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A Feasibility Study On Clinical Implementation of 4D-CBCT in Lung Cancer Treatment

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Y Hu

Y Hu1*, C Ruan2 , J Stanford3 , W Duggar4 , P Rajaguru5 , R He6 , C Yang7 , (1) University of Mississippi Med. Center, Jackson, MS, (2) Brigham and Women''s Hospital / Harvard Medical School, Boston, MA, (3) University of Mississippi Med. Center, Jackson, MS, (4) University of Mississippi Med. Center, Jackson, MS, (5) Univ. Mississippi Medical Center, UMC CancerCenter, Jackson, MS, (6) University of Mississippi Med. Center, Ridgeland, MS, (7) University of Mississippi Medical Center, Jackson, MS


SU-E-J-6 Sunday 3:00PM - 6:00PM Room: Exhibit Hall

Purpose: Four-dimensional cone-beam CT (4D-CBCT) is a novel imaging technique to setup patients with pulmonary lesions in radiation therapy. This paper is to perform a feasibility study on the implementation of 4D-CBCT as image guidance for (1) SBRT and (2) Low Modulation (Low-Mod) IMRT in lung cancer treatment.

Methods: Image artifacts and observers variability are evaluated by analyzing the 4D-CT QA phantom and patient 4D image data. There are two 4D-CBCT image artifacts: (1) Spatial artifact caused by the patient irregular breathing pattern will generate blurring and anatomy gap/overlap; (2) Cone beam scattering and hardening artifact will affect the image spatial and contrast resolution. The couch shift varies between 1mm to 3mm from different observers during the 4D-CBCT registration. Breath training is highly recommended to improve the respiratory regularity during CT simulation and treatment, especially for SBRT. Elekta XVI 4.5 Symmetry protocol is adopted in the patient 4D-CBCT scanning and intensity-based registration. Physician adjustments on the auto-registration are involved prior to the treatment. Physician peer review on 4D-CBCT image acquisition and registration is also recommended to reduce the inter-observer variability. The average 4D-CT in reference volume coordinates is exported to MIM Vista 5.6.2 to manually fuse to the planning CT for further evaluation.

Results: (1) SBRT: 4D-CBCT is performed in dry-run and in each treatment fraction. Image registration and couch shift are reviewed by another physician on the 1st fraction before the treatment starts. (2) Low-Mod IMRT: 4D-CBCT is performed and peer reviewed on weekly basis.

Conclusion: 4D-CBCT in SBRT dry-run can discover the ITV discrepancies caused by the low quality 4D-CT simulation. 4D-CBCT during SBRT and Low-Mod IMRT treatment provides physicians more confidence to target lung tumor and capability to evaluate inter-fractional ITV changes. More advanced 4D-CBCT scan protocol and reconstruction algorithm may be needed in the future.

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