Cone-beam computed tomography (CBCT) is widely used for image-guided radiotherapy (IGRT). It provides real time visualization at low cost and dose. However, photon scattering and beam hindrance cause artifacts in CBCT. These include inaccurate Hounsfield Units (HU), reducing reliability for dose calculation, and adaptive planning. By contrast, computed tomography (CT) offers better image quality and accurate HU calibration but is usually acquired offline and fails to capture intra-treatment anatomical changes. Thus, accurate CBCT-to-CT synthesis is needed to close the imaging-quality gap in adaptive radiotherapy workflows. To cater to this, we propose a novel diffusion-based conditional generative model, coined EqDiff-CT, to synthesize high-quality CT images from CBCT. EqDiff-CT employs a denoising diffusion probabilistic model (DDPM) to iteratively inject noise and learn latent representations that enable reconstruction of anatomically consistent CT images. A group-equivariant conditional U-Net backbone, implemented with e2cnn steerable layers, enforces rotational equivariance (cyclic C4 symmetry), helping preserve fine structural details while minimizing noise and artifacts. The system was trained and validated on the SynthRAD2025 dataset, comprising CBCT-CT scans across multiple head-and-neck anatomical sites, and we compared it with advanced methods such as CycleGAN and DDPM. EqDiff-CT provided substantial gains in structural fidelity, HU accuracy and quantitative metrics. Visual findings further confirm the improved recovery, sharper soft tissue boundaries, and realistic bone reconstructions. The findings suggest that the diffusion model has offered a robust and generalizable framework for CBCT improvements. The proposed solution helps in improving the image quality as well as the clinical confidence in the CBCT-guided treatment planning and dose calculations.

Cone-beam computed tomography (CBCT) has become an invaluable imaging modality in dentistry, enabling 3D visualization of teeth and surrounding structures for diagnosis and treatment planning. Automated segmentation of dental structures in CBCT can efficiently assist in identifying pathology (e.g., pulpal or periapical lesions) and facilitate radiation therapy planning in head and neck cancer patients. We describe the DLaBella29 team's approach for the MICCAI 2025 ToothFairy3 Challenge, which involves a deep learning pipeline for multi-class tooth segmentation. We utilized the MONAI Auto3DSeg framework with a 3D SegResNet architecture, trained on a subset of the ToothFairy3 dataset (63 CBCT scans) with 5-fold cross-validation. Key preprocessing steps included image resampling to 0.6 mm isotropic resolution and intensity clipping. We applied an ensemble fusion using Multi-Label STAPLE on the 5-fold predictions to infer a Phase 1 segmentation and then conducted tight cropping around the easily segmented Phase 1 mandible to perform Phase 2 segmentation on the smaller nerve structures. Our method achieved an average Dice of 0.87 on the ToothFairy3 challenge out-of-sample validation set. This paper details the clinical context, data preparation, model development, results of our approach, and discusses the relevance of automated dental segmentation for improving patient care in radiation oncology.

Cone-Beam Computed Tomography (CBCT) is widely used for intraoperative imaging due to its rapid acquisition and low radiation dose. However, CBCT images typically suffer from artifacts and lower visual quality compared to conventional Computed Tomography (CT). A promising solution is synthetic CT (sCT) generation, where CBCT volumes are translated into the CT domain. In this work, we enhance sCT generation through multimodal learning by jointly leveraging intraoperative CBCT and preoperative CT data. To overcome the inherent misalignment between modalities, we introduce an end-to-end learnable registration module within the sCT pipeline. This model is evaluated on a controlled synthetic dataset, allowing precise manipulation of data quality and alignment parameters. Further, we validate its robustness and generalizability on two real-world clinical datasets. Experimental results demonstrate that integrating registration in multimodal sCT generation improves sCT quality, outperforming baseline multimodal methods in 79 out of 90 evaluation settings. Notably, the improvement is most significant in cases where CBCT quality is low and the preoperative CT is moderately misaligned.

Time-resolved CBCT imaging, which reconstructs a dynamic sequence of CBCTs reflecting intra-scan motion (one CBCT per x-ray projection without phase sorting or binning), is highly desired for regular and irregular motion characterization, patient setup, and motion-adapted radiotherapy. Representing patient anatomy and associated motion fields as 3D Gaussians, we developed a Gaussian representation-based framework (PMF-STGR) for fast and accurate dynamic CBCT reconstruction. PMF-STGR comprises three major components: a dense set of 3D Gaussians to reconstruct a reference-frame CBCT for the dynamic sequence; another 3D Gaussian set to capture three-level, coarse-to-fine motion-basis-components (MBCs) to model the intra-scan motion; and a CNN-based motion encoder to solve projection-specific temporal coefficients for the MBCs. Scaled by the temporal coefficients, the learned MBCs will combine into deformation vector fields to deform the reference CBCT into projection-specific, time-resolved CBCTs to capture the dynamic motion. Due to the strong representation power of 3D Gaussians, PMF-STGR can reconstruct dynamic CBCTs in a 'one-shot' training fashion from a standard 3D CBCT scan, without using any prior anatomical or motion model. We evaluated PMF-STGR using XCAT phantom simulations and real patient scans. Metrics including the image relative error, structural-similarity-index-measure, tumor center-of-mass-error, and landmark localization error were used to evaluate the accuracy of solved dynamic CBCTs and motion. PMF-STGR shows clear advantages over a state-of-the-art, INR-based approach, PMF-STINR. Compared with PMF-STINR, PMF-STGR reduces reconstruction time by 50% while reconstructing less blurred images with better motion accuracy. With improved efficiency and accuracy, PMF-STGR enhances the applicability of dynamic CBCT imaging for potential clinical translation.

Medical imaging is essential in modern radiotherapy, supporting diagnosis, treatment planning, and monitoring. Synthetic imaging, particularly synthetic computed tomography (sCT), is gaining traction in radiotherapy. The SynthRAD2025 dataset and Grand Challenge promote advancements in sCT generation by providing a benchmarking platform for algorithms using cone-beam CT (CBCT) and magnetic resonance imaging (MRI). The dataset includes 2362 cases: 890 MRI-CT and 1472 CBCT-CT pairs from head-and-neck, thoracic, and abdominal cancer patients treated at five European university medical centers (UMC Groningen, UMC Utrecht, Radboud UMC, LMU University Hospital Munich, and University Hospital of Cologne). Data were acquired with diverse scanners and protocols. Pre-processing, including rigid and deformable image registration, ensures high-quality, modality-aligned images. Extensive quality assurance validates image consistency and usability. All imaging data is provided in MetaImage (.mha) format, ensuring compatibility with medical image processing tools. Metadata, including acquisition parameters and registration details, is available in structured CSV files. To maintain dataset integrity, SynthRAD2025 is divided into training (65%), validation (10%), and test (25%) sets. The dataset is accessible at https://doi.org/10.5281/zenodo.14918089 under the SynthRAD2025 collection. This dataset supports benchmarking and the development of synthetic imaging techniques for radiotherapy applications. Use cases include sCT generation for MRI-only and MR-guided photon/proton therapy, CBCT-based dose calculations, and adaptive radiotherapy workflows. By integrating diverse acquisition settings, SynthRAD2025 fosters robust, generalizable image synthesis algorithms, advancing personalized cancer care and adaptive radiotherapy.

The multi-modality imaging system offers optimal fused images for safe and precise interventions in modern clinical practices, such as computed tomography - ultrasound (CT-US) guidance for needle insertion. However, the limited dexterity and mobility of current imaging devices hinder their integration into standardized workflows and the advancement toward fully autonomous intervention systems. In this paper, we present a novel clinical setup where robotic cone beam computed tomography (CBCT) and robotic US are pre-calibrated and dynamically co-registered, enabling new clinical applications. This setup allows registration-free rigid registration, facilitating multi-modal guided procedures in the absence of tissue deformation. First, a one-time pre-calibration is performed between the systems. To ensure a safe insertion path by highlighting critical vasculature on the 3D CBCT, SAM2 segments vessels from B-mode images, using the Doppler signal as an autonomously generated prompt. Based on the registration, the Doppler image or segmented vessel masks are then mapped onto the CBCT, creating an optimally fused image with comprehensive detail. To validate the system, we used a specially designed phantom, featuring lesions covered by ribs and multiple vessels with simulated moving flow. The mapping error between US and CBCT resulted in an average deviation of 1.72+-0.62 mm. A user study demonstrated the effectiveness of CBCT-US fusion for needle insertion guidance, showing significant improvements in time efficiency, accuracy, and success rate. Needle intervention performance improved by approximately 50% compared to the conventional US-guided workflow. We present the first robotic dual-modality imaging system designed to guide clinical applications. The results show significant performance improvements compared to traditional manual interventions.

A key step in Adaptive Radiation Therapy (ART) workflows is the evaluation of the patient's anatomy at treatment time to ensure the accuracy of the delivery. To this end, Cone Beam Computerized Tomography (CBCT) is widely used being cost-effective and easy to integrate into the treatment process. Nonetheless, CBCT images have lower resolution and more artifacts than CT scans, making them less reliable for precise treatment validation. Moreover, in complex treatments such as Total Marrow and Lymph Node Irradiation (TMLI), where full-body visualization of the patient is critical for accurate dose delivery, the CBCT images are often discontinuous, leaving gaps that could contain relevant anatomical information. To address these limitations, we propose ARTInp (Adaptive Radiation Therapy Inpainting), a novel deep-learning framework combining image inpainting and CBCT-to-CT translation. ARTInp employs a dual-network approach: a completion network that fills anatomical gaps in CBCT volumes and a custom Generative Adversarial Network (GAN) to generate high-quality synthetic CT (sCT) images. We trained ARTInp on a dataset of paired CBCT and CT images from the SynthRad 2023 challenge, and the performance achieved on a test set of 18 patients demonstrates its potential for enhancing CBCT-based workflows in radiotherapy.

Generating synthetic Computed Tomography (CT) images from Cone Beam Computed Tomography (CBCT) is desirable for improving the image quality of CBCT. Existing synthetic CT (sCT) generation methods using Convolutional Neural Networks (CNN) and Transformers often face difficulties in effectively capturing both global and local features and contrasts for high-quality sCT generation. In this work, we propose a Global-Local Feature and Contrast learning (GLFC) framework for sCT generation. First, a Mamba-Enhanced UNet (MEUNet) is introduced by integrating Mamba blocks into the skip connections of a high-resolution UNet for effective global and local feature learning. Second, we propose a Multiple Contrast Loss (MCL) that calculates synthetic loss at different intensity windows to improve quality for both soft tissues and bone regions. Experiments on the SynthRAD2023 dataset demonstrate that GLFC improved the SSIM of sCT from 77.91% to 91.50% compared with the original CBCT, and significantly outperformed several existing methods for sCT generation. The code is available at https://github.com/HiLab-git/GLFC

Computer-Assisted Interventions enable clinicians to perform precise, minimally invasive procedures, often relying on advanced imaging methods. Cone-beam computed tomography (CBCT) can be used to facilitate computer-assisted interventions, despite often suffering from artifacts that pose challenges for accurate interpretation. While the degraded image quality can affect image analysis, the availability of high quality, preoperative scans offers potential for improvements. Here we consider a setting where preoperative CT and intraoperative CBCT scans are available, however, the alignment (registration) between the scans is imperfect to simulate a real world scenario. We propose a multimodal learning method that fuses roughly aligned CBCT and CT scans and investigate the effect on segmentation performance. For this experiment we use synthetically generated data containing real CT and synthetic CBCT volumes with corresponding voxel annotations. We show that this fusion setup improves segmentation performance in $18$ out of $20$ investigated setups.

Cone-beam computed tomography (CBCT), is an important tool facilitating computer aided interventions, despite often suffering from artifacts that pose challenges for accurate interpretation. While the degraded image quality can affect downstream segmentation, the availability of high quality, preoperative scans represents potential for improvements. Here we consider a setting where preoperative CT and intraoperative CBCT scans are available, however, the alignment (registration) between the scans is imperfect. We propose a multimodal learning method that fuses roughly aligned CBCT and CT scans and investigate the effect of CBCT quality and misalignment on the final segmentation performance. For that purpose, we make use of a synthetically generated data set containing real CT and synthetic CBCT volumes. As an application scenario, we focus on liver and liver tumor segmentation. We show that the fusion of preoperative CT and simulated, intraoperative CBCT mostly improves segmentation performance (compared to using intraoperative CBCT only) and that even clearly misaligned preoperative data has the potential to improve segmentation performance.