Characteristics and clinical application of a treatment simulator with Ct-option

The integration of a scanner for computed tomography (CT) and a treatment simulator (Sim-CT, Elekta Oncology Systems, Crawley, UK) has been studied in a clinical situation. Image quality, hounsfield units (HU) and linearity have been evaluated as well as the implications for treatment planning. The additional dose to the patient has also been highlighted.

Image data is acquired using an array of solid state X-ray detectors attached externally to the simulator's image intensifier. Three different fields of view (FOV: 25.0 cm, 35.0 cm and 50.0 cm) with 0.2 cm, 0.5 cm and 1.0 cm slice thickness can be selected and the system allows for an aperture diameter of 92.0 cm at standard isocentric height. The CT performance has been characterized with several criteria: spatial resolution, contrast sensitivity, geometric accuracy, reliability of hounsfield units and the radiation output level. The spatial resolution gauge of the nuclear associates quality phantom (NAQP) as well as modulation transfer functions (MTF) have been applied to evaluate the spatial resolution. Contrast sensitivity and HU measurements have been performed by means of the NAQP and a HU conversion phantom that allows inserts with different electron densities. The computed tomography dose index (CTDI) of the CT-option has been monitored with a pencil shaped ionization chamber. Treatment planning and dose calculations for heterogeneity correction based on the Sim-CT images generated from an anthropomorphic phantom as well as from ten patients have been compared with similar treatment plans based on identical, yet diagnostic CT (DCT) images.

The last row of holes that are resolved in the spatial resolution gauge of the NAQP are either 0.150 cm or 0.175 cm depending on the FOV and the applied reconstruction filter. These are consistent with the MTF curves showing cut-off frequencies ranging from 5.3 lp/cm to 7.1 lp/cm. Linear regression analysis of HU versus electron densities revealed a correlation coefficient of 0.99. Contrast, pixel size and geometric accuracy are within specifications. Computed tomography dose index values of 0.204 Gy/As and 0.069 Gy/As have been observed with dose measurements in the center of a 16 cm diameter and 32 cm diameter phantom, respectively for large FOV. Small FOV yields CTDI values of 0.925 Gy/As and 0.358 Gy/As which is a factor ten higher than the results obtained from a DCT under similar acquisition conditions. The phantom studies showed excellent agreement between dose distributions generated with the Sim-CT and DCT HU. The deviations between the calculated settings of monitor units as well as the maximum dose in three dimensions were less than 1% for the treatment plans based on either of these HU both for pelvic as well as thoracic simulations. The patient studies confirmed these results.

The CT-option can be considered as an added value to the simulation process and the images acquired on the Sim-CT system are adequate for dose calculation with tissue heterogeneity correction. The good image quality, however, is compromised by the relative high dose values to the patient. The considerable load to the conventional X-ray tube currently limits the Sim-CT to seven image acquisitions per patient and therefore the system is limited in its capability to perform full three-dimensional reconstruction.