From Data Completeness to Data Sufficiency: A Task-Driven Imaging Framework for Intraoperative CBCT under Quality-Time-Dose Trade-offs

Medical image quality plays a critical role in diagnostic accuracy, especially in X-ray-based imaging modalities such as cone-beam computed tomography (CBCT), where image quality must be balanced against radiation dose. While expert visual evaluation remains the clinical standard for image quality evaluation, it is time-consuming, subjective and affected by inter-observer variability, emphasizing the need for reliable quantitative image quality assessment (IQA) methods. However, the development and validation of such IQA methods have been limited by the lack of publicly available CBCT datasets with expert image quality annotations. In this study, we provide the first open-access CBCT IQA dataset containing 1,764 annotated image slices acquired using systematic variations in image acquisition and reconstruction parameters. Three clinical experts graded the overall image quality and a predefined regions of interest (ROI) using a four-level scoring scheme. In addition, we benchmark 26 full reference- and no reference-based IQA measures against expert annotations and introduce an exploratory IQA measure-based ranking capable of distinguishing subtle image quality differences. This dataset introduced a standardized benchmark for future CBCT IQA research and provides a valuable resource for the development and validation of new IQA methods, enabling reproducible research and advancing CBCT IQA.

Four-dimensional cone beam CT (4D CBCT) is important for image-guided radiation therapy of thoracic cancers, but its use is limited by long scan times, causing high patient dose and motion/sparse-sampling artifacts. We propose a deep learning method for motion-resolved 4D CBCT reconstruction from conventional free-breathing scans, without a respiratory signal or explicit projection binning. Our CNN takes free-breathing 3D CBCT projections as input and predicts a static volume at maximum inhalation plus ten displacement vector fields (DVFs) spanning a breathing cycle. The network extends U-Net: the encoder acts on filtered projection stacks, the decoder acts in the volume domain, and skip connections are replaced with non-trainable back-projection functions at multiple resolutions to transfer features between domains. The model is trained on simulated CBCT scans and evaluated on 11 unseen simulated patients and 13 clinical free-breathing scans. Two additional models (60 s and 6 s scans) were evaluated by clinical experts on three and two scans, comparing single phases of our 4D reconstruction to reference 3D SART-TV images for tumor and esophagus visibility. Experts preferred our method for tumor visibility (59% vs. 36% no preference, 5% reference) and esophagus visibility (47% vs. 42%, 11%). On simulated data, image quality matched SART-TV (mean RMSE: -1.19 HU, PSNR: +0.09 dB, SSIM: -0.009) while enabling 4D reconstruction. On clinical scans, our method showed sharper dynamic structures (e.g., diaphragm) and fewer motion streak artifacts than traditional reconstruction. This non-patient-specific CNN predicts static volumes and full 4D respiratory motion models from a single free-breathing scan, without a respiratory surrogate or projection binning, reducing motion artifacts while adding motion-modeling capability.

During standard radiotherapy planning, repeated CT acquisitions are often required for patient registration, verification, and adaptive planning, resulting in increased cumulative X-ray dose. To mitigate this, low-dose cone-beam CT (CBCT) is routinely acquired during treatment delivery. However, CBCT image quality remains insufficient for accurate dose calculation and adaptive radiotherapy planning due to increased scatter, noise, beam hardening, and reconstruction related artifacts. This study develops a supervised deep learning based CBCT to CT synthesis framework using a conditional denoising diffusion probabilistic model (DDPM), where the generation of a CT-based planning for accurate positioning and dose calculation is obtained using generative models with low dose CBCT imaging. Beyond demonstrating CBCT to CT synthesis, the primary objective is to investigate how the representation of CBCT input data, either standard clinical DICOM CBCT images or filtered back-projection (FDK) reconstructions from raw projection data, affects the performance of diffusion based CT synthesis. The overarching aim is to assess whether physics aware CBCT representations better support CT-equivalent image quality while maintaining reduced imaging dose in radiotherapy workflows.