A novel comprehensive metric balancing imaging dose and setup accuracy in image-guided radiotherapy: concept proposal and clinical validation.

Purpose: To propose and validate a comprehensive novel metric balancing the registration accuracy and imaging dose for image-guided-radiotherapy based on real patient data. Materials and methods: With written informed consent and ethical approval, 56 patients were scanned using 6MV CBCT, 140 kV CBCT, and 100 kV CBCT on Halcyon system for three consecutive treatment fractions. Online registration was performed by various on-duty therapists under routine clinical pressure and time limitation. Offline registration was carried out by an experienced physicist without pressure. The consistency between the online and offline results was used as a surrogate of the missing ground-truth of registration accuracy, which was usually developed by introducing 'known' setup errors and rescan the phantoms, yet is ethnically not applicable to real patients. The registration differences (ΔD) between various imaging methods and observers were analyzed. The weighted CT dose index (CTDIw) for kV and MV CBCT was acquired using the PTW CTDI head phantom. The weighted-Dose-Accuracy-Product (DAPw) index was defined as DAPw =ΔD(mm) Results: The mean and interquartile range (IQR) of ΔD decreased monotonically for MV CBCT, 100 kV CBCT, and 140 kV CBCT, supporting the registration consistency as a surrogate metric of image quality. Significant differences of ΔD were observed between the online and offline registration across three imaging methods (P<0.05). The 140 kV CBCT provides superior positioning accuracy, less dependency on observer subjectivity and time pressure of clinical workflow. Using w1=w2 = 0.5 as an example, the smallest mean, standard deviation, and IQR of DAPw were observed on the 100 kV CBCT, indicating optimal balance between dose and accuracy than the other two methods. Analysis of variance (ANOVA) showed statistically significant differences in DAPw among the different imaging methods (P<0.01, F=50.57). Conclusion: Using registration consistency as a surrogate indicator of image quality, this study proposed and validated a novel "DAPw" parameter based on real patient data, providing a purpose-specific tool for balancing setup accuracy and radiation dose in clinic.