Respiratory gating and 4-D (bellows, belts, CT data reconstruction)

When a patient presents with a lung cancer or abdominal tumor close to the diaphragm there is a
4th dimension that needs to be accounted and that is time and more importantly movement over
time. The movement of the tumor over time can be substantial and either a large PTV margin
needs to be added to the CTV or there is a chance of possibly missing the volume, unless you
take into account this movement with the use of a 4D CT scan. There are two different
applications of pulmonary gating that Philips has available:

Bellows this system is a deformable rubber belt that when placed across the patients
chest or abdomen and measures the changes in lung volume. It generates a breathing
signal corresponding to the lung volume. (system that I am most familiar with)

Image1: Bellows system image from Phillips website1

RPM this system uses an infrared camera that follows a positional reflective marker
placed on the patients chest. The sensor type used for respiratory monitoring and gating
is the RPM (respiratory gating system) which controls image acquisition with a trigger
signal. The imaging device responds to the trigger and starts or stops the image
acquisition.1
 Image 2: RPM system image from Phillips website1
There are also three different methods of image acquisition which include:

Prospective gating axial scan at a particular breath level this will reduce artifact from
respiratory motion.
Prospective Spiral enables you to visualize the breathing waveform and begin a spiral
scan at a desired breath level. This mode is used in conjunction with breath-hold imaging.
Retrospective Spiral (4D CT) ability to generate multiple phases allowing visualization
of motion during the respiratory cycle. This mode entails acquiring an over sampled
ultra-low pitch spiral can of the thorax and correlating it in reconstruction with the
patients breathing. The images are then used to assess tumor and organ motion and
delineate a target volume that encompasses the entire range of tumor motion.1 (method
that I am most familiar with)
Image 3: Image of tumor motion over one breathe cycle image from Phillips website1

Respiratory gating is used to better localize abnormalities next the borders between organs such
as lung and liver, as well as for the detection of very small lesions that are blurred into the
background activity by respiratory motion.

Once your 4D scan is acquired you need to send the phases requested by the physician or a MIP
(maximum intensity projection) to the TSP along with the standard scan. These images need to
be fused together and if more than one phase is requested each phase needs to be fused. After the
fusion the physician can analyze and contour the tumor volume. This fused image gives the
physician an accurate image of the movement the tumor. Some tumors move superior to inferior,
some left to right, and in special cases they move in an oval shape this is called hysteresis.
Image 4: Left is a CT/CT fusion of end inspiration (green) and end expiration (yellow) 4DCT
phases showing natural tumor path. Right is a CT/CT fusion of end expiration 4DCT and breathe
hold (red). This tumor movement is an example of hysteresis.2
For 4DCT acquisition using the bellow system you need to monitor the respiration rate and enter
a corresponding number into your pitch for the scan. This pitch is important because it helps the
system know what bin to put the images into. The breathing pattern is visualized during the
entire scan once the scan is complete you can manually enter any inhale points that may have
been missed. For helical scans the controlling parameter is the pitch factor which determines the
couch velocity of the scan. The velocity must be low enough that the duration of every voxel that
passes the detectors is at least one breathing cycle.

Table1: Example of respiration rate and corresponding pitch from the Bismarck Cancer center
that needs to be entered into the scan.
1. Suhy J, Maniawski P. Routine clinical application of 4D time-of-flight PET/CT. 2011.
http://clinical.netforum.healthcare.philips.com/us_en/Explore/White-
Papers/PetCT/Routine-clinical-application-of-4D-Time-of-Flight-PET-CT. Accessed
4/12/2017
2. Mathieu D, Martel C, Campeau m, et al. Accuracy of breath-hold CT in treatment
planning for lung stereotactic ablative radiotherapy. 2014.
http://dx.doi.org/10.7759/cureus.236