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Jenny Kouri
March 28, 2015
Treatment Planning
Image Guidance: KV-CBCT and MVCT
The goal of simulation is to create a treatment position that will be comfortable
for the patient and reproducible for day-to-day setups. Due to human nature, change in
patient positioning between treatment sessions will occur despite an accurate,
reproducible set-up. Changes in patient anatomy such as tumor shrinkage or the filling of
an organ, such as the bladder or rectum, contributes to interfractional motion. Flatulence,
breathing, coughing, sneezing, or an uncooperative patient results in change, known as
intrafractional motion.1,2 This is depicted below in Figures 1-4.2
Figure 1: Intrafaction Motion vs. Interfraction Motion

Figure 2: Therapy Induced Changes

Figure 3: Organ Filling of Bladder

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Figure 4: Organ Filling of Rectum

Targets can move within the patient and normal tissues can move within the
patient as well, but the target and normal tissues do not necessarily move together.
Lehmann states, If image guidance is not managed, delivery of a treatment session
increases a greater risk of low accuracy of radiation.
The desire for greater precision and accuracy in the treatment delivery is
accessible with image guidance such as kilo-voltage cone beam computed tomography
(kV-CBCT).2 Higher dose rates, stereotactic treatments, and hypofractionation can be
achieved with fewer side effects and less time under treatment with CBCT. With the
resulting steep dose gradients, motion management becomes an even more critical part of
the treatment process.2,3 However, it is necessary to note that image guidance reduces,
but does not eliminate geographic uncertainties, according to Jaffray.
Prior to treatment delivery, CBCT acquires projections of a patient while on the
treatment table using an area detector.1 Single volumetric projections are taken at certain
degree intervals during the rotation of the gantry.1,2 Washington states, The rotational
speed of the gantry remains at 1 revolution per minute. Full single CT scans are taken,

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reconstructed into a net of scans, and returned into a three-dimensional (3D) image. The
reconstructed scan is automatically registered to the CT taken during simulation, which
can project images in three orthogonal planes: sagittal, transversal, and coronal. This
allows for verification of patient positioning and for the ability to reposition the patient
within precise and accurate relation to the isocenter. Shifts necessary to align image sets
correspond to couch shifts needed to correct patient setup. Registration is completed
using a 3D mutual information algorithm.1,2,3
Below is a list of CBCT patient workload as stated by Lehmann:
1. Select/load patient
2. Extend imaging gear
3. Select imaging parameters
4. Bring gantry in start position
5. Fire kV while moving gantry
6. Reconstruct CBCT
7. Align CBCT with reference
8. Adjust patient position/shift
9. Record shifts
10. Retract imaging gear
11. Treat
It is important to consider patient motion during the process of CBCT and may
cause variation in the location of the isocenter. Degrading of CT can also occur when
imaging thicker body parts, such as the pelvis. This is due to the scattered x-rays.1
The patient dose from CBCT is system dependent and patient dependent. The
following contribute to the amount of dose received by the patient: kV, mAs settings,
number of projections, angle or rotation, images per degree, filter type, kV field size.
The size, shape, and body part of the patient affects the amount of dose as well.2,3 Image
quality only needs to be good enough for the purpose of the scan as dose and image
quality are closely related, states Jaffray.

MVCT provides the capability for image registration, treatment verification, and
treatment reconstruction. The linear accelerators small focal spot provides highresolution images. However, the x-rays produced from the MV sources result in poorly

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contrasted images of the soft tissue. TomoTherapy is designed to house an x-ray source
that is used both for MVCT imaging and MV treatment delivery in a helical manner.1
Likewise of a linear accelerator, the MV images produced from TomoTherapy have poor
low-contrast resolution in comparison to kV images. Unlike kV images, the MVCT
TomoTherapy images avoid metal artifact.1 A comparison is shown below in Figure 5.3
Figure 5

References

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1. Lehmann J. Cone beam computed tomography (CBCT) for radiation therapy
patient positioning. [Power point]. Medical Dosimetry.
http://www.medicaldosimetry.org/pub/39737c92-2354-d714-518c-ab0085378d39.
Accessed March 29, 2015.
2. Jaffray D. Image-Guided Radiation Therapy: A Refresher. [Power point].
Departments of Radiation Oncology and Medical Biophysics University of
Toronto.
http://www.astro.org/uploadedFiles/Main_Site/Meetings_and_Events/Spring_Refr
esher_Course/Meeting_Program/Jaffray%20Physics.pdf. Accessed March 29,
2015.
3. Washington C, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St.
Louis, MO: Mosby-Elsevier. 2010.