The optimisation of paediatric CT examinations in Scotland: phase one; benchmarking current performance.

To benchmark the dose from paediatric head and chest examinations on computed tomography (CT) scanners throughout Scotland, to identify scanners that may require optimisation and to provide optimisation advice based on the protocols from better performing scanners. Anthropomorphic phantoms corresponding to 1, 5 and 10 year olds were sent to 50 CT scanners around Scotland. Head and chest examinations were undertaken by local staff using local techniques on each scanner with each phantom, and details of the protocols used were recorded. Computed tomography dose index (CTDI)voland dose length product (DLP) were recorded post-scan. There is a significant variation in performance throughout Scotland. For head examinations, the highest DLP is 13 times the lowest for an equivalent sized phantom. For chest examinations, the highest is 128 times the lowest for an equivalent sized phantom. The wide range of CT dose measurements indicates the potential for variation in image quality across Scotland. Feedback has been provided to all participating sites on their individual results compared to the national data set. Specific feedback was provided where relevant on potential considerations for optimisation. Scanners that may be undertaking paediatric CT head and chest examinations in a sub-optimal manner throughout Scotland have been identified along with those aspects of a scan protocol that are most likely to lead to sub-optimal performance.

Organ doses can be estimated from the computed tomography (CT) dose index for cone-beam CT on radiotherapy equipment.

Cone beam computed tomography (CBCT) systems are fitted to radiotherapy linear accelerators and used for patient positioning prior to treatment by image guided radiotherapy (IGRT). Radiotherapists' and radiographers' knowledge of doses to organs from CBCT imaging is limited. The weighted CT dose index for a reference beam of width 20 mm (CTDIw,ref) is displayed on Varian CBCT imaging equipment known as an On-Board Imager (OBI) linked to the Truebeam linear accelerator. This has the potential to provide an indication of organ doses. This knowledge would be helpful for guidance of radiotherapy clinicians preparing treatments. Monte Carlo simulations of imaging protocols for head, thorax and pelvic scans have been performed using EGSnrc/BEAMnrc, EGSnrc/DOSXYZnrc, and ICRP reference computational male and female phantoms to derive the mean absorbed doses to organs and tissues, which have been compared with values for the CTDIw,ref displayed on the CBCT scanner console. Substantial variations in dose were observed between male and female phantoms. Nevertheless, the CTDIw,ref gave doses within ±21% for the stomach and liver in thorax scans and 2 × CTDIw,ref can be used as a measure of doses to breast, lung and oesophagus. The CTDIw,ref could provide indications of doses to the brain for head scans, and the colon for pelvic scans. It is proposed that knowledge of the link between CTDIw for CBCT should be promoted and included in the training of radiotherapy staff.

Evaluation of cumulative dose for cone-beam computed tomography (CBCT) scans within phantoms made from different compositions using Monte Carlo simulations.

Measurement of cumulative dose ƒ(0,150) with a small ionization chamber within standard polymethyl methacrylate (PMMA) CT head and body phantoms, 150 mm in length, is a possible practical method for cone-beam computed tomography (CBCT) dosimetry. This differs from evaluating cumulative dose under scatter equilibrium conditions within an infinitely long phantom ƒ(0,∞), which is proposed by AAPM TG-111 for CBCT dosimetry. The aim of this study was to investigate the feasibility of using ƒ(0,150) to estimate values for ƒ(0,∞) in long head and body phantoms made of PMMA, polyethylene (PE), and water, using beam qualities for tube potentials of 80-140 kV. The study also investigated the possibility of using 150 mm PE phantoms for assessment of ƒ(0,∞) within long PE phantoms, the ICRU/AAPM phantom. The influence of scan parameters, composition, and length of the phantoms was investigated. The capability of ƒ(0,150) to assess ƒ(0,∞) has been defined as the efficiency and assessed in terms of the ratios ε(ƒ(0,150) / ƒ(0,∞)). The efficiencies were calculated using Monte Carlo simulations for an On-Board Imager (OBI) system mounted on a TrueBeam linear accelerator. Head and body scanning protocols with beams of width 40-500 mm were used. Efficiencies ε(PMMA/PMMA) and ε(PE/PE) as a function of beam width exhibited three separate regions. For beam widths < 150 mm, ε(PMMA/PMMA) and ε(PE/PE) values were greater than 90% for the head and body phantoms. The efficiency values then fell rapidly with increasing beam width before levelling off at 74% for ε(PMMA/PMMA) and 69% for ε(PE/PE) for a 500 mm beam width. The quantities ε(PMMA/PE) and ε(PMMA/Water) varied with beam width in a different manner. Values at the centers of the phantoms for narrow beams were lower and increased to a steady state for ~100-150 mm wide beams, before declining with increasing the beam width, whereas values at the peripheries decreased steadily with beam width. Results for ε(PMMA/PMMA) were virtually independent of tube potential, but there was more variation for ε(PMMA/PE) and ε(PMMA/Water). ƒ(0,150) underestimated ƒ(0,∞) for beam widths used for CBCT scans, thus it is necessary to use long phantoms, or apply conversion factors (Cƒs) to measurements with standard PMMA CT phantoms. The efficiency values have been used to derive (Cƒs) to allow evaluation of ƒ(0,∞) from measurements of ƒ(0,150). The (Cƒs) only showed a weak dependence on scan parameters and scanner type, and so may be suitable for general application.

Investigation of the influence of image reconstruction filter and scan parameters on operation of automatic tube current modulation systems for different CT scanners.

Variation in the user selected CT scanning parameters under automatic tube current modulation (ATCM) between hospitals has a substantial influence on the radiation doses and image quality for patients. The aim of this study was to investigate the effect of changing image reconstruction filter and scan parameter settings on tube current, dose and image quality for various CT scanners operating under ATCM. The scan parameters varied were pitch factor, rotation time, collimator configuration, kVp, image thickness and image filter convolution (FC) used for reconstruction. The Toshiba scanner varies the tube current to achieve a set target noise. Changes in the FC setting and image thickness for the first reconstruction were the major factors affecting patient dose. A two-step change in FC from smoother to sharper filters doubles the dose, but is counterbalanced by an improvement in spatial resolution. In contrast, Philips and Siemens scanners maintained tube current values similar to those for a reference image and patient, and the tube current only varied slightly for changes in individual CT scan parameters. The selection of a sharp filter increased the image noise, while use of iDose iterative reconstruction reduced the noise. Since the principles used by CT manufacturers for ATCM vary, it is important that parameters which affect patient dose and image quality for each scanner are made clear to operator to aid in optimisation.

Investigation of practical approaches to evaluating cumulative dose for cone beam computed tomography (CBCT) from standard CT dosimetry measurements: a Monte Carlo study.

A function called Gx(L) was introduced by the International Commission on Radiation Units and Measurements (ICRU) Report-87 to facilitate measurement of cumulative dose for CT scans within long phantoms as recommended by the American Association of Physicists in Medicine (AAPM) TG-111. The Gx(L) function is equal to the ratio of the cumulative dose at the middle of a CT scan to the volume weighted CTDI (CTDIvol), and was investigated for conventional multi-slice CT scanners operating with a moving table. As the stationary table mode, which is the basis for cone beam CT (CBCT) scans, differs from that used for conventional CT scans, the aim of this study was to investigate the extension of the Gx(L) function to CBCT scans. An On-Board Imager (OBI) system integrated with a TrueBeam linac was simulated with Monte Carlo EGSnrc/BEAMnrc, and the absorbed dose was calculated within PMMA, polyethylene (PE), and water head and body phantoms using EGSnrc/DOSXYZnrc, where the body PE body phantom emulated the ICRU/AAPM phantom. Beams of width 40-500 mm and beam qualities at tube potentials of 80-140 kV were studied. Application of a modified function of beam width (W) termed Gx(W), for which the cumulative dose for CBCT scans f (0) is normalized to the weighted CTDI (CTDIw) for a reference beam of width 40 mm, was investigated as a possible option. However, differences were found in Gx(W) with tube potential, especially for body phantoms, and these were considered to be due to differences in geometry between wide beams used for CBCT scans and those for conventional CT. Therefore, a modified function Gx(W)100 has been proposed, taking the form of values of f (0) at each position in a long phantom, normalized with respect to dose indices f 100(150)x measured with a 100 mm pencil ionization chamber within standard 150 mm PMMA phantoms, using the same scanning parameters, beam widths and positions within the phantom. f 100(150)x averages the dose resulting from a CBCT scan over the 100 mm length. Like the Gx(L) function, the Gx(W)100 function showed only a weak dependency on tube potential at most positions for the phantoms studied. The results were fitted to polynomial equations from which f (0) within the longer PMMA, PE, or water phantoms can be evaluated from measurements of f 100(150)x. Comparisons with other studies, suggest that these functions may be suitable for application to any CT or CBCT scan acquired with stationary table mode.

A Monte Carlo investigation of cumulative dose measurements for cone beam computed tomography (CBCT) dosimetry.

Many studies have shown that the computed tomography dose index (CTDI100) which is considered as a main dose descriptor for CT dosimetry fails to provide a realistic reflection of the dose involved in cone beam computed tomography (CBCT) scans. Several practical approaches have been proposed to overcome drawbacks of the CTDI100. One of these is the cumulative dose concept. The purpose of this study was to investigate four different approaches based on the cumulative dose concept: the cumulative dose (1) f(0,150) and (2) f(0,∞) with a small ionization chamber 20 mm long, and the cumulative dose (3) f100(150) and (4) f100(∞) with a standard 100 mm pencil ionization chamber. The study also aimed to investigate the influence of using the 20 and 100 mm chambers and the standard and the infinitely long phantoms on cumulative dose measurements. Monte Carlo EGSnrc/BEAMnrc and EGSnrc/DOSXYZnrc codes were used to simulate a kV imaging system integrated with a TrueBeam linear accelerator and to calculate doses within cylindrical head and body PMMA phantoms with diameters of 16 cm and 32 cm, respectively, and lengths of 150, 600, 900 mm. f(0,150) and f100(150) approaches were studied within the standard PMMA phantoms (150 mm), while the other approaches f(0,∞) and f100(∞) were within infinitely long head (600 mm) and body (900 mm) phantoms. CTDI∞ values were used as a standard to compare the dose values for the approaches studied at the centre and periphery of the phantoms and for the weighted values. Four scanning protocols and beams of width 20-300 mm were used. It has been shown that the f(0,∞) approach gave the highest dose values which were comparable to CTDI∞ values for wide beams. The differences between the weighted dose values obtained with the 20 and 100 mm chambers were significant for the beam widths <120 mm, but these differences declined with increasing beam widths to be within 4%. The weighted dose values calculated within the infinitely long phantoms with both the chambers for the beam widths ≤140 were within 3% of those within the standard phantoms, but the differences rose to be within 15% at wider beams. By comparing the approaches studied in this investigation with other methodologies taking into account the efficiency of the approach as a dose descriptor and the simplicity of the implementation in the clinical environment, the f(0,150) method may be the best for CBCT dosimetry combined with the use of correction factors.

An assessment of the efficiency of methods for measurement of the computed tomography dose index (CTDI) for cone beam (CBCT) dosimetry by Monte Carlo simulation.

The IEC has introduced a practical approach to overcome shortcomings of the CTDI100 for measurements on wide beams employed for cone beam (CBCT) scans. This study evaluated the efficiency of this approach (CTDIIEC) for different arrangements using Monte Carlo simulation techniques, and compared CTDIIEC to the efficiency of CTDI100 for CBCT. Monte Carlo EGSnrc/BEAMnrc and EGSnrc/DOSXYZnrc codes were used to simulate the kV imaging system mounted on a Varian TrueBeam linear accelerator. The Monte Carlo model was benchmarked against experimental measurements and good agreement shown. Standard PMMA head and body phantoms with lengths 150, 600, and 900 mm were simulated. Beam widths studied ranged from 20-300 mm, and four scanning protocols using two acquisition modes were utilized. The efficiency values were calculated at the centre (εc) and periphery (εp) of the phantoms and for the weighted CTDI (εw). The efficiency values for CTDI100 were approximately constant for beam widths 20-40 mm, where εc(CTDI100), εp(CTDI100), and εw(CTDI100) were 74.7 ± 0.6%, 84.6 ± 0.3%, and 80.9 ± 0.4%, for the head phantom and 59.7 ± 0.3%, 82.1 ± 0.3%, and 74.9 ± 0.3%, for the body phantom, respectively. When beam width increased beyond 40 mm, ε(CTDI100) values fell steadily reaching ~30% at a beam width of 300 mm. In contrast, the efficiency of the CTDIIEC was approximately constant over all beam widths, demonstrating its suitability for assessment of CBCT. εc(CTDIIEC), εp(CTDIIEC), and εw(CTDIIEC) were 76.1 ± 0.9%, 85.9 ± 1.0%, and 82.2 ± 0.9% for the head phantom and 60.6 ± 0.7%, 82.8 ± 0.8%, and 75.8 ± 0.7%, for the body phantom, respectively, within 2% of ε(CTDI100) values for narrower beam widths. CTDI100,w and CTDIIEC,w underestimate CTDI∞,w by ~55% and ~18% for the head phantom and by ~56% and ~24% for the body phantom, respectively, using a clinical beam width 198 mm. The CTDIIEC approach addresses the dependency of efficiency on beam width successfully and correction factors have been derived to allow calculation of CTDI∞.