Improved quality of intrafraction kilovoltage images by triggered readout of unexposed frames.

PURPOSE The gantry-mounted kilovoltage (kV) imager of modern linear accelerators can be used for real-time tumor localization during radiation treatment delivery. However, the kV image quality often suffers from cross-scatter from the megavoltage (MV) treatment beam. This study investigates readout of unexposed kV frames as a means to improve the kV image quality in a series of experiments and a theoretical model of the observed image quality improvements. METHODS A series of fluoroscopic images were acquired of a solid water phantom with an embedded gold marker and an air cavity with and without simultaneous radiation of the phantom with a 6 MV beam delivered perpendicular to the kV beam with 300 and 600 monitor units per minute (MU/min). An in-house built device triggered readout of zero, one, or multiple unexposed frames between the kV exposures. The unexposed frames contained part of the MV scatter, consequently reducing the amount of MV scatter accumulated in the exposed frames. The image quality with and without unexposed frame readout was quantified as the contrast-to-noise ratio (CNR) of the gold marker and air cavity for a range of imaging frequencies from 1 to 15 Hz. To gain more insight into the observed CNR changes, the image lag of the kV imager was measured and used as input in a simple model that describes the CNR with unexposed frame readout in terms of the contrast, kV noise, and MV noise measured without readout of unexposed frames. RESULTS Without readout of unexposed kV frames, the quality of intratreatment kV images decreased dramatically with reduced kV frequencies due to MV scatter. The gold marker was only visible for imaging frequencies≥3 Hz at 300 MU/min and ≥5 Hz for 600 MU/min. Visibility of the air cavity required even higher imaging frequencies. Readout of multiple unexposed frames ensured visibility of both structures at all imaging frequencies and a CNR that was independent of the kV frame rate. The image lag was 12.2%, 2.2%, and 0.9% in the first, second, and third frame after an exposure. The CNR model predicted the CNR with triggered image readout with a mean absolute error of 2.0% for the gold marker. CONCLUSIONS A device that triggers readout of unexposed frames during kV fluoroscopy was built and shown to greatly improve the quality of intratreatment kV images. A simple theoretical model successfully described the CNR improvements with the device.