Cone Beam Ct On Radiotherapy Treatment - Cone Beam

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By Nink Lasi - http://imageriemedicale.fr/

Cone beam technology was first developed using mega voltage radiation. This obviously gave the patient a significantly high dose and the resulting images gained were relatively poor. The advantages of being able to construct a 3D volume were recognised and manufacturers developed kilo-voltage cone beam computed tomography (kV-CBCT). This can be used for adaptive radiotherapy (ART) to produce a plan which for example, cone beam reflects the volume of the bladder at the time of treatment. The RMH in Sutton is writing a paper (un-published) on bladder ART. They produce 3 plans for each patients phase 2 treatment, with 3 different bladder sizes.

They then construct a cone beam CT of the patient prior to treatment for each fraction of the phase 2 treatment plan. The radiographers then match and select the most appropriate plan for the size of the ptients bladder that day. This provides the optimum plan, but does not take into account any intra-

fraction movement. Researchers wrote about how they are using cone beam CT to adapt their plans. On prostate patients they use the data obtained from the cone beam ct in the first week of treatment to predict where the prostate is likely to be, in relation to bony anatomy, for the phase 2. One problem they experienced was the movement of gas in the rectum, which could negatively affect the quality of the cone beam ct images. This highlights the limitation of the relatively slow acquisition time, but also shows the problems with intra-fraction movement. Some centers are even routinely using laxatives, during the patient's radiotherapy treatment, and are still showing that rectal movement does affect, prostate positioning intra-fractionally. Doctors have looked back at the cone beam CT images that had been taken during the patient's treatment, and used a back planning method to calculate the isodoses to each key area. This meant they were able to calculate the difference between the dose the medical team had thought the patient was to receive, and the dose that the patient really did receive.

They did this by taking the data obtained from the cone beam CT's and overlaid the original IMRT plan to hypothesis the dose which each actually structure received, they found a large variation in both bladder and rectal volumes. Centers have found that their approach was very time consuming and would require automation if it was to be used routinely. Given the variability of organ motion relatively high margins still have to be used and this intern limits the dose escalation possibilities. Some have therefore concluded that kV-CBCT was adequate for prostate localization, but suggests ultrasound should be used to confirm prostate position daily.

One of the main problems experienced with kV-CBCT is the scan alone can take 45 - 60 seconds. If the patient moves at all during this period of time, then the quality of the constructed images may hinder their usability. Researchers developed an in house algorithm to account for this and manufacturers were quick to follow suit. The images modern kV-CBCT machines produce images that are adequate for clinical applications. Diagnostic CT scans have always been accepted as giving a relatively high dose of radiation to the patient. Over the many years they have been in routine clinical use manufacturers and clinical scientists have developed new methods to reduce the dose pre scan. These technologies have yet to be applied to the kV-CBCT. Doctors have used a number of simple methods and was able to reduce the dose delivered by to a phantom from 45mGy to 30mGy using standard setting. They point out that if IGRV is to be used daily for radiotherapy treatment localisation then this does needs to be reduced significantly further. Scanning before each fraction is a pre-requisite of ART so this has to be an area that needs development. Comparatively to the dose received through the radiotherapy treatment the kV-CBCT dose is low, but this should not be used as an excuse for not reducing kV-CBCT dose.

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