Feasibility of 4DCBCT-based proton dose calculation: An ex vivo porcine lung phantom study

Inter-fractional variations of breathing pattern and patient anatomy introduce dose uncertainties in proton therapy. One approach to monitor these variations is to utilize the cone-beam computed tomography (CT, CBCT) scans routinely taken for patient positioning, reconstruct them as 4DCBCTs, and generate 'virtual CTs' (vCTs), combining the accurate CT numbers of the diagnostic 4DCT and the geometry of the daily 4DCBCT by using deformable image registration (DIR). In this study different algorithms for 4DCBCT reconstruction and DIR were evaluated. For this purpose, CBCT scans of a moving ex vivo porcine lung phantom with 663 and 2350 projections respectively were acquired, accompanied by an additional 4DCT as reference. The CBCT projections were sorted in 10 phase bins with the Amsterdam-shroud method and reconstructed phase-by-phase using first a FDK reconstruction from the Reconstruction Toolkit (RTK) and again an iterative reconstruction algorithm implemented in the Gadgetron Toolkit. The resulting 4DCBCTs were corrected by DIR of the corresponding 4DCT phases, using both a morphons algorithm from REGGUI and a b-spline deformation from Plastimatch. The resulting 4DvCTs were compared to the 4DCT by visual inspection and by calculating water equivalent thickness (WET) maps from the phantom's surface to the distal edge of a target from various angles. The optimized procedure was successfully repeated with mismatched input phases and on a clinical patient dataset. Proton treatment plans were simulated on the 4DvCTs and the dose distributions compared to the reference based on the 4DCT via gamma pass rate analysis. A combination of iterative reconstruction and morphons DIR yielded the most accurate 4DvCTs, with median WET differences under 2mm and 3%/3mm gamma pass rates per phase between 89% and 99%. These results suggest that image correction of iteratively reconstructed 4DCBCTs with a morphons DIR of the planning CT may yield sufficiently accurate 4DvCTs for daily time resolved proton dose calculations.