques with respect to imaging dose and image quality. We chose five types of imaging methods applicable for APBI and measured their dose exposure on four different accelerators (Synergy, TrueBeam, Artiste and CyberKnife). Absorbed dose was measured with ionization chamber in thorax phantom. Besides dose exposure image quality was also compared. The lowest dose exposure was measured with kV-kV planar imaging followed by kV-CBCT, MV-MV pair and MV-CBCT in ascending order. Average phantom dose with kV-kV image pair on CyberKnife was 0.01 cGy as the lowest and with MV-CBCT on Artiste was 7.11 cGy as the highest. Average dose exposures of MV-MV images with TrueBeam, Synergy and Artiste were 1.18 cGy, 2.13 cGy and 1.61 cGy, respectively, with similar image quality. For the same machines the doses of kV-CT imaging were comparable: 0.65 cGy, 0.65 cGy and 0.52 cGy, with some differences in image quality. MV-CBCT technique resulted in the highest dose and poorest image quality. In APBI the position of the patient and tumour bed can be verified with many tools. When fiducials are available, often 2D imaging is enough to achieve appropriate positioning and the kV-kV method is recommended. Imaging with 2.5MV can also be a good solution instead of 6MV. Without fiducials 3D images should be acquired and the recommended method is the kV-CBCT. [ABSTRACT FROM AUTHOR]

Purpose: The Varian Halcyon includes an ultrafast 6 MV flattening filter free (FFF) cone-beam computed tomography (MV-CBCT). Although a kV-CBCT add-on is available, in the basic configuration MV is used for image guided radiotherapy (IGRT). We characterized the MV-CBCT imager in terms of reproducibility, linearity, field of view (FOV) dependence, detectability of soft-tissue, and the effect of metal implants. The performance of the MV-CBCT in the clinic, including resulting dose to organs, is also discussed herein. Methods: A Gammex phantom was scanned using a Halcyon MV-CBCT and a 120 kVp Siemens Definition Edge CT. Mean and standard deviation of Hounsfield Units (HUs) for different electron density relative to water ( ρ e W ) inserts were extracted. Doses to clinical patients due to MV-CBCT are calculated within Eclipse during treatment planning. Results: A stable and near-linear HU-to- ρ e W curve was obtained using the MV-CBCT. As the scan length increased from 10 to 28cm, the linearity of curve improved while the mean HUs decreased by 30%. All soft tissue inserts in the Gammex phantom were distinguishable. A crescent artifact affected HU measurements by up to 40 HUs. Soft-tissue contrast was sufficient for clinical online image-guidance in the low dose (5 MU) mode. Mean doses per fraction to organs-at-risk (OARs) were as high as 6 cGy for head and neck, 5 cGy for breast, and 4 cGy for pelvis patients. Metal rods did not affect HU values or introduce noticeable artifacts. Conclusions: Halcyon's MV-CBCT has sufficient soft tissue contrast for IGRT and lacks metal-induced artifacts. Even though the absolute HU values vary with phantom size and scanning length, the HU-to- ρ e W conversions are linear and stable day-to-day. In clinical cases, highest tissue doses from MV-CBCT ranged from 2-7cGy per fraction for various treatment sites, which could be significant for some organs at risk. Dose to out-of-treatment-field organs can be limited by reducing the scan length definition during planning and using the low dose mode. The high quality imaging mode did not provide material advantages over the low dose mode. Adequate IGRT was successfully delivered to multiple tumor sites using MV-CBCT. [ABSTRACT FROM AUTHOR]

Abstract We aimed to comprehensively evaluate the quality, dose, and registration of cone beam computed tomography (CBCT) images acquired with different angular range (θ) and angular separation (Δθ). Elekta XVI volumetric imaging system was used in this study. CBCT images of a Catphan 503 phantom were reconstructed with projections that were acquired under 17 × 8 different combinations of θ (200° to 360°) and Δθ (0.27° to 3.24°). The evaluation indices were contrast-to-noise ratio (CNR), spatial resolution (modulation transfer function [MTF 50% ]), uniformity, and registration accuracy. The weighted computed tomography dose index (CTDI w) of CTDI Head dosimetry phantom was measured for estimating radiation exposure. CNR changed little from θ = 200° to 260°, but increased by ≈ 2.0 times from θ = 260° to 360°. CNR also increased by ≈ 2.5 times from Δθ = 2.16° to 0.27°. MTF 50% increased with Δθ being decreased, but had no dependence on θ. Image uniformity became better when θ was smaller or larger than 260°, but there was no correlation with Δθ. Registration of the overall body had a maximum error of 0.3 mm. The error of low-contrast objects' registration could reach as much as 1.3 mm. CTDI w showed a linear dependence on θ and 1/Δθ. Although the imaging dose is reduced with θ being decreased or Δθ being increased, the image quality may be degraded. Accuracy of image registration of a rigid body can be achieved; however, low-contrast objects' registration using images with inferior quality will introduce unacceptable errors for clinical use. Further, the benefits and extra dose received by the patients should be balanced, and scan protocols with θ between 210° and 260° or Δθ smaller than 0.54° should not be recommended. [ABSTRACT FROM AUTHOR]

Highlights • The accuracy of Eclipse-calculated Halcyon MVCBCT dose was validated by measurement. • Default calculation may err especially at imaging field edges due to couch shifts. • Random shifts and heterogeneous treatment dose integration can smear image dose error. • Recalculation by applying daily shift is recommended to monitor the accumulated dose deviations. Abstract Purpose To assess the criticality of calculation deviations induced by fractional image-guided-couch-shifts for Halcyon MV cone beam CT (CBCT) dose, which is incorporated as part of total treatment dose. Methods Eclipse-calculated imaging dose was first validated in 'Cheese Phantom' by measurement. Then, the actual imaging dose (D act) for 18 historical patients of various sites were recalculated based on 513 MV CBCT-guided-couch-shift data, and compared with reference computations based on treatment isocentre (D ref). Patient- and plan-specific dose from treatment fields was integrated with D act and D ref respectively for comparison. Results The average absolute relative disagreements between the measured and calculated dose were less than 1.23%. The mean ± 1SD of gamma passing rates of the accumulated imaging dose and total dose were 80.71 ± 6.22% and 99.81 ± 0.32% respectively based on 3 mm/3%/local/10% threshold criteria. The accumulated errors of minimum imaging dose to PTV were no larger than −14.38 cGy, which were reduced to −0.82 cGy after the heterogeneous treatment dose was overlaid. The mean relative discrepancies of PTV minimum dose were −0.61 cGy (−0.71%) and −0.00 (0.00%), before and after incorporating the treatment dose respectively. Conclusions The Eclipse-calculated Halcyon MV CBCT dose was validated. Although the isocentre displacement-induced imaging dose calculation errors for Halcyon MV CBCT were partially cancelled out by couch shifts of various directions and distances, especially after the incorporation of heterogeneous treatment dose, it was still advisable to monitor the accumulated deviations and replan when unacceptable target under-dose or organ over-dose were observed. [ABSTRACT FROM AUTHOR]

Highlights • The potential contribution of imaging dose from kV-CBCT to the CIED was evaluated. • Three dosimeters were considered in a multi-center study, XRQA2, MOSFET and TLDs. • Detailed results of imaging doses to CIED from different CBCT-protocols were found. • An approach for more accurate risk classification of CIED patients was suggested. Abstract The increasing use of daily CBCT in radiotherapy has raised concerns about the additional dose delivered to the patient, and it can also become a concern issue for those patients with cardiovascular implantable electronic devices (CIEDs) (Pacemaker [PM] and Implantable Cardioverter Defibrillator [ICD]). Although guidelines highly recommend that the cumulative dose received by CIEDs should be kept as low as possible, and a safe threshold based on patient risk classification needs to be respected, this additional imaging dose is not usually considered. Four centers with different dosimetry systems and different CBCT imaging protocols participated in this multicenter study to investigate the imaging dose to the CIEDs from Elekta XVI and Varian OBI kV-CBCT systems. It was found that although imaging doses received by CIEDs outside the CBCT field are negligible, special attention should be paid to this value when CIEDs are inside the field because the daily use of CBCT can sometimes contribute considerably to the total dose received by a CIED. [ABSTRACT FROM AUTHOR]

Purpose: We explore the optimal cone‐beam CT (CBCT) acquisition parameters to improve CBCT image quality to enhance intracranial stereotactic radiosurgery (SRS) localization and also assess the imaging dose levels associated with each imaging protocol. Methods: Twenty‐six CBCT acquisition protocols were generated on an Edge® linear accelerator (Varian Medical Systems, Palo Alto, CA) with different x‐ray tube current and potential settings, gantry rotation trajectories, and gantry rotation speeds. To assess image quality, images of the Catphan 504 phantom were analyzed to evaluate the following image quality metrics: uniformity, HU constancy, spatial resolution, low contrast detection, noise level, and contrast‐to‐noise ratio (CNR). To evaluate the imaging dose for each protocol, the cone‐beam dose index (CBDI) was measured. To validate the phantom results, further analysis was performed with an anthropomorphic head phantom as well as image data acquired for a clinical SRS patient. Results: The Catphan data indicates that adjusting acquisition parameters had direct effects on the image noise level, low contrast detection, and CNR, but had minimal effects on uniformity, HU constancy, and spatial resolution. The noise level was reduced from 34.5 ± 0.3 to 18.5 ± 0.2 HU with a four‐fold reduction in gantry speed, and to 18.7 ± 0.2 HU with a four‐fold increase in tube current. Overall, the noise level was found to be proportional to inverse square root of imaging dose, and imaging dose was proportional to the product of total tube current‐time product and the cube of the x‐ray potential. Analysis of the anthropomorphic head phantom data and clinical SRS imaging data also indicates that noise is reduced with imaging dose increase. Conclusions: Our results indicate that optimization of the imaging protocol, and thereby an increase in the imaging dose, is warranted for improved soft‐tissue visualization for intracranial SRS. [ABSTRACT FROM AUTHOR]

Aim: The purpose of this study was to investigate whether significant difference exists on radiation dose delivered to organs at risks in megavoltage computed tomography (MVCT) verification using three predefined scanning modes, namely fine (2 mm), normal (4 mm) and coarse (6 mm). This will provide information for the imaging protocol of tomotherapy for the left breast. Materials and methods: Organ doses were measured using thermoluminescent dosimeters (TLD-100) placed within a female Rando phantom for MVCT imaging. Kruskal–Wallis test was conducted with p<0·05 to evaluate the significant difference between the three MVCT scanning modes. Results: Statistically significant difference existed in organ absorbed dose between different scan mode selections (p<0·001). Relative to the normal scan selection (4 mm), the absorbed dose to the organs of interests can be scaled down by 0·7 and scaled up by 2·1 for coarse (6 mm) and fine scans (2 mm) respectively. Conclusions: Optimisation of imaging protocols is of paramount importance to keep the radiation exposure ‘as low as reasonably achievable’. The recommendation of undergoing daily coarse mode for MVCT verification in breast tomotherapy not only mitigates the radiation exposure to normal tissues, but also trims the scan-acquisition time. [ABSTRACT FROM AUTHOR]

Purpose This work provides the beam characteristics and evaluates the imaging dose to patients for a 2.5 MV portal imaging beam. Method and materials The Monte Carlo technique has been used to simulate the 2.5 MV imaging beam. Beam characteristics have been analyzed including the energy spectra and the fluence distributions as a function of position away from the beam central axis. The accuracy of a simulated beam was validated through comparisons between the Monte Carlo calculated and measured dose distributions in a water phantom. The simulated 2.5 MV beam was also used to obtain the absorbed-dose beam quality conversion factor, k Q, for absorbed dose calibration. The simulated beams were then used to evaluate the imaging dose to patients compared with that from a conventional therapeutic 6 MV beam. Results The mean energies of photons and electrons in the 2.5 MV beam are 0.48 MeV and 0.37 MeV respectively. The photon fluence decreases at 20 cm away from the central axis by only up to 30% for this flattening-filter free beam. The values of % dd curves at depth = 10 cm are 53% and 63% for 10 × 10 cm 2 and 40 × 40 cm 2 fields respectively. Portal imaging doses (D50 of the DVHs) to the eyes, heart and bladder from representative pairs of 2.5 MV (or 6 MV) setup images are 1.8 cGy (3.5 cGy), 1.1 cGy (2.5 cGy) and 1.0 cGy (2.4 cGy) for head, thorax and pelvis image acquisitions respectively. Conclusion We provide dosimetric data, as well as estimates of organ imaging doses, for this 2.5 MV beam. When clinical default imaging protocols are used, the imaging dose from the 2.5 MV beam is about 50% of that from a 6 MV beam. The information can be used to select image procedures and to estimate organ dose from imaging procedures. [ABSTRACT FROM AUTHOR]

Purpose To compare abdominal imaging dose from 3D imaging in radiology (standard/low-dose/dual-energy CT) and radiotherapy (planning CT, kV cone-beam CT (CBCT)). Methods Dose was measured by thermoluminescent dosimeters (TLD’s) placed at 86 positions in an anthropomorphic phantom. Point, organ and effective dose were assessed, and secondary cancer risk from imaging was estimated. Results Overall dose and mean organ dose comparisons yield significantly lower dose for the optimized radiology protocols (dual-source and care kV), with an average dose of 0.34±0.01 mGy and 0.54±0.01 mGy (average ± standard deviation), respectively. Standard abdominal CT and planning CT involve considerably higher dose (13.58 ± 0.18 mGy and 18.78±0.27 mGy, respectively). The CBCT dose show a dose fall-off near the field edges. On average, dose is reduced as compared with the planning or standard CT (3.79 ± 0.21 mGy for 220° rotation and 7.76 ± 0.37 mGy for 360°), unless the high-quality setting is chosen (20.30 ± 0.96 mGy). The mean organ doses show a similar behavior, which translates to the estimated secondary cancer risk. The modelled risk is in the range between 0.4 cases per million patient years (PY) for the radiological scans dual-energy and care kV, and 300 cases per million PY for the high-quality CBCT setting. Conclusions Modern radiotherapy imaging techniques (while much lower in dose than radiotherapy), involve considerably more dose to the patient than modern radiology techniques. Given the frequency of radiotherapy imaging, a further reduction in radiotherapy imaging dose appears to be both desirable and technically feasible. [ABSTRACT FROM AUTHOR]

This study investigates the potential benefits of planning target volume (PTV) margin reduction for whole breast radiotherapy in relation to dose received by organs at risk (OARs), as well as reductions in radiation-induced secondary cancer risk. Such benefits were compared to the increased radiation-induced secondary cancer risk attributed from increased ionizing radiation imaging doses. Ten retrospective patients' computed tomography datasets were considered. Three computerized treatment plans with varied PTV margins (0, 5 and 10 mm) were created for each patient complying with the Radiation Therapy Oncology Group (RTOG) 1005 protocol requirements. The BEIR VII lifetime attributable risk (LAR) model was used to estimate secondary cancer risk to OARs. The LAR was assessed for all treatment plans considering (a) doses from PTV margin variation and (b) doses from two (daily and weekly) kilovoltage cone beam computed tomography (kV CBCT) imaging protocols during the course of treatment. We found PTV margins from largest to smallest resulted in a mean OAR relative dose reduction of 31% (heart), 28% (lung) and 23% (contralateral breast) and the risk of radiation-induced secondary cancer by a relative 23% (contralateral breast) and 22% (contralateral lung). Daily image-guidance using kV CBCT increased the risk of radiation induced secondary cancer to the contralateral breast and contralateral lung by a relative 1.6-1.9% and 1.9-2.5% respectively. Despite the additional dose from kV CBCT for the two considered imaging protocols, smaller PTV margins would still result in an overall reduction in secondary cancer risk. [ABSTRACT FROM AUTHOR]

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This study presents estimation of typical kV fluoroscopic imaging doses for image-guided real-time adaptive radiotherapy. For a cohort of 10 lung SABR patients the estimated imaging dose to ipsi-lateral lung with real-time adaptation is 9.9–15.1 cGy, which is less than the extra lung dose from treatment with potentially larger ITV-based PTV approach. [ABSTRACT FROM AUTHOR]

Imaging dose in radiation therapy has traditionally been ignored due to its low magnitude and frequency in comparison to therapeutic dose used to treat patients. The advent of modern, volumetric, imaging modalities, often as an integral part of linear accelerators, has facilitated the implementation of image-guided radiation therapy (IGRT), which is often accomplished by daily imaging of patients. Daily imaging results in additional dose delivered to patient that warrants new attention be given to imaging dose. This review summarizes the imaging dose delivered to patients as the result of cone beam computed tomography (CBCT) imaging performed in radiation therapy using current methods and equipment. This review also summarizes methods to calculate the imaging dose, including the use of Monte Carlo (MC) and treatment planning systems (TPS). Peripheral dose from CBCT imaging, dose reduction methods, the use of effective dose in describing imaging dose, and the measurement of CT dose index (CTDI) in CBCT systems are also reviewed. [ABSTRACT FROM AUTHOR]