Fiducial markers in prostate for kV imaging: Quantification of visibility and optimization of imaging conditions

The purpose of this work is to investigate possible smaller, less-dense fiducial markers implantable into the prostate for target localization and patient repositioning verification in an on-board kVkV imaging system on a proton gantry. The experiments used a pelvic phantom and a variety of commercially available fiducial markers: CIVCO carbon marker of ; 1×3 mm, gold seed markers of ; 0.8×3 mm and ; 1.2×3 mm, and IBA Visicoil helical gold linear markers in diameters of 0.35, 0.50, 0.75 and 1.15 mm. Two orthogonal on-board kV imagers were arranged for digital radiographic imaging of the phantom through the lateral and anteriorposterior directions. The contrast-to-noise ratio (CNR) for a given marker was calculated and used as a quantitative measure of its visibility. The patient entrance skin exposure (ESE) was measured and parameterized for kVp, mAs and source-to-surface distance. The ratio of CNR to ESE was first introduced to characterize the efficiency for imaging a marker using a given x-ray technique in order to optimize the marker's visibility and simultaneously minimize the x-ray imaging dose. If CNR > 2, which corresponds to a significance p < 0.05, is required for acceptable visibility, the carbon marker and the smallest Visicoil marker are not suitable for imaging through dense bone but the others are capable of being employed in the clinic. It is predicted that other markers in development should have a greater thickness than equivalent of 0.14 mm thick gold in order to produce the acceptable visibility in the lateral kV imaging. The linear Visicoil marker of ; 0.50×5 mm is most suitable for kV imaging in the prostate for proton therapy as it induces the least proton dose perturbation amongst the acceptable markers. An optimal range of 120130 kVp and 4080 mAs is determined using the maximal CNR/ESE and CNR > 2 for laterally imaging this marker in the prostate.