Quantifying the reproducibility of lung ventilation images between 4-Dimensional Cone Beam CT and 4-Dimensional CT

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Computed tomography ventilation imaging derived from four-dimensional cone beam CT (CTVI4DCBCT) can complement existing 4DCT-based methods (CTVI4DCT) to track lung function changes over a course of lung cancer radiation therapy. However, the accuracy of CTVI4DCBCT needs to be assessed since anatomic 4DCBCT has demonstrably poor image quality and small field of view (FOV) compared to treatment planning 4DCT. We perform a direct comparison between short interval CTVI4DCBCT and CTVI4DCT pairs to understand the patient specific image quality factors affecting the intermodality CTVI reproducibility in the clinic.

Methods and materials

We analysed 51 pairs of 4DCBCT and 4DCT scans acquired within 1 day of each other for nine lung cancer patients. To assess the impact of image quality, CTVIs were derived from 4DCBCT scans reconstructed using both standard Feldkamp-Davis-Kress backprojection (Symbol) and an iterative McKinnon-Bates Simultaneous Algebraic Reconstruction Technique (Symbol). Also, the influence of FOV was assessed by deriving CTVIs from 4DCT scans that were cropped to a similar FOV as the 4DCBCT scans (Symbol), or uncropped (Symbol). All CTVIs were derived by performing deformable image registration (DIR) between the exhale and inhale phases and evaluating the Jacobian determinant of deformation. Reproducibility between corresponding CTVI4DCBCT and CTVI4DCT pairs was quantified using the voxel-wise Spearman rank correlation and the Dice similarity coefficient (DSC) for ventilation defect regions (identified as the lower quartile of ventilation values). Mann–Whitney U-tests were applied to determine statistical significance of each reconstruction and cropping condition.


The (mean ± SD) Spearman correlation between Symbol and Symbol was 0.60 ± 0.23 (range −0.03–0.88) and the DSC was 0.64 ± 0.12 (0.34–0.83). By comparison, correlations between Symbol and Symbol showed a small but statistically significant improvement with = 0.64 ± 0.20 (range 0.06–0.90, P = 0.03) and DSC = 0.66 ± 0.13 (0.31–0.87, P = 0.02). Intermodal correlations were noted to decrease with an increasing fraction of lung truncation in 4DCBCT relative to 4DCT, albeit not significantly (Pearson correlation R = 0.58, P = 0.002).


This study demonstrates that DIR based CTVIs derived from 4DCBCT can exhibit reasonable to good voxel-level agreement with CTVIs derived from 4DCT. These correlations outperform previous cross-modality comparisons between 4DCT-based ventilation and nuclear medicine. The use of 4DCBCT scans with iterative reconstruction and minimal lung truncation is recommended to ensure better reproducibility between 4DCBCT- and 4DCT-based CTVIs.

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