Available online at http://www.biij.

org/2011/2/e11
doi: 10.2349/biij.7.2.e11

biij
Biomedical Imaging and Intervention Journal
ORIGINAL ARTICLE

Evaluation of imaging performance of major image

guidance systems
Chan MF1,*, Yang J2, Song Y1, Burman C1, Chan P3, Li S3
1 Memorial Sloan-Kettering Cancer Center, New York, United States of America
2 Monmouth Medical Center, Long Branch, United States of America
3 Temple University Hospital, Philadelphia, United States of America
Received 6 August 2010; received in revised form 12 January 2011; accepted 13 January 2011

ABSTRACT

Purpose: The imaging characteristics of two popular kV cone-beam CT (CBCT) and two MVCT systems utilised in
image-guided radiation therapy (IGRT) were evaluated.
Materials and methods: The study was performed on Varian Clinac iX, Elekta Synergy S, Siemens Oncor, and
Tomotherapy. A CT phantom (Catphan-504, Phantom Laboratory, Salem, NY) was scanned for measurements of image
quality including image noise, uniformity, density accuracy, spatial resolution, contrast linearity, and contrast resolution.
The measurement results were analysed using in-house image analysis software. Reproducibility, position correction,
and geometric accuracy were also evaluated with markers in a smaller alignment phantom. The performance evaluation
compared volumetric image properties from these four systems with those from a conventional diagnostic CT (CCT).
Results: It was shown that the linearity of the two kV CBCT was fairly consistent with CCT. The Elekta CBCT
with half-circle 27-cm FOV had higher CT numbers than the other three systems. The image noises of the Elekta kV
CBCT, Siemens MV CBCT, and Tomotherapy fan-beam CT (FBCT) are about 2-4 times higher than that of the Varian
CBCT. The spatial resolutions of two kV CBCTs and two MV CBCTs were 8-11 lp/cm and 3-5 lp/cm, respectively.
Conclusion: Elekta CBCT provided a faster image reconstruction and low dose per scan for half-circle scanning.
Varian CBCT had relatively lower image noise. Tomotherapy FBCT had the best uniformity. 2011 Biomedical
Imaging and Intervention Journal. All rights reserved.
Keywords: Cone beam CT, MVCT, tomotherapy, image quality, IGRT

INTRODUCTION

Image-guided radiation therapy (IGRT) is an

emerging radiation treatment modality. A key advantage
of IGRT, as compared to conventional radiation
treatment techniques, is its ability to maximally spare
* Corresponding author. Address: Memorial Sloan-Kettering Cancer
Center, New York, NY 10065, United States of America. Tel.:
+908-542-3046; E-mail: [email protected] (Maria Chan).

critical organs and localise the target through correlation

of the pre-treatment images with planning images.
Conceptually, IGRT consists of two distinct processes:
image-guided target delineation and image-guided dose
delivery. Several techniques have been developed for
IGRT in recent years, with cone-beam CT (CBCT) being
one of the most popular and accurate methodologies. The
prominent features in CBCT are the acquisition of
volumetric images at radiotherapy machines with
patients in their treatment positions and the ability to

Chan et al. Biomed Imaging Interv J 2011; 7(2):e11

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adjust the patient treatment location by correlating the

target, critical organs and/or fiducial markers between
daily setup CBCT and conventional planning CT (CCT).
Thus, intensity-modulated radiation therapy (IMRT) can
be delivered with better accuracy of target localisation.
Several major radiation oncology vendors have
released their state-of-the-art CBCTs. In the past few
years, there have been some studies [1-3] on the
comparisons of flat-panel imager-based MV versus kV
CBCT, or Tomotherapy MVCT versus helical kV CT.
However, since there has been no systematic study to
compare their performance, it is not surprising that
radiation oncology centres often have difficulties in
selecting a suitable CBCT technique for their IGRT
treatment delivery [4]. This study attempted to
systematically evaluate the imaging performance of two
popular kV CBCT and two MVCT systems for IGRT
implementation. The goal was to provide an objective
assessment and comparison of these widely used CBCT
systems.

MATERIALS AND METHODS

The study was performed on Varian Cl-iX CBCT,

Elekta XVI kV CBCT, Siemens Oncor MV CBCT, and
Tomotherapy Hi-Art Helical MV fan-beam CT (FBCT)
systems. The performance evaluation involved
comparison of volumetric image data acquired from
these four systems with a conventional CT scanner
(Philips Brilliance Big Bore). A phantom (Catphan-504,
Phantom Laboratory, Salem, NY), shown in Figure 1,
was used to characterise image quality in terms of image
noise, uniformity, density accuracy, spatial resolution,
contrast linearity and contrast resolution. The phantom
was scanned using pre-selected parameters and crossreferenced for constancy checks. A 27-cm field of view
(FOV) was used for all CBCT scans except for the
Tomotherapy FBCT system, which uses a fixed 40-cm
FOV. In-house image analysis software developed by
Memorial Sloan-Kettering Cancer Center (MSKCC) was
used for the image analysis. All imaging systems were
accepted and commissioned prior to their use in clinics
and quarterly preventive maintenance was done by the
manufacturers engineers thereafter. Physicists also
carried out quality assurance (QA) routinely according to
the established protocols [5,6] to ensure that the imaging
systems were at their best performance.
Operational descriptions of CBCT systems

Figure 1 Catphan-504 is designed to evaluate the performance of

axial and spiral CT scanners with enhanced sensitometry
samples for radiation therapy planning. Its modular
design includes test modules CTP404 (slice geometry &
contrast linearity), CTP528 (high resolution), CTP515
(low contrast), and CTP486 (uniformity) modules.

image acquisition. In the full-fan mode used for small

anatomic sites such as the head and neck, the centre of
the KVD is aligned with the isocentre in the
longitudinal-lateral plane and 50 cm away from the
isocentre in the vertical direction, while the reconstructed
volumetric FOV is a cylinder of 25.6 cm in diameter and
16 cm in length. If the required FOV in the transverse
plane is larger than 25.6 cm, the half-fan acquisition
mode is used with the image panel offset laterally by
14.6 cm. The clinical protocols of CBCT call for the use
of a bowtie filter for better image quality and lower
skin dose. The full bowtie and half bowtie filters are
used for full and half-fan scans, respectively. Both filters
are made of aluminum with 1.5-mm thickness in the
centre. The user has the option to create new imaging
protocols or modify the existing ones by changing
imaging geometry, the X-ray techniques, and the
reconstruction parameters. In this study, the parameters
were 2.5-mm slice thickness, with the full-fan and halffan modes of 24-cm and 27-cm FOV, respectively. Both
scanning modes were used in this study.

Varian kV CBCT
The On-Board Imager (OBI) system consists of a
kV X-ray source (KVS) and a kV amorphous-silicon
digital imaging detector (KVD) mounted on the linear
accelerator using robotic arms (ExactTM), which are
orthogonal to the electronic portal imaging device (aSi1000, PortalVisionTM, Varian Medical Systems). The raw
images can be acquired by rotating the linac gantry over
360o for 660 projections (or frames) with a typical setting
of 125 kV, 80 mA, and 25 ms. There are two modes of

Elekta kV CBCT
The X-ray Volume Imaging (XVI) system consists
of a kV X-ray source and a detector panel mounted
orthogonally to the MV portal imager. There are three
sizes of FOV: small, medium, and large. Medium and
large FOVs are selected by offsetting the centre of the
40x40 cm2 detector panel to 11.5 cm and 19 cm,
respectively, from the central axis of the kV X-ray beam,
while the small FOV is obtained by centering the panel.

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The panel is located 53.6 cm beyond the machine

isocentre with FOV ranging from approximately 26 to 52
cm. Collimators are inserted to restrict the kV beam to
the FOV and to the longitudinal length being imaged,
usually 12.8 or 26.4 cm. Preset parameters are
configured per anatomical site for imaging geometry,
beam characteristics, and reconstruction method. The
parameters include, but are not limited to, tube potential,
number of frames, mA and ms per frame, start and stop
gantry angles, and reconstruction resolution (1-mm pixel
size for medium resolution and 0.5-mm pixel size for
high resolution). Commonly used presets were used in
this study. Tube potential of 100 kV is used for head and
neck, and 120 kV for pelvis and chest. A 200-degree
gantry rotation (namely half-circle) with small FOV is
used for the head and neck while full rotation with
medium FOV is used for the pelvis and chest. In this
study, both full-circle and half-circle were used for 27cm FOV without the use of bowtie filter at Temple
University.
Siemens MV CBCT
The beam conditions in CBCT mode are fixed by
the manufacturer using the low (i.e., 6 MV) X-ray beam
of the machine and the amorphous-silicon electronic
portal imager (a-Si EPID). The gantry makes a 200 arc
rotation around the isocentre from 270 to 110
(International Electrotechnical Commission Convention).
Two hundred projection images are acquired on a 40x40
cm2 a-Si EPID at a source-to-image distance of 145 cm.
The field width and length are fixed with a square
27.4x27.4 cm2 field. Delivery protocols are identified by
the nominal number of monitor units (MU) selected by
the user (from 2 to 60). In Monmouth Medical Center,
the 3, 5, 8, 10, 12, and 15 MU protocols have been used
clinically, and the 60 MU protocol is for calibration
purposes. The protocol of 8 MU was used in this
phantom measurement.
Tomotherapy MV FBCT
The imaging process consists of a MV fan-beam CT
acquisition. A conventional 6 MV linear accelerator and
a detector array system are mounted opposite each other
on a ring gantry that continuously rotates during the
imaging acquisition while the treatment couch
continuously translates through the gantry, thus scanning
in a helical pattern. For MVCT imaging, the operation of
the linear accelerator is adjusted such that the nominal
energy of the incident photon beam is reduced to 3.5 MV.
The fan beam is collimated to a length of 0.5 cm and a
width of 40 cm at isocentre. Three clinical MVCT
acquisition modes (fine, normal, and coarse) are
available for (2, 4, and 6 mm) slice thickness,
respectively. The slice thickness is determined by the
pitch value (longitudinal distance that the couch moves
during one gantry rotation). The phantom measurement
in this study was imaged in the normal mode. The image
reconstruction pixel matrix is defaulted at 512x512, and
the FOV has a diameter of 40 cm.

Image noise and uniformity

Image noise and uniformity were measured by
scanning the Catphan-504 phantom in air. On the central
slice of the CTP486 module, five square (3.5x3.5 cm2)
regions of interest (ROI) were cropped in the centre and
in the peripheries at top, bottom, left, and right of the
image. Noise in the image was calculated using the
standard deviation of the pixel values divided by the
mean values in the ROIs. Uniformity was measured
using the spread of the mean values over the five ROIs.
Varian half-fan mode and Elekta half-circle scans were
used in this comparison.
Spatial resolution and contrast resolution
Spatial resolution study was performed by scanning
CTP528 module in the same phantom. The resolution
insert has a radial design pattern. The 2-mm thick
aluminum contrast figures are cast into position on the
radial gauge, which has resolution sections ranging from
1 to 21 line pairs (lp) per cm. Streaking artifacts in kV
CBCTs are commonly enhanced due to missing
projections, beam hardening, and scatter radiation.
However, the radial design of the module eliminates the
possibility of streaking artifacts from other test inserts.
The highest number of visible lp was considered the
spatial resolution in lp/cm. The CTP515 module consists
of a series of cylindrical rods of various diameters and
three contrast levels to measure low contrast
performance. Varian full-fan mode and Elekta full-circle
scans were used in this comparison.
Contrast linearity
Contrast linearity was performed by scanning
CTP404 module for all CBCT/FBCT systems. The
measurements were done by cropping ROI (5x5 mm2)
from 7 different density-inserts and calculating their
average pixel values. The values for the different
materials of the CBCT/FBCT systems were compared
with those of standard CT numbers from CCT data sets.
Varian half-fan mode and Elekta half-circle scans were
used in this comparison.

RESULTS AND DISCUSSION

Image noise and uniformity

The mean pixel values of five ROIs in waterequivalent medium and their standard deviations were
991 and 7.2, 936 and 13.3, 1061 and 28.2, 1080 and 29.8
for Varian, Elekta, Siemens, and Tomotherapy,
respectively. The calculated noise levels were 0.7%,
1.4%, 2.7% and 2.8% for Varian, Elekta, Siemens, and
Tomotherapy, respectively. The uniformities for the
above four CBCT/FBCT systems, in order, were 0.27%,
0.44%, 3.6%, and 0.26%. For a fair comparison, the
calculated values from ROIs on the transverse images
should be normalised to the volume of interest (VOI) of
100 mm3 since the noises do increase with the mean scan
volume of ROIs. In the current study, we did not perform

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(a)

(b)

(c)

(d)

Figure 2 Images of CTP528 module of the Catphan acquired to determine spatial resolution with the four CBCT/FBCT systems; a) Varian kV
CBCT; b) Elekta kV CBCT; c) Siemens MV CBCT; d) Tomo MV FBCT

the normalisation because this study attempts to conduct

evaluations based on the clinical settings, not a
mathematical formalisation. Image reconstruction quality
of these four IGRT modalities varies from disease site,
reconstruction algorithm, reconstructed slice thickness,
and image matrix resolution, etc. Therefore, the results
were clinical measures for the introductory comparison,
not a full scale detailed imaging analysis.
Spatial resolution and contrast resolution
Figure 2 shows slices of CTP528 module of the
Catphan acquired with the four systems. Bars in group
11 were visible, corresponding to 11 lp/cm for Varian
CBCT. MV CBCT/FBCT systems have relatively poor
spatial resolution (3-5 lp/cm) [7]. However, the
difference in spatial resolution between the MV
CBCT/FBCT and kV CBCT data sets was small
compared to the difference in noise and contrast. This
allows the use of fixed small objects in the image
registration. These small objects, such as surgical clips,
can be helpful in the determination of target location if
they are located around a tumour [8]. The use of higher
matrix size during reconstruction decreases the pixel size
accordingly, thus increasing the spatial resolution;
however, it is not used for localisation purposes because
of the additional time required to reconstruct the CBCT
image. A previous study has shown that the image
quality of Siemens CBCT from the 3 MU protocol, 2.5

cGy at isocentre, was sufficient for bony registration, but

that a higher dose of 610 cGy, typically corresponding
to 8 to 16 MU protocols, was necessary to distinguish
soft tissue contrast [6]. Another study has shown that 1%
contrast resolution (soft tissue contrast) can be resolved
by using 3-16 cGy for Siemens MV CBCT images [9].
Good low contrast resolution can be found in both
Varian and Elekta CBCT systems: it is evident that
circles 8, 5, and 1 for contrast of 1% (smallest diameter
3-mm), 0.5% (smallest diameter 6-mm), and 0.3%
(smallest diameter 15-mm) were visible in the images of
CTP515 module.
Contrast linearity/Sensitometry
Figure 3 shows slices of CTP404 module of the
Catphan acquired with the four systems. There were
seven different density-inserts in the module (Air, PMP,
LDPE, Polystryene, Acrylic, Delrin, and Teflon). The
linearity for the two kV CBCT was fairly consistent with
CCT. The Elekta CBCT with half-circle 27-cm FOV had
higher CT number variations than the other three modes
because Elekta half-circle scan was preset with very low
exposure to low scanning doses important for the head
and neck scanning. For low-density materials, the CT
numbers with Varian CBCT were 300-600 units lower
than those of the Elekta CBCT. Those differences would
be diminished when full-circle scan was used by Elekta
CBCT. Figure 4 shows the mean pixel values of different

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(a)

(b)

(c)

(d)

Figure 3 Images of CTP404 module of the Catphan acquired to determine contrast linearity with the four CBCT/FBCT systems; a) Varian kV
CBCT; b) Elekta kV CBCT; c) Siemens MV CBCT; d) Tomo MV FBCT

density-inserts for the CBCT/FBCT systems versus those

of CCT. As shown, CT numbers for both kV CBCT
systems were very close to those of CCT - within 2%
and 3% for Varian and Elekta systems, respectively.
Discussion
The image quality measurements of the current
study included image noise, uniformity, image resolution,
and density linearity. The Elekta CBCT image noise of
half circle 27-cm FOV scans were higher than that of the
Varian CBCT, while the image noise levels in Elektas
other operational modes, similar to those of Siemens and
Tomotherapy CBCT/FBCT systems, were 3-4 times
higher than the Varian CBCT. The uniformity of all
CBCT/FBCT systems, except Siemens, was better than
1%. The linearity of the two kV CBCT systems was
fairly consistent with CCT. The accuracy of all
CBCT/FBCT systems was comparable and has no
significant difference. Using the same kV X-ray beams,
there are differences between the scanning techniques
between Varians half-fan for large FOV with bowtie
filter and full-fan for small FOV versus the Elekta halfcircle for small FOV and whole circle for large FOV.
Since Siemens and Tomotherapy CT are MV CT images,
their spatial resolution and contrast resolution were poor
relative to those of the kV CBCT. This is due to inherent
blurring for the relatively large size of high energy X-ray
detectors in the image panel, as well as more Compton

Figure 4 Average pixel values measured with CTP404 module of

the Catphan phantom on Varian, Elekta, Siemens, and
Tomotherapy versus standard CT for 7 different density
materials.

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Table 1 Comparisons among two kV CBCT and two MV CBCT/FBCT systems

Varian

Elekta

Siemens

Tomotherapy

CCT

Mechanical Adjustment
kV Source Position

< 1 mm

< 1 mm

NA

NA

< 1 mm

kV Detector Position

< 1 mm

< 1 mm

NA

NA

NA

MV Detector Position

< 1 mm

< 1 mm

< 1 mm

< 1 mm

NA

Image Quality
High Resolution

8-11 lp/cm

8-10 lp/cm

4-5 lp/cm

3-5 lp/cm

8-12 lp/cm

Low Contrast
Spatial Linearity

0.3%
< 1 mm

0.9%
< 1 mm

1%
< 1 mm

3%
< 1 mm

0.1%
< 1 mm

Resolution and Geometry

Sensitometry
Average Pixel Values

< 2%

< 3%

< 20%

< 13%

< 0.5%

991+7.2

936+13.3

1061+28.2

1080+29.8

999.6+4.0

Image Noise

0.7%

1.4%

2.7%

2.8%

0.4%

Uniformity

0.27%

0.44%

3.6%

0.26%

0.12%

Imaging Time

2-min

2-min

3-min

3-min

< 1-min

Imaging Dose

1-4 cGy

0.3-4 cGy

3-16 cGy

1-3 cGy

0.2-4 cGy

scattering and pair production in the patient with MV

beams. Considering the effects of broad-beam scattering
on CBCT, one can shorten the scanning distance or
narrow cone beam along the longitudinal direction to
improve the image quality. Both Varian and Elekta
CBCT have the visible ring artifacts due to unbalanced
projection raw data for a large body using a large FOV
setting. Bowtie filters can improve the image quality in
some cases but not always, depending on the scanning
parameters. Based on this investigation with Elekta XVI
on phantom, the use of Bowtie filter (F1) can increase
the contrast-to-noise ratio (CNR) for the typical scans
with 100 kV cone beams, while decreasing the CNR for
the typical scans with high energy (138 kV) cone beams.
Bad image cells in the flat image panel may cause the
ring artifacts if cell response has not been corrected or
recalibrated by interpolating neighbouring cells data.
Dose from kV CBCT and MV CT is in the range of few
cGy per scan but could be much lower for the Elekta
system because of possible settings of lower mAs and
less scan angles. Varian CBCT dose could be lowered
with the lower mAs settings. The differences in imaging
geometry of these systems may also contribute to the
differences in image quality and to the scope of
application as well. Clinically, Elekta CBCT can provide
larger FOV and longer length along the longitudinal
direction than Varian due to its larger flat-panel imager
design. The spatial resolution of both Varian and Elekta
systems acceptance tests are 7 lp/cm (10 lp/cm for
updated version XVI Release 4.2 b11 of Elekta CBCT
acceptance test protocol), and we can usually observe
11-12 lp/cm at high resolution mode with a full-circle

scan. Table 1 compared the clinical properties among the

four CBCT systems being studied.
Based on a CBCT QA study conducted by MSKCC
[10], variation of OBI isocentre with time was
summarised as follows: random isocentre shift was
relatively small, but systematic isocentre shifts of 0.4-1.4
mm due to misalignment of OBI were observed.
Accurate patient setup using OBI requires monitoring of
systematic errors in OBI isocentre, such as misalignment
with radiation isocentre, gantry rotation and translational
motion of the imager. Isocentre shifts and CBCT
numbers for OBI were stable over time, as observed by
the same group as well as in a previous study [11]. Both
kV CBCT uniformity and linearity were comparable to
CCT within 2-3%. In general, CCT using more accurate
filtered-backprojection reconstruction (FBPR) and more
rigid configuration of the X-ray tube, fan-beam
collimation, and detectors has superior contrast with less
noise, less streaking and ring artifacts as compared to
CBCT.
From our annual CBCT dose measurements, the
CBCT dose for half-fan beam is about 1 cGy at isocentre
and the peripheral dose is about 3 cGy, whereas CT
simulator dose at isocentre is about 1 cGy for 35-cm
diameter body phantom measurement. As for low
contrast resolution, CCT contrast is superior to kV
CBCT, and kV CBCT is superior to MV CBCT/FBCT.
kV CBCT has pronounced ring artifacts and more noise
than CCT due to a less accurate imaging hardware
alignment and reconstruction algorithm. Clinically, at a
dose of 23 cGy, the Tomotherapy MV FBCT images
are of sufficient quality for verification of treatment
setup, but low contrast object may not be perceptible

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with MV energies due to the relatively poor signal-tonoise ratio (SNR) performance [9,12-14]. Siemens MV
CBCT has poor soft tissue contrast and higher dose to
patients. In order to maintain comparable doses for
MVCT and kVCT, the number of MV photons incident
on the patient must be considerably reduced and this
reduction decreases the SNR ratio [9]. Unlike kV CBCT
systems, the presence of high atomic number (Z)
materials such as tooth fillings or implanted markers did
not result in visible metal artifacts for MV CBCT
systems [15].
Although contrast linearity of MV CBCT/FBCT
imaging is not as close to CCT as the kV CBCT is, MV
CBCT/FBCT is superior in its linear relationship
between relative electron density and CT number for
dose calculation [16]. Because artifacts due to metal
objects and beam hardening are less critical for MV
sources, MV CBCT/FBCT scans have been used to
complement CCT scans when these artifacts are severe
[16]. The two MVCT systems utilise the same X-ray
sources for both imaging and treatment and hence
provide more accurate geometrical information than the
kV CBCT systems although the kV CBCT systems
provide better quality images [4]. The isocentre
accuracies of Tomotherapy and Siemens were reported
to be approximately 0.2 mm and 0.5 mm, respectively, in
all directions, which were confirmed by their isocentre
accuracy testing.

CONCLUSION

This study confirmed the comparability of imaging

performance of four popular clinically available
CBCT/FBCT systems. Our objective evaluation of
imaging performance revealed that the volumetric data
rendered by the four CBCT/FBCT systems are accurate,
as compared with conventional CT. In a summary,
Elekta CBCT provided faster image reconstruction,
Varian CBCT had relatively lower image noise, and
Tomotherapy had the best uniformity.

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