TH‐D‐BRD‐01: X‐Ray Based Real Time Imaging Verification
Authors: Ren L. 
Published: June 2015

Radiotherapy of moving targets, such as lung, liver or prostate tumors, is prone to treatment errors due to the uncertainties in the target position. Minimizing such error is critical for radiotherapy treatments, especially hypofractionated SBRT treatments. On‐board real time imaging verification and tracking of moving targets has become one of the most exciting areas in radiotherapy. The tremendous developments in this area enable us to improve targeting accuracy and reduce the healthy tissue toxicity, which paves the road to further margin reduction and dose escalation in conventionally fractionated or SBRT treatments.Over the past few years, several real‐time imaging techniques have been clinically implemented, including techniques using ionizing radiation, such as x‐ray based imaging, and radiation‐free techniques such as MRI, imaging based on implanted electromagnetic transponders and optical imaging. The x‐ray imaging techniques are widely accessible in clinics, although they have limited soft tissue contrast and contribute to patient exposure. Recently, MRI has gained wide interests in radiotherapy due to its better soft tissue contrast and no radiation dose. Imaging based on electromagnetic transponders and optical imaging have also gained popularity in many clinical scenarios due to their unique capabilities.Based on these imaging techniques, various tracking approaches have been developed. The room mounted orthogonal 2D x‐ray system (CyberKnife system) was the first medical device capable to perform real‐time target tracking by combining image guidance with robotically targeted radiation delivery. In the Vero system, tumor tracking is achieved by combining image‐guidance with a two‐dimensional pivot assembly of the linear accelerator. In gantry‐based linear accelerators, target motion can be tracked in real time by repositioning the MLC based on the signal from x‐ray images or electromagnetic transponders implanted.The rapid development of new imaging and tracking technologies raises new challenges in revolutionizing our treatment procedures. It becomes important to understand the functionality, limitations and clinical impact of each technique so that they can be chosen wisely for different clinical settings. The goal of this educational session is to compare and contrast different imaging and tracking techniques implemented in CyberKnife, Vero, MRI based, and gantry‐based radiotherapy machines. The general concepts of real‐time imaging and tracking, from imaging the target to adapting the treatment, will be reviewed for each modality. While discussing the technical aspects of the systems including the overall uncertainties and residual imaging and tracking errors, emphasis will be placed on the clinical implementation and workflow. The increased patient dose due to x‐ray imaging and quality assurance procedures will be described. Additionally, the impact of tracking on treatment volume and margin reduction will be discussed. The session will close with an outlook at future developments.Learning Objectives:

Understand the opportunities and challenges of real time imaging and tumor tracking.
Understand the advantages and limitations of different imaging and tracking techniques, as well as the clinical implementation of each technique.
Understand the clinical impact of real time tumor tracking and future directions in this area.
Supported by National Institutes of Health, Varian Medical System, Accuray Inc.