Quality Assurance in Radiation Therapy:

Simulators & Ancillary Equipment

ICPT School on Medical Physics for Radiation Therapy

Justus Adamson PhD
Assistant Professor
Department of Radiation Oncology
Duke University Medical Center
Topics

Overview & Quality Assurance of:

•  Radiographic Simulators
•  CT-Simulators
•  MV image guidance
•  kV image guidance
•  Patient support systems
•  Patient immobilization devices

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 Radiographic Simulators

field light X-ray source with

adjustable collimation &
source-to-axis distance

rotating
gantry
localizing laser
(not shown)

Imager with adj.

distance to axis

patient support
assembly

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 Radiographic Simulators
X-ray source with CBCT capability
adjustable collimation

field light
rotating
gantry

patient support
assembly

Imager with adj.

distance to axis
localizing laser
(not shown)
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Radiographic Simulators:
Components & Purpose
•  Components:
–  Imaging source & detector
–  Localizing lasers
–  Optical distance indicator
–  Field light
–  Patient support assembly
•  Purpose: to reproduce the geometric conditions of
the radiation therapy equipment
–  Should be subject to the same mechanical checks as linear
accelerators
–  Image quality should be checked following guidelines for
diagnostic radiography

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Radiographic Simulators QA:
Reports, Recommendations, & Guidelines
•  AAPM:
–  Report 46, Task Group 40, “Comprehensive QA for
Radiation Oncology” (1994)
–  http://www.aapm.org/pubs/reports/RPT_46.PDF

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Radiographic Simulators QA:
Recommended Frequency & Tolerances (AAPM)

essentially the
same as linac

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AAPM Report 46, Task Group 40, “Comprehensive QA for Radiation
Oncology” (1994)
 CT Simulators
External lasers for water bath for
marking origin/isocenter CT contrast injector thermoplastic masks

CT control room CT bore Internal CT lasers flat patient

support table

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CT Simulation Process

1.  CT Scan, patient positioning, immobilization

1.  similar to diagnostic CT
2.  added requirements of localization (lasers) &
immobilization
2.  Treatment planning & CT simulation
1.  performed in treatment planning system: contouring,
isocenter placement, selection of treatment geometry,
documentation
3.  Treatment setup
1.  setup at machine according to instructions from CT-
simulation & treatment planning

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Simulation Process at CT

•  Patient aligned in
treatment position
•  Immobilization
prepared
•  Laser origin marked
(location of lasers
during CT)
•  CT image acquired
•  Isocenter marked
(optional)
•  Patient setup
instructions recorded

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 CT Simulation Setup Examples:

laser location
Marked
(often fiducials placed for CT)
Immobilization
details noted

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CT Simulator: Components

•  Bore / CT apparatus
•  Internal/external localizing lasers
•  Patient support (flat table top to mimic treatment
table)

12
AAPM Report 83, Task Group 66, “Quality assurance for computed-tomography simulators and the
computed tomography simulation process” (2003)
QA of CT Simulators:
Reports, Recommendations, & Guidelines
•  AAPM:
–  Report 46, Task Group 40, “Comprehensive QA for
Radiation Oncology” (1994)
•  http://www.aapm.org/pubs/reports/RPT_46.PDF
–  Report 83, Task Group 66, “Quality assurance for CT and
the CT simulation process” (2003)
•  http://www.aapm.org/pubs/reports/RPT_83.pdf
–  Report 39, Task Group 2, “Specification and Acceptance
Testing of Computed Tomography Scanners” (1993)
•  http://aapm.org/pubs/reports/RPT_39.pdf

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 CT Simulators:
AAPM TG66 Recommended QA
•  Radiation Safety: shielding Imaging tests:
survey •  CT number accuracy
•  Radiation dosimetry: CTDI •  Image noise
•  Lasers: alignment with imaging •  In plane spatial integrity
planes •  Field uniformity
•  Tabletop: •  Electron density to CT
–  alignment with imaging planes conversion
–  indexing & position
•  Spatial resolution
•  Gantry tilt accuracy
•  Contrast resolution
•  Scan localization
•  CT dosimetry:
–  dose from CT scan (CTDI)
–  radiation profile width
–  sensitivity profile width
•  Generator tests

14
AAPM Report 83, Task Group 66, “Quality assurance for computed-tomography simulators and the
computed tomography simulation process” (2003)
 CT Simulator QA: Laser Alignment
distance between external lasers and
the gantry (& imaging plane) is typically
•  Three sets of lasers: fixed at 50cm

wall mounted overhead sagittal

gantry lasers lasers (external) laser (external)

gantry lasers should accurately external lasers should be

identify scan plane accurately spaced from imaging
& should be parallel and plane
orthogonal with scan plane & & should be parallel and
orthogonal with scan plane &
intersect center
intersect at a point co-incident
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with center
CT Simulator QA: Laser Alignment

16
AAPM Report 83, Task Group 66, “Quality assurance for computed-tomography simulators and the
computed tomography simulation process” (2003)
CT Simulator QA: Laser Alignment

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 CT Simulator QA: Laser Motion

•  External lasers can often be

shifted to mark a new isocenter
after CT
•  Laser motion should be
accurate, linear, & reproducible

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 CT Simulator QA: Tabletop

•  (often) has ability to

“register” immobilization
devices at specified
positions
•  Necessary criteria:
–  should mimic treatment
table
–  flat, level, orthogonal
–  similar sag properties
–  motion indicators & table
position should be
accurate & reproducible
interlocking immobilization devices 19
CT Simulator QA: Tabletop

ensure table is level

relative to both gravity &
imaging plane

verify accuracy of longitudinal

& vertical table motion

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 CT Simulator QA: Gantry Tilt

•  Many CT gantries can be

tilted for diagnostic scans
–  not typically used for CT
simulations
•  Accuracy of tilt (especially
at 0˚) should be verified
–  TG66 recommendation:
verify with film
•  Suggestion: mark the
external laser position on
the scanner with the
gantry level
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CT Simulator QA: Scan Localization
(from Scout Image)

•  Scan range is
defined using a
scout image
•  Verify actual
scanned volume
corresponds to
requested scan
volume
•  Also verify radiation
& sensitivity profile
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CT Simulator QA: Radiation Profile

•  evaluates “pre-patient” collimation

•  dose profile prior to detector collimation
•  excessively wide radiation profile can result in
unnecessary patient dose
•  excessively narrow radiation profile can result in
increased quantum noise
•  measurement: full width at half maximum of
exposed film (measured for each slice thickness)

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CT Simulator QA: Sensitivity Profile

•  evaluates “post-patient”
collimation (it is a function of
pre- and post- patient
collimation)
•  defines actual width of imaged
slice
•  excessive sensitivity profile
width can lead to loss of
resolution in longitudinal
direction
•  excessively narrow sensitivity
profile can result in increased
quantum noise
•  measurement:
–  use inclined metal ramp
–  length of ramp in image slice can
be used to calculate slice
thickness

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Catphan manual
CT Simulator QA: Sensitivity Profile

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Catphan 700 manual
 CT Simulator QA: CTDI

•  CTDI: Integrated dose

(along z-axis) from one
CTDIw = 2/3 CTDI100(surface) + 1/3
axial CT slice CTDI100(center)
•  CTDI100mm is what is
measured in practice N=number of simultaneous axial
•  CTDI is usually ~2x higher scans per rotation (multi-slice CT)
at the surface Axial:
•  Dose Length Product
(DLP): defines total energy
absorbed by a scanned
volume: I=table increment T=thickness of
per axial scan one axial scan

Helical:

26
AAPM Report 83, Task Group 66, “Quality assurance for computed-tomography simulators and the
computed tomography simulation process” (2003)
CT Simulator QA: CTDI

•  2 phantoms utilized:
–  head:
•  length=15cm
•  diameter=16cm
–  body
•  length=15cm
•  diameter=32cm
–  holes for chamber:
•  central hole
•  4-8 periphery holes

27
AAPM Report 83, Task Group 66, “Quality assurance for computed-tomography simulators and the
computed tomography simulation process” (2003)
 CT Simulator QA: CTDI
chamber exposure calibration factor (R/C)

converts exposure in air to

electrometer correction (C/Rdg) absorbed dose in medium. (0.94
cGy/R for muscle @ Eeff=70keV)
temperature & pressure
correction

28
AAPM Report 83, Task Group 66, “Quality assurance for computed-tomography simulators and the
computed tomography simulation process” (2003)
CT Simulator QA: Generator Tests

•  Tests include:
–  peak potential (kVp)
–  half value layer (HVL)
–  mAs linearity
–  mAs reproducibility
–  time accuracy
–  (possible focal spot size)
•  Measurement
preferences:
–  Non-invasive
measurement preferred
–  Performed with kV tube
“parked”

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 CT Simulators:
AAPM TG66 Recommended QA
Component   Frequency   Tolerance  
Radiation safety survey   initially   regulatory limits  
Patient dosimetry from CT annually & after component ±20% manufacturer
(CTDI)   replacement   specs  
daily/monthly & after laser
Laser alignment   adjustment   ±2mm  
Table: orientation relative to
imaging plane   monthly & after laser adjustment  ±2mm  
Table: vertical & long. motion   monthly   ±1mm  
Table: indexing & position   annually   ±1mm  
Gantry tilt accuracy   annually   ±1˚  
Scan localization   annually   ±1mm  
Radiation profile width   annually   manufacturer specs  
Sensitivity profile width   semi-annually   ±1mm  
initially & after component
Generator tests   replacement   manufacturer specs  
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AAPM Report 83, Task Group 66, “Quality assurance for computed-tomography simulators and the
computed tomography simulation process” (2003)
CT Simulators:
AAPM TG66 Recommended Imaging Tests
•  CT number accuracy
•  Image noise
•  In plane spatial integrity
•  Field uniformity
•  Electron density to CT conversion
•  Spatial resolution
•  Contrast resolution

31
AAPM Report 83, Task Group 66, “Quality assurance for computed-tomography simulators and the
computed tomography simulation process” (2003)
 CT Simulator Imaging QA:
CT# accuracy & in high contrast
plane spatial integrity resolution

low contrast
resolution uniformity & noise

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 CT Simulators:
AAPM TG66 Recommended (Imaging) QA

Imaging Test   Frequency   Tolerance  

daily / monthly / annually
CT number accuracy   (less to more comprehensive)  0 ± 5 HU for water  
Image noise   daily   manufacturer specs  
In plane spatial integrity   daily / monthly   ±1mm  
monthly (most common kVp),
Field uniformity   annually all kVps   within ±5HU  
Electron density to CT
number conversion   annually & after calibration   consistent with baseline  
Spatial resolution   annually   manufacturer specs  
Contrast resolution   annually   manufacturer specs  

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AAPM Report 83, Task Group 66, “Quality assurance for computed-tomography simulators and the
computed tomography simulation process” (2003)
MV Image Guidance:

MV (portal) imager
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MV Image Guidance: 2D Imaging

Digitally Reconstructed
Radiograph (DRR) MV Projection Image

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 MV (Portal) Imaging

Why do megavoltage portal images have such poor

contrast compared to diagnostic images?

•  Compton effect has weak Z

dependence, very little
differential absorption
•  diagnostic: photoelectric
dominates
•  MV: Compton dominates
•  Scattered photons +
secondary electrons -> not
easily removed
•  Large penumbra: geometric +
phantom scatter

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3D MV Imaging: MVCT (Tomotherapy)

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 MV CBCT (Linac): kV CT (diagnostic)
vs MV CBCT
kV CT (diagnostic) MV CBCT

5-15 cGy 38
kV Image Guidance:

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kV Based IGRT

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William Beaumont Hospital, 2002
Conventional CT

CBCT

~2 cGy
kV Image Guidance:
3D image registration

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MV & kV Image Guidance Systems:
Reports, Recommendations, & Guidelines
•  AAPM:
–  Task Group 142, “Quality assurance of medical accelerators” (2009)
•  http://www.aapm.org/pubs/reports/RPT_142.pdf
–  Task Group 104, “The Role of In-Room kV X-Ray Imaging for Patient
Setup and Target Localization” (2009)
•  http://www.aapm.org/pubs/reports/RPT_104.pdf
–  Task Group 179, “QA for IGRT utilizing CT-based technologies” (2012)
•  http://www.aapm.org/pubs/reports/RPT_179.pdf
–  Task Group 58, “Clinical use of electronic portal imaging” (2001)
•  http://www.aapm.org/pubs/reports/RPT_75.pdf
–  Task Group 148, “QA for helical tomotherapy” (2010)
•  http://www.aapm.org/pubs/reports/RPT_148.pdf
–  Task Group 75, “Management of imaging dose during IGRT” (2007)
•  http://www.aapm.org/pubs/reports/RPT_95.pdf
–  Task Group 23, “The measurement, reporting, and management of
radiation dose in CT” (2008)
–  Task Group 179, “QA for IGRT utilizing CT-based technologies” (2012)
•  Islam et. al., “Patient dose from kV CBCT imaging in radiation
therapy” (2006)
–  http://dx.doi.org/10.1118/1.2198169
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3D (Tomographic) IGRT:

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 3D IGRT Geometric Calibration

geometric calibration of kV x-
ray imaging system relative to
MV

“flexing” of detector is
corrected as a function of
gantry angle

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 3D IGRT Geometric Calibration

daily check of geometric accuracy

absolute flex

residual flex
~0.25mm

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Imaging Panel Calibration

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3D CBCT:
panel shift to achieve larger field of view

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3D CBCT: Bowtie Filter(s)
half fan full fan

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kV/MV Image Guidance Routine QA:

Planar (2D) Imaging: 3D Imaging

•  Collision interlocks •  Collision interlocks
•  Positioning / Repositioning •  Positioning / Repositioning
•  Imaging & Treatment •  Imaging & Treatment
Coordinate Coincidence Coordinate Coincidence
•  Scaling •  Geometric Distortion
•  Spatial Resolution •  Spatial Resolution
•  Contrast •  Contrast
•  Uniformity & Noise •  HU Constancy
•  Imaging Dose •  Uniformity & Noise
•  Beam quality / energy (kV) •  Imaging Dose
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AAPM Task Group 142, “Quality Assurance of Medical Accelerators” (2009)
kV/MV Image Guidance QA:
Positioning / Repositioning
•  More important than
image quality in
IGRT setting!
•  Basic functionality
test for image
guidance
–  setup phantom
–  image
–  shift based on
imaging
–  verify shift

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kV/MV Image Guidance QA:
Imaging & Treatment Coordinate Coincidence
device for 2D imaging:
•  Each imaging system
has its own
coordinate system
•  Correlation with
delivery coordinate MV image:
system through a kV image:
calibration process
•  Example: verify kV
isocenter coincidence
with MV isocenter
–  image same setup
with MV & kV
device for
3D imaging:
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Scaling
2D

•  Ensure accurate
image scaling
•  Performed by using
imaging software to
measure known
3D
distances in each
axis
•  For 2D: distance from
source is important
due to magnification

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 2D IGRT QA:
Contrast & Spatial Resolution

kV phantom: MV phantom:

spatial resolution

contrast resolution orientation of

phantom relative
to detector array
matters!

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2D IGRT QA:
Uniformity & Noise

kV uniformity MV uniformity

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3D IGRT Image Quality Tests:
Similar to diagnostic CT
CT# accuracy: CT# accuracy:
diagnostic CT kV CBCT

CT#s are relative for

Often CT#s are calibrated
CBCT due to large
using a phantom scan to
proportion of scatter in
match the expected values.
projection images
Accurate CT# in phantom may
not translate to accurate CT#s
in a patient!
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3D IGRT Image Quality Tests:
Similar to diagnostic CT
high contrast resolution: high contrast resolution:
diagnostic CT kV CBCT

high contrast resolution will

be dependent on the imaging
protocol

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 3D IGRT Image Quality Tests:
Similar to diagnostic CT
low contrast resolution low contrast resolution
diagnostic CT kV CBCT

poorer low contrast resolution uniformity & noise uniformity & noise
for CBCT (expected) diagnostic CT kV CBCT

CT#s monitored relative to a

baseline (due to expected
differences from truth)
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MV IGRT Imaging Dose:

•  Imaging is done with the treatment beam hence

dose can be directly calculated using treatment
planning system / hand calculation
•  Exception: some linear accelerators have a lower
energy (1MV / 2.5MV) used only for imaging

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 kV IGRT Imaging Dose & Beam Quality

•  2D: many meters are •  3D:

available to measure –  Farmer chamber in
kVp, HVL, exposure to cylindrical phantom
skin, etc. (CTDI phantom)
–  Nk calibration factor

61
kV/MV Image Guidance:
Recommendations for Daily QA

daily:
functionality &
geometric
accuracy

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kV/MV Image Guidance:
Recommendations for Monthly QA

monthly: geometric
+ image quality

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kV/MV Image Guidance:
Recommendations for Annual QA

annual: geometry,
imaging dose,
beam quality

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Recommended QA & Tolerances

65
 Patient Support Systems:

QA
•  Geometric:
–  accuracy of table index, &
patient re-positioning
–  accuracy of couch angle
–  pitch & roll accuracy (for 6-
degree capable tables)
•  Dosimetric:
–  increased skin dose
–  reduced tumor dose
–  altered dose distribution

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 Weight Limits:

Bore

 Weight Limit
Diameter Image FOV (cm)!
# (Lbs)!
(cm)!
Exact couch# 500#
Truebeam 500 (440 end)
Brainlab Robotic Couch# 275#
Brainlab Non-Robotic# 350#
TrueBeam STX (Perfect Pitch) 440
Linac (CBCT)# 440# 45 or 25 (~ 15 in S/I)#
Simulator# 600#
CT Simulator (GE OptimaCT580RT)# 500# 80# 65#
CT Simulator (Siemens)# 660# 78# 50 (78 ext. recon)#
PET/CT Simulator (Siemens)# 500# 78# 50 (78 ext. recon)#
CT Simulator (Phillips)# 650# 85# 60 (70 ext. recon)#
MR (GE)# 350# 60# 48#
MRI (GE OptimaMR45W)# 500# 70# 50#
Know your machine limits, & keep available for reference
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Couchtop Dosimetric Considerations:
Increased Skin Dose

increased surface dose

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AAPM Task Group 176, “Dosimetric effects caused by couch tops and immobilization devices” (2014)
Couchtop Dosimetric Considerations:
Attenuation (at Depth)

attenuation can be
considerable even for
carbon fiber couches (this
one has a foam core)

the amount of
attenuation can vary
based on geometry

69
 Patient Support Systems:
Couch Attenuation

•  Couch attenuation can be managed by:

–  using transmission factor in hand calculation
–  modeling the couch in the treatment planning
system
–  do nothing (when attenuation is negligible)

couch models in the treatment planning system

HU values
can be
specified

70
 Patient Support Systems:
Couch Attenuation

•  Some tables
have adjustable
support bars with
high attenuation!
•  Take care to
make sure the
beam doesn’t
enter through
them

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AAPM Task Group 176, “Dosimetric effects caused by couch tops and immobilization devices” (2014)
Immobilization Devices:
Dosimetric Considerations
•  Can be accounted for manually (using attenuation
factor) or within the planning system
•  Within TPS:
–  include in CT at time of simulation
•  Measurements:
–  attenuation point measurements: ion chamber at depth in
phantom
–  surface dose measurements:
•  extrapolation chamber
•  plane parallel chamber
•  OSL/TLD
•  Film

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Immobilization Devices:
Measured Transmission Factors:

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Immobilization Devices

74
AAPM Task Group 176, “Dosimetric effects caused by couch tops and immobilization devices” (2014)
Immobilization Devices

•  Avoid entrance
through devices
when possible

75
AAPM Task Group 176, “Dosimetric effects caused by couch tops and immobilization devices” (2014)
THANK YOU

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Additional Notes:

•  CT Simulators often include tools for motion

management
–  4DCT
•  MIP
•  AIP
•  Min-IP
–  Breath hold CT

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 x-ray off (table translation)

4DCT

end expiration

end inspiration

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4DCT Breathing Signal

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 4DCT Reconstruction

Maximum Average Minimum

Intensity Intensity Intensity
Individual Projection Projection Projection
phases (MIP) (AIP) (MinIP) Color AIP

80
 4DCT

3D Free
Breathing (FB) 4DCT AIP 4DCT MIP

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Gating:

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