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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
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. An increase of greater
risk results during daily treatment sessions if image guidance is not managed.1
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 It is very important
to understand that image guidance does not eliminate geographical uncertainties. It only reduces
the uncertainties.2
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 1 revolution per minute is equivalent to the rotational speed
of the gantry.3 Full single CT scans are taken, 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 workload1:

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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
Because image quality and dose are close in relation, image quality does not need to be at
its greatest, only good enough for the purpose of the scan.2 MVCT provides the capability for
image registration, treatment verification, and treatment reconstruction. The linear accelerators
small focal spot provides high-resolution images. However, the x-rays produced from the MV
sources result in poorly 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

References
1. Lehmann J. Cone beam computed tomography (CBCT) for radiation therapy patient
positioning. [Power point]. Medical Dosimetry Website.

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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 Web Site.
http://www.astro.org/uploadedFiles/Main_Site/Meetings_and_Events/Spring_Refresher_
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.