title: Automated algorithm for CBCT-based dose calculations of prostate radiotherapy with bilateral hip prostheses.
abstract: OBJECTIVE
  Cone beam CT (CBCT) images contain more scatter than a conventional CT image and therefore provide inaccurate Hounsfield units (HUs). Consequently, CBCT images cannot be used directly for radiotherapy dose calculation. The aim of this study is to enable dose calculations to be performed with the use of CBCT images taken during radiotherapy and evaluate the necessity of replanning.
  
  
  METHODS
  A patient with prostate cancer with bilateral metallic prosthetic hip replacements was imaged using both CT and CBCT. The multilevel threshold (MLT) algorithm was used to categorize pixel values in the CBCT images into segments of homogeneous HU. The variation in HU with position in the CBCT images was taken into consideration. This segmentation method relies on the operator dividing the CBCT data into a set of volumes where the variation in the relationship between pixel values and HUs is small. An automated MLT algorithm was developed to reduce the operator time associated with the process. An intensity-modulated radiation therapy plan was generated from CT images of the patient. The plan was then copied to the segmented CBCT (sCBCT) data sets with identical settings, and the doses were recalculated and compared.
  
  
  RESULTS
  Gamma evaluation showed that the percentage of points in the rectum with γ < 1 (3%/3 mm) were 98.7% and 97.7% in the sCBCT using MLT and the automated MLT algorithms, respectively. Compared with the planning CT (pCT) plan, the MLT algorithm showed -0.46% dose difference with 8 h operator time while the automated MLT algorithm showed -1.3%, which are both considered to be clinically acceptable, when using collapsed cone algorithm.
  
  
  CONCLUSIONS
  The segmentation of CBCT images using the method in this study can be used for dose calculation. For a patient with prostate cancer with bilateral hip prostheses and the associated issues with CT imaging, the MLT algorithms achieved a sufficient dose calculation accuracy that is clinically acceptable. The automated MLT algorithm reduced the operator time associated with implementing the MLT algorithm to achieve clinically acceptable accuracy. This saved time makes the automated MLT algorithm superior and easier to implement in the clinical setting.
  
  
  CONCLUSIONS
  The MLT algorithm has been extended to the complex example of a patient with bilateral hip prostheses, which with the introduction of automation is feasible for use in adaptive radiotherapy, as an alternative to obtaining a new pCT and reoutlining the structures.
authors.affiliation: 1 College of Medicine, Swansea University, Swansea, UK.
authors.forename: Turki
authors.initials: T
authors.lastname: Almatani
authors.affiliation: 1 College of Medicine, Swansea University, Swansea, UK.|2 Department of Medical Physics and Clinical Engineering, Singleton Hospital, ABM University Health Board, Swansea, UK.
authors.forename: Richard P
authors.initials: RP
authors.lastname: Hugtenburg
authors.affiliation: 2 Department of Medical Physics and Clinical Engineering, Singleton Hospital, ABM University Health Board, Swansea, UK.
authors.forename: Ryan D
authors.initials: RD
authors.lastname: Lewis
authors.affiliation: 3 Oncology Systems Limited, Shrewsbury, UK.
authors.forename: Susan E
authors.initials: SE
authors.lastname: Barley
authors.affiliation: 2 Department of Medical Physics and Clinical Engineering, Singleton Hospital, ABM University Health Board, Swansea, UK.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Edwards
mesh_terms: D000465:Algorithms; D054893:Cone-Beam Computed Tomography; D006622:Hip Prosthesis; D006801:Humans; D008297:Male; D009010:Monte Carlo Method; D011471:Prostatic Neoplasms / Q000532:radiotherapy*; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted; D050397:Radiotherapy, Intensity-Modulated