Cone-beam Computed Tomography Acquisition Research Articles

Depth Dose According to Depth during Cone Beam Computed Tomography Acquisition and Dose Assessment in the Orbital Area Using a Three-Dimensional Printer

Background: Cone beam computed tomography (CBCT) is essential for correcting and verifying patient position before radiation therapy. However, it poses additional radiation exposure during CBCT scans. Therefore, this study aimed to evaluate radiological safety for the human body through dose assessment for CBCT.Materials and Methods: For CBCT dose assessment, the depth dose was evaluated using a cheese phantom, and the dose in the orbital area was evaluated using a human body phantom self-fabricated with a three-dimensional printer.Results and Discussion: The evaluation of radiation doses revealed maximum doses of 14.14 mGy and minimum doses of 6.12 mGy for pelvic imaging conditions. For chest imaging conditions, the maximum doses were 4.82 mGy, and the minimum doses were 2.35 mGy. Head imaging conditions showed maximum doses of 1.46 mGy and minimum doses of 0.39 mGy. The eyeball doses using a human body phantom model averaged at 2.11 mGy on the left and 2.19 mGy on the right. The depth dose ranged between 0.39 mGy and 14.14 mGy, depending on the change in depth for each imaging mode, and the average dose in the orbit area using a human body phantom was 2.15 mGy.Conclusion: Based on the experimental results, CBCT did not significantly affect the radiation dose. However, it is important to maintain a minimal radiation dose to optimize radiation protection following the as low as reasonable achievable principle.

Validation and comparison of 2D grading scales and 3D volumetric measurements for outcome assessment of bone-grafted alveolar clefts in children.

Several methods have been proposed to assess outcome of bone-grafted alveolar clefts on cone beam computed tomography (CBCT), but so far these methods have not been compared and clinically validated. To validate and compare methods for outcome assessment of bone-grafted clefts with CBCT and provide recommendations for follow-up. In this observational follow-up study, two grading scales (Suomalainen; Liu) and the volumetric bone fill (BF) were used to assess the outcome of 23 autogenous bone-grafted unilateral alveolar clefts. The mean age at bone grafting was 9 years. The volumetric BF was assessed in five vertical sections. The bone-grafted cleft outcome was based on a binary coding (success or regraft) on a clinical multidisciplinary expert consensus meeting. Grading scales and volumetric assessment were compared in relation to the bone-grafted cleft outcome (success or regraft). Reliability for the different outcome variables was analyzed with intra-class correlation and by calculating kappa values. The study had a limited sample size. Clinical CBCT acquisitions had a varying tube current and exposure time. Volumetric 3D measurements allowed for outcome assessment of bone-grafted alveolar clefts with high reliability and validity. The two grading scales showed highly reliable outcomes, yet the validity was high for the Suomalainen grading scale but low for the Liu grading scale. Volumetric 3D measurement as well as the Suomalainen grading can be recommended for outcome assessment of the bone-grafted cleft. Yet, one must always make a patient-specific assessment if there is a need to regraft.

Paediatric radiation therapy without anaesthesia – Are the children moving?

PurposeChildren who require radiation therapy (RT) should ideally be treated awake, without anaesthesia, if possible. Audiovisual distraction is a known method to facilitate awake treatment, but its effectiveness at keeping children from moving during treatment is not known. The aim of this study was to evaluate intrafraction movement of children receiving RT while awake. MethodsIn this prospective study, we measured the intrafraction movement of children undergoing treatment with fractionated RT, using pre- and post-RT cone beam CT (CBCT) with image matching on bony anatomy. Study CBCTs were acquired at first fraction, weekly during RT, and at last fraction. The primary endpoint was the magnitude of vector change between the pre- and post-RT scans. Our hypothesis was that 90 % of CBCT acquisitions would have minimal movement, defined as <3 mm for head-and-neck (HN) treatments and <5 mm for non-HN treatments. ResultsA total of 65 children were enrolled and had evaluable data across 302 treatments with CBCT acquisitions. Median age was 11 years (range, 2–18; 1st and 3rd quartiles 7 and 14 years, respectively). Minimal movement was observed in 99.4 % of HN treatments and 97.2 % of non-HN treatments. The study hypothesis of >90 % of evaluations having minimal movement was met. Children who were age >11 years moved less at initial evaluation but tended to move more as a course of radiation progressed, as compared to children who were younger. ConclusionChildren receiving RT with audiovisual distraction while awake had small magnitudes of observed intrafraction movement, with minimal movement in >97 % of observed RT fractions. This study validates methods of anaesthesia avoidance using audiovisual distraction for selected children.

Topology observing 3D device reconstruction from continuous-sweep limited angle fluoroscopy.

Minimally invasive procedures usually require navigating a microcatheter and guidewire through endoluminal structures such as blood vessels and airways to sites of the disease. For numerous clinical applications, two-dimensional (2D) fluoroscopy is the primary modality used for real-time image guidance during navigation. However, 2D imaging can pose challenges for navigation in complex structures. Real-time 3D visualization of devices within the anatomic context could provide considerable benefits for these procedures. Continuous-sweep limited angle (CLA) fluoroscopy has recently been proposed to provide a compromise between conventional rotational 3D acquisitions and real-timefluoroscopy. The purpose of this work was to develop and evaluate a noniterative 3D device reconstruction approach for CLA fluoroscopy acquisitions, which takes into account endoluminal topology to avoid impossible paths between disconnectedbranches. The algorithm relies on a static 3D roadmap (RM) of vessels or airways, which may be generated from conventional cone beam CT (CBCT) acquisitions prior to navigation. The RM is converted to a graph representation describing its topology. During catheter navigation, the device is segmented from the live 2D projection images using a deep learning approach from which the centerlines are extracted. Rays from the focal spot to detector pixels representing 2D device points are identified and intersections with the RM are computed. Based on the RM graph, a subset of line segments is selected as candidates to exclude device paths through disconnected branches of the RM. Depth localization for each point along the device is then performed by finding the point closest to the previous 3D reconstruction along the candidate segments. This process is repeated as the projection angle changes for each CLA image frame. The approach was evaluated in a phantom study in which a catheter and guidewire were navigated along five pathways within a complex vessel phantom. The result was compared to static cCBCT acquisitions of the device in the finalposition. The average root mean squared 3D distance between CLA reconstruction and reference centerline was mm. The Euclidean distance at the device tip was mm. The correct pathway was identified during reconstruction in of frames ( ). The percentage of 3D device points reconstructed inside the 3D roadmap was with an average distance of mm between the device points outside the roadmap and the nearest point within theroadmap. This study demonstrates the feasibility of reconstructing curvilinear devices such as catheters and guidewires during endoluminal procedures including intravascular and transbronchial interventions using a noniterative reconstruction approach for CLA fluoroscopy. This approach could improve device navigation in cases where the structure of vessels or airways is complex and includes overlappingbranches.

Custom-Trained Deep Learning-Based Auto-Segmentation for Male Pelvic Iterative CBCT on C-Arm Linear Accelerators

Purpose: To evaluate the clinical applicability of a commercial artificial intelligence (AI)-driven deep learning auto-segmentation (DLAS) tool on enhanced iterative cone-beam CT (iCBCT) acquisitions for intact prostate and prostate bed treatments. Methods and MaterialsDLAS models were trained using 116 iCBCT datasets with manually delineated organs-at-risk (OARs – bladder, femoral heads, and rectum) and target volumes (intact prostate and prostate bed) adhering to institution-specific contouring guidelines. An additional 25 intact prostate and prostate bed iCBCT datasets were utilized for model testing. Segmentation accuracy relative to a reference structure set was quantified using various geometric comparison metrics and qualitatively evaluated by trained physicists and physicians. These results were compared to those obtained for an additional DLAS-based model trained on planning CT (pCT) datasets and for a deformable image registration (DIR)-based automatic contour propagation method. Results: In most instances, statistically significant differences in the Dice similarity coefficient (DSC), 95% directed Hausdorff distance, and mean surface distance metrics were observed between the models, as the iCBCT-trained DLAS model outperformed the pCT-trained DLAS model and DIR-based method for all OARs and the intact prostate target volume. Mean DSC values for the proposed method were ≥0.90 for these volumes-of-interest. The iCBCT-trained DLAS model demonstrated a relatively suboptimal performance for the prostate bed segmentation, as the mean DSC value was <0.75 for this target contour. Overall, 90% of bladder, 93% of femoral head, 67% of rectum, and 92% of intact prostate contours generated by the proposed method were deemed clinically acceptable based on qualitative scoring, while approximately 63% of prostate bed contours required moderate or major manual editing to adhere to institutional contouring guidelines. Conclusion: The proposed method presents the potential for improved segmentation accuracy and efficiency when compared to the DIR-based automatic contour propagation method as commonly applied in CBCT-based dose evaluation and calculation studies.

Data Driven Approach to Exactrac Setup Parameters after CBCT for Cranial Radiotherapy

The purpose of this study is to 1) Determine the congruence of shifts derived from Cone-Beam CT (CBCT) and from Exactrac dynamic KV X-rays 2) To setup action levels for Exactrac imaging to determine if patient potentially moved between CBCT and Exactrac acquisition and 3) To analyze if Exactrac alone can be reliably used for cranial setup forgoing the CBCT step MATERIALS/METHODS: Exactrac dynamic, uses in-room KV X-ray imaging that is mounted on the floor to monitor patient positioning during treatment. The congruence of imaging and radiation isocenter for the LINAC and Exactrac system was verified using the Winston-Lutz (WL) test over a period of one year. The WL pointer was set up and its coincidence with imaging and radiation isocenter was confirmed. Exactrac images were then acquired at various couch angles and the pointer deviation from Exactrac imaging isocenter is noted. Secondly, translation and rotation shifts for 175 consecutive cranial cases were examined to determine the deviation between shifts as denoted by CBCT and Exactrac. These patients were initially set up using CBCT and then once in treatment position, Exactrac KV images were acquired to check for any deviation. The deviation between the two systems was collected and a Kolomogorov-Smirnov (KS) test was performed on the data to check for the normality of the distribution. Statistical Process Control (SPC) was performed to derive action levels for Exactrac based shifts after CBCT. Based on repeated Winston-Lutz tests over a period of one year, the maximum deviation between radiation and imaging isocenters and Exactrac isocenter was 0.3mm and 0.3 deg over all couch angles. This number remained stable over the entire time period without necessitating any recalibration of Exactrac isocenter. Based on patient data for cranial cases, the mean and standard deviations for the largest shifts were (0.45 mm, 0.40 mm) for translations (range 0 - 2.03mm) and (0.44 deg and 0.32 deg) for rotations (range 0 - 2.21 degree). Using SPC, it was decided that the action level for translations and rotations could be set to 0.8mm and 0.5 deg respectively. Any deviation beyond this action level necessitates re-imaging to verify that the patient did not move in between the CBCT and Exactrac imaging acquisitions CONCLUSION: Exactrac system derived shifts show excellent agreement with CBCT. The isocentricity of the systems is maintained over a long period of time and shows no drift. Either system can be reliably used to set up cranial patients. With the added advantage of speed of acquisition, matching and shifts, the Exactrac system could replace CBCT for daily setup of patients undergoing cranial radiotherapy.

Virtual injection software for endovascular management of spinal dural arteriovenous fistula.

Endovascular management of spinal dural arteriovenous fistula (DAVF) is arduous because of complex angioarchitecture and motion artifacts and is limited by the two-dimensional (2D) view. However, cone beam computed tomography (CBCT) acquisitions with selective injections allow 3D multiplanar reconstructions contributing to high diagnostic, anatomical and safety value. In this study, we described the use of virtual injection software (VIS) computed from CBCT acquisition and already used for prostatic and cerebral embolization, for the endovascular management of spinal DAVFs (EmboAssist, GE HealthCare, Chicago, USA). The VIS has been designed to facilitate the analysis of the patient's vasculature during the planning of embolization procedures to define the afferent pedicles to the shunt and the incidence of oblique projection, allowing for a better anatomical understanding and helping for the selection of 2D incidence. Combined with 3D roadmapping, VIS allows vessel tracking for selective catheterism and embolization. The VIS is a useful tool for planification and navigation during endovascular treatment of spinal DAVF with a safety value.

Comparative Evaluation of a Lower-Dose CBCT Acquisition Protocol for Preoperative Implant Site Assessment in Dry Human Skulls: A Proof-of-Concept Study.

Restoration of edentulous sites with dental implants is increasingly becoming a popular choice. Cross-sectional 3-dimensional imaging using cone-beam computed tomography (CBCT) provides a better depiction of the implant site to help the clinician plan the procedure better. In spite of the advantages, radiation dose will always remain a concern. The evolution of lower-dose protocols is ongoing, but whether those acquisition protocols yield comparable diagnostic information is still not well established. The objective of this study was to evaluate the diagnostic efficacy of a low-dose, 180° rotational CBCT acquisition protocol for evaluating a potential implant site in comparison with a conventional 360° rotational acquisition. Ten dentate and partially edentulous dry human skulls providing 82 randomized implant sites-40 in the maxilla and 42 in the mandible-were chosen for this study. Each skull was imaged using a 360° and a 180° rotational acquisition on a J. Morita Accuitomo CBCT scanner. Evaluation of cortical and trabecular bone, height, width, and proximity to critical structures, such as the inferior alveolar nerve canal and the maxillary sinus, were measured. An oral surgeon and an oral radiologist rated the diagnostic efficacy of the scans by evaluating the above characteristics. Statistical evaluation of the data with linear regression showed significant agreement between both protocol measurements. Kappa analyses yielded a good interobserver agreement. In this proof-of-concept study, CBCT imaging using the lower-dose, modified arc, and 180° acquisition protocol shows comparable results to the conventional 360° protocol for preoperative implant assessment.

Evaluation of 2- and 3-dimensional anatomic parameters of C-shaped root canals with cone beam computed tomography, microcomputed tomography, and nanocomputed tomography

The objective of this study was to evaluate 2-dimensional (2D) and 3D morphometric parameters of C-shaped root canals on cone beam computed tomography (CBCT) and microcomputed tomography (microCT) images using nanocomputed tomography (nanoCT) as the reference standard. Sixty mandibular molars with C-shaped canals were individually scanned using nanoCT and microCT. Cone beam computed tomography acquisitions were then performed with 4 CBCT systems, using high and standard resolutions. The 2D parameters of roundness and major and minor diameters were obtained in the cross sections of the root canals at 1, 2, and 3 mm from the root apex. The 3D parameters of surface area, volume, and structure model index were measured considering the entire extension of the root canals. Absolute error (AE) in measurement was calculated against the nanoCT values. Data were statistically analyzed with the Shapiro-Wilk test and analysis of variance (α=0.05). No significant differences in AE were discovered for the 2D parameters among microCT and the CBCT scans. The AE values for the 3D parameters of volume and surface area were significantly smaller in microCT compared to all CBCT units (P < .05). Significantly lower AE values for surface area were observed in high resolution compared to standard resolution for all CBCT units (P < .05). Structure model index did not differ significantly among microCT and all CBCT protocols. Cone beam computed tomography images showed accuracy for evaluating 2D parameters and over- and underestimation for 3D parameters.

DENTAL PROFESSION STUDENT KNOWLEDGE ON CBCT AT FACULTY OF DENTISTRY UNIVERSITAS SUMATERA UTARA

Cone-beam computed tomography (CBCT) is a three-dimensional radiographic imaging method that offers accurate data on the structure of hard tissues. The aim of this study was to estimate the CBCT knowledge level held by dental profession student at the Faculty of Dentistry, Universitas Sumatera Utara. The design of this study was a cross-sectional descriptive-analytic study using a questionnaire for collecting the data. The study included 385 dental profession student from the class of 2017, 2018, 2019, 2020, and 2021. The results showed that the percentage of students correctly identifying CBCT as a form of ionizing radiation radiography and CBCT's advantages over conventional CT was 52.2% and 48.1%, respectively. The percentage of students correctly identifying CBCT hardware 45.2%, CBCT con angle 64.4%, patient preparation 38.4%, and patient position was 36.6%, while only 24.2% of students correctly answered CBCT acquisition time. The study's findings concluded that the knowledge of dental profession student in the Faculty of Dentistry, Universitas Sumatera Utara, could be categorized into three levels: good (11.2%; 43 students), sufficient (21.8%; 84 students), and poor (67.0%; 258 students)

Effect of the Small Field of View and Imaging Parameters to Image Quality and Dose Calculation in Adaptive Radiotherapy

Abstract Background The use of cone beam computed tomography (CBCT) for dose calculation in adaptive radiotherapy has been investigated in many studies. Proper acquisition and reconstruction of preset parameters could improve the accuracy of dose calculation based on CBCT images. This study evaluated the impact of the modified image acquisition and preset reconstruction parameter available in X-Ray Volumetric Imaging (XVI) to improve CBCT image quality and dose calculation accuracy. Materials and methods Calibration curves were generated by scanning the CIRS phantom using CBCT XVI Elekta 5.0.4 and Computed Tomography (CT) Simulator Somatom, which served as CT image reference. Rando and Catphan 503 phantoms were scanned with various acquisition and reconstruction parameters for dose accuracy and image quality tests. The image quality test is uniformity, low contrast visibility, spatial resolution, and geometrical scale test for each image by following the XVI image quality test module. Results Acquisition and reconstruction parameters have an impact on the Hounsfield Unit (HU) value that is used as the HU-Relative Electron Density (RED) calibration curve. The dose difference for all the calibration curves was within 1% and passed the gamma passing rate. Images acquired using 120 kVp, F1 (with Bowtie Filter), and 50 mA (F1-120-50-10) scored the highest Gamma Index (GI) of 98.5%. For the image quality test, it scored 1.20% on the uniformity test, 2.14% on the low contrast visibility test, and 11 lp/cm on the spatial resolution test. However, F1-120-50-10 reconstructed with different reconstructions scored 3.83% and 4 lp/cm in contrast and spatial resolution test, respectively. Conclusion CBCT reconstruction parameters work as a scatter correction. It could improve the dose accuracy and image quality. Nevertheless, without adequate CBCT acquisition protocols, it would produce an image with high uncertainty and cannot be fixed with reconstruction protocols. The F1-120-50-10 protocols generate the highest dose accuracy and image quality.

PO-2351 Can artificial intelligence bring cone beam CT acquisitions to planning CT quality?

PO-2351 Can artificial intelligence bring cone beam CT acquisitions to planning CT quality?

Prostate stereotactic body radiotherapy: quantifying intra-fraction motion and calculating margins using the new BIR geometric uncertainties in daily online IGRT recommendations.

To measure the magnitude of intra-fraction prostate motion (IFPM) during stereotactic radiotherapy (SBRT) delivered without intra-fraction tracking.To assess if current margins adequately cover IFPM.To derive margins using new guidelines. IFPM was determined in 20 patients receiving 36.25 Gy in 5 fractions using 97 pairs of pre- and post-treatment cone beam CT (CBCT) scans. Correlation of time between CBCT acquisitions and motion was determined. The magnitude of IFPM was compared to current margins (6 mm isotropic, 3 mm posterior). Margins were calculated using IFPM alone and updated guidelines. The averaged 3D root mean square IFPM was 2.5 mm (4.2 mm). Independent prostate motion was predominantly posterior (70%) and inferior (63%). There was weak correlation between posterior (ρ = 0.38) and inferior (ρ = 0.36) IFPM and time. IFPM greater than current margins occurred in 8 of 97 fractions, six in the posterior direction. Margins were ≤3.5 mm using IFPM alone and ≤3.3 mm Left 3.5 mm Right, 7.0 mm inferior, 3.7 mm superior, 4.4 mm anterior and 3.3 mm posterior using new guidelines, compensating for motion in 92% of fractions. Our current SBRT margins account for 92% of IFPM, predominantly posterior and inferior. Although updated guidelines suggest an increase in margins inferiorly, any increase must be balanced against the possibility of increased toxicity, particularly if biochemical control and side-effects are favourable with current practice. The difference between current clinical margins and those determined using updated guidance is demonstrated. The implications must be considered against clinical outcomes.

2D versus 3D comparison of angiographic imaging biomarkers using computational fluid dynamics simulations of contrast injections.

Quantitative angiography (QAngio) may provide hemodynamic information during neurointerventional procedures through imaging biomarkers related to contrast flow. The standard clinical implementation of QAngio is limited by projection imaging: analysis of contrast motion within complex 3D geometries is restricted to 1-2 projection views, truncating the potential wealth of imaging biomarkers related to disease progression or efficacy of treatment. To understand the limitations of 2D biomarkers, we propose the use of in-silico contrast distributions to investigate the potential benefits of 3D-QAngio within the context of neurovascular hemodynamics. Ground-truth in-silico contrast distributions were generated in two patient-specific intracranial aneurysm models, accounting for the physical interactions of contrast media and blood. A short bolus of contrast was utilized to obtain full a wash-in/ wash-out cycle within the aneurysm ROI. Simulated angiograms mimicking clinical cone-beam CT (CBCT) acquisitions were then generated, and volumetric contrast distributions were reconstructed to analyze bulk contrast flow. The ground-truth 3D-CFD, reconstructed 3D-CBCT-DSA, and 2D-DSA projections were used to extract QAngio parameters related to contrast time dilution curves, such as area under the curve (AUC), peak height (PH), mean-transit-time (MTT), time-to-peak (TTP), and time to arrival (TTA). An initial comparison of quantitative flow parameters in both 2D and 3D, in a smaller and larger aneurysm, indicated that 3D-QAngio can provide a good description of bulk flow characteristics (TTA, TTP, MTT), but recovery of integral parameters (PH, AUC) aneurysms is limited. Nonetheless, incorporation of 3D-QAngio methods may provide additional insight into our understanding of abnormal vascular flow patterns.

Does Head and Neck Posture Affect Cone-Beam Computed Tomography Assessment of the Upper Airway?

Radiographic analysis is often used as a screening tool to assess for risk of sleep-related breathing disorders. This study aimed to address 2 questions: (1) Does head posture significantly affect the minimum cross-sectional area (MCA)? and (2) Is the NBC3 (nasion-basion-C3) angle a reliable measurement to control for alteration of head position in cone-beam computed tomography (CBCT) scans? Study design: prospective cohort study. Private practices affiliated with a research institution. convenience sample of adult volunteers. CBCT scans were taken in 2 conditions: baseline (natural head position, NHP) and 1 of 5 experimental conditions (head tilted up, head tilted down, sitting vs standing, use of chin-rest, and swallow variation). For the primary aim of our study, the primary predictor variable was head posture and the main outcome variable was percentage change in MCA. For the secondary aim, the primary predictor variable was head posture and the main outcome variable was degree change in NBC3 angle. Ninety subjects were included (age 40.7±13.7years, 70% female). Mean NBC3 at baseline was 112.4±8.3°. Head tilted down significantly decreased (-41.4±18.5mm2, P=.03∗) and head tilted up significantly increased MCA (+147.4±43.3mm2, P=.0018∗). Head tilted down significantly reduced the NBC3 angle measurement (-10.5±6.8°, P=.006) and head tilted up significantly increased the NBC3 angle measurement (+14.4±5.8°, P=.0004). A quadratic regression model was fitted with moderately strong correlation (R2=0.54) showing an exponential effect of small changes in the NBC3 angle on MCA, P<.0001. The model predicts that increasing NBC3 by+5 and+10° resulted in MCA changes of+25% and+88%, whereas a decrease in NBC3 by -5 and -10° results in MCA changes of -21% and -23%, respectively. Alterations in head posture significantly affect the MCA of the upper airway on CBCT. The NBC3 angle can be used to reliably assess changes in cranio-cervical extension and validate comparisons of MCA between CBCT scans for the same patient. A standardized protocol for CBCT acquisition is proposed.

Dentin Thickness of the Danger Zone in the Mesial Roots of the Mandibular Molars: A Cone Beam Computed Tomography Analysis

Mandibular first molars appear to be the most commonly tooth subjected to a root canal treatment, therefore a better understanding of the anatomy critical zones for resistance of this teeth may decrease the treatment's failure rate. So, this study was conducted to evaluate the dentin thickness of the danger zone in mesial roots of mandibular first molars using cone beam computed tomography in an Iranian population. In this cross-sectional study, 210 Cone Beam Computed Tomography acquisition of the mandibular first molars were collected from a radiology center in Qazvin. The dentin thickness of the mesial roots (mesiobuccal and mesiolingual canals) was measured from the furcation to 5 mm below. The relationship between the dentin thickness in the danger zone and parameters, like age, gender, placement side, root length, the curvature of the canal, canal type, presence of middle mesial canal, and distance between the orifices of the mesial canals was investigated. Frequency, mean and standard deviation for variables were calculated, and data analysis was done by SPSS using simple and multiple linear regression and Pearson correlation coefficient. Also, two-sample t-test was used to compare mesiobuccal and mesiolingual on two sides. The significant level was also considered at (p < 0.05). The average minimum thickness of danger zone dentin was found to be 0.885 ± 0.259 mm in the mesiobuccal canal and 0.906 ± 0.206 mm in the mesiolingualcanal. Also, the minimum thickness of dentin in the mesiobuccal and mesiolingual canals in the range of 0 to 1 mm from the furcation was more than in other areas. There was no significant relationship between the minimum dentin thickness of the danger zone with gender, placement side, root length, canal type, and mesial canal entrance distance. But with increasing age, the thickness of dentin in the danger zone in the mesiolingualcanal increased significantly (p = 0.008). It was also observed that with the increase in the curvature of the canal, the thickness of the dentin in the danger zone in the mesiobuccal canal decreased (moderately curved (p = 0.008), severely curved (p = 0.046)). In addition, the thickness of the dentin in the mesiobuccal and mesiolingual canal was less in the samples with the middle mesial canal (p = 0.047, 0.044). Less dentin thickness in the danger zone in the mesial roots of mesiolingual mandibular first molars was seen in younger patients in mesiolingual canal, with a greater degree of canal curvature in the mesiobuccal canal and teeth with a middle mesial canal. Therefore, it is suggested that large taper instruments should be used with more precision to prevent complications.

Implementing cone-beam computed tomography-guided online adaptive radiotherapy in cervical cancer

Background and purposeAdaptive radiotherapy (ART) in locally advanced cervical cancer (LACC) has shown promising outcomes. This study investigated the feasibility of cone-beam computed tomography (CBCT)-guided online ART (oART) for the treatment of LACC. Material and methodsThe quality of the automated radiotherapy treatment plans and artificial intelligence (AI)-driven contour delineation for LACC on a novel CBCT-guided oART system were assessed. Dosimetric analysis of 200 simulated oART sessions were compared with standard treatment. Feasibility of oART was assessed from the delivery of 132 oART fractions for the first five clinical LACC patients. The simulated and live oART sessions compared a fixed planning target volume (PTV) margin of 1.5 cm around the uterus-cervix clinical target volume (CTV) with an internal target volume-based approach. Workflow timing measurements were recorded. ResultsThe automatically-generated 12-field intensity-modulated radiotherapy plans were comparable to manually generated plans. The AI-driven organ-at-risk (OAR) contouring was acceptable requiring, on average, 12.3 min to edit, with the bowel performing least well and rated as unacceptable in 16 % of cases. The treated patients demonstrated a mean PTV D98% (+/-SD) of 96.7 (+/- 0.2)% for the adapted plans and 94.9 (+/- 3.7)% for the non-adapted scheduled plans (p<10−5). The D2cc (+/-SD) for the bowel, bladder and rectum were reduced by 0.07 (+/- 0.03)Gy, 0.04 (+/-0.05)Gy and 0.04 (+/-0.03)Gy per fraction respectively with the adapted plan (p <10−5). In the live.setting, the mean oART session (+/-SD) from CBCT acquisition to beam-on was 29 +/- 5 (range 21–44) minutes. ConclusionCBCT-guided oART was shown to be feasible with dosimetric benefits for patients with LACC. Further work to analyse potential reductions in PTV margins is ongoing.

Cone-beam computed tomography-assisted percutaneous gastrostomy tube insertion in children with challenging anatomy.

Percutaneous radiological gastrostomy tube insertion is a common procedure in children. An approach using ultrasound and fluoroscopy may not be feasible in patients with challenging anatomy; therefore, advanced techniques or other imaging modalities may be required. To describe our experience using cone-beam computed tomography (CT)-assisted percutaneous gastrostomy insertion in pediatric patients with challenging anatomy. A retrospective review was performed in children who underwent cone-beam CT-assisted percutaneous radiologic gastrostomy between January 2015 and July 2019. Indications, technique, outcomes, complications, and radiation dose (reference-point air kerma, air kerma area product) were assessed through chart and imaging review. Descriptive statistics only were used. Twenty-seven procedures were attempted in 26 patients. Reasons for utilizing cone-beam CT guidance were high-positioned stomach (n = 10), interposing bowel loops and liver (n = 19), omphalocele (n = 1), severe scoliosis (n = 1), and ventriculoperitoneal shunt (n = 1). Technical success was 85% (23/27). Mean procedure time was 96min (range 50-131min). No safe access route into the stomach was encountered in four patients; three were referred for surgical gastrostomy and one had a successful re-attempt. Radiation dose data was obtained from 19 procedures (17 successful) with a total dose in successful procedures ranging from 8.1 to 63.6mGy (average 26.2mGy, median 24.9mGy). The number of cone-beam CT acquisitions per procedure ranged from 1 to 4. Major complication frequency was 11% (3/27) (bleeding, peritonitis, and aspiration pneumonia); minor complication frequency was 3.7% (1/27). This study shows that cone-beam CT guidance can be useful for assisting percutaneous radiologic gastrostomy in children with challenging anatomy.

Thoracic motion-compensated cone-beam computed tomography in under 20 seconds on a fast-rotating linac: A simulation study.

Rapid kV cone-beam computed tomography (CBCT) scans are achievable in under 20 s on select linear accelerator systems to generate volumetric images in three dimensions (3D). Daily pre-treatment four-dimensional CBCT (4DCBCT) is recommended in image-guided lung radiotherapy to mitigate the detrimental effects of respiratory motion on treatment quality. To demonstrate the potential for thoracic 4DCBCT reconstruction using projection data that was simulated using a clinical rapid 3DCBCT acquisition protocol. We simulated conventional (1320 projections over 4 min) and rapid (491 projections over 16.6 s) CBCT acquisitions using 4D computed tomography (CT) volumes of 14 lung cancer patients. Conventional acquisition data were reconstructed using the 4D Feldkamp-Davis-Kress (FDK) algorithm. Rapid acquisition data were reconstructed using 3DFDK, 4DFDK, and Motion-Compensated FDK (MCFDK). Image quality was evaluated using Contrast-to-Noise Ratio (CNR), Tissue Interface Width (TIW), Root-Mean-Square Error (RMSE), and Structural SIMilarity (SSIM). The conventional acquisition 4DFDK reconstructions had median phase averaged CNR, TIW, RMSE, and SSIM of 2.96, 8.02mm, 83.5, and 0.54, respectively. The rapid acquisition 3DFDK reconstructions had median CNR, TIW, RMSE, and SSIM of 2.99, 13.6mm, 112, and 0.44 respectively. The rapid acquisition MCFDK reconstructions had median phase averaged CNR, TIW, RMSE, and SSIM of 2.98, 10.2mm, 103, and 0.46, respectively. Rapid acquisition 4DFDK reconstruction quality was insufficient for any practical use due to sparse angular projection sampling. Results suggest that 4D motion-compensated reconstruction of rapid acquisition thoracic CBCT data are feasible with image quality approaching conventional acquisition CBCT data reconstructed using standard 4DFDK.

Improved Cone-Beam Reconstruction Using a Prior Breathing Motion Model

<h3>Purpose/Objective(s)</h3> To demonstrate whether incorporating a pre-measured breathing motion model into algebraic cone-beam CT (CBCT) reconstruction could improve daily target imaging for radiotherapy delivery of lung tumors. <h3>Materials/Methods</h3> We employed our clinic's 5DCT simulation technique to generate the breathing motion model. 5DCT provides a voxel-by-voxel representation of breathing motion as a function of breathing amplitude and rate, and the motion model was used to characterize the breathing motion during CBCT acquisition. We acquired CBCT projections before treatment and simultaneously acquired a breathing amplitude signal using a respiratory bellows. The 5DCT reference image was registered to the CBCT geometry using a rigid registration of the spine. To enable the use of the 5DCT motion model on the CBCT data, a correspondence between the simulation and CBCT surrogates needed to be made. The breathing surrogates of the simulation were correlated with the CBCT using the diaphragm shadow in the CBCT projections and the 5DCT reference image deformed using the motion model. By adjusting the 5DCT model breathing amplitude, the diaphragm shadow moved until the CBCT projection and 5DCT diaphragm shadows overlapped, yielding the correspondence between the two surrogates such that the 5DCT motion model could be directly applied to the CBCT reconstruction. To reconstruct the CBCT image, we modified the motion-compensated simultaneous algebraic reconstruction technique (MC-SART) by introducing the aligned and scaled 5DCT motion model parameters. The modified MC-SART compared the raw projections to corresponding model-generated projections with various levels of binning. To quantify the 5DCT model's ability to describe the breathing motion during the CBCT, we reconstructed the CBCT dividing the breathing amplitude into 1, 2, 4 and 8 bins. We examined the corresponding sharpness of the diaphragm to see if the diaphragm boundary continuously sharpened with increasing bins. <h3>Results</h3> We found that the diaphragm appeared most blurred when only 1 amplitude bin was used, appearing sharper as bins were added. At 8 bins, the diaphragm boundary was only 2 voxels, consistent with typical breath-hold CT reconstruction. This demonstrated that the motion model from the CT simulation could quantitatively track breathing motion during the CBCT. However, while the diaphragm appeared sharper, the reconstructed images with increasing bins also had poorer image contrast. <h3>Conclusion</h3> We have shown that using a previously determined breathing motion model with algebraic reconstruction can improve image sharpness. We will expand the current study to more patients and fractions and develop techniques to improve image contrast. However, since the purpose of this approach will be to localize lung tumors and characterize their motion at the treatment table, the image contrast may be sufficient. We will also compare our approach to published 4DCT approaches to determine if ours better manages irregular breathing.