Technical Note: Combination of multiple EPID imager layers improves image quality and tracking performance of low contrast‐to‐noise objects

Purpose We hypothesized that combining multiple amorphous silicon flat panel layers increases photon detection efficiency in an electronic portal imaging device (EPID), improving image quality and tracking accuracy of low‐contrast targets during radiotherapy. Methods The prototype imager evaluated in this study contained four individually programmable layers each with a copper converter layer, Gd2O2S scintillator, and active‐matrix flat panel imager (AMFPI). The imager was placed on a Varian TrueBeam linac and a Las Vegas phantom programmed with sinusoidal motion (peak‐to‐peak amplitude = 20 mm, period = 3.5 s) was imaged at a frame rate of 10 Hz with one to four layers activated. Number of visible circles and CNR of least visible circle (depth = 0.5 mm, diameter = 7 mm) was computed to assess the image quality of single and multiple layers. A previously validated tracking algorithm was employed for auto‐tracking. Tracking error was defined as the difference between the programmed and tracked positions of the circle. Pearson correlation coefficient (R) of CNR and tracking errors was computed. Results Motion‐induced blurring significantly reduced circle visibility. During four cycles of phantom motion, the number of visible circles varied from 11–23, 13–24, 15–25, and 16–26 for one‐, two‐, three‐, and four‐layer imagers, respectively. Compared with using only a single layer, combining two, three, and four layers increased the median CNR by factors of 1.19, 1.42, and 1.71, respectively and reduced the average tracking error from 3.32 mm to 1.67 mm to 1.47 mm, and 0.74 mm, respectively. Significant correlations (P~10−9) were found between the tracking error and CNR. Conclusion Combination of four conventional EPID layers significantly improves the EPID image quality and tracking accuracy for a poorly visible object which is moving with a frequency and amplitude similar to respiratory motion.