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Can CT scan protocols used for radiotherapy treatment planning be adjusted

to optimise image quality and patient dose? A systematic review

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DOI: 10.1259/bjr.20160406

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Davis AT, Palmer AL, Nisbet A. Can CT scan protocols used for radiotherapy treatment planning be adjusted to optimize image quality and
patient dose? A systematic review. Br J Radiol 2017; 90: 20160406.

REVIEW ARTICLE
Can CT scan protocols used for radiotherapy treatment
planning be adjusted to optimize image quality and patient
dose? A systematic review
1,2 1,2 1,3
ANNE T DAVIS, BSc, MIPEM, ANTONY L PALMER, PhD, FIPEM and ANDREW NISBET, PhD, MSc
1
Department of Physics, Faculty of Engineering and Physical Science, University of Surrey, Guildford, UK
2
Department of Medical Physics, Portsmouth Hospitals NHS Trust, Portsmouth, UK
3
Department of Medical Physics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK

Address correspondence to: Miss Anne Teresa Davis

E-mail: [email protected]

ABSTRACT
This article reviews publications related to the use of CT scans for radiotherapy treatment planning, specifically the
impact of scan protocol changes on CT number and treatment planning dosimetry and on CT image quality. A search on
PubMed and EMBASE and a subsequent review of references yielded 53 relevant articles. CT scan parameters
significantly affect image quality. Some will also affect Hounsfield unit (HU) values, though this is not comprehensively
reported on. Changes in tube kilovoltage and, on some scanners, field of view and reconstruction algorithms have been
found to produce notable HU changes. The degree of HU change which can be tolerated without changing planning dose
by .1% depends on the body region and size, planning algorithms, treatment beam energy and type of plan. A change in
soft-tissue HU value has a greater impact than changes in HU for bone and air. The use of anthropomorphic phantoms is
recommended when assessing HU changes. There is limited published work on CT scan protocol optimization in
radiotherapy. Publications suggest that HU tolerances of 620 HU for soft tissue and of 650 HU for the lung and bone
would restrict dose changes in the treatment plan to ,1%. Literature related to the use of CT images in radiotherapy
planning has been reviewed to establish the acceptable level of HU change and the impact on image quality of scan
protocol adjustment. Conclusions have been presented and further work identified.

INTRODUCTION images and subsequently introduce inaccuracies to the

CT images used in radiotherapy treatment planning must dosimetric information produced in the TPS. The disad-
serve two key purposes: to allow, with high geometric fidelity, vantage of this approach is that the quality of the images
the position of the tumour and surrounding tissues along can be compromised, meaning that the identification and
with organs at risk to be accurately identified and to provide outlining of key structures is performed on a suboptimal
a map of the electron density information for the various image. Inaccuracies and variability in the outlining process
tissues to be used in the treatment planning system (TPS) are well known and can represent a significant source of
dose calculation. Most radiotherapy centres now have access uncertainty in the radiotherapy process.3–6 Their causes
to dedicated CT scanners which are designed solely for ra- include the level of expertize and training of the clinician in
diotherapy. The opportunity therefore exists to optimize scan anatomical and image interpretation; pathological varia-
protocols to best support imaging objectives for radiotherapy. tion in the patient; decision making with regard to the level
of likely spread of disease; and difficulties with dis-
CT scan protocols used in diagnostic imaging departments tinguishing between tissues of similar densities.7–9 For the
routinely vary reconstruction algorithm, slice width, tube last point, poor-quality CT images will certainly be detri-
current, field of view (FOV) and other parameters to mental to the process. Additionally, the use of auto-
produce high-quality images to match the imaging task. contouring systems might require the adjustment of CT
On radiotherapy CT scanners, a “one-size fits all” approach image acquisition to allow the autocontouring systems to
is sometimes taken with minimal variation of scan work effectively. Whitfield et al,10 in their review article on
parameters.1,2 This conservatism relates to the concern that automatic delineation, comment that the definition of
varying scan parameters will change HU values in the a minimum standard for image quality is necessary.
 BJR Davis et al

The technological developments in CT are advancing rapidly and electron density. The TPS models the interactions of the treat-
new features such as metal artefact reduction, dual-energy im- ment beams within the patient and through use of a dose cal-
aging, iterative reconstruction and automatic kilovoltage selection culation algorithm produces density-corrected dose calculations.
are becoming common on CT scanners.11–16 Some of these Different types of planing algorithms are used by commercial
developments could help to improve the quality of radiotherapy TPSs. They differ in complexity and the methodology used to
planning CT (PCT) scans. Additionally, adjustment of more model the beam interactions.20 The choice of the algorithm
fundamental scan parameters such as reconstruction algorithms affects the accuracy of the dose calculation for different treat-
and FOV to better match the body region imaged would deliver ment regimes and the speed of calculation.21,22 In practice, the
higher image quality and potentially improve accuracy at the CT calibration is a plot of HU vs relative electron density (RED)
outlining stage. If these new techniques are to be considered or values for a range of different materials. The RED is the electron
existing scan protocols optimized, it is important that there is density of a material relative to water. Typical RED values are 0.2
a good understanding about the level of HU variation which can for lung, 1.0 for water and 1.5 for bone.23 The relationship is
be tolerated for different CT imaging techniques, without ad- generally bilinear with different linear equations describing the
versely affecting the dose distribution in the planning process. The relationship between RED and HU for different materials above
objective of this review is two-fold: to review the literature so as to and below approximately 100 HU.24–26 The reason for this
establish the accuracy of HUs required in CT images when used change for high atomic number materials is the proportion of
for radiotherapy and to summarize the work that has already been compton vs photoelectric interactions of the X-ray.27 The curve
published related to CT scan protocol adjustment to ensure good is usually defined when a TPS is commissioned.28 Some plan-
quality imaging for radiotherapy at reasonable levels of dose. ning systems allow the use of several curves to accommodate
information from different CT protocols. Some TPSs use
It should be noted that the focus of this review is voxel-by-voxel- physical density instead of electron density.
based CT planning. Alternative planning methods used involve
bulk electron density allocation. This categorizes tissues into typ- A number of TPS-commissioning guidance documents discuss
ically three or four types such as bone, air, soft tissue and muscle the CT calibration curve and tolerances for accuracy. The In-
and allocates them pre-defined electron density values. Studies ternational Atomic Energy Agency (IAEA) quotes a requirement
have shown that planning dosimetry using this method can match of 3% accuracy for calculated doses.23 Other authors have quoted
the voxel method to within a few percentages.17–19 It is often used 1–2%.22,29 The IAEA tolerance for accuracy of HU is given as 6
in MRI and cone beam imaging where HU data are unavailable or 20 HU, corresponding to RED variation of 60.02.23,30,31 This is
unreliable. This area of work is beyond the scope of this article. used for materials of different densities ranging from air to water
and up to bone. Example data in IAEA document Techdoc-1583
METHODS AND MATERIALS shows that the CT calibration curve may vary for different CT
Search strategy scanners, particularly for materials which are denser than wa-
Searches were carried out using PubMed and EMBASE. The ter.31 Data also show the variation of CT values measured on the
search was restricted to articles in English and initially to articles CRIS 002LFC thorax phantom (CIRS Treatment; Simulation and
published between 2000 and 2016. Key terms used were radio- Phantom Technology, Norfolk, VA). For bone-equivalent mate-
therapy planning, computed tomography, calibration, phan- rial, HU values varied from 780 to 900 for different scanners.
toms, electron density and image quality. The search was The authors indicate that in radiotherapy treatment, this would
narrowed by positively excluding articles including the following result in a 2% error for a 6-MV photon beam passing through
terms: PET, SPECT, ultrasound, 4D gated and brachytherapy. 5 cm of the bone-equivalent material. This equates to a variation
The search was subsequently supplemented by reviewing the lists of 660 HU producing a 61% error in calculated dose for these
of references in the articles which were read in detail. Addi- beam conditions. This appears to imply, though it is not stated,
tionally, summary articles related to the use of imaging in ra- that a tolerance wider than 620 HU is acceptable at the higher
diotherapy and published in the Institute of Physics and density end of the CT calibration curve.
Engineering in Medicine’s professional magazine SCOPE were
reviewed for further references. Only publications which dis- Guidance has been produced by several professional bodies and
cussed the use of CT for radiotherapy planning and related is summarized in Table 1. Referencing the 2% tolerance of RED
sources of inaccuracy were selected for detailed review. for lung given in Institute of Physics and Engineering in Med-
icine Report 88, Kilby et al33 later commented that the tolerance
RESULTS is tight and demonstrated that, for routine quality control results
165 articles were identified and, after the title and abstracts were collected over a year, a CT scanner struggled to meet it.32 The
reviewed, 53 were selected as relevant. 19 of these discussed European Society for Radiotherapy and Oncology and the Swiss
aspects of image quality in CT, the rest focused predominately on Society for Radiobiology and Medical Physics have set tolerances
commissioning the TPS or dosimetry changes in planning due to for quality control constancy tests for non–intensity-modulated
variations in the CT image. No review articles were found. radiation therapy beams.33,34 Both the American Association of
Physicists in Medicine and the Netherlands Commission on
Acceptable variation for Hounsfield units Radiation Dosimetry have produced detailed test protocols but
Tolerances defined in guidance documents no specific tolerances for this parameter.28,36,37 It is possible to
A TPS needs a CT calibration curve to convert the HU values calculate an HU tolerance for the quoted RED tolerance using
of different tissue types or materials in the planning scan to the appropriate equation of the calibration curve.38 Typical

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equations published by Thomas24 were RED 5 (HU/1000) 1 inserts within the phantom will all affect the HU values. An-
1.00 for materials with HU ,100 and RED 5 (HU/1950) 1 1.00 thropomorphic phantoms which mimic patient size and shape are
for HU $100. Calculated values of HU are included in Table 1. recommended.31,40 Craig et al41 used a new design of phantom to
assess three radiotherapy TPSs and found an error in the CT
Experimental investigations related to planning CT calibration curve used in two of them. An incorrect assumption
Rutonjski et al39 audited Elekta CMS XiO TPSs (Elekta In- had been made when the calibration curve was initially defined in
strument AB, Stockholm, Sweden) in three radiotherapy centres the TPS that Teflon could be used as a substitute for cortical bone.
using the IAEA protocol.30 Using the CRIS 002LFC thorax The impact was that at the upper end of the curve, the estimated
phantom, they generated CT calibration curves and compared RED for bone was approximately 40% too high. At 1500 HU, the
the results against the manufacturer-supplied or generic curves RED used was 2.4 instead of 1.7. The authors calculated that using
which were in the TPSs. No information was provided about the 1-cm-thick bone material at a depth of 2 cm in water, the cor-
origin of those curves. The biggest differences between the responding error in dosimetry for an 18-MV X-ray beam was
measured HU values and those already in the TPSs were seen at ,3% at a depth of 5–15 cm in water along the central axis.
the upper end of the calibration curve (RED 5 1.5). For one
centre, the measured HU was 790 compared with the TPS value Cozzi et al42 discussed a scenario where the CT calibration curve
of 890. For the other two centres, the differences were smaller. in the TMS Helax TPS (MDS Nordion Therapy Systems, Uppsala,
Planning calculations were carried out using a point kernel Sweden) could not be edited to account for calibration values
convolution/superposition planning algorithm. The conclusion from the local CT scanner. The difference between the measured
was that this variation would impact on dose accuracy by ,2% data and the default CT calibration data was the greatest for the
for 6-MV photons with 5-cm-thick bone-like material. Al- higher density materials. Where RED 5 1.3, the HU difference
though the study noted that the results at the high-density end was approximately 100 HU and where RED 5 1.5, the difference
of the calibration curve exceeded the IAEA criteria, the decision was approximately 150 HU. The two calibration curves were used
was made not to change the information in the TPS due to the to produce plans for 6- and 15-MV photon beam treatments. The
small impact on dose accuracy. Tests had also been made on CT values used in the fixed TPS calibration curve were higher
a pencil beam convolution, equivalent path length algorithm than the measured values resulting in a degree of underdosing.
which gave significantly different results. Further work and re- The worst case dose difference was 1.9% for 10-cm bone at 6 MV.
view of the literature allowed the authors to conclude that this At a more realistic 3-cm bone thickness at 6 MV, the error was
type of algorithm was not appropriate for lung treatments. ,0.5% and deemed acceptable. A summary is given in Table 2.

The choice of phantom used when collecting data for the CT Chu et al43 looked at HU variation with FOV on a conventional
calibration curve is important.26 The phantom size and shape, CT scanner and a simulator. They established that using
volume of scattering material and the position of the different equivalent path length a change of 20 HU would result in a 2%

Table 1. Summary of tolerances in guidance documents

Tissue type References RED value Defined RED or HU tolerance Corresponding HUa
ESTRO, SGSMP34,35 0.2 60.05 (625%) 650
IPEM 32
0.2 60.004 (62%) 64
Lung IPEM 32
0.4 60.008 (62%) 68
IAEA 23,30,31
0.21 60.02 (610%) or 20 HU 620
AAPM 46
0.2 650 HU –
ESTRO, SGSMP34,35 1.0 60.05 (65%) 650
IPEM32 1.0 60.01 (61%) 610
Soft tissue
IAEA 23,30,31
1.06 60.02 (62%) or 20 HU 620
AAPM 46
1.0 630 HU 630
ESTRO, SGSMP 34,35
1.5 60.1 (67%) 6170
IPEM 34
1.3 60.03 (62%) 650
Bone IPEM 34
1.8 60.04 (62%) 670
IAEA23,30,31 1.6 60.02 (61%) or 20 HU 634
AAPM46 1.3 650 HU –
AAPM, American Association of Physicists in Medicine; ESTRO, European Society for Radiotherapy and Oncology; HU, Hounsfield unit; IAEA,
International Atomic Energy Agency; IPEM, Institute of Physics and Engineering in Medicine; RED, relative electron density; SGSMP, Swiss Society for
Radiobiology and Medical Physics.
a
HU tolerance calculated using Thomas24 equations.

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uncertainty in electron density for soft tissue and a change of bone. The article also presented tolerances for 15-MV pho-
250 HU would result in a 5% uncertainty for the cortical bone. tons which were broader than 6 MV.
Considering different depths of tissue, they concluded that at
6 MV, there was uncertainty in dose of 2% at depths up to 20 cm Kirwin et al38 looked at the HU variation produced by different
of soft tissue. With the addition of 1 cm of bone, this increased head and body reconstruction algorithms on a Siemens Emotion
by ,0.5%. For higher energy beams, the uncertainties were Duo CT scanner (Siemens Healthcare, Erlangen, Germany).
lower. At 18 MV, the 2% dose uncertainty corresponded to soft- They reviewed the articles by Thomas,24 Kilby et al33 and Knoos
tissue thickness of up to 30-cm depth. Finally, the authors et al45 and developed HU tolerances for water (RED val-
looked at clinical cases for brain, lung and pelvis plans. The ue 5 1.002), lung (RED value 5 0.190) and bone (RED 5 1.117
results are given in Table 3. for trabecular bone and RED 5 1.5 for dense bone). The elec-
tron density tolerances developed by Kilby et al and the different
Kilby et al33 aimed to produce electron density tolerances formulae by Thomas and Knoos et al were used to produce HU
with a clear link to the dosimetric error under different tolerances which were 160 (Thomas method) or 210 (Kilby
treatment conditions. Electron density tolerances were gen- method) for bone, 30 for water and 50 for lung. The authors
erated for 6-MV photon beams, with a maximum dose error chose to use the tighter 160 tolerance for bone for their work.
of 2% and for maximum tissue thicknesses of 20 cm of water,
10 cm of lung and 7 cm of bone. The TPS used was Nucle- Recently, there has been extensive investigation into the use-
tron® system (Nucletron BV, Veenendaal, Netherlands) using fulness of on-board cone beam CT (CBCT) systems to support
a Hogstrom model.44 The electron density tolerances were image-guided radiotherapy.46,47 Some studies have assessed the
calculated as 60.03 for water, 60.05 for lung and 60.08 for accuracy of HU values produced by these systems and the

Table 2. Summary of Hounsfield unit (HU) change and resultant dose change from experimental investigations on a single
tissue type

Air or Soft
Tissue type Planning PCT Bone, Dose
Energy lung, tissue,
and algorithm or HU change Reference
(MV) HU HU
thickness (TPS) CBCT change (%)
change change
Hogstrom
25 (RED
6 Lung, 10 cm model PCT – – 0.9 Kilby et al33
change 0.025)
(Nucletron®)
Tissue
6 Lung, 8 cm maximum PCT 35 – – 1.0 Thomas24
ratios
Soft
6 Helax PCT – 20 – 0.7 Cozzi et al42
tissue, 10 cm
Soft
15 Helax PCT – 20 – 0.3 Cozzi et al42
tissue, 10 cm
Soft
6 Helax PCT – 20 – 0.1 Cozzi et al42
tissue, 3 cm
Hogstrom
30a RED
6 Water, 10 cm model PCT – – 1.1 Kilby et al33
change 0.03
(Nucletron)
Tissue
6 Liver, 8 cm maximum PCT – 30 – 1.0 Thomas24
ratios
6 Bone, 3 cm Helax PCT – – 100 0.3 Cozzi et al42
Hogstrom 107a RED
6 Bone, 10 cm model PCT – – change 2.0 Kilby et al 33
(Nucletron) 0.055
6 Bone, 10 cm Helax PCT – – 100 1.6 Cozzi et al42
Tissue
Cranium
6 maximum PCT – – 540 1.0 Thomas24
bone, 1.5 cm
ratios
CBCT, cone beam CT; PCT, planning CT; RED, relative electron density; TPS, treatment planning system.
The Nucletron system was obtained from Nucletron BV, Veenendaal, Netherlands.
a
HU tolerance calculated using Thomas24 equations.

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Table 3. Summary of Hounsfield unit (HU) change and resultant dose change on clinical plans

Air or Soft
Planning PCT Bone, Dose
Energy lung, tissue,
Type of plan algorithm or HU change in Reference
(MV) HU HU
(TPS) CBCT change plan (%)
change change
Collapsed cone
convolution
6 Clinical brain (Pinnacle; Philips, CBCT Not given 20 250 ,1 Chu et al43
Amsterdam,
Netherlands)
Modified Batho
Clinical brain, CBCT
6 method (Eclipse™; Not given 45 Not given ,1 Yoo et al51
five wedged fields vs PCT
Varian, CA)
Modified Batho
Clinical brain, 156a (RED
power law (Varian 50a (RED 30a (RED
6 four PCT change 1.0 Kilby et al33
Cadplan®; change 0.05) change 0.03)
conformal fields 0.08)
Varian, CA)
Collapsed cone
6 Clinical lung convolution CBCT Not given 20 250 HU ,2 Chu et al43
(Pinnacle)
Modified Batho 156a (RED
Clinical lung, 50a (RED 30a (RED
6 power law (Varian PCT change 1.3 Kilby et al33
three field change 0.05) change 0.03)
Cadplan) 0.08)
Collapsed cone
Clinical lung, CBCT 2300 to Disher
6 convolution Not given Not given 210
VMAT 225° vs PCT 2100 HU et al50
(Pinnacle)
Collapsed cone
Clinical lung, CBCT 2200 to Disher
6 convolution Not given Not given 110
VMAT 225° vs PCT 1200 et al50
(Pinnacle)
Collapsed cone
Clinical lung, CBCT Disher
6 convolution 200 to 1100 Not given Not given Close match
VMAT 225° vs PCT et al50
(Pinnacle)
Collapsed cone
6 Clinical pelvis convolution CBCT Not given 20 250 ,2 Chu et al43
(Pinnacle)
Clinical pelvis, Anisotropic analytic CBCT Hatton
6 100 0 100 ,1
five field algorithm (Eclipse) vs PCT et al49
Clinical pelvis, Anisotropic analytic CBCT Guan
6 20 20 500 3.4
seven field IMRT algorithm (Eclipse) vs PCT and Dong48
Clinical pelvis, Anisotropic analytic CBCT Guan
6 20 20 200 0.6
seven field IMRT algorithm (Eclipse) vs PCT and Dong48
Clinical prostate, Modified Batho 156a (RED
50a (RED 30a (RED
16 three field power law (Varian PCT change 1.7 Kilby et al33
change 0.05) change 0.03)
conformal Cadplan) 0.08)
Clinical pelvis, Anisotropic analytic CBCT Guan
18 20 20 500 2.4
four field algorithm (Eclipse) vs PCT and Dong48
Clinical pelvis, Anisotropic analytic CBCT Guan
18 2 20 200 0.3
four field algorithm (Eclipse) vs PCT and Dong48
CBCT, cone beam CT; IMRT, intensity-modulated radiation therapy; PCT, planning CT; RED, relative electron density; TPS, treatment planning system;
VMAT, volumetric modulated arc therapy.
a
HU tolerance calculated using Thomas24 equations.

associated impact on planning dose accuracy. Guan and Dong48 anisotropic analytic algorithm. Firstly, a RED-HU curve was used
planned on CBCT images of a pelvis phantom using a number of which had been acquired on the CBCT system and then a second
different RED-HU curves. Several 18-MV four-field pelvis treat- curve which had been acquired on the PCT. The difference be-
ment plans were produced using the Eclipse TPS with the tween the two RED-HU curves was that the bone HU was

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400 lower for the CBCT curve than the PCT curve. Soft tissue HU Scanner variables which affect Hounsfield units
values were within 20 for both curves. In the resultant plans for There are many variables in a CT scan protocol, and there is
the CBCT image, the central axis dose (Dcax) value was 2.3% evidence that some but not all parameters will change HU values.
lower for the one using the CBCT RED-HU curve. Further work Ebert et al52 investigated the use of the X-ray tube current
was carried out using a third RED-HU curve which had been modulation software on a GE LightSpeed-RT scanner (GE
acquired on the CBCT with a different phantom. Here, the bone Healthcare, Milwaukee, WI). They looked at different materials
HU compared with the PCT RED-HU curve was 200 higher, and including lung and water plus high-density metals such as tita-
in this case, the Dcax dose was 0.3% higher. For a seven-field 6- nium and stainless steel which are used for prostheses. This study
MV intensity-modulated radiation therapy plan, there were larger and others concluded that varying the delivered tube current,
dose differences, with Dcax 3.1% lower where bone HU was 400 either manually or by automatic modulation during scanning,
lower in the CBCT RED-HU curve and 0.3% higher where bone resulted in only minimal variation in HU.27,41,46 None of these
HU was 200 higher in the CBCT RED-HU curve. publications state the degree of HU variation with tube current.
The only exception was in the study by Ebert where a 300 3 160-
Another study, also using the Eclipse TPS with anisotropic an- mm block of solid water containing a stainless steel insert was
alytic algorithm, used a pelvis phantom and a four-field plan. scanned.41 Tube current was 100 mA and tube voltage was 120.
The work investigated the dose difference at the PTV centre RED was very high at 6.7. For 200–400 mA, the measured HU
between plans produced with different TPS calibration curves.49 was 16,500; for 100 mA, the measured HU was 18,000. It should
The baseline plan for the CBCT pelvis image used the RED-HU be noted that 100 mA is an untypical tube current setting for this
calibration curve obtained on the PCT. Another RED-HU curve thickness of tissue. The high degree of noise measured in the
was obtained on the CBCT system and a second plan produced. stainless steel insert indicates underexposure. The CT number at
HU differences on the two calibration curves were, for the CBCT 80 kV was 22,000 6 8000 HU compared with 16,500 6 500 at
curve, 2100 HU for air, 0 HU for soft tissue and 1100 HU for 120 kV. This study highlighted the need to carefully review ex-
bone. This curve gave a dose difference of less than 10.5% at posure settings when high-density materials are scanned but
a reference point in the planning target volume centre com- otherwise concluded that tube current modulation could be used.
pared with when the PCT curve was used to plan the CBCT
image. Planning on a brain was also investigated, comparing Studies have generally identified that varying CT tube voltage
CBCT and PCT plans.51 The TPS was Eclipse using a Modified produces one of the biggest variations of HU. This has been seen
Batho Method planning algorithm. Patients had scans acquired on GE LightSpeed-RT, Siemens Somatom Sensation Open and
on both CBCT and PCT scanners. A single RED-HU calibration Siemens Somatom AR scanners (Siemens, Erlangen, Germany)
curve was used for both sets of plans. The HU values for brain when the tube voltage settings were varied between 80 and
in the CBCT image were 45 HU higher than those in the PCT. 140 kV.2,53,54 For a bone-like material (RED 5 1.2), Ebert et al52
This resulted in up to 1% dose difference in the two treat- measured approximately 450 HU at 80 kV compared with 280 HU
ment plans. at 140 kV, a difference of 170 HU. For metals, the differences were
much greater at .5000 HU. The same degree of HU variation
Disher et al50 investigated a number of different ways to modify with varying tube voltage has been found on Philips (Philips
CBCT HU values for patients with lung cancer. For a 6-MV Healthcare, Netherlands) and Toshiba (Toshiba Medical Systems
volume-modulated arc therapy plan on a Rando Phantom, using Co. Ltd, Japan) scanners.42,56 Kearns and McJury2 measured HU
the collapsed cone convolution algorithm on a Pinnacle TPS, values of 895, 960 and 1320 for dense bone at 80, 120 and 140 kV,
a CBCT image had lung tissue CT values which differed from respectively. After processing the images in their TPS, and with
the PCT image by between 2300 and 2100 HU. A plan was reference to electron density tolerances from Kilby et al,33 they
produced using the RED-HU curve collected on the PCT scan- concluded that 80 kV should not be used for planning scans. In
ner and also another using a second curve collected on the practice, 80 kV is only likely to be of use when imaging paediatric
CBCT system. The dose difference between the plans, based on patients since the lower beam energy would result in under ex-
mapping doses levels across the planning target volume, was posure with adult-sized patients.55 The use of 80 kV could be
210% on the CBCT plan. A correction method manually accommodated where the planning system allowed more than
assigned a pre-determined HU value to the lung tissue in the one calibration curve, provided an appropriately sized phantom
CBCT image and changed the range of HU value differences for was used to produce the RED-HU calibration curve.
lung tissue to between 2200 and 1200 when compared with the
PCT scan. The dose difference was then 110%. Another cor- On some scanners, the acquisition FOV used can affect the HUs.
rection method manually assigned a HU value to only pixel On a GE Hi Speed DX/i CT scanner, the HU values changed
values at the lower end of that typically found in the lungs, when the switch from a large to small FOV forced a change in the
below 2882. This reduced the HU difference to 2200 to 1100 physical filter in the X-ray beam.54 The degree of change of HUs
and resulted in a much improved dose match with negligible was not stated. On a Toshiba Aquilion One scanner, there was
difference between the CBCT and PCT plans. a change of only 2 HU for water between the small, medium and
large FOVs.57 For cortical bone material of HU value 5 1400,
Tables 2 and 3 show the HU and associated changes in radio- another study using a Toshiba Aquilion 16 scanner found the
therapy dose calculations for lung, soft tissue and bone. A mix of variation to be 2% when switching from 240- to 400-mm FOV.58
clinical plans and experimental scenarios based on known tissue The reason for this was also suggested to be the physical filter
thicknesses are covered by the articles reviewed. which changed at 320-mm FOV. Negligible changes in the HUs

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were seen with different FOVs for materials where HU was ,100. axial plane and artefacts when compared with conventional CT.63
Understanding the mechanism by which the physical filter is This variation of HU needs to be considered and appropriately
changed in the scan protocol is important because it is not always allowed for when collecting HU values from CBCT images.
FOV dependent. Some scanners provide an extended re-
construction FOV to allow imaging of regions of the body which Impact of scan parameter changes on image quality
are outside the scan FOV. Evaluations of the Philips Brilliance Big Tube voltage, tube current, slice thickness and interval, pitch, re-
Bore scanner and the GE LightSpeed wide-bore scanner found construction algorithm, scan time, acquisition and reconstruction
large differences of approximately 500 HU for bone for the ex- FOV are all parameters which will influence image quality in CT.36
tended FOV compared with the standard FOV.59,60 It is well known that reducing tube current will increase noise and
reduce the signal-to-noise ratio which can reduce the visibility of
Only minimal change in HU values arising from changes in slice low-contrast details.61,64–69 A reduction of slice thickness has the
thickness, X-ray tube rotation time and spiral vs sequential same effect, though the positive impact of using smaller slice
scanning was noted on a Toshiba Aquilion scanner.56 The degree thicknesses is reduced partial volume effect and potentially in-
of variation was not given. Special reconstruction algorithms creased resolution of small details in the longitudinal
FC23 and FC64 on that scanner which used beam-hardening direction.61,64,65 An increase in pitch or feed per rotation has the
filters did, however, produce variability in the CT values, though benefit of reducing patient dose but will also result in increased
the extent of variation is not clearly stated. On a Siemens Emotion noise, unless tube current is increased to compensate.55 Varying
Duo scanner, a range of head and body reconstruction algorithms, tube voltage to match the size of the patient will improve X-ray
H10s to H80s, B10s to B90s and U90s were tested.38 Across the beam penetration and reduce image noise and absorbed dose.17,55
different head algorithms, the maximum difference seen was
25 HU for air and 50 HU for bone when considering 110- or 130- The reconstruction algorithms selected affected the image slice
kV scans. The maximum variation for body algorithms was less at width on the Toshiba Aquilion One scanner with smoother
,12 HU. Some algorithms produced very little HU difference. algorithms broadening the slice width.57 Similarly, the resolution
in the axial plane also varied significantly depending on the
The findings from the literature are summarized in Table 4. The reconstruction algorithm used, with sharper algorithms pro-
literature does not comprehensively cover all makes and models ducing increased noise but improved high-contrast resolution.
of CT scanner used in radiotherapy nor the wide variety of This has also been seen on other scanner makes and
possible settings. Scanner performance will always depend on models.64,66–69 The reconstruction FOV and related matrix will
the design, calibration and the settings used. have a significant impact on the visibility of small details.60,65 A
smaller FOV will improve visibility of fine details compared with
Although publications related to CBCT have been reviewed in the that seen with a larger FOV. The selection of X-ray tube focal
section on HU change, it is not intended that this review includes spot size will also slightly influence how well a fine detail is seen
an in-depth review of CBCT settings and image quality because the in the image with a smaller focus giving improved detail
focus is on PCT. CBCT, by nature of the fact that it is a wide-beam visibility.64–69 Tube voltage, current and pitch generally influence
imaging technique with high scatter levels when compared with HU and image quality in a similar manner when varied irre-
standard CT, produces images with reduced contrast and higher spective of the make or model of the scanner. The changes
noise levels.46,62 The current CBCT systems used in radiotherapy introduced when changing FOV and the reconstruction algo-
also suffer from significant non-uniformity of HU values across the rithms, however, vary considerably from one manufacturer to

Table 4. Summary of scan parameters and level of Hounsfield unit (HU) change in articles reviewed

CT scan parameter Impact on HU and scanner manufacturers covered by review

No change unless very low current used—GE, Toshiba (Toshiba Medical,
Tube current
Zoetermeer, Netherlands)42,52,53,57
Significant level of HU change—Philips, Toshiba, GE, Siemens (Philips, Amsterdam,
Kilovoltage
Netherlands)2,42,52,53,57
Depends on CT scanner make/model and which FOV is selected—GE, Toshiba
Acquisition FOV
(GE Healthcare, Milwaukee)53,57,58
Standard FOVs—no information in articles reviewed
Reconstruction FOV
Extended FOVs—significant change across FOV—Philips, GE59,60
Slice thickness Minimal change—Toshiba56
X-ray tube rotation time Minimal change—Toshiba56
Spiral vs sequential Minimal change—Toshiba56
Depends on CT scanner make/model and which algorithm is selected—Siemens,
Reconstruction algorithms
Toshiba (Siemens Healthcare, Erlangen, Germany)38,56
FOV, field of view.

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another. Reconstruction algorithms, in particular, are generally Association of Physicists in Medicine tolerances for use of CBCT
less well understood by clinical users. for bone and air and the IAEA tolerances for soft tissue.30,31,46

Where the CT data set is used to produce digitally reconstructed There are clear advantages of having appropriately defined tol-
radiographs (DRRs), the DRR image quality is determined by erances for HU variation. When adjusting CT scan protocols, it is
both the CT scan parameters and the DRR calculation algo- helpful to know quickly whether changes to scan protocols are
rithm.70 The parameters which will affect DRR image quality are likely to be detrimental to the dosimetric aspects of the planning
primarily image slice thickness, FOV diameter, total exposure scan. HUs can be easily measured with a phantom on the scanner,
time and focal spot size.36,69,70 Pitch factor has been shown to thereby allowing early exclusion of inappropriate adjustment to
affect the ability to see low-contrast objects in the DRR even scan parameters. Both image quality and HU changes could be
when effective mAs was kept constant.71,72 Higher pitches reduce assessed with a multipurpose phantom before undertaking
the DRR contrast but also reduce patient dose. Increasingly, the a more detailed check to assess the level of dose change in the TPS
use of DRRs is being replaced by three-dimensional matching, with an anthropomorphic phantom. This review has highlighted
therefore only a few relevant references are included here. the need to use phantoms which approximately match the size
and shape of patients when measuring HUs.31,40
CONCLUSION
From the publications related to planning dose change arising from When reviewing the influence of scan protocol settings, published
RED or HU change, the following conclusions can be drawn: data is sparse. Considering the number of scanners and the variety
a given change of HU or RED will result in a larger change in dose of settings within CT protocols, the impact of scan parameters in
for a greater thickness of tissue than for reduced tissue thickness, radiotherapy CT is not well detailed in the literature. Publications
therefore the impact of HU change will vary for different body tend to look at a limited set of scan parameters and only give
regions; a single-field treatment plan will deliver a greater dose detailed information on variability when it is considered signifi-
change for a specific HU change than a multiple field plan; the use cant. No publications were found which fully assessed the per-
of lower energy treatment beam results in a higher dose change for formance of a radiotherapy CT scanner based on variation in both
a given HU change than the use of higher energy treatment beam. image quality parameters and HU or RED. The high number of
Owing to the proportion of soft tissue in the body compared with publications supporting optimization in diagnostic CT underlines
bone or air, a change in HU for soft tissue has a greater impact than the fact that scan protocol settings affect image quality.74,75 The
a change in HU for bone or air. It is well known that the planning radiation dose delivered from CT imaging must also be consid-
algorithm used has an influence on the accuracy of the planning ered and justified.76 The use of scan protocols in radiotherapy CT
dose. Some are more accurate for treatment of different body which are tailored for specific disease sites should, where possible,
regions than others.23,73 Therefore, any attempts to link HU change be used to ensure good-quality imaging with careful assessment
to TPS dose change must consider the algorithm used and also the made of the dosimetric impact for clinical treatment conditions.27
body region. The articles reviewed, however, would suggest that the
following HU tolerances could be set to achieve a 1% dose change This area of work would benefit from more publications related
limit: 620 HU for soft tissue and 650 HU for lung and bone. Some to the adjustment of CT protocols used in radiotherapy. This
publications suggest that it may be possible to allow a higher change should include the assessment of image quality changes in CT
than this for bone and still remain within 1% for dose change. It is planning scans alongside changes in HU values and subsequent
important to remember that effects of changes must be considered dose changes in the TPS. It would also be interesting to in-
for all tissue types (air, bone, soft tissue) together when present in vestigate whether the effectiveness of autocontouring packages
the clinical plan. These proposed tolerances match the American can be improved by CT scan protocol adjustment.

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