title: Using dual-energy x-ray imaging to enhance automated lung tumor tracking during real-time adaptive radiotherapy.
abstract: OBJECTIVE
  Real-time, markerless localization of lung tumors with kV imaging is often inhibited by ribs obscuring the tumor and poor soft-tissue contrast. This study investigates the use of dual-energy imaging, which can generate radiographs with reduced bone visibility, to enhance automated lung tumor tracking for real-time adaptive radiotherapy.
  
  
  METHODS
  kV images of an anthropomorphic breathing chest phantom were experimentally acquired and radiographs of actual lung cancer patients were Monte-Carlo-simulated at three imaging settings: low-energy (70 kVp, 1.5 mAs), high-energy (140 kVp, 2.5 mAs, 1 mm additional tin filtration), and clinical (120 kVp, 0.25 mAs). Regular dual-energy images were calculated by weighted logarithmic subtraction of high- and low-energy images and filter-free dual-energy images were generated from clinical and low-energy radiographs. The weighting factor to calculate the dual-energy images was determined by means of a novel objective score. The usefulness of dual-energy imaging for real-time tracking with an automated template matching algorithm was investigated.
  
  
  RESULTS
  Regular dual-energy imaging was able to increase tracking accuracy in left-right images of the anthropomorphic phantom as well as in 7 out of 24 investigated patient cases. Tracking accuracy remained comparable in three cases and decreased in five cases. Filter-free dual-energy imaging was only able to increase accuracy in 2 out of 24 cases. In four cases no change in accuracy was observed and tracking accuracy worsened in nine cases. In 9 out of 24 cases, it was not possible to define a tracking template due to poor soft-tissue contrast regardless of input images. The mean localization errors using clinical, regular dual-energy, and filter-free dual-energy radiographs were 3.85, 3.32, and 5.24 mm, respectively. Tracking success was dependent on tumor position, tumor size, imaging beam angle, and patient size.
  
  
  CONCLUSIONS
  This study has highlighted the influence of patient anatomy on the success rate of real-time markerless tumor tracking using dual-energy imaging. Additionally, the importance of the spectral separation of the imaging beams used to generate the dual-energy images has been shown.
authors.affiliation: Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London SM2 5NG, United Kingdom.
authors.forename: Martin J
authors.initials: MJ
authors.lastname: Menten
authors.affiliation: Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London SM2 5NG, United Kingdom.
authors.forename: Martin F
authors.initials: MF
authors.lastname: Fast
authors.affiliation: Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London SM2 5NG, United Kingdom.
authors.forename: Simeon
authors.initials: S
authors.lastname: Nill
authors.affiliation: Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London SM2 5NG, United Kingdom.
authors.forename: Uwe
authors.initials: U
authors.lastname: Oelfke
mesh_terms: D001842:Bone and Bones / Q000000981:diagnostic imaging; D003198:Computer Simulation; D006801:Humans; D008168:Lung / Q000000981:diagnostic imaging; D008175:Lung Neoplasms / Q000000981:diagnostic imaging* / Q000532:radiotherapy*; D008954:Models, Biological; D009010:Monte Carlo Method; D010363:Pattern Recognition, Automated / Q000379:methods*; D011878:Radiotherapy / Q000379:methods*; D012119:Respiration; D014057:Tomography, X-Ray Computed / Q000379:methods*; D014965:X-Rays