CT simulator

M. Saiful Huq, Ph.D., FAAPM, FInstP

Professor and Director

Department of Radiation Oncology

University of Pittsburgh Cancer Institute

Pittsburgh, Pennsylvania, USA
 Outline

• What is a CT simulator?
• CT simulation process
• Functional performance characteristics of CT
equipment
• QA of CT simulators
• QA for CT simulation software
• Evaluation of CT simulation process
• Conclusion
 CT simulator

• CT scanner with
flat table top
• Laser positioning
and marking
system
(preferable with
external lasers)
• Virtual simulation
software
• Various hardcopy
output devices
 CT Simulation Process

• Varies from center to center

• 3 major categories:

1. CT-scan, patient positioning and immobilization

2. Treatment planning and CT-simulation
3. Treatment setup
 CT Simulation Process
1. CT-scan, patient positioning and
immobilization

• Scanner acquires volumetric scan of a patient, which

represents a virtual or digital patient
• Scan is acquired with
– the patient immobilized in treatment position
– treatment specific scan protocols
– often increased scan limits
– use of contrast
– placement of localization marks on the patient skin
 CT Simulation Process

2. Treatment planning and CT-simulation

• The virtual simulation software provides virtual

representations of the geometric capabilities of a
treatment machine
• It also allows import, manipulation, display, and storage
of images from CT and/or other imaging modalities
 CT Simulation Process
2. Treatment planning and CT-simulation
• Beam placement and treatment design is performed using
virtual simulation software
– Contouring of target and OAR using information obtained from
different imaging modalities
– Treatment isocenter placement
» can be a final isocenter marked (needs physician presence)
» a reference point marked (does not need physician’s presence)
» localization marks are placed on the patient’s skin
– Placement of the beams, design of treatment portals and
communication of information to TPS
– Printing of DRRs and patient setup instruction
 CT Simulation Process

3. Treatment setup

• Patient is setup on the treatment machine according to

instructions created from the CT-sim software
• Port films are acquired and compared with CT-sim DRRs
 CT simulation process
CT simulation includes the
CT scanner and
components of treatment 4 5
planning system and
provides input for dose
calculation 3

2
1 CT Simulator

Virtual Dose
CT Scanner
Simulation Calculation

Treatment Planning System

 Functional performance characteristics
of CT equipment

A. CT scanner and virtual simulation system

– X-ray tube
» Large no of images and rapid data acquisition time requires
the tube to withstand high heat and dissipate heat quickly
– Collimator and attenuator
» pre-patient collimator used to produce a narrow beam
» Post-patient collimator used to reduce scatter to detector
– Patient support table
» Must have a flat table top
 Functional performance characteristics
of CT equipment

A. CT scanner and virtual simulation system

– Computer workstation
» Multiple microprocessors coordinate setup of the scan
parameters, x-ray production, data acquisition, processing
of transmission data and display of reconstructed image
– External patient marking/positioning lasers
» Used for marking for patients
» important that sagittal laser be mobile because the CT
table cannot move laterally
 Functional performance characteristics
of CT equipment

B. Conventional and spiral CT

– Conventional CT acquires data one slice at a time
– Spiral CT allows data to be acquired while the table translates
and the tube rotates continuously. Path of the tube forms a
helical pattern around the patient
C. Multislice scanners
─ Projection data from multiple slice is acquired simultaneously
─ Uses multiple row of detectors in the z axis
─ Enables acquisition of imaging studies faster than single slice
scanners
 Image Generation – Single Slice

One Rotation – One Image

 1
Multislice CT
2

One Rotation – Multiple Images

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
 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

 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

 Functional performance characteristics
of CT equipment
D. Large bore scanners
85 cm Bore Opening 70 cm Bore Opening
CT scanner – Bore size
Patient Size
 CT scanner – Bore size
Mantle Field
 Functional performance characteristics
of CT equipment

E. CT performance E. CT performance
parameters parameters
– X-ray system calibration – Image uniformity and noise
– Collimator assessment – Spatial resolution
– Localization laser alignment – Contrast resolution
– Slice width and sensitivity – CT number calibration and
profile linearity
– Radiation exposure and dose – Artifact evaluation
Quality assurance of CT
simulators
 Commissioning

• Ensure that the equipment performs within the

specifications agreed on by the vendor and user
• Establish a record of baseline performance
• An opportunity for a physicist to become an expert
user
• Develop clinical procedures and policies
• Develop a quality assurance program
 CT Sim QA – AAPM TG66

• QA recommendations and guidelines for diagnostic

radiology and radiation therapy for CT-Simulators
• Equipment description
• Tests for
– CT scanners
– Virtual simulation software
– Image registration
– Overall CT-Simulation process
• Test frequencies, methods, and tolerances
 Quality assurance of CT scanners

• The AAPM Report Number

39- “Specification and
acceptance testing of
computed tomography
scanners”

– Radiation safety
– CT Dosimetry
– Electromechanical tests
– X-ray Generator
– Image performance tests
 QA program

• Purpose
– To assure proper equipment and program operation
– To assure safety of patient, staff, and public
• Should include
– specification of tests
– test frequency
– tolerance limits
– corrective actions
– QA assignments
 QA components

• Radiation and patient safety

• CT dosimetry
• Evaluation of electromechanical components
• Evaluation of image quality
 Radiation Safety/Interlocks

• Exposure Measurements
– Two shielding design methods commonly employed
» direct use of isoexposure contours
» NCRP Report No. 49 & 147
• Interlocks (x-ray interruption, dead man)
• Patient Dose (CTDI, MSAD)
 Survey Sites

G F

L E K

B
A
C J
I
D

H
Staff and Public NCRP 49:

Weekly Exposure Controlled Areas: 100 mR/week

Non-Controlled Areas: 10 mR/week

Brilliance AcQSim
Weekly Weekly
Measured
Exposure Exposure
Instantaneous Occupancy
Location Based on Based on
Exposure Rate Factors
Workload Workload
(mR/hr)
(mR/week) (mR/week)
A. Room 450 Door 0.18 1.00 0.026 0.645
B. Room 450 Window 0.30 1.00 0.043 1.075
C. Room 450 Countertop 0.33 1.00 0.047 1.183
D. Room 450 Chair 0.22 1.00 0.031 0.788
E. Room 451 0.23 0.25 0.008 0.206
F. Corridor 474 Door 0.10 0.25 0.004 0.090
G. Corridor 474 0.17 0.25 0.006 0.152
H. Corridor 362 0.15 0.25 0.005 0.134
I. Room 454 0.10 0.25 0.004 0.090
J. Room 448 0.10 1.00 0.014 0.358
K. Room 447 0.10 0.25 0.004 0.090
L. First floor lobby background
 Patient Dose

• CTDI - Computed
Tomography Dose
Index represents
average dose per slice
• MSAD - Multiple Scan
Average Dose
represents average
dose per scan
• Body Dose from CT
Scans ~ 1 cGy

Continually evolving concept – due to multislice technology

CTDI
 CTDI Measurement Technique

• Pencil Ionization Chamber

(long cylindrical ionization
chamber)
• TLD array
• “Body” and “Head” phantom
• Technique
– kVp
– mAs
– Slice Width
– Index
– Other parameters
 CTDI
• CT dose Index (CTDI)
• For axial scan only
• Ideally from ±∞, in reality 10 cm
• fmed = 0.78 cGy/R (acrylic)
• n is number of slices
• T is slice width

Rdg * C tp * k el * N x * f med *100mm

CTDI 100 = [ cGy ]
n*T (mm)
1 + 50 mm
CTDI 100 = ∫ D ( z ) dz
nT − 50 mm
 Electromechanical Tests

• Localization Laser • Collimation

Accuracy – Radiation Profile
• Table/Image Plane Width
Orthogonality – Sensitivity Profile
Width
• Gantry Tilt
• X-ray Generation
• Slice Localization from
– kVp
Scout Image (Topogram,
Pilot Image) – HVL
– Timer accuracy
• Table Indexing
– mAs Linearity
– mAs Reproducibility
 Electromechanical components
Laser Alignment/Accuracy
• Gantry lasers should accurately identify scan plane
within the gantry opening
• Gantry lasers should be parallel and orthogonal with
the scan plane and should intersect in the center of
scan plane
• Vertical side-wall lasers should be accurately spaced
from imaging plane
• Wall lasers should be parallel and orthogonal with
the scan plane, and should intersect at a point which
is coincident with the center of the scan plane
• The overhead (sagittal) laser should be orthogonal to
the imaging plane
• The overhead (sagittal) laser movement should be
accurate, linear and reproducible
 Electromechanical components
Table Alignment/Accuracy

• The tabletop should be level and

orthogonal with respect to the
imaging plane
• Table vertical and longitudinal motion
according to digital indicators should
be accurate and reproducible
• Table indexing and position under
scanner control should be accurate
• Flat tabletop should not contain any
objectionable artifact producing
objects
 Electromechanical components
Gantry Alignment/Accuracy

• The angle of the gantry

tilt with respect to
nominal vertical imaging
plane should be accurate
• After the tilt, the gantry
should return to the
nominal vertical imaging
plane
 Electromechanical Components
x-ray Generator

• Need a non-invasive
meter
– kV accuracy
– Timer accuracy
– mA linearity
– HVL
measurements
 X-ray Generation

• As many possible modes as practical should

be verified:
– kVp, time, HVL - non-invasive tests device
– mA Linearity - inferred indirectly using a mAs
linearity measurement. For a constant tube
potential and slice width, the integral
exposure should be a linear function of mAs.
– mAs Reproducibility
CT simulator mechanical alignment
 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 uniformity

• The average CT number of water should always be 0,

independent of the position within the homogeneous
phantom
• Measurements are performed using head and body
uniformity phantoms
• Measure average CT numbers in center and at the
periphery (several locations) of the phantom
Uniformity
Image performance evaluation
 Quantitative CT

• Phantom with sections of known electron densities

• Determine CT numbers for each section
• Compare measured CT numbers with vendors
specifications
• Should be independent of phantom size
• CT numbers are a function of kVp
• Edge enhancement algorithms should be avoided
 CT Number Accuracy
(MIR with Manufacturer’s Phantom)

M aterial Big Bore (HU) Std Bore (HU) M anufacturer

(HU)
Polyethylene −70.9 −75.1 −75 ± 15
W ater −2.5 −2.5 0±4
Nylon 100.0 100.5 100 ± 15
Lexan 114.0 117.5 116 ± 15
Acrylic 136.0 137.5 140 ± 15
Teflon 1020.0 1033.0 1016 ± 50

Both scanners exhibited CT number accuracy well

within manufacturer’s specifications
 Spatial accuracy

• Spatial accuracy within the image plane

can be verified by imaging a convenient
object of known dimensions
 Virtual simulation software tests

• Beam geometry
• Target localization
• Target contour verification (using BEV)
• Isocenter calculation
• Isocenter movement
• Virtual field size
• Virtual gantry, collimator, and table rotation
• Evaluation of digitally reconstructed radiographs (DRRs)
 Virtual simulation software QA

• Fraass et al. AAPM TG 53: Quality assurance for clinical

radiotherapy treatment planning. Med Phys,25:1773-
1829,1998
• Spatial and geometric accuracy
– contour delineation
– isocenter localization
– treatment port definition
– virtual treatment machine operation
• Evaluation of DRRs and DCRs
• Accuracy of the multimodality image fusion and
registration
 QA for the CT simulation process

• CT scan
• transfer of images
• isocenter localization
• treatment plan design
• multimodality image fusion
• transfer of virtual simulation data for calculation of dose
distributions
• DRR generation
• transfer of the plan to treatment machine
• treatment of the patient
• treatment verification
 Quality assurance frequency

• Daily (Therapists)
• Weekly (Therapists)
• Monthly (Clinical Engineering)
• Annual (Medical Physics)
 Daily QA
(Sim Therapists)

• Radiographic Uniformity
– Most important - look for noise and
distortions in CT image
• Laser Alignment and Tracking
– Critical for patient setup
– Most critical - Couch in/out 500 mm
tracking
• Audio/Visual System
 Weekly Inspection (ok, not ok)
(Sim Therapists)

• Scanner couch • Software functions

• Couch and gantry • Networking and archiving
controls
• Audio communication
• Gantry lasers
• Machine operation during
• Wall lasers scanning
• Overhead laser • Room condition
• General image quality • Treatment aids condition
• Control console
 Monthly QA
(Clinical Engineering)

• Couch Digital Position Accuracy

• Laser Digital Position Accuracy
• Laser Alignment
• Slice Thickness
• Spatial Resolution
• Contrast resolution
• CT# Accuracy, Uniformity, and Noise
• MTF
• Distance Measuring Tool Accuracy
 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
 Acknowledgements

I would like to thank Sasa Mutic for giving me many

of the slides that I presented in this talk