Effect of audio instruction on tracking errors using a four-dimensional image-guided radiotherapy system

The Vero4DRT (MHI-TM2000) is capable of performing X-ray image-based tracking (X-ray Tracking) that directly tracks the target or fiducial markers under continuous kV X-ray imaging. Previously, we have shown that irregular respiratory patterns increased X-ray Tracking errors. Thus, we assumed that audio instruction, which generally improves the periodicity of respiration, should reduce tracking errors. The purpose of this study was to assess the effect of audio instruction on X-ray Tracking errors. Anterior-posterior abdominal skin-surface displacements obtained from ten lung cancer patients under free breathing and simple audio instruction were used as an alternative to tumor motion in the superior-inferior direction. First, a sequential predictive model based on the Levinson-Durbin algorithm was created to estimate the future three-dimensional (3D) target position under continuous kV X-ray imaging while moving a steel ball target of 9.5 mm in diameter. After creating the predictive model, the future 3D target position was sequentially calculated from the current and past 3D target positions based on the predictive model every 70 ms under continuous kV X-ray imaging. Simultaneously, the system controller of the Vero4DRT calculated the corresponding pan and tilt rotational angles of the gimbaled X-ray head, which then adjusted its orientation to the target. The calculated and current rotational angles of the gimbaled X-ray head were recorded every 5 ms. The target position measured by the laser displacement gauge was synchronously recorded every 10 msec. Total tracking system errors (ET) were compared between free breathing and audio instruction. Audio instruction significantly improved breathing regularity (p < 0.01). The mean ± standard deviation of the 95th percentile of ET (E95T ) was 1.7 ± 0.5 mm (range: 1.1-2.6mm) under free breathing (E95T,FB) and 1.9 ± 0.5 mm (range: 1.2-2.7 mm) under audio instruction (E95T,AI). E95T,AI was larger than E95T,FB for five patients; no significant difference was found between E95T,FB and E95T,AI (p = 0.21). Correlation analysis revealed that the rapid respiratory velocity significantly increased E95T. Although audio instruction improved breathing regularity, it also increased the respiratory velocity, which did not necessarily reduce tracking errors.