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A theoretical model for respiratory motion artifacts in free-breathing CT scans

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2009 Phys. Med. Biol. 54 745

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IOP PUBLISHING PHYSICS IN MEDICINE AND BIOLOGY

Phys. Med. Biol. 54 (2009) 745–755 doi:10.1088/0031-9155/54/3/018

A theoretical model for respiratory motion artifacts in

free-breathing CT scans
John H Lewis1,2 and Steve B Jiang1
1 Department of Radiation Oncology, University of California, San Diego, La Jolla, CA 92093,

USA
2 Department of Physics, University of California, San Diego, La Jolla, CA 92093, USA

E-mail: sbjiang@ucsd.edu

Received 4 August 2008, in final form 30 October 2008

Published 9 January 2009
Online at stacks.iop.org/PMB/54/745

Abstract
Successful radiotherapy treatment depends heavily upon the accuracy of patient
geometry captured during treatment simulation using computed tomography
(CT) scans. Radiotherapy patients are often scanned under free breathing, and
respiratory motion can cause severe artifacts in CT scans, including shortening,
elongation or splitting of the shapes and shifting of the midpoint positions of
the tumor and organs. This paper presents a theoretical model that explains
the source of motion artifacts and the relationship between motion artifacts
and the motion parameters of the scanner, treatment couch and tumor/organ.
It is shown that an understanding of the relationship between the translational
table velocity and the maximum tumor/organ velocity might enable one to
mitigate certain types of motion artifacts. We show that splitting artifacts
can be eliminated if the scanning speed is above the maximum tumor/organ
velocity. Slow scanning speeds are shown to be useful for obtaining accurate
internal target volumes (ITVs), and fast scanning speeds are shown to be useful
for obtaining accurate tumor/organ shapes. In both cases, an upper bound on
the maximum possible error is calculated as a function of the scanning speed.
A set of special scanning speeds which allow for an accurate representation
of tumor/organ length along the craniocaudal direction is obtained, and a
relationship between the maximum displacement of a tumor/organ image’s
midpoint position and the magnitude of its length distortion is derived.

1. Introduction

Precise and accurate patient imaging is of critical importance to radiotherapy. All steps in
a radiation treatment rely on one’s ability to determine the location of the tumor and nearby
critical structures. Tumors or organs that move with high enough speed such that their
positions may change significantly over the course of one CT scan, such as some lung tumors,
0031-9155/09/030745+11$30.00 © 2009 Institute of Physics and Engineering in Medicine Printed in the UK 745
746 J H Lewis and S B Jiang

are particularly difficult to image accurately under free-breathing conditions. In these cases,
the tumor/organ images often exhibit distortions created by the interplay of their motion with
that of a CT scanner and treatment couch. These artifacts can cause the tumor/organ to appear
shortened, elongated or split into several pieces along the craniocaudal direction (Chen et al
2004). Treatment plans developed based on incorrect estimates of the uncertainties associated
with these distortions may lead to improper predictions of the dose to the tumor and nearby
critical structures. A clearer understanding of how to minimize these artifacts could allow for
more accurate segmentation of structures and ultimately a better treatment plan.
Several studies have been done in an attempt to understand and quantify the appearance
of motion artifacts, but a clear mathematical model has not yet been produced. Some studies
showed how these artifacts could lead to incorrect predictions of a tumor’s position and size,
and quantified the associated uncertainties for thoracic tumors (Balter et al 1996). Chen et al
(2004) captured images exhibiting a variety of motion artifacts by conducting a phantom study
in which objects undergoing periodic motion were CT scanned. They were also able to produce
similar distortions with a computer simulation of a sphere undergoing periodic motion while
being imaged by a scanner moving with constant velocity. Their work showed that the resulting
distortion type and size depended on the initial phase of an object’s periodic motion when the
scan started. The results of these and other studies have contributed to the development of 4D
CT scanning methods to reduce the effects of motion-induced distortions. It is the hope of the
authors that this paper will offer a more theoretical and analytic understanding of the motion
distortion problem, which may lead to improvements in scanning techniques for regular free
breathing or 4D CT.
In this paper, we will try to explain and characterize the source of motion artifacts in CT
scanning. We will offer some suggestions as to how these artifacts may be reduced in regular
free-breathing CT scans, though it is almost always preferable to acquire 4D CT scans when
possible. The problem will be approached through a simple one-dimensional model of tumor,
scanner and treatment couch motions, which is shown to adequately predict the appearance
of shortening, elongation, splitting and midpoint position shift motion artifacts. Equations of
motion for tumor and couch position will be written and solved using an intuitive geometrical
method akin to that used in a mathematically similar problem involving the interplay of organ
and multileaf collimator motion in intensity-modulated radiation therapy (IMRT) treatment
delivery (Yu et al 1998). The dependence of the resultant tumor image upon the motion
parameters will be investigated. Equations limiting the magnitude of length distortion are
derived for both slow and fast scanning speeds.

2. Model

In current radiotherapy treatment simulation of lung cancer patients, patients are often scanned
in a helical mode under free breathing. There are three moving objects involved in this process:
the scanner, the couch and the tumor. The scanner rotates around the patient and the couch
moves with the patient in the craniocaudal direction, both at constant speeds. The tumor
moves sinusoidally inside the patient, primarily along the craniocaudal axis. Given the facts
that the scanner rotates much faster than the couch moves and the tumor moves mainly along
the craniocaudal direction, we are able to build a simple yet general model to investigate the
motion artifacts. The model has the following key features:
(1) The model is one-dimensional (1D) along the craniocaudal direction.
(2) The model is in the couch coordinate system.
(3) The tumor is represented with a line segment.
A theoretical model for respiratory motion artifacts in free-breathing CT scans 747

(4) The tumor oscillates along the craniocaudal axis.

(5) In the couch coordinate system, the scanner translates at constant velocity in the
craniocaudal direction.
(6) The scanner rotation has no effect on the craniocaudal motion, and is completely ignored
in this 1D model.
We write equations of motion for points representing the locations of: the bottom of the
tumor (xb), the top of the tumor (xt) and the CT scanner (s). In the couch coordinate system,
the scanner appears to undergo translation along the craniocaudal axis. The scanner’s motion
in this coordinate system is a linear function of time (t), written as
s(t) = s0 + vs t, (1)
where s0 represents the starting position of the scanner, and vs is the apparent translational
velocity of the scanner in the couch coordinate system, which is equal to the translational
velocity of the couch in the treatment room coordinate system. The motions of the top and
bottom of the tumor are represented in terms of the center of the tumor at its minimum position
(x0) and the tumor’s length (L) plus a periodic function of time (r), which can be fit to model
the craniocaudal motion of a patient’s tumor due to respiration:

L
xb (t) = x0 − + r(t) (2)
2
L
xt (t) = x0 + + r(t). (3)
2

At any instant during a scan, in order for the scanner to capture the tumor, and thus for the
tumor to appear on the CT image, the scanner’s location must be within the boundaries of
the tumor. Mathematically, this means that the scanner’s position is greater than or equal
to the position of the bottom of the tumor, and less than or equal to the position of the top
of the tumor. These conditions are represented as

s(t)  xb (t) (4)

s(t)  xt (t). (5)

Equations (4) and (5) can be used to find the time intervals during which the scanner captures
the tumor. These time intervals can then be translated into the positions for which the scanner
captures the tumor by plugging the time intervals into the equation of motion for the scanner,
equation (1).
In practice, the function r is often represented by an equation of the form
 
πt
r(t) = A cos2n + ϕ0 (6)
T
(Lujan et al 1999). Here A is the amplitude, T is the period, and ϕ 0 is the phase of the
respiratory motion when the scan starts. The parameter n is an integer that is fit to a patient’s
breathing pattern. For the sake of simplicity, graphical examples in this paper will use a simple
case where
    
1 2π t
r(t) = A cos + 2ϕ0 + 1 . (7)
2 T
The extra factor of 1/2 and addition of 1 are included so that equation (7) has the same range
as equation (6), specifically [0, A].
748 J H Lewis and S B Jiang

(a) (b)

(c)

Figure 1. Position versus time plots of scanner and tumor motions. The dashed line represents
the scanner’s motion, while the shaded area between the curves represents the tumor’s motion.
The black bar to the right is the true tumor length, centered at the tumor’s true midpoint position.
The light gray bar represents the tumor image. Each plot represents a different ϕ0 , with A =
2 cm, L = 2.5 cm, x0 = 2 cm, T = 4s, s0 = 0 cm, and vs = 1.2 cm s−1. (a) Here ϕ0 = 0. The
tumor image appears elongated. (b) Here ϕ0 = π . The tumor image appears shortened. (c) Here
ϕ0 = 3π/4. The tumor image appears split into two pieces.

By rewriting equations (4) and (5) in terms of equations (2), (3), (6) and (1), we have


L πt
s0 + vs t  x0 − + A cos2n+ ϕ0 (8)
2 T
 
L πt
s0 + vs t  x0 + + A cos2n + ϕ0 . (9)
2 T

These inequalities represent a transcendental system, so numerical or geometrical methods

must be used to solve them. The geometrical method provides a more intuitive view of the
problem, and will be the primary focus of this paper.
The geometrical solution is achieved by plotting equations (1)–(3) as functions of time.
Figure 1 shows three plots, each with r given by equation (7), and A = 2 cm, L = 2.5 cm,
x0 = 2 cm, T = 4 s, s0 = 0 cm and vs = 1.2 cm s−1. Figure 1(a) has ϕ0 = 0. Figure 1(b)
has ϕ0 = π . Figure 1(c) has ϕ0 = 3π/4. Scanner motion is represented with a dashed line,
and tumor motion is represented by the shaded area. The black bar represents the true tumor
length centered at the tumor’s true mean position. The intervals during which the scanner
detects a tumor can be visualized as the regions for which the dashed line is in the shaded
region. The position and size of the tumor’s image can be read off of the vertical axis, and
are shown as the gray bar on the far right. In this way, the graphs show how a tumor will
be shortened, elongated or split based on the motion parameters. Figure 1(a) represents a
situation where motion artifacts will cause the tumor image’s length to appear longer than the
A theoretical model for respiratory motion artifacts in free-breathing CT scans 749

true tumor length because the vertical distance between the two points of intersection of the
scanner and tumor region is greater than the true length of the tumor. In mathematical terms,
L = s(tt∗ ) − s(tb∗ ) > L, (10)
where tb∗ and tt∗ represent the times of intersection between the scanner and the top and bottom
of the tumor, respectively. L represents the length of the tumor’s image. If a situation arises
where the inequality in equation (10) becomes reversed, as in figure 1(b), the tumor appears
shortened. If there are more than two points of intersection, as in figure 1(c), the tumor will
appear split in the CT image.

3. Results and discussion

While the final appearance of a tumor’s image will depend on all of the motion parameters
in a complicated manner, we will focus primarily on the way in which scanning speed will
affect the manifestation of tumor motion artifacts. The model can only be fully solved with
knowledge of the parameters s0 , ϕ0 and x0 . These initial conditions affect the solution to
the motion equations in a similar way, by shifting the position of the motion graphs without
affecting their slope or shape. However, these values are usually unknown in a clinical setting.
We will instead focus on parameters from which we can draw more practical conclusions.
We examine two scanning speed regimes: (1) speeds greater than the maximum tumor
velocity (vm ) and (2) speeds less than the maximum tumor velocity. The maximum tumor
velocity is given by the maximum value of the derivative of the tumor’s motion equation.
For a simple sinusoidal motion as in equation (7), vm = 2π A/T . For motion modeled by
equation (6), the general solution for vm is given by
⎡   ⎤
1 n
π A ⎣ 2 1 − 2n ⎦.
vm =  (11)
T 2n−1
n2

3.1. Fast scanning speeds (regime (1))

In regime (1), where vs > vm , there will be no splitting artifact in the resultant tumor image.
Conceptually, if the scanner is moving in one direction faster than the tumor ever moves, the
tumor will never catch up with the scanner once the scanner passes it. Mathematically, one
can prove that the plot of the scanner’s motion will never intersect either tumor edge more
than once because its slope (vs ) is greater than the maximum slope of the tumor’s plot (vm ).
Figure 2 shows an example of a scanning speed faster than a tumor’s maximum velocity. Here,
all of the parameter values are as in figure 1(a), except that the scanning speed has increased
to 1.8 cm s−1. The value of vm is 1.6 cm s−1.
For scanning speeds much greater than the maximum tumor velocity, both elongation and
shortening artifacts can be minimized. This is because, much like a snapshot, a fast scanning
speed does not allow much time for the tumor to move during the scan. In terms of the graph,
when the scanning speed is very fast compared to the maximum tumor velocity, the scanner
will intersect the top of the tumor at nearly the same breathing phase as it intersects the bottom
of the tumor.
An upper bound on the magnitude of elongation artifact can be quantified by assuming
an artificial worst case scenario in which the tumor is moving at its maximum speed in the
same direction as the scanner for the entire duration of the scan. This scenario is not meant
as a realistic situation, but as a limiting case which would create more elongation than any
750 J H Lewis and S B Jiang

Figure 2. A plot showing a scanning speed which is faster than the maximum tumor velocity.
Here, all parameters are as in figure 1(a), except that the scanning speed has increased to
1.8 cm s−1. The value of vm is 1.6 cm s−1.

real tumor motion. In this scenario, the time interval it would take for the scanner to cross the
tumor in its entirety (te ) is te = L/(vs − vm ). Multiplying te by vs gives the corresponding
maximum tumor image length (Le), and by subtracting off the true length L, we can write the
following equation as an upper bound on the magnitude of elongation artifact (Le ):
vm
Le = Le − L = L. (12)
vs − vm
Correspondingly, one could assume that the tumor was moving at its maximum speed in the
opposite direction of the scanner and derive an equation for an upper bound on the magnitude
of shortening artifact. This corresponds to flipping the sign of vm , and finding that the upper
bound on the magnitude of shortening artifact (Ls ) is
vm
Ls = L − Ls = L. (13)
vs + vm
As expected, both equations (12) and (13) become smaller as vs becomes larger compared
to vm , and vanish as vs approaches infinity, demonstrating that higher scanning speeds can
achieve more accurate length measurements. It is important to note that these equations
are only useful for high enough scanning speeds such that the limits derived for maximum
shortening and elongation are less than the absolute limits of L ± A. The absolute limits are
defined by considering the distance between the minimum position of the tumor’s bottom and
the maximum position of the tumor’s top (L + A), and by considering the distance between
the maximum position of the tumor’s bottom and the minimum position of the tumor’s top
(L − A).
When a tumor is imaged with a fast scanning speed, equations (12) and (13) can be used
to estimate the range of possible true tumor lengths based on the tumor image’s length and the
relevant velocities. For example, in a situation where the scanning speed is four times faster
than the maximum tumor velocity, equation (12) shows that a tumor image may appear up to
33% larger than the true tumor length. Equation (13) correspondingly shows that the image
may appear shortened by up to 20% of the true tumor length.
Equations (12) and (13) can be used to generate limits on the possible true tumor length
in terms of the measured tumor image length:
   
vm vm
1− L  L  1 + L . (14)
vs vs
In other words, the measured tumor length can be shorter or longer than the true tumor length
by a factor of up to vm /vs .
A theoretical model for respiratory motion artifacts in free-breathing CT scans 751

Figure 3. A plot of tumor motion showing that a scanning speed of vs = L/nT can be used to
obtain a correct measure of a tumor’s length. Here, A = 1 cm, T = 4s, ϕ0 = 0, x0 = 2.5 cm,
L = 3.2 cm, and vs = L/T = .8 cm s−1. While the tumor’s midpoint position appears shifted,
the correct tumor length is captured.

There is a set of scanning speeds for which the length of the tumor will be correctly
imaged. These are the speeds such that the intersection of the scanner and tumor bottom
occurs at the same phase of the tumor’s motion as the intersection of the scanner and tumor
top. An example of this situation is shown in figure 3. This special speed (vl ) is given by the
following equation:
L
vl = , (15)
mT
where m is an integer. This equation is only useful in regime (1), where no tumor splitting
occurs. In regime (2), the tumor image may appear split, and image length will not necessarily
represent the correct tumor length. When a patient is being scanned in a clinical setting,
tuning the scanning speed to match the value given by equation (15) as closely as possible may
help to eliminate length distortion artifacts, as long as no splitting artifacts are present. The
patient’s breathing period can be measured before the treatment simulation while the tumor
length could initially be estimated from a diagnostic scan, or any other available information.
A diagnostic scan may also exhibit lengthening artifacts, and any error in the estimation of the
tumor’s length used in equation (15) would lead to more artifacts in the new CT scan. These
speeds are only potentially useful if the length of the tumor can be estimated with relatively
little uncertainty from previous data.

3.2. Slow scanning speeds (regime (2))

In regime (2), where vs < vm , splitting artifacts can appear corresponding to situations where
there are more than two intersection points between the scanner and the tumor boundaries, as
seen in figure 1(c). The number of intersection points, and hence image tumor segments, tends
to increase as the scanning speed decreases, approaching infinity as the speed approaches zero
(one could picture this scenario as a scanner which remains almost stationary while a tumor
moves repeatedly in and out of its view). Three plots of progressively slower scanning speeds
are shown in figure 4. All motion parameters are the same as for figure 1(a), except that
figure 4(a) has a scanning speed of 0.7 cm s−1, figure 4(b) has a scanning speed of
0.4 cm s−1, and figure 4(c) has a scanning speed of 0.2 cm s−1. As in regime (1), elongation
and shortening artifacts still occur.
Very slow scanning speeds in regime (2) can be used to obtain an accurate measurement
of the tumor’s internal target volume (ITV) accounting for intrafraction tumor motion. This is
752 J H Lewis and S B Jiang

(a) (b)

(c)

Figure 4. Three plots with decreasing scanning speeds. All parameters are the same as in
figure 1(a), with the exception of vs , which equals 0.7 cm s−1 in (a), 0.4 cm s−1 in (b) and
0.2 cm s−1 in (c). As scanning speed decreases, more splitting can occur in the tumor image.

because a scanner which is moving very slowly compared to the tumor’s maximum velocity
will intersect the tumor bottom near to the minimum point of its motion, and will not leave
the tumor region for the last time until it is very close to the tumor’s maximum position.
Between these two points, the scanner will pass in and out of the tumor region many times,
causing multiple splits. Figure 4(c) is an example of this type of situation. The ITV should
be considered as the continuous area linking the bottom of the first image segment with the
top of the last. An upper bound on the error in this method of determining the ITV can be
quantified by calculating the distance the scanner moves between two successive minima (or
maxima) of the tumor’s motion, as shown in figure 5. The error in the minimum position of
the tumor bottom is thus no greater than vs T . Likewise, the error in the maximum position
of the tumor top is no greater than vs T , and the ITV will appear no more than 2vs T shorter
than the true ITV of L + A. When using slow scanning speeds to measure a patient’s ITV,
these equations can be used to estimate how much larger the true ITV may be than what is
predicted by the slow scan.
For asymmetrical breathing patterns, as modeled by equation (6) when n > 1, averaging
effects may complicate ITV delineation. Since a tumor will spend more time in the exhale
position, it will appear more clearly in a CT scan at this position than at the inhale positions.
The relatively low contrast at inhale positions may cause difficulty in contouring this portion
of the ITV. Our model does not address this issue, and instead assumes that the contrast at the
inhale tumor positions is sufficient to accurately contour the ITV.

3.3. Correlation of mean position displacement and length distortion magnitude

A relationship can be derived between the magnitude of the shortening or elongation of a
tumor’s image, and the displacement of that image’s center from the tumor motion’s true
midpoint.
A theoretical model for respiratory motion artifacts in free-breathing CT scans 753

(a)

(b)

Figure 5. Plots illustrating an upper bound on the error in predicting the ITV under a very
slow scanning speed. All motion parameters are the same as in figure 1(a), except that vs =
0.11 cm s−1; (b) represents an enlarged view of the black rectangle shown in (a).

To derive the relationship between the shift in midpoint position (xc ) and a given length
distortion magnitude (L = |L − L|), we first define the midpoint of the tumor image
xc = (xt (tt∗ ) + xb (tb∗ ))/2. The true midpoint of a tumor’s motion is given by xm = x0 + A/2.
The shift in midpoint position is then given by
 
(xt (tt∗ ) + xb (tb∗ )) A
xc = xc − xm = − x0 + . (16)
2 2
The maximum value for xc will occur when xt and xb are at their maximum values.
Specifically, xt = x0 + L/2 + A and xb = x0 − L/2 + A. Plugging these equations into
equation (16) shows that the maximum midpoint position displacement is xc = A/2. In the
situation described above, no length distortion is present. However, since xt and xb are at their
maximum values, if a distortion L is introduced it must be realized either as a downward
shift of xt, a downward shift of xb or a combination of both. Therefore, it can be seen from
equation (16) that a distortion L will correspond to a downward shift in the tumor image’s
midpoint by L/2. This downward shift constitutes a shift back toward the tumor motion’s
true midpoint, and we can write the following condition:
A L
xc  − . (17)
2 2
The same logic used to obtain equation (17) can be used to obtain a condition for the
minimum, or most negative, midpoint position displacement. In this case, one would consider
the minimum positions for xt and xb, corresponding to a midpoint position displacement of
xc = −A/2. Any length distortion would then correspond to an upward shift in the perceived
midpoint position, and we write the following condition:
L A
xc  − . (18)
2 2
754 J H Lewis and S B Jiang

Figure 6. A plot of possible midpoint position shifts of a tumor image (xc ) versus length
distortion magnitude (L). The gray-shaded region represents the possible values of xc for a
given L. In this graph A = 2 cm.

A graph of the inequalities given in equations (17) and (18) is shown in figure 6. The midpoint
position displacement (xc ) is plotted versus the length distortion magnitude (L). In this
graph, A = 2 cm. The shaded area represents the possible values of xc for a given L.
The graph shows that a tumor image which exhibits a large amount of length distortion will
have tighter limits on its possible midpoint position displacement. These results are valid even
when splitting artifacts are present, as long as one considers the length of a tumor image to
be the continuous distance between the bottom of the first and the top of the last tumor image
segments. As an extreme example, when a slow scan is used to estimate an ITV a tumor
image will be elongated to near its maximum value of L + A, and the tumor image’s midpoint
position is not significantly shifted from its true midpoint position.
The plot in figure 6 could be modified by considering limits on the tumors maximum
length distortion in terms of the ratio of maximum tumor velocity to scanner speed. As shown
in equation (14), the maximum value for L is (vm /vs )L. Therefore, any values of L
beyond (vm /vs )L in figure 6 need not be included in the graph.
Equations (17) and (18) could be used in a clinical setting to estimate the displacement
of a tumor image’s midpoint position, based on the amount of length distortion in the image,
assuming that the tumor’s true length is known within more precise limits than the current
image’s length distortion magnitude.

4. Conclusions

In this paper, we presented a mathematical model to study respiratory motion artifacts in a

free-breathing CT scan. The model was used to explain the occurrence of length distortion,
splitting and mean position displacement artifacts in terms of the interplay of the tumor and
scanning velocities. The model was used to explain why fast scanning speeds allow for
accurate measurement of a tumor’s length, while slow scanning speeds can be used to estimate
a tumor’s ITV that accounts for respiratory motion. Upper bounds on the error margins for
both of these scenarios were found as functions of the scanner and tumor velocities. We have
also shown that no splitting artifact will occur in situations where the scanning speed is greater
than the maximum tumor velocity, and that it is possible to select scanning speeds that will
accurately measure a tumor’s length, as long as these speeds are greater than the maximum
tumor velocity. Lastly, a relationship between the distortion of a tumor image’s length and
the displacement of its midpoint position from the tumor’s true midpoint position was found,
showing that a tumor image which exhibits a larger length distortion will have narrower limits
on the magnitude of its perceived mean position displacement. While these conclusions may
A theoretical model for respiratory motion artifacts in free-breathing CT scans 755

be used to mitigate the appearance of motion artifacts in regular free-breathing CT scans,

the use of 4D CT is a preferable solution, and its use has become widespread. We plan to
investigate how this model could be applied to 4D CT scanning techniques to reduce residual
motion artifacts in future studies. The conclusions of this paper are based on a simplified 1D
model with regular periodic breathing patterns. In future studies, we also plan to investigate
how irregular breathing patterns affect our results.

Acknowledgment

The authors would like to thank Drs Loren Mell and Laura Cerviño for constructive comments
on the manuscript and Dr Herbert Levine for useful discussions.

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