The

Applicability
of Stitching
Cone Beam
CT Scans for
H&N Patients
Nicole Pitzer
 Constantly Changing,
Refreshing, and Improving8
o IGRT
o Means of localizing exact target of treatment within
the body
o The ultimate goal: to increase in target dose →
“only possible by reducing field margins. Thus, the
field margin is the limiting factor…”
o IGRT is to reduce field margins by managing tumor
motion and provide optimal treatment plans using
images with the patient in the treatment position
immediately prior to or during the treatment.
o Overall has potential to improve side effects
o Gives confidence in patient set up and placement of
dose
Quality Assurance3

Lasers Field Light Rotations

 Types of IGRT

kV image MV image CBCT

Bony anatomy with more detail Bony anatomy with less detail Soft tissues + bony anatomy
CBCT8

o First implemented in dentomaxillofacial imaging in

2001
o “The use of CBCT with kV x-rays (30-140 kV) offers
superior low contrast resolution when compared to
EPIDs. Additionally, high spatial resolution and high
quantum efficiency have made CBCT a popular choice
in radiotherapy applications.”
Head and Neck Patients
o Large amount of critical structures to be
concerned with → have very little room for error
when treating
o Requires a very precise set up

o Half trajectory CBCT vs imaging of the pelvis,

abdomen, chest, etc. which require a full
trajectory

o Most H&N patients the info acquired is sufficient

o For others:
o Treating into upper thorax as well → need more
information
What is cone beam stitching?8

o The normal Varian kV imaging panel only has a 39.73x29.80

cm2 physical size
o This translates to a 30cm x 24cm image size
o Utilizes 2 normal cone beams
o To accomplish this, take the first cone beam like normal
o Then shift the table ___cm superior (iso moves inferior) and
take a second cone beam
o Shifts from iso are determined on the first day
o There is some overlap
o Merge the two together = one large CBCT image
o Match just like normal
Some points to consider
❑ Accuracy & reliability
❑ Added dose
❑ Purpose
 Where was it
Dentomaxillofacial
first field & orthopedic
implemented? interventions

The beginning Is there

of CBCT dimensional
stability?

stitching6,8
How
accurate are
these
images?
Accuracy and reliability of stitched images
Egbert et al.5
o Summarizes several studies that have o “a new 3D acquisition mode that automatically combines
concluded few to no differences exist in
the dimensional accuracy of conventional
computed tomography and CBCT
o All of these studies were performed
utilizing implants for the maxillofacial
region
o Utilizes the same principle of merging the
images
Kopp & Ottl7
o Study focused in the dental field
two or three small FOV volumes to construct a larger,
composite 3D image that is needed for a wider region of
examination.”
o Mounted mandible positioned centrally using laser lights
much like the treatment room
o Conclusion: differences in anatomic and stitched small FOV
CBCT dimensions statistically significant but clinically
insignificant
o the difference is “beyond the resolution of the human eye and
hand”
Some points to consider
✓ Accuracy & reliability
❑ Added dose
❑ Purpose
*Head and Neck cases especially are in need for imaging verification due to the
fact that the anatomical region comes with a complex shape in need of steep
dose gradients and exact patient positioning.
Alaei et al.2,8

o 40 patients diagnosed with pharyngeal cancer, cancer of Assessed how

the mouth – or base of tongue, tonsil, parotid and larynx much dose a
o Range of fractions → most receiving 30-35 treatments patient receives
with a total dose of 50 Gy from daily CBCT
o Used a 6 MV photon beam imaging
compared to the
o Assessed daily imaging in the kV range for CBCT
total dose to
o Thermoplastic masks aligned with room lasers to surrounding
corresponding marks tissues and
o Findings: 3-9 mGy for each H&N CBCT normal tissue
o Similar study done found additional dose of around 30-40 mGy tolerances
for a 35 fraction H&N treatment with daily CBCT imaging
 Food for thought…
For a 35 fraction treatment if stitching is
prescribed on the imaging order, this adds at
least 7-14 extra CBCTs to add to the total
imaging dose

Keep in mind, if this is done on a pelvis patient it will require

more frames and a full 360 degree rotation of the machine
to acquire the full image = even more dose
Some points to consider
✓ Accuracy & reliability
✓ Added dose
❑ Purpose
 Dzierma et al.1,4

o Wanted to study how patient set ups were influenced from different imaging techniques
and what errors occurred due to the exchange of imaging techniques
o Would be very useful in determining if the stitched CBCT had a direct effect on a patient’s set up
for that day
o Ran into a few complications which prevented a full conclusion
1. No direct comparison of set up shifts made from one imaging modality to another on the same
patient on the same fraction
2. Results were not being evaluated on the basis of taking a verification image after shifts have
been made to verify that where you think you shifted is where you treated
• When referring to the ACR-ASTRO Practice Parameter for Communication: Radiation
Oncology, there is no statement that requires this as documentation.
o Conclusion: Deviations in patient set up from day to day could arise from chance and the
patient lying down differently on a different day
Discussion
Is it worth
PROS CONS
it? 2,4,5,7,8

*cone beam geometry in

general covers a large field
of view in 1 rotation
contributing to a larger
scattered radiation
component vs even a
normal CT
o More body marks
o Taking another type of IGRT
image with less dose to get
patient in ball park area Where do we go
o Theoretically the more marks the
better from here?
o The overall goal is to find the best
clinical outcome for the patient
without increasing the risk for
secondary malignancies
 References

1. ACR-ASTRO Practice Parameter for Communication: Radiation Oncology. 2014.

2. Alaei P, Spezi E, and Reynolds M. Dose calculation and treatment plan optimization including imaging dose from kilovoltage
cone beam computed tomography. Acta Oncologica, 53:6, 839-844, DOI: 10.3109/0284186X.2013.875626.
3. Ayan, A. Isocenter Powerpoint. Lecture in Atwell Hall. 2019.
4. Dzierma Y, Beyhs M, Palm J, Niewald M, et al. Set-up errors and planning margins in planar and CBCT image-guided
radiotherapy using three different imaging systems: A clinical study for prostate and head-and-neck cancer. Physica Media.
2015.
5. Egbert N, Cagna D, Ahuja S, and Wicks R. Accuracy and reliability of stitched cone-beam computed tomography images. Imaging
Science in Dentistry. 2015; 45: 41-7.
6. Fotouhi J, Fuerst B, Unberath M, Reichenstein S, and Lee S. Automatic intraoperative stitching of nonoverlapping cone-beam CT
acquisitions. 2018.
7. Kopp S and Ottl P. Dimensional stability in composite cone beam computed tomography. Dentomaxillofacial Radiology. 2010;
39: 512-516.
8. Srinivasan K, Mohammadi M, Shepherd J. Applications of linac-mounted kilovoltage Cone-beam Computed Tomography in
modern radiation therapy: A review. Pol J Radiol. 2014;79:181–193. Published 2014 Jul 3. doi:10.12659/PJR.890745