Cone Beam CT Verification

Cone Beam CT Verification
PROCEDURE
OBI Advanced Imaging version 1.4
Cone Beam CT version 2.1
4D ITC version 8.2
Clinac version 7.5
Revision 2.0.0
Objective:
After completing this module the student will have performed the following tasks
using the OBI Operations Manual as a resource:
Setup the patient
Perform a Cone Beam CT
Acquire a Topogram
Export the Images to OBI
Analyze images
Shift the Exact Couch into treatment position
Treat the patient
A. Exercise Key
1. Right mouse click denoted as RMC.
2. Left mouse click denoted as LMC.
3. Bracket () denotes additional options.
4.
The > symbol denotes drill down from menus.
B. Procedure Content:
1. Load Session on 4D ITC
2. On Board Imager Graphical User Interface
3. Acquire Images
4. Imaging and Verification Tools
Varian Medical Systems
FOR TRAINING PURPOSES ONLY!
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5. Review CBCT Images
C. 4D ITC
1. Check-in the patient
2. Select the patient from the treatment queue and click OK (Figure 1).
Figure 1: 4D ITC; Treatment Queue
3. Select the CBCT Setup Field and click Mode Up (Figure 2).
Figure 2: CBCT Setup Field; Mode Up
4. Set up the patient. Make sure couch rails are removed.

5. Insert appropriate Bow-Tie Filter. For information on Bow-Tie Filters refer to the
System Components Procedure.
6. The OBI arms can be extended using the hand pendant to verify clearance
while inside the treatment room.
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D. OBI workstation
1. If not already positioned, extend the arms from outside the room by clicking
Download Axes.
Press Motion Enable and Auto buttons on the OBI Console to position the
arms.
WARNING: Always verify clearance prior to extending the OBI arms from the
OBI console.
2. On OBI workstation click 3D/3D Match to start acquisition (Figure 3). The
CBCT application will open automatically. The original planning CT will be
downloaded on to the OBI for matching.
Figure 3: 3D/3D Match Button
3. The following warning message may appear: Make sure Couch Rails are
removed if fitted.
Remove the couch rails and confirm the warning message by clicking OK
(Figure 4). This message can be disabled in CBCT Administration.
Figure 4: Remove Couch Rails Dialog Box
4. If this is the patients first Cone Beam CT the following options will be available.
Click Acquire New Scan (Figure 5).
Quick Scan (Param. Display) will be covered in section G of this procedure.

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Figure 5: Acquire New Scan
5. Patient Setup Wizard page appears (Figure 6).
1. The Default CBCT Mode will be

selected the first time a patient is
scanned. If a different mode is selected
the system will then default to that mode
for all subsequent scans.
2. If Patient Orientation is provided with
the plan this field will populate
automatically, if not it must be selected.
3. Diameter [cm] of the scan correlates
to the selected CBCT mode.
4. Acquisition Mode correlates to the
selected CBCT Mode.
5. Reconstruction Volume defaults to
512x512. This can be changed if
desired.
6. Slice Distance [mm] defaults to
2.5mm and can be changed if desired.
Planning CT slice thickness and CBCT
slice thickness do not have to match.
Figure 6: Patient Set Up Page

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6. Select the appropriate predefined CBCT mode from the CBCT Mode Menu and
if necessary select the appropriate patient orientation. (Figure 7)
Diameter and
Acquisition Mode will
vary based on the
selected CBCT mode.
Figure 7: CBCT Mode
7. Click Next. (Figure 6)

8. If a Topogram is required refer to the Topogram Acquisition procedure for
instructions, otherwise click next. The Topogram step can be turned off in OBI
administration in which case the system will continue to step 9.
9. The system will calculate maximum scan range based on the CBCT mode
selected, approximately 18cm for Full Fan scans and 16cm for Half Fan scans.
(Figure 8) Scan Range Definitions will be displayed. (Figure 9)
Figure 8: Scan Range
*OBI only allows Single

Scan CBCTs.
1. Width- Axial length of
the scan.
2. Center- Defines the
Isocenter of the scan.
Changing the value will
result in a couch shift.
3. Z-Zero Pos.- Defines the
position of the DICOM
Origin for the scan.
Figure 9: Scan Range Definition

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10. Press Start Scan (Figure 10). The following message will appear: Acquiring
Dark Field Please Wait (Figure 11).
The system performs a Dark Field to account for and eliminate background
noise.
Figure 10
Figure 11: Dark Field Message
11. Once the dark field has been acquired the gantry needs to be moved to the start
position. This will be 185 or 175 whichever is closer to the actual gantry
position. The couch may also move to a safe position for the Cone Beam CT.
Press and hold MEB and >> on the Clinac dedicated keyboard to move gantry
and/or couch into position (Figure 12).
The following message will appear if the couch movement is aborted. Couch
Position error the couch is outside of the allowed area (Figure 13).
Figure 12: Enable Clinac Movement
Figure 13: Couch out of range for Scan
12. At Start Position Dialog Box will appear.
Read instructions and then click OK (Figure 14).
Figure 14: Start Scan Position
13. Press and hold X-ray footswitch or the Hand Pendant. Then press and hold
the MEB and >> on the Clinacs dedicated keyboard. This will start CT
acquisition.
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Hold all three depressed until the acquisition has finished (audio signal will
stop).
Once the scan is complete release the MEB and >> first and then release the
X-ray footswitch.
14. Acquisition and reconstruction progress will be displayed on the screen (Figure
15).
The Acquisition Progress is the data being acquired and sent from the CBCT
cache to the Reconstructor computer.
The Reconstruction Progress is the process of reconstructing the projection

data by the Reconstructor computer.
The Serialization Progress is the process of sending the data back from the
Reconstructor computer to the OBI computer.
Figure 15: Acquisition Progress
15. If the scan is interrupted due to a purposeful action (ex. Breath-hold CBCT) or
an accident (release of dedicated keyboard or foot/handswitch) the scan can be
resumed. Select Resume Acquisition(Figure 16a). The system will request
the gantry be repositioned approximately 10 degrees prior to the interruption
position (Figure 16b). The system will then request that the acquisition be
resumed(Figure 16c)

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Figure 16a: Resume Figure 16b: Reposition Gantry
Figure 16c: Resume Acquisition
16. If the couch was moved to a safe position for scanning it will need to be returned
to the original set up position prior to beginning the match process (Figure 17).
Figure 17: Restoring Couch Positions
Press and hold MEB and >> on the Clinac dedicated keyboard to move the
couch into position (Figure 18).
The following message will appear if the couch movement is aborted.

Reminder the couch positions have been changed since startup (Figure 19).

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Figure 18: Enable Clinac Movements
Figure 19: Couch Position
17. Once the scan is complete the reconstructed images will be displayed on the
screen. Review them if needed (Figure 20).
Select Accept and Export Scan (File > Export to DICOM).
If the patient moved during the scanning process, select Decline Scan and restart the process.
Figure 20: CT Image Review Page
18. Once the Accept and Export Scan button has been selected, the CBCT image is
stored on the OBI workstation. The CBCT image will then be imported into the
3D/3D Match workspace of OBI. The entire process may take a few seconds to
complete. Upon completion, the Acquisition workspace closes and the OBI
Analyze workspace opens automatically.
E. OBI 3D/3D Workspace
1. At this point there are two options for matching: Automatic Match (see step 3)
and Manual Match (see step 5). They can be used individually or in
combination.
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2. To perform an Automatic Match, click on the Automatic Match Icon (Figure

21).
OBI will perform an automatic match using the Mutual Information Algorithm
(see Appendix E for more information on the Algorithm)
Figure 21: 3D/3D Toolbar
3. The Auto Match Control dialog box opens and the matching process starts
(Figure 22).
Figure 22: Auto Match Control Dialog Box
4. The system shifts the two superimposed images relative to each other during
the match and calculates the couch correction values (Figure 23 and 24).

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Figure 23: Automatic Match in progress
Figure 24: Dashboard; Couch Values
Always manually verify an automatic match using the match verification

tools.
5. To perform a Manual Match, make sure the Manual Match Icon

Then use the mouse or the arrow keys on the keyboard (Figure 25).
is active.
Adjust the image using the arrow keys on the keyboard. This allows for small
adjustments in the match alignment. Make large adjustments by clicking and
dragging the image with the mouse or hold the Alt key and press the
appropriate arrow key.
Rotate the image by holding the left mouse button and then click and drag
outside of the dotted red circle or hold the Ctrl key and use the right or left
arrow keys. Rotate the image in large steps by holding the Alt+Ctrl keys and
using the right or left arrow key.
To rotate the main viewing window between Transversal, Sagittal, and Coronal
views press Ctrl+R or this icon

in the main viewing window.

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Verify the match using the match verification tools (see Step 6).
Figure 25: Manual Match
6. Verify the match using the Match Verification Tools.
Select Window and Level

. This allows manual adjustment of
brightness and contrast (Figure 26a).
Right Click on the Window and Level bar to select Range which automatically
adjusts to a specific anatomical selection and can be used on both the CBCT
and the reference CT (Figure 26b). (Can also be used in the CBCT window
(Figure 20).)

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Figure 26a: Window and Level
Figure 26b: Range
From the Dynamic Window check or uncheck contours as needed during the
verification process (Figure 27a).
Contours can be turned off and on as a group using the Contour button
(Figure 27b)
Figure 27a: Dynamic Window
Figure 27b: Contour button
Select Split Window

. This allows for viewing of 50% Reference CT and
50% Cone Beam CT (Figure 28).

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Figure 28: Matching; Split Window View
Select Moving Window

. This allows viewing of the acquired Cone
Beam CT within the rectangle (Figure 29).
Figure 29: Matching; Moving Window View
Select Color Blending

. The blend function is used to overlay one image
over another and shows the two images in complimentary colors to assist in
matching. Colors can be changed in OBI administration (Figure 30).

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Figure 30: Matching; Color Blending
Other Tools used during the Match Verification Process
Tool
Description
Page Up and Page

Down Keys
You can scroll through the sagittal, coronal, and transversal views of CBCT or CT
images by pressing the Page Up/Page Down keys.
Flicker Display
To activate this tool, take the following steps:

1. Move the Blend slider to the extreme left or right.
2. Press Ctrl+A to make the display switch between the one blend setting (100%
reference image) and the other (100% acquired image). When you see no motion or the
smallest amount of motion, then the two images are superimposed properly.
Table 1: Other Match Verification Tools
WARNING: If the match is performed incorrectly and the images

are mismatched, corrections to the treatment setup values will be
incorrect, causing the wrong area to be irradiated during treatment.
Be sure to follow department mandatory clinical quality assurance
procedures to prevent wrong treatments. Before making any
corrections to the treatment setup values, always verify all matches
visually. To determine whether the images are properly overlaid,
use the matching verification tools.
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7. Once you have verified the match result and accepted the couch correction
values, you can apply the couch shift. If for some reason you do not want to
send a specific shift it can be deselected by un-checking the include box.
Reset Shift will zero out any shifts and realign the images to there initial
positions.
The Save Match button saves the match back to the database for immediate
review in Offline Review.
Click Apply Shifts to send the Target positions to the clinac console. (Figure
31).
Figure 31: Dashboard; Apply Shift
Use the MEB and the >> key on the Clinac dedicated keyboard to move the
couch into the new position.
8. Click Done on the OBI workstation (Figure 32).
Figure 32: OBI workstation; Select Done
9. Prior to treating, retract the OBI arms to reduce damage to the kV detector from
scattered radiation.
NOTE: After acquiring a CBCT the OBI is unable to communicate
correctly with the generator causing a problem with radiographic
acquisitions. Switch the generator from radiographic to fluoro mode and
back to radiographic mode. This will reset generator communication and
solve the problem.
F. 4D ITC
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1. The 4D ITC Apply Couch Shift dialog box opens.
Select Apply for Session and then click Apply (Figure 33).
Select Apply Permanently only if its desired to apply the couch values
permanently (Figure 34).
Figure 33: Apply Shifts; Session
Figure 34: Apply Shifts; Permanently
2. Plan, Shifted and Actual Couch parameters (Figure 35).
Figure 35: Couch Parameters
3. Select the first field to treat and click Mode Up (Figure 36).

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Figure 36: Mode Up
4. If the couch values are out of tolerance the following message will appear
asking for confirmation of table parameters (Figure 37).
Enter User name and password and then click OK.
Figure 37: Out of Tolerance Override
5. Continue treatment as usual.
WARNING: When OBI is being used, closed circuit video and an

audio intercom must be available to the user to observe and
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communicate with the patient. The priority here is to avoid all

collision risks.
G. Quick Scan (Param. Display)
1. The Quick Scan (Param. Display) button (Figure 38) opens up the Scan
Parameter menu for quick and easy selection of CBCT settings (Figure 39).
After selections have been made continue from step D-10.
Figure 38: Quick Scan (Param. Display)
Reconstruction Filter:
Standard: 50/50 smooth and
sharp
Smooth: Best at defining soft
tissue
Sharp: Emphasis on bone
Ultra Sharp: Max emphasis on
bone
Ring Artifact Suppression:
You can control the strength of the
image correction by selecting one of
the following levels of ring artifact
suppression:
None: allows you to switch ring
artifact suppression off
Weak: might miss some rings
Medium: is recommended
Strong: might remove essential
information
Figure 39: Scan Parameters
H. Quick Scan
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1. When Quick Scan is selected the system will apply the same parameters that
were selected in the previous CBCT acquisition for that patient. (Only settings in
the parameter window are saved, dashboard changes will not be saved.)
Continue from step D-10.
I. Reconstruct Existing Scan

1. Reconstruct Existing Scan can be used in situations where changes to the
reconstruction parameters would be beneficial to the matching process or when
certain system errors occur during the CBCT process. Clinically this would be
performed immediately following a CBCT acquisition. For example, following
the CBCT acquisition the therapist decides that the smooth filter would have
been a better option than the selected sharp filter.
2. Select Accept and Export Scan (Step D17).
3. Select Cancel in the 3D/3D match analyze workspace (Figure 40).
Figure 40: Cancel
4. Select 3D/3D (Figure 41)
Figure 41: 3D/3D
5. The CBCT application will reopen. Select Reconstruct Existing Scan and
select the most current (just performed) scan (Figure 42a and 42b). Click Next.

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Figure 42a: Reconstruct Existing Scan
Figure 42b: Verify most current scan.
6. Make changes to the reconstruction parameters if necessary (Figure 43a) then

click Reconstruct (Figure 43b)
Figure 43a: Parameters
Figure 43b: Reconstruct
7. When reconstruction has finished select Accept and Export Scan (Step D17)
and continue with section E.

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Cone Beam CT Verification

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The > symbol denotes drill down from menus.