Noise-robust breathing-phase estimation on marker-free, ultra low dose X-ray projections for real-time tumor localization via surrogate structures.

Purpose: This paper presents a novel strategy for feature-based breathing-phase estimation on ultra low-dose X-ray projections for tumor motion control in radiation therapy.
Methods: Coarse-scaled Curvelet coefficients are identified as motion sensitive but noise-robust features for this purpose. For feature-based breathing-phase estimation, an ensemble strategy with two classifiers is used. This consensus-based estimation substantially increases tracking reliability by rejection of false positives. The algorithm is evaluated on both synthetic and measured phantom data: Monte Carlo simulated ultra low dose projections for a C-arm X-ray and on the basis of 4D-chest-CTs of eight patients on one hand side and real measurements based on a motion phantom.
Results: To achieve an accuracy of breathing-phase estimation of more than 95% a fluence between 20 and 400 photons per pixel (open field) is required depending on the patient. Furthermore, the algorithm is evaluated on real ultra low dose projections from an XVI R5.0 system (Elekta AB, Stockholm, Sweden) using an additional lead filter to reduce fluence. The classifiers-consensus-based-gating method estimated the correct position of the test projections in all test cases at a fluence of ∼180 photons per pixel and 92% at a fluence of ∼40 photons per pixel. The deposited dose to patient per image is in the range of nGy.
Conclusions: A novel method is presented for estimation of breathing-phases for real-time tumor localization at ultra low dose both on a simulation and a phantom basis. Its accuracy is comparable to state of the art X-ray based algorithms while the released dose to patients is reduced by two to three orders of magnitude compared to conventional template-based approaches. This allows for continuous motion control during irradiation without the need of external markers.
(Copyright © 2021. Published by Elsevier GmbH.)