The Average Imaging Dose From Cone Beam Computed

Tomography and Average Daily Table Shifts for Patients

Undergoing Head and Neck Radiation Therapy Treatments
and the Effect on Risks for Secondary Malignancies
Olivia Rozsits
The Ohio State University Department of Radiation Oncology
July 29th, 2016

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Introduction:
Improvements in imaging technology have greatly improved radiation therapy
treatments for cancer patients. The ability to use kilovoltage (kV) and megavoltage (MV)
imaging on linear accelerators for radiation therapy treatments has drastically increased
the accuracy of these precise treatments. The introduction of modern, volumetric,
imaging modalities has led to the implementation of imaging guided radiation therapy
(IGRT). Taking a conebeam image while the patient is aligned on the treatment table
allows the therapists and physicians to view the internal alignment of the patient. This
ensures the patient is correctly treated and that nearby organs at risk are not overdosed.
The added radiation dose from imaging, however, may be significant enough to increase
the patients risk for secondary malignancies due to increased radiation exposures.
Radiation therapy departments adopt the ALARA principle (as low as reasonably
achievable) to avoid overdose. The use of IGRT varies from clinical sites, physicians,
and even linear accelerator models. Some patients may only have weekly imaging
performed to ensure alignment, while others are prescribed daily imaging prior to
treatment. While the imaging dose is significantly less than the therapeutic radiation
dose, the small imaging doses may accumulate over the course of treatment and increase
the chance of secondary malignancies, overdose to nearby critical structures, or may
increase side effects. One study evaluates the effect of daily conebeam imaging for head
and neck patients and the additional dose to the lens of the eyes. The lenses of the eyes
are extremely sensitive to radiation and can quickly form cataracts at low radiation
doses.1 Another study specifically evaluates the effects of additional imaging on children
undergoing radiation therapy treatments and addresses strategies to further minimize
exposure risk in children by reducing effective IGRT dose.2 As technology continues to
improve and the use of IGRT in radiation therapy treatment increases, the impact of
additional radiation dose from imaging increases immensely. Measuring the additional
dose from imaging prior to radiation treatments will provide insight on the added risk of
secondary malignancies. Image guided radiation therapy, however, is crucial for
confirming the alignment for high dose and high risk treatments. This study will measure
the additional dose from conebeam imaging for patient alignment for patients imaged
once a week, twice a week, and five days a week. The shifts made after each alignment

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will be measured and reviewed to evaluate the number of imaging days with the least
shifts per week and lowest radiation dose per week.
Hypothesis:
If patients who are treated with radiation therapy daily to the head and neck
region have IGRT implemented in their treatment once a week, twice a week, and daily,
it is hypothesized that the patients who are have IGRT planned twice per week will have
lower dose received to the skin than the patients imaged daily and will have smaller table
shifts after imaging than the patients imaged once per week. It is predicted that the
patients imaged daily for alignment prior to treatment will have the lowest average shifts
per week but have the greatest dose accumulated to the skin per week. Additionally, the
patients who are imaged once a week for alignment prior to treatment are estimated to
have the lowest dose to the skin per week, but the largest average shifts per week.
Patients who are imaged daily are predicted to have the smallest average daily table shift
because their internal alignment can be more precise and the therapists can then make
new external marks on the skin that reflect a more accurate alignment. The patients who
are imaged only once a week prior to treatment may be improperly positioned daily
according to the external marks, so the shift will be large if the internal alignment does
not correctly correspond to the external marks. The therapists cannot make new marks
on the patient since they will not know if the internal alignment is correct or not until the
only day of imaging. On the other hand, the patients who are imaged once per week will
have the lowest dose accumulation to the skin per week, than the patients imaged daily
and twice per week because they are less exposed to the radiation from the imaging. It is
important, however, to ensure the patients are correctly and precisely aligned for their
treatment to avoid treating nearby critical structures and to accurately deliver the
treatment dose to the prescribed tumor volume. Therefore, there must be a balance
between keeping the additional radiation dose low to avoid overdose while also
maintaining accurate alignment through IGRT. Patients who are imaged twice per week
will have a lower accumulated skin dose per week than the patients imaged daily, and
they will have lower average table shifts per week than the patients imaged only once a
week.

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Literature Review:
Many studies have been conducted to evaluate the effects of image guided
radiation therapy (IGRT) from the additional doses of ionizing radiation, to critiquing the
alignment, and planning around critical structures. Cone beam computed tomography
(CBCT) was developed in the late 1990s and clinically used for radiation therapy
purposes in the 2000s.3 CBCT can utilize kilovoltage or megavoltage energies on the
linear accelerator. The benefits of CBCT are the ability to obtain a 3-dimensional
volumetric image of the patients internal anatomy and visualize the soft tissue of interest
while the patient is aligned on the treatment table. From this image, the therapists or
physicians can make table shifts to precisely align the patients internal anatomy to the
digitally reconstructed image in which the plan is based off. Historically, the additional
imaging dose used for imaging in radiation therapy has been ignored due to the low
magnitudes of energy used and low risk of additional side effects. However, the
implementation of new volumetric imaging technologies has led to increased use of
IGRT for radiation treatment plans. Professional societies have acknowledged this rapid
growth of the use of IGRT in clinical settings and have begun publishing guidelines for
implementation and use of these systems.3 The imaging dose delivered from daily CBCT
procedures has become of concern for the increased dose to potentially lead to increased
risk of secondary malignancies. A large distribution of papers has such been written to
evaluate the additional dose due to IGRT for radiation therapy and is illustrated in Figure
1.3 Many of these studies conducted, however, utilize phantoms to collect dose rather
than patient data. Phantoms are convenient for use, but they due present challenges as to
the detector calibration and minimal response when using kilovoltage CBCT.3 The
results from the phantom studies ranged from daily CBCT doses of 0.1cGy to 13cGy.3
There were a variety of techniques used and measurement equipment used for this study,
however, which may suggest the reason for the large variation in doses measured. More
controls need to be implemented to reduce the risk of confounding variables impact on
the results in this study.
A study conducted in 2014 at the Department of Radiation Oncology at the
University of Minnesota utilized patient plans to estimate the additional dose delivered

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from daily IGRT to head and neck treatments and pelvic site treatments.4 This study
utilized the plans of 20 patients and the added dose from the daily kilovoltage CBCT was
retrospectively calculated using a treatment planning system previously comissioned.4
The results of the study suggested the isocenter would receive a total additional dose of
3-4 cGy from daily kv CBCT imaging over the course of 35 fractions for head and neck
patients.4 Figure 2 illustrates the calculated planned dose to critical structures in the head
and neck and pelvic treatments. While this study did provide measurements based off of
patient planned data, it did not measure the actual absorbed dose from the kv CBCT, it
only estimated the dose based off the planning system. Additionally, this study also
presented the problem of variation in patient BMI impacting the calculated dose. By
limiting the BMI of the patients selected, the results could better represent the estimated
CBCT dose per patient BMI.
CB Hess et al. evaluated the exposure risk among pediatric patients undergoing
IGRT. Pediatric patients are specifically susceptible to late effects from radiation
toxicities affecting their growth and reproductive ability. This is another reason why the
issue of daily IGRT is important to investigate and to practice ALARA principles. In this
study two scenarios were implemented: a 14 year old female with craniopharyngioma
undergoes thirty fractions of radiation treatments with daily IGRT and a four year old
male with lower extremity rhabdomyosarcoma underwent radiation with daily IGRT for
twenty fractions.2 In each scenario, the estimated dose from IGRT was estimated for
nearby structures and the lifetime attributable risk (LAR) for secondary malignancies
from daily IGRT calculated.2 With daily IGRT, the females LAR for thyroid cancer
became 0.5% (1 in 200), lifetime meningioma incidence risk of 18.2%, and increased the
dose to the lens by 3% increasing the long term risk of cataract formation.2 From the
IGRT dose alone, the males LAR for cancer of the bladder became 1 in 19.7 patients and
66% of the dose to the unshielded testes was contributed by IGRT.2 This study places
significant evidence for the importance of ALARA when treating pediatric patients with
daily IGRT.

A study published in October of 2015 measured the dose to the lens from

CBCT of phantoms. The International Commission on Radiation Protection (ICRP)

provides guidelines to limit the dose to the lens of the eye to a threshold of 500mGy to
prevent increased risk of cataract formation.1 The study used thermo-luminescent

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dosimeters (TSLD) on phantoms to measure the dose of CBCT images taken by Clinac
iX and Varian Truebeam linear accelerators.1 Findings of 0.71mGy per CBCT on the
Clinac iX and 0.7mGy per CBCT on the Truebeam were well within the 500mGy
threshold defined by the ICRP.1 However, the study does suggest the effect of several
CBCT acquisitions during an entire treatment course be taken into consideration for the
dose accumulation to the lenses of the eye.
Zhao et al. conducted an experiment to evaluate two different imaging modalities:
CBCT and orthogonal x-ray guidance system (XGS-10).5 The setup errors measured at
the treatment system were evaluated for 30 patients with nasopharyngeal cancer and the
radiation dose from each imaging system was measured using an ionization chamber and
phantom. Results revealed the setup errors between the XGS-10 and CBCT were within
less than 1.5mm, but XGS-10 took a much shorter registration and acquisition time and
delivered less extra radiation dose than CBCT.5 This study reveals a potential alternative
to CBCT for daily IGRT for alignment purposes to reduce patient dose while limiting
setup errors.
An additional study compares daily versus non-daily IGRT for patients with head
and neck cancer. Using data from 103 patients treated with IMRT for head and neck
cancer, patients were either imaged only on the first fraction, imaged once weekly,
imaged first five treatments then once weekly, and imaged every other day.6 The
incidence of geometric miss for 3mm, 5mm, and 10mm margins of the PTV were
evaluated.6 Results revealed the least geometric miss for all three margins for alternating
day IGRT.6 Further studies are needed, however, to quantify the clinical consequences of
geometric miss for less than daily IGRT.
The need to evaluate the effects of IGRT dose is evident, but it is clear that IGRT
is necessary to ensure correct and precise patient alignment for daily treatment. While
the late effects of additional dose from IGRT can only be estimated for now, it is
important to consider these effects as the use of IGRT continues to grow. Limiting the
amount of dose delivered from IGRT while still maintaining minimal setup errors will be
crucial to providing accurate treatments and practicing ALARA principles to reduce
additional side effects and toxicities.

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Methods:
Patient Population:
Data was collected from 60 patients undergoing daily head and neck radiation
therapy treatments. A table of characteristics of the patient population under study is
listed in Figure 3. All patients were treated under the same protocol using the same 6Mv
energy for intensity modulated radiation therapy on Varian TrueBeam Linear
Accelerators at the James Comprehensive Cancer Center and Solove Research Institute.
The average number of fractions between all the patients was 30 fractions, and each
patient was treated five days per week Monday through Friday. The dose per fraction is
180cGy. The immobilization used for each patient was held constant using a thermoplast
aquaplast head and neck mask and a custom headrest on the Q2 headrest. For patients
who could not tolerate the Q2 headrest, the Q4 headrest was selected to provide a more
neutral position for the patient to lie. Each patient was simulated for treatment on a CT
simulator from which the scans were used for treatment planning. The isocenter for each
patient was placed by the physician in the center of the gross tumor volume defined by
the physician.
Daily Patient Alignment and Imaging:
All patients were aligned using a three point setup on external marks. The
therapists aligned the external marks to match the lasers from the wall. Six diodes were
placed on each patients skin in the center of the field 60 degree intervals around the
patient of the skin (diodes placed at 0, 60, 120, 180, 240, and 300 degrees). After
external alignment was achieved, patients were either treated or imaged based on their
defined imaging sequence. Patients were randomly placed in one of three groups: 20
patients imaged once per week, 20 patients imaged twice per week, and 20 patients
imaged daily. On imaging days, the patients were imaged using kilovoltage CBCT for
one whole arc of 360 degrees. While the patient is being imaged, the therapists will
record the measured dose read from the diodes. The total dose from all six diodes will be
recorded and saved in the patients chart to be evaluated at the end of each week. The
digitally reconstructed (DRR) image used from the simulation CT for treatment planning
was compared to the image taken each imaging day. The therapists aligned the bony

Rozsits 8
anatomy of the base of skull and cervical spine to the DRR. Two therapists and the
physician must agree with the table shifts before the table is shifted and treatment begins.
The shifts from each plane (vertical, longitudinal, and lateral) will be recorded and saved
in the patients chart to be evaluated at the end of each week. The patients imaged once
per week will be shifted daily according to the shifts applied on the day of imaging. The
group of patients who are imaged twice per week will be shifted the day after the first
image of the week from the shifts the day before and after the second day, the average of
the two shifts will become the daily shift after until the first image day of the next week.
Calculation of Alignment Error
Setup uncertainty was calculated using the data from the daily shifts made for
each patient in each group. The random error and systematic error for setup uncertainty
was calculated to evaluate the amount of setup error due to uncontrollable variables and
for the error caused by a specific factor. The average error, systematic error, and random
error, or M, , and , respectively, are calculated to describe the setup uncertainty for
each group of patients. The precision and accuracy of the daily setup are measured by
the average and standard deviation of the daily table shifts. Using the measured average
and standard deviation, the average error, systematic error, and random error can be
calculated. The average error is calculated by averaging the weekly average table shift
per patient for all patients per group. The systematic error is calculated by taking the
standard deviation of the weekly table shift averages per week and per entire treatment
course. Lastly, the random error is calculated by taking the root-mean-square of the
patient SD for each patient in each group.
Calculation of Added Imaging Dose
To calculate the added dose due to imaging, the measured dose per image per
patient was added and averaged over the entire group. This gives an average imaging
dose per patient per entire course of treatment in each group. The graph of the average
imaging dose per patient per group is plotted and the standard deviation of the dose
among each group is calculated.

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Results
The group of patients imaged daily received the largest average dose per patient
per imaging day and largest overall dose from imaging. The patients imaged once per
week received the lowest dose average dose per patient per imaging day and lowest
overall dose from imaging. Figure 4 illustrates the average imaging dose per patient per
week and the average total dose per patient over the entire treatment course.
The average shifts per group are listed in the table below. Table shifts are
measured in mm and are averaged over the entire course of treatment. The table shifts
from the lateral, longitudinal, and vertical planes are measured and listed in Figure 5.
The patient group imaged daily had the smallest average table shift in all directions. The
patient group imaged once per week had the largest average table shift in all directions.
The results of this study suggest that to maintain ALARA principle while still performing
accurate treatments, the number of imaging days per week should be decreased but not so
much that the daily table shifts are large and suggest inaccurate setup and alignment.
Therefore, in this study, imaging twice per week provided reduced radiation exposure
with lower daily shifts than imaging only once per week. Further research is needed to
measure these results for different treatment sites, age groups, and different populations.

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Abstract
Figure 1

Alaei et al. 2015

Figure 2

Alaei et al. 2014

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Figure 3
Characteristics of Patients included in the study
No. of patients

60

Sex
Male

34

Female

26

Oropharynx

24

Oral cavity

15

Nasopharynx

11

Other

10

Site

Histology
Squamous Cell Ca

44

Mucoepidermoid

Other

11

Age, y
Range

34-78

Mean

62

Chemotherapy
Concurrent

34

No chemotherapy

26

Surgery
Postsurgical

32

No surgery

28

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Figure 4
Average Imaging Dose for Different Imaging Protocols
Average Imaging Dose Per week (cGy)

Average Total Imaging Dose

(cGy)

Image Once

6.3

1.9

14.2

5.4

30.1

per Week
Imaged Twice
Per Week
Imaged Daily
(five times per
week)

Figure 5
Average Daily Shifts for Different Imaging Protocols
Imaged Daily

Imaged Twice Per

Imaged Once Per

Week

Week

All

Non

All

Non

All

Non

Fractions

Imaged

Fractions

Imaged

Fractions

Imaged

Fractions

Fractions

Fractions

Vertical

2mm

n/a

4mm

4.2mm

8mm

8.1mm

Lateral

3mm

n/a

7mm

7.8mm

12mm

12.2mm

Longitudinal 2mm

n/a

5mm

6mm

9mm

9.3mm

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References
1. Palomo R, Pujades MC, Gimeno-Olmos J, et al. Evaluation of lens absorbed dose
with Cone Beam IGRT procedures. Journal of Radiological Protection J Radiol
Prot. 2015;35(4). doi:10.1088/0952-4746/35/4/n33.
2. Hess CB, Thompson HM, Benedict SH, et al. Exposure Risks Among Children
Undergoing Radiation Therapy: Considerations in the Era of Image Guided
Radiation Therapy. International Journal of Radiation
Oncology*Biology*Physics.
3. Alaei P, Spezi E. Imaging dose from cone beam computed tomography in
radiation therapy. Physica Medical. 2015;31(7):647-658.
doi:10.1016/j.ejmp.2015.06.003.
4. Alaei P, Spezi E, Reynolds M. Dose calculation and treatment plan optimization
including imaging dose from kilovoltage cone beam computed tomography. Acta
Oncologica. 2014;53(6):839-844. doi:10.3109/0284186x.2013.875626.
5. Zhao L-R, Zhou Y-B, Li G-H, et al. The clinical feasibility and performance of an
orthogonal X-ray imaging system for image-guided radiotherapy in
nasopharyngeal cancer patients: Comparison with cone-beam CT. Physica
Medical. 2016;32(1):266-271. doi:10.1016/j.ejmp.2015.11.010.
6. Yu Y, Michaud AL, Sreeraman R, Liu T, Purdy JA, Chen AM. Comparison of
daily versus nondaily image-guided radiotherapy protocols for patients treated
with intensity-modulated radiotherapy for head and neck cancer. Head Neck Head
& Neck. 2013;36(7):992-997. doi:10.1002/hed.23401.