COMMISSIONING AND USE OF
CONVENTIONAL CT
Sasa Mutic
Department of Radiation Oncology
Siteman Cancer Center
Mallinckrodt Institute of Radiology
Washington University School of Medicine
St. Louis, Missouri 63110
Outline
• Introduction and historical review
• CT-Technology
• Multislice Benefits
• Commissioning
• Conclusions
Disclaimer: Our university uses Philips scanners in radiation therapy and I
have easy access to their images which are used in this presentation. This
should in no way be interpreted as our endorsement of these products.
CT in Radiation Therapy
CT simulator history
• 1983 - Goitein and Abrams described multidimensional
treatment planning based on CT images
– Beams eye view (BEV)
– film created from a divergent projection through the
CT study data
• 1987-1990 - Sherouse et al – “software analog to
conventional simulation”
– Volumetric CT scan represents virtual patient
– Software functions create a virtual simulator
• 1990 Nishidai et al and Nagata et al and 1994 Perez et al –
CT simulator systems with laser beam projecting device
• 1993-1994 – Commercial systems introduced
CT simulator
• CT scanner with
external lasers
• Flat tabletop
• Virtual
simulation
software
CT simulation process
4 5
2
1 CT Simulator
Virtual Dose
CT Scanner
Simulation Calculation
Treatment Planning System
Technology
CT Simulator Evaluation
• Task • Solution?
– Radiation and – AAPM report number 39,
patient safety – AAPM TG53 report
– CT dosimetry – AAPM TG66 report
– Evaluation of
electromechanical –www.impactscan.org
components
– Evaluation of image
quality
Generations
3rd Generation CT Scanner
• Fan Beam
• Rotate/Rotate
Generations
4th Generation CT Scanner
• Fan Beam
• Rotate/Stationary
X-ray Tube – Historical Limitation
• Heat generation - inefficiency
• Large number of images per
study
– DRR quality
– Target delineation
• Rapid study acquisition time
– Spatial and temporal integrity
– Motion artifacts
• Large heat anode storage
ability (MHU): 5+ MHU tubes
• Fast anode cooling rate
(MHU/min)
Image Generation – Single Slice
One Rotation – One Image
CT scanner – Single and multi-slice scanning
• Wider collimator widths
• Post patient collimation
• Multiple area detectors
– 1992 - Elscint CT Twin - first CT
scanner capable of simultaneously
acquiring more than one transaxial
slice
– 1998 – Four major manufacturers
introduce scanners capable of
scanning 4 slices simultaneously
– Today - 64+ slice scanners
commercially available
Multislice CT
1
One Rotation – Multiple Images
Detector Configuration
16-Slice Scanner
4 x 1.5 mm 8x0.75 mm 8x0.75 mm 4 x 1.5 mm
24 detector elements
Courtesy Philips Medical Systems, Inc.
Detector Configuration
16-Slice Scanner
TUBE
24mm collimation
8 x 3mm collimation
3mm slice
thickness
3mm 3mm 3mm 3mm 3mm 3mm 3mm 3mm
CT scanner – Multi-slice scanning
• Faster scan times
– 4 slice scanner example (8 times faster):
» multi: 0.5 sec/rotation and 4 slices/rotation
» single: 1 sec/rotation and 1 slice/rotation
• Lower tube heat loading
– Longer volume covered per rotation
• Improved temporal resolution - faster scan times
• Improved spatial resolution – thinner slices
• Decreased image noise – more mA available
Resolution
• The lower limit on slice thickness for most
single slice scanners in radiotherapy is 3 mm
• Often 5 and 8 mm slices were used
• Multislice scanners can acquire 0.75 mm thick
slices with equivalent scan parameters
• Everything else being equal thinner slice
thickness produces better DRRs
DRR Image Quality
• Everything else being equal, thinner slices produce better images
• Balance between large amounts of data and image quality
5mm Slices 3mm 0.8mm
DRR Image Quality
5mm Slices 3mm 0.8mm
DRR Image Quality
800 Images – 0.8 mm slice thickness
Image Reconstruction
•Voxel:
–Volume element representing the slice thickness or
depth of the image.
–3 Dimensional
•X
Y
•Y
X
•Z
Z
Isotropic Imaging
• Square isotropic voxels X = Y = Z
• Sub-millimeter slice thicknes
• Multi Planar Reconstruction
– Sagittal
– Coronal
Y
• Multi Planar Contouring
X
Z
Isotropic Resolution
• Multi-planar contouring
– Axial
– Sagittal
– Coronal
• Resolution the same
in all three planes
• It does not matter
which plane is used
for contouring
Isotropic Resolution
Data Issues
• Image viewing speed
• Network Traffic
• Archiving
• Dose calculation
• Need tools to allow use of data without
compromise in treatment planning speed
Multi-slice CT - Speed
• Single slice scanner – 30 seconds
• Multi slice scanner – 2 to 4 seconds
• Dynamic CT
• 4D CT
• 5D CT
• Gating
• Tumor motion
Multi-slice CT - Dynamic CT
Approximately – 7000 images
Multi-slice CT - Dynamic CT
Multi-slice CT- mAs
• mAs – proportional to number of photons
• Number of photons affects noise (image quality)
• Single slice scanner – 150 to 300 mAs
• Multi slice scanner – up to 2000 mAs
• Increasing mAs increases patient dose from a CT scan
• Increase in dose is a significant concern in diagnostic
scanning
• Dose from a CT scan is insignificant compared to
therapy dose
• Can take advantage of available mAs in radiotherapy
scanning
Contrast Resolution
– A measure of a scanners – Soft tissue contrast
sensitivity, or the ability to – Affects ability to
discriminate small changes contour structures
in density
200 mAs 1000 mAs
200 mAs 300 mAs 400 mAs
600 mAs 700 mAs 1000 mAs
300 mAs 1000 mAs
Spatial Resolution
• Rows and columns form
a matrix.
– 512x512
– 768x768
– 1024x1024
Image Reconstruction
• Pixel:
– Picture element representing both the density and area of
a small portion of the image.
– Size is very important!
– Pixel size = Field of View (FOC) divided by the display
matrix.
– 480/512 = 0.94 mm
– 300/512 = 0.59 mm Y
– 480/1024 = 0.47 mm X
– 300/1024 = 0.29 mm
Resolution
Low resolution High resolution
CT scanner – Bore size
85 cm Bore Opening 70 cm Bore Opening
CT scanner – Bore size
Patient Size
CT scanner – Bore size
Mantle Field
CT Time Line
Helical Commercial Large 16 slice 64 slice
Scanning CT-simulator Bore SS sub 0.5
85 89 92 94 98 00 01 02 04
Dual slice 4-slice 8-slice Large
Slip Ring Scanning 0.5 sec 0.5 sec Bore MS
Paradigm Shift
• CT scanners used to be made for
diagnostic radiology and then modified
for radiotherapy
• There are new CT scanners that were
specifically designed for radiotherapy
• Or they have special features that are
designed for radiotherapy
CT Scanner Selection
• Small Bore vs. Large Bore
– Patient population
– Conventional simulator availability
– The question will (has) become:
» How large? (80, 82, or 85 cm)
• Single Slice vs. Multi Slice
– DRR quality
– Image quality
– 4D CT
– The question will (has) become:
» How many? (2, 4, 6, 10, 16, 40, … cone beam)
Commissioning and QA
Geometric Accuracy
Tasks
– Radiation and patient safety
– CT dosimetry
– Evaluation of electromechanical
components
– Evaluation of image quality
Radiation and Patient safety
• Patient Safety • Radiation Safety
– Interlocks – Workload – potential pitfall
» Significant increase
– Electromechanical
» Shielding design
– Door Interlock
» NCRP 147
– CTDI
» Radiation survey
» Definition
» Multislice CT
Electromechanical Components
• X-ray Generator
• Gantry Alignment
• Table Alignment/Accuracy
• Laser Alignment/Accuracy
Electromechanical Components
x-ray Generator
• Need a non-invasive
meter
– kV accuracy
– Timer accuracy
– mA linearity
– HVL
measurements
CT Simulator Mechanical Alignemnt
Electromechanical Components
Gantry Alignment/Accuracy
• Gantry tilt accuracy
• Gantry vertical
– Imaging plane
orthogonal to the couch
top
• Gantry vertical
placement
reproducibility
– Especially important for
dual purpose scanners
Electromechanical Components
Table Alignment/Accuracy
• Tested with weight
– Settle
– Sag
• Tabletop motion
orthogonal/parallel with
the imaging plane
• Table positional
accuracy/reproducibility
– Vertical
– Longitudinal
Electromechanical Components
Laser Alignment/Accuracy
• Lasers orthogonal/parallel
with the imaging plane
• Lasers spacing
• Laser positional accuracy
– Absolute
– Linearity
– Reproducibility
• Coordinate system
orientation
Image Quality Indicators
• Quantitative • Qualitative
– Phantom Measurements – Physician Preferences
» High Contrast » Tumor
» Low Contrast » Normal Structures
» Uniformity » DRR/DCR Objects
» Spatial Integrity » Workflow
» Artifacts » Customized protocols
» Slice thickness
» CT # accuracy
Image Performance
Catphan 500
CTP401 CTP515
CTP445 CTP528 CTP486
Resolution (High Contrast)
• Ability of the system
to record separate
images of small
objects that are
placed very close
together
Subject Contrast (Low Contrast)
• Ability of a system
to resolve adjacent
objects with small
density differences
• Noise limited
Field of View (FOV)
60 cm
Uniformity
True vs. Extrapolated FOV
From impactscan.org report 05071
Evaluation of Extrapolated FOV
From impactscan.org report 05071
Image Performance Evaluation
Evaluation of CT Simulation Software
• What is CT-simulation Software
• Image input verification (data transfer)
– Orientation
– Spatial accuracy
• Structure delineation
• Isocenter calculation and movement
• Output parameters and connectivity
Dynamic DCRs
Dynamic DRR
Conclusions
• CT will remain the primary imaging modality in
radiotherapy
• CT simulator only departments
• Large bore multislice CT will become standard
scanners for radiotherapy
• Existing documents (Report #39, tG66, TG53) are
a good foundation
• New CT scanning capabilities/parameters can be
evaluated with the existing recommendations
