IAEA Regional Training Course on Radiotherapy Techniques with Emphasis on Imaging and Treatment Planning Tuesday Sept 4, 2012,

Beijing, China

Imaging for Radiation Treatment Planning II: CT: Principles & applications. Howard Amols, Ph.D. Memorial Sloan Kettering Cancer Center New York, USA
1.0 hr

IA

EA

Acknowledgements
Many slides kindly provided by Dr. Lawrence N. Rothenberg, Member Emeritus, Memorial Sloan Kettering Cancer Center

IA

EA

Talk Outline 1.History and Properties of CT Scanning 2.Commissioning and Quality Assurance 3.Using CT for 3D treatment planning

IA

EA

IA EA

RSNA/AAPM On-Line Physics Modules

Computed Tomography CT Image Quality and Protocols CT Systems Radiation Dose in CT

IA

EA

Radiography - Disadvantages
Two-dimensional image of three-dimensional object Poor low contrast performance However, Doses are low (entrance surface): PA Chest-0.1 mGy, Skull-2 mGy, Abdomen-4mGy, Hand-0.3 mGy CT doses are several cGy (10 mGy = 1cGy = 1 rad = 1000 mrad)

IA

EA

Two Images
Radiography Computed Tomography

IA

EA

What is CT?
X-ray CT is a cross-sectional imaging modality that derives a two dimensional distribution of x-ray attenuation from one dimensional projections In x-ray CT, the primary quantity is attenuation, derived from transmission measurements Using a stack of relatively thin slices, the three dimensional problem is reduced to a two dimensional one

IA

EA

The CT measurement process

Thus, for each slice, we make X-ray transmission measurements with many rays covering the full width of the patient at each of many angles This gives us sufficient data to reconstruct the two dimensional cross-section The reconstruction is done using filtered backprojection

Axial CT: Scanner rotates, then patient/couch translates to measure the next slice, rotate, translate, etc. Helical or spiral CT: continuous motion of couch and gantry rotation

IA

EA

Computed Tomography
Image shows gray levels for Hounsfield units associated with each of 5122 pixels Typical settings: 120 - 140 kV, 200 - 300 mA (Note: 80 or 100 kV being used to reduce dose and/or enhance iodine contrast, lower mA for screening or pediatric exams to reduce dose) Gantry rotation times: 0.33s to 2.0 s depends on CT scanner design and type of exam

IA

EA

CT Numbers-Hounsfield Units (HU)

CT# (water) CT# (air) CT# (soft tissue) CT# (bone, I)

IA

EA

(x, y) - water CT# (x, y) 1000 water

= 0 = -1000 = -300 to +100 = up to +3000
11

History of CT
1895 Roentgen discovers X-rays 1917 Radon solves mathematical problem of determining a 2D distribution from its 1D projections (or line integrals) 1958 Soviet scientists develop plans for x-ray CT scanner. Work unknown outside of USSR until many years later 1960s Oldendorf, Cormack, and Kuhl independently investigated this concept in medical imaging 1967 Hounsefield initiates development of an x-ray brain CT scanner for clinical use at EMI Ltd. (some money came from the Beatles!) 1971 First CT scanner installed at Atkinson Morely Hospital, London 1972 First scanners installed in US 1975+ CT scanners first used for radiation therapy 3D treatment planning 1979 Hounsfield and Cormack share Nobel Prize for Medicine 1989 First Spiral CT scanners 1998 First Multi-slice CT scanners 2000 > 3000 clinical CT installations

IA

EA

Before CT:

Film cassette parallel to beam direction, no mathematical reconstruction purely optical!

IA

EA

Conventional Tomography Transverse Axial Tomography (TAT)

Toshiba TAT

IA

EA

TAT-Transverse Axial Tomography: Toshiba Unit in Radiation Oncology

IA

EA

Early CT development
EMI Mk1 head only scanner, introduced 1971 1st generation, i.e. translate-rotate geometry, parallel rays, pencil beam, one NaI detector per slice 180 rotation, 5 mins per acquisition (2 slices), 5 mins per reconstruction Only 160 x 160 matrix Water bag/box

IA

EA

EMI Mk1 1972

EA IA

GE VCT 64 Slice 2006-Present

Phillips Big Bore 80cm bore diameter, flat table top

PET/CT Simulator GE Discovery ST w LightSpeed Ultra CT (8 Slice)

Front View

Rear View

IA

EA

4 Generations of CT Scanners

First generation: pencil x-ray beam and a combination of translation and rotation

IA
Third generation: fan beam and a combined rotational motion of the x-ray source and ~ 500 to 900 detectors Fourth generation: rotational motion of the x-ray tube and a stationary array of ~ 1200 detectors

EA

Second generation: fan x-ray beam, multiple detectors and a combination of translation and rotation

Helical (Spiral) scanning

Note: Tomotherapy is based on the concept of helical CT, except kV x-ray tube is replaced by 6MV Linac

IA
Patient couch continuously translates

EA

Tube and detector continuously rotate

Helical CT (Also called Spiral)

table movement (mm) per rotation Pitch collimator width (mm) at isocenter
Note: Pitch < 1.0 means slices overlap. Gives better image quality, but 21 higher patient dose and longer scan times. Required for respiratory gated scans.

IA

EA

Single slice helical scanning

IA

EA

IA EA

Size reduction & continuous rotation slip rings

Improved high voltage generator technology made units smaller Slip ring technology enabled them to be placed on the rotating part of gantry This permitted continuous rotation without interscan delays Set the stage for spiral scanning

Key:

1. Tube, 2. Collimator, 3. Tube Controller, 4. HV Gen (-), 5. Detector, 6. DAS, 7. HV Gen (+), H. OB Comp., 9. Stat Comp.

IA

EA

X-ray tubes

IA

EA

IA EA

IA EA

Note: detector response time must be < 1ms: >1000 projection images acquired during <0.5 sec scan rotation.

IA

EA

Multi-slice or multi-detector row CT

Multi-slice or multi-detector row CT Driven by X-ray tube heat loading Faster scans More practical thin slices Improved spiral interpolation

Note: Modern CT scanners have 8-256 rows of detectors

IA

EA

Computed Tomography Summary

1st Generation: Rotate - Translate - 5 min 2nd Generation: Multi-detector - 20 sec 3rd Generation: Detectors and source rotate 0.33 sec or less per rotation 4th Generation: Source Rotates, detectors fixed 5th Generation: Sweeping electron beam cardiac studies - ms per image Detectors: Solid State or xenon

IA

EA

Technical developments 1972 - 2000

Note: Massive amounts of imaging data acquired by a busy Department Terabytes/yr. >40% of all digital data in the entire world will soon be medical images! Need PACS.

IA

EA

(decreases as more x-rays interact in slice being imaged)

IA

EA

(produced by high-Z objects)

Note: Results from fact that linear attenuation coefficient is proportional to electron density AND atomic number (Z3)

IA

EA

IA EA

CT reconstruction
1. Each slice in the patient consists of 512x512 pixels 2. We make thousands of individual attenuation measurements thru the slice from many directions 3. Essentually, `x unknowns (voxel attenuation values) and `x equations (attenuation measurements 4. Can in principle be solved as `x simultaneous equations

IA

EA

The basic transmission attenuation equations

Transmission through a uniform block of material I = Io exp(-X) , where (linear attenuation coefficient) depends on r, Z, Ex Transmission through a heterogeneous block of material I = Io exp(-(1x1 + 2x2 + 3x3 + 4x4 + 5x5 ++ nxn))
Or, if we define the pixel size I = Io exp(-x(1 + 2 + 3 + 4 + 5 ++ n))

Rearranging with measurable or known quantities on the left, and the unknowns to be determined on the right -(1/x)ln(I/Io) = (1 + 2 + 3 + 4 + 5 ++ n)

IA

EA

CT reconstruction
Note: Although mathematically correct, solving thousands of simultaneous equations is not a practical way to calculate image reconstructions.

IA

EA

Backprojection

IA

EA

IA EA

Filtered Backprojection

IA

EA

IA EA

Digital Display: Window/Level

IA

EA

CT Numbers - HU

Hounsfield units = 1000 x ( - water) / water

IA

EA

CT Numbers vs. Electron Density

Because the CT numbers bear a linear relationship with the attenuation coefficients, it is possible to infer electron density (electrons cm-3) as shown in Figure 12.4 from Khan. Although CT numbers can be correlated with electron density, the relationship is not linear in the entire range of tissue densities. The nonlinearity is caused by the change in atomic number of tissues, which affects the proportion of beam attenuation by Compton versus photoelectric interactions. Figure 12.5 shows a relationship that is linear between lung and soft tissue but nonlinear between soft tissue and bone.

IA

EA

CT Number (HU) vs. Electron Density

EA IA

Fig. 12.5 Khan 4th Ed.

Why is this so Important?

With CT we are measuring linear attenuation coefficient with x-rays of <100 keV, for which Photo-Electric effect is very important, especially for high-Z materials Thus, two materials having same physical density but different Z-values will have different attenuation coefficient and hence different Hounsfield values But for therapy we treat with x-rays of >1MeV for which Compton Effect is dominant interaction, for which the linear attenuation coefficient depends mostly on electron density

IA

EA

33 cm

IA

EA
47

IA EA

48

Relative Electron Density

1.0 for hydrogen 0.5 for helium thru calcium (Z = 20, A = 40)) 0.4 for uranium (z=92) Photoelectric cross section proportional to Z3

IA

EA

kV fan beam 120 kV

PMMA 974.140.53%

Air Brass
Aluminium

18.76195% 39760 (saturated?) 2366.4422.6%

Steel

IA
PMMA

EA

39760 (saturated?)

838.220.92%

50

2x MVCB, 0.005 MU/frame 2.6 MU total

PMMA 2228.947.95% Air Brass Aluminium 577.5729.7% 80000 (saturated?) 4068.57.95%

Steel

IA
PMMA

EA

80000 (saturated?)

2012.667.75%

51

Patient doses from CT

IA

EA

NCRP Report No. 160

IA

EA

Operating parameters
X-ray Tube Voltage (kVp)
X-Ray Tube Current (mA) Scan Time (sec) Beam On - Start Angle Scanner Rotation Angle

Filtration

Patient Position within Field

Patient Orientation
Source Collimation Slice Thickness

Slice Spacing - Pitch

Number of Adjacent Slices

IA

Field Size - Scan Diameter

EA

CT pencil ionization chamber For CT Dose Measurements

IA

EA

NCRP Report No. 160

IA

EA
56

Typical CT scattered dose levels

IA

EA

GE Medical Systems

Effective Dose (E) Factors

E for adults can be calculated from product of DLP and normalized effective dose factors from (Shrimpton et al, BJR 2006) Head 0.0021 (mSv / mGy-cm) Neck 0.0059 Chest 0.014 Abdomen 0.015 Pelvis 0.015

IA

EA

Effective Dose, E
(Prev. Effective Dose Equivalent, HE)

Thorax: 11 - 15 mSv (Gelieijns) Abdomen: 15 - 20 mSv Head: 1 - 2 mSv Note: CTDIvol Higher for Head

Higher for Children

IA

EA

Same Probability of Occurrence of Cancer and Genetic Effects as for Whole Body Uniform Dose

CT Simulation
CT simulator combines some of the functions of imaging for radiation therapy planning, the computerized treatment planning system, and the conventional simulator CT Simulator contains: CT Scanner Patient couch that simulates Linac treatment couch Laser localization System similar to Linac treatment room lasers Computer graphics workstation image manipulation, target volume and normal tissue delineation, beam geometry display Interface to treatment planning system: scanner can export images, contours, plus isocenter coordinates to treatment planning system via electronic network or via `sneaker net

IA

EA

Simulation Procedure

IA

Patient Positioning and immobilization Scouts for patient alignment CT Scan Isocenter definition Isocenter Marking using laser localization system Isocenter tattoos and bi-angulation or triangulation tatoos, cast lines

EA

IA EA

Special Issues for RT Treatment Planning

Body casts, frames, masks, and immobilizers Couch top sag Alignment lasers Slice thickness and number of slices Generating DRRs and 3D reference images for OBI Sometimes thinner slices needed to generate DRRs than for treatment planning CT scanner images do NOT look the same as CBCT images! Fusion with MR or PET Converting CT-numbers to electron density Respiratory gating Structure contouring

IA

EA

IA EA

Digitally Reconstructed Radiographs (DRR) and reference images for kVCBCT

IA

EA

IA EA

(Contouring)

IA

EA

IA EA

IA EA

IA EA

IA EA

IA EA

IA EA

IA EA

Third Generation

IA

EA

IA EA

IA EA

Helical Scanning

IA

EA

Resolution Rays and Views

IA

EA

Rays

IA

EA

Views

IA

EA

Multi-slice CT pitch

P' = Table travel per rotation / Nt

Where

N= number of data channels

t = the z-axis width of one data channel of an Nchannel multi-slice detector.

IA

EA

Multi-planar Reconstruction (not just axial views)

IA

EA

GE Lightspeed 16

IA

EA

Pitch: Single Slice CT vs. MDCT

For Single Slice:

Detector Pitch

Table movement (mm) per 360-degree rotation of gantry Detector width(mm) at isocenter

Collimator Pitch

Use collimator pitch for MDCT to be consistent with pitch for single slice

IA

For MDCT:

EA

Collimator Pitch

Table movement (mm) per 360-degree rotation of gantry Collimator width(mm) at isocenter

Detector Pitch N

85

Computed tomography dose index - CTDI

CTDI Ideal = 1 T

D 1 (z) dz
-

CTDI Reg =

1 nT
-7 T
+50 mm

D (z) dz

CTDI 100 =
CTDIw =

1 nT

-50 mm

(2/3) x CTDI100-peripheral + (1/3) x CTDI100-axial

IA

D a (z) dz Note: Use f-factor for air (8.69 mGy/R),

not PMM (7.8 mGy/R)

EA
(New IEC CT Dose Quantity)
(New IEC CT Dose Quantity)

+7 T

Volume CTDI
Spiral: CTDIvol = CTDIw / Pitch or Axial: CTDIvol = CTDIw * NT/I

IA

EA

Operating parameters
Bolus

Patient Position Within Field

Patient Orientation

Image Parameters Special Techniques

Other Factors

The Patient Size and Tissue Composition Anatomy Being Imaged Generally: Increased Dose Provides Better Low Contrast Performance

IA

EA

Repeat Scans

IA EA

IA EA

IA EA

IA EA

IA EA

IA EA

IA EA

Normal tissue damage vs. radiation dose for organs with large volume effect (e.g., liver, lung, kidney)
1.2

0.8
NTCP

2/3

EA
1/3
100 Dose (Gy) 150

1/6

0.4 0.2 0 0

IA
50 200

0.6

D50 = 29.5 Gy, m = 0.18

Normal tissue damage vs. radiation dose for organs with small volume effect (e.g., spinal cord, optic chiasm)
1.2

0.8
NTCP

0.4 0.2 0 0

IA
50 100 Dose (Gy) 150 200

0.6

D50 = 29.5 Gy, m = 0.18

EA

IA

Tube Motion Principles Reappearing In Digital Tomosynthesis

EA

Conventional Radiography

IA

EA

Helical, or Spiral CT
The Patient couch advances at a constant speed through the gantry while the x-ray tube rotates continuously around the patient (slip ring technology) The acquired transmission data can be reconstructed to provide images at any point along the patients axis during scan and slices as thin as 1 mm can be obtained quickly Reduces conventional scan times of 20-30 min to 5-10 min Pitch distance, in mm, the couch moves during one revolution of the x-ray tube Pitch Factor pitch divided by the collimated slice thickness (range between 1 and 2)

IA

EA

Single Slice vs. Multi-row

IA

EA

Multi-row (slice) CT

IA

EA