Use of four-dimensional cone-beam CT (4D-CBCT) and fiducial markers for image guidance during radiation therapy (RT) of mobile tumors is challenging due to the trade-off among image quality, imaging dose, and scanning time. This study aimed to investigate different 4D-CBCT acquisition settings for good visibility of fiducial markers in 4D-CBCT. Using these 4D-CBCTs, the feasibility of marker-based 4D registration for RT setup verification and manual respiration-induced motion quantification was investigated. For this, we applied a dynamic phantom with three different breathing motion amplitudes and included two patients with implanted markers. Irrespective of the motion amplitude, for a medium field of view (FOV), marker visibility was improved by reducing the imaging dose per projection and increasing the number of projection images; however, the scanning time was 4 to 8 min. For a small FOV, the total imaging dose and the scanning time were reduced (62.5% of the dose using a medium FOV, 2.5 min) without losing marker visibility. However, the body contour could be missing for a small FOV, which is not preferred in RT. The marker-based 4D setup verification was feasible for both the phantom and patient data. Moreover, manual marker motion quantification can achieve a high accuracy with a mean error of <1.4 mm.
The use of 4D cone-beam computed tomography (CBCT) and fiducial markers for guidance during radiation therapy of mobile tumors is challenging due to the trade-off between image quality, imaging dose, and scanning time. We aimed to investigate the visibility of markers and the feasibility of marker-based 4D registration and manual respiration-induced marker motion quantification for different CBCT acquisition settings. A dynamic thorax phantom and a patient with implanted gold markers were included. For both the phantom and patient, the peak-to-peak amplitude of marker motion in the cranial-caudal direction ranged from 5.3 to 14.0 mm, which did not affect the marker visibility and the associated marker-based registration feasibility. While using a medium field of view (FOV) and the same total imaging dose as is applied for 3D CBCT scanning in our clinic, it was feasible to attain an improved marker visibility by reducing the imaging dose per projection and increasing the number of projection images. For a small FOV with a shorter rotation arc but similar total imaging dose, streak artifacts were reduced due to using a smaller sampling angle. Additionally, the use of a small FOV allowed reducing total imaging dose and scanning time (~2.5 min) without losing the marker visibility. In conclusion, by using 4D CBCT with identical or lower imaging dose and a reduced gantry speed, it is feasible to attain sufficient marker visibility for marker-based 4D setup verification. Moreover, regardless of the settings, manual marker motion quantification can achieve a high accuracy with the error <1.2 mm.