PMP

Progress in Medical Physics 30(4), December 2019

Technical Note https://doi.org/10.14316/pmp.2019.30.4.160
eISSN 2508-4453

Acceptance Test and Clinical Commissioning of

CT Simulator
Hyun Joon An1,2 , Jaeman Son1,2 , Hyeongmin Jin1,2 , Jiwon Sung1,2 , Minsoo Chun1,2,3
1
Department of Radiation Oncology, 2Biomedical Research Institute, Seoul National University Hospital, 3Institute of Radiation Medicine,
Seoul National University Medical Research Center, Seoul, Korea

Received 13 December 2019 This study examined the clinical use of two newly installed computed tomography (CT) simulators
Revised 17 December 2019 in the Department of Radiation Oncology. The accreditation procedure was performed by the
Accepted 18 December 2019 Korean Institute for Accreditation of Medical Imaging. An Xi R/F dosimeter was used to measure
the CT dose index for each plug of the CT dose index phantom. Image qualities such as the
Corresponding author Hounsfield unit (HU) value of water, noise level, homogeneity, existence of artifacts, spatial
Minsoo Chun resolution, contrast, and slice thickness were evaluated by scanning a CT performance phantom.
([email protected]) All test items were evaluated as to whether they were within the required tolerance level. CT
Tel: 82-2-2072-4151 calibration curves━the relationship between CT number and relative electron density━were
Fax: 82-2-765-3317 obtained for dose calculations in the treatment planning system. The positional accuracy of the
lasers was also evaluated. The volume CT dose indices for the head phantom were 22.26 mGy and
23.70 mGy, and those for body phantom were 12.30 mGy and 12.99 mGy for the first and second
CT simulators, respectively. HU accuracy, noise, and homogeneity for the first CT simulator were
一0.2 HU, 4.9 HU, and 0.69 HU, respectively, while those for second CT simulator were 1.9 HU,
4.9 HU, and 0.70 HU, respectively. Five air-filled holes with a diameter of 1.00 mm were used for
assessment of spatial resolution and a low contrast object with a diameter of 6.4 mm was clearly
discernible by both CT scanners. Both CT simulators exhibited comparable performance and are
acceptable for clinical use.

Keywords: CT simulator, Acceptance test, CT dose index, Image quality

Introduction mobilization devices.4,5) Furthermore, a flat-bed couch and

moving laser system are required for treatment simula-
Since the late 1970s, computed tomography (CT) has tion.5) Notably, the characteristics and performance of a
been widely used for radiotherapy planning with the radiation oncology-dedicated CT scanner should be vali-
advantages of improved patient positioning, target delin- dated in advance of patients’ CT simulations to ensure ac-
eation, treatment beam arrangement, and dose calcula- curacy.5,6)
1-3)
tion. Unlike a diagnostic CT scanner, a wide bore (>80 According to the American College of Radiology (ACR)
cm) scanner is generally used for CT simulations. This is CT accreditation program, a submission of clinical and
largely to accommodate extremely large patients, breast phantom images, dose measurements and scanning pro-
cancer patients for whom the ipsilateral arm is subtended tocols is mandatory for any institution using CT devices
to approximately 90°, and patients with specialized im- in the United States.7) Image qualities such as CT number

Copyright © 2019 Korean Society of Medical Physics

CCThis is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-
nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Progress in Medical Physics Vol. 30, No. 4, December 2019 161

Table 1. Verification of scan parameters

Scan parameter setting kV mAs*
kV mA Seconds mAs CT SIM1 CT SIM2 CT SIM1 CT SIM2
80 300 0.5 150 80.416 80.537 151.592 152.616
80 200 1 200 80.616 80.726 201.348 201.648
80 50 2 100 80.050 81.115 100.434 101.413
120 300 0.5 150 122.091 122.441 150.360 151.618
120 200 1 200 122.458 122.266 200.373 201.108
120 50 2 100 122.258 122.338 100.233 101.228
140 300 0.5 150 141.295 142.006 150.170 151.430
140 200 1 200 141.928 142.778 200.480 200.901
140 50 2 100 143.029 143.823 100.300 101.278
CT, computed tomography; SIM1, the first CT simulator; SIM2, the second CT simulator.
*Product of tube current and time.

accuracy, low-contrast resolution, image uniformity, and institute for CT simulation for radiotherapy. The accredita-
volume CT dose index (CTDIvol) are assessed in the ac- tion procedures were performed by the KIAMI during the
creditation process. The acceptance criteria for CTDIvol are acceptance testing stage of the CT simulators.
80 mGy and 30 mGy for adult head and abdominal scans,
respectively.7) In Europe, a reference level of 60 mGy for 1. S
can parameters and computed tomography
weighted CTDI was proposed for a routine head protocol.8) dose index
A similar accreditation program is performed in South
Korea by the Korean Institute for Accreditation of Medical The scan parameters were evaluated to confirm whether
Imaging (KIAMI). For this program, spatial resolution, low the kV and mAs set by users are appropriately and accu-
contrast resolution, linearity, image noise, and the pres- rately delivered by the CT simulators. An Xi R/F detector
ence of artifacts are evaluated along with CTDI for each (Unfors RaySafe AB, Billdal, Sweden) capable of measur-
9)
plug position. The CTDI acceptance criterion for each ing tube potential, dose, dose rate, pulse, pulse rate, dose/
plug position is much stricter in South Korea than those frame, time, half-value layer, and total filtration simultane-
stated by international guidelines. Although CTDIvol does ously was used for this purpose. Scan parameters are listed
10,11)
not imply the actual patient dose, CTDIvol can be used in Table 1, and the tolerance limits for the measurements
7-9)
for the verification and monitoring of imaging doses. were ±7% and ±10% for kVp and mAs, respectively. CTDI
Although several studies insist that noise is the primary was measured with dedicated a head and body CTDI
variable affecting image quality and diagnostic perfor- phantom (Fluke Corporation, Everett, WA, USA). An Xi CT
12,13)
mance, other quality indices should also be examined detector (Unfors RaySafe AB) and a black piranha Qual-
5,14)
for CT scanner assessment. ity Assurance (QA) meter (RTI Electronics AB, Moelndal,
Recently, two CT simulators were newly installed in our Sweden) were used. CTDIs for each plug position were
institute. The aim of this study was thus to evaluate the im- evaluated as to whether the measurement was within the
age quality and radiation dose of these CT simulators, and acceptable range (Table 2).
to ensure their clinical acceptance for use in radiotherapy
planning. 2. Image quality

Materials and Methods A modular 76-410 AAPM CT Performance Phantom

(Fluke Corporation; Fig. 1a) was scanned to evaluate im-
Two Brilliance CT Big Bore (Philips Medical System, age quality. The phantom contained a contrast test object,
Cleveland, OH, USA) systems were newly installed in our a CT number linearity insert, a resolution insert, and a

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162 Hyun Joon An, et al：ATP and Commissioning of CT Simulator

slice thickness insert. The phantom was scanned with 120 as the standard deviation of HU for 4 ROIs and should be
kVp, 250 mAs, and a slice thickness of 10 mm, and was less than 5 HU. The existence of artifacts was subjectively
reconstructed with a standard reconstruction algorithm. evaluated by determining if reviewers could identify any
The Hounsfield unit (HU) of water, noise level, homogene- visible artifacts. In the image of the spatial resolution insert
ity, presence of artifacts, spatial resolution, contrast, and (Fig. 1c) where eight sets of five air-filled holes are imaged
slice thickness were evaluated in the reconstructed im- (with diameters of 1.75, 1.5, 1.25, 1.00, 0.75, 0.61, 0.5, and
2
ages. The mean and standard deviation of 4×4 cm regions 0.4 mm), reviewers should be able to discern all five holes
of interest (ROI) drawn in water were defined as the HU of each set at least 1.00 mm diameter in order to pass the
of water and noise level, respectively. The HU of water spatial resolution test. Six pairs of the low contrast inserts
should be between –7 HU and 7 HU, and the noise level (Fig. 1d) with diameters of 25.4, 19.1, 12.7, 9.5, 6.4, and 3.2
should be less than 7 HU. Homogeneity was calculated mm were filled with dextrose or sodium chloride solutions
of various densities with 2%–3% differentials in density be-
tween cavities. Reviewers must be able to identify the two
Table 2. CTDI measured with an Xi CT detector 6.4 mm spheres in the image in order to pass the low con-
Acceptable CTDI (mGy)
Phantom Location trast resolution test. The slice thickness as determined by
range CT SIM1 CT SIM2
measuring the distance of the aluminum strips should be
Head Center 24.8 mGy±35% 21.059 21.867
accurate within ±1 mm to pass the slice thickness test (Fig.
0° (12 o’clock) 28.7 mGy±35% 24.713 25.886
1e). Complete assessments were performed independently
90° (3 o’clock) 27.3 mGy±35% 23.079 24.597
180° (6 o’clock) 25.8 mGy±35% 21.146 22.633 by two KIAMI-trained reviewers.
270° (9 o’clock) 27.4 mGy±35% 22.520 25.375
Body Center 8.7 mGy±35% 7.362 7.383 3. Hounsfield unit curves and laser position
0° (12 o’clock) 18.4 mGy±35% 16.336 16.745
90° (3 o’clock) 18.5 mGy±35% 15.144 15.957
An electron density phantom (Model 62M; CIRS Inc.,
180° (6 o’clock) 18.1 mGy±35% 12.326 13.647
270° (9 o’clock) 16.3 mGy±35% 15.274 16.802 Norfolk, VA, USA) was used to acquire the HU value cor-
Both scans were taken with 120 kVp, 250 mAs, and 2.4 cm of slice responding to each tissue-equivalent insert. The phantom
thickness. Values are presented as mean±standard deviation. was scanned with a body scan protocol of 120 kVp, 213
CTDI, computed tomography dose index; CT, computed tomo­
graphy; SIM1, the first CT simulator; SIM2, the second CT sim­ mAs, and 2 mm slice thickness. The acquired HU to elec-
ulator. tron density curve and the acquired HU to physical density

0.40 mm
Ave: 1.3 HU
SD: 4.0 HU 0.50 mm
0.61 mm
0.75 mm
1.00 mm
1.25 mm
Ave: 1.1 HU Ave: 1.1 HU 1.50 mm
SD: 3.9 HU SD: 3.9 HU
1.75 mm
Ave: -0.2 HU
SD: 4.9 HU b c

3.2 mm
6.4 mm
9.5 mm
12.7 mm
9.08 cm
19.1 mm
25.4 mm

a d e

Fig. 1. (a) A modular 76-410 AAPM computed tomography (CT) Performance Phantom (Fluke Corporation, Everett, WA, USA); CT slices
of (b) water Hounsfield unit (HU), noise level, homogeneity evaluation, (c) spatial resolution, (d) low contrast resolution insert, and (e)
slice thickness. Ave, average; SD, standard deviation.

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Progress in Medical Physics Vol. 30, No. 4, December 2019 163

Table 3. Physical characteristics and HU acquired during the clinical commissioning stage
Physical density Electron density Relative electron density
Plug bar description HU for CT SIM1 HU for CT SIM2
(g/mL) (×1023 electrons/mL) (relative to H2O)
Lung inhale 0.20 0.634 0.190 −795.3 −792.1
Lung exhale 0.50 1.632 0.489 −457.2 −458.8
Adipose 0.96 3.171 0.949 −65.2 −67.4
Breast (50% gland/50% adipose) 0.99 3.261 0.976 −33.3 −31.6
Muscle 1.06 3.483 1.043 50.6 50.2
Liver 1.07 3.516 1.052 56.3 59.2
Trabecular bone (200 mg/mL) 1.16 3.730 1.117 213.1 216.4
Solid dense bone (800 mg/mL) 1.53 4.862 1.456 867.8 868.2
HU, Hounsfield unit; CT, computed tomography; SIM1, the first CT simulator; SIM2, the second CT simulator.

curve were imported to the treatment planning system for and the homogeneity were –0.2 HU, 4.9 HU, and 0.69 HU,
dose calculation. respectively, for CT SIM1. These parameters for CT SIM2
A DORADOnova 3 laser system (LAP GmbH Laser Ap- were 1.9 HU, 4.9 HU, and 0.70 HU, respectively. All review-
plications, Lüneburg, Germany) along with a CARINAnav ers agreed that there were no visible artifacts as shown in
smart control system (LAP GmbH Laser Applications) Fig. 1b. Five air-filled holes with a diameter of 1.00 mm
for patient alignment were installed. A Wilke phantom and a low contrast object with a diameter of 6.4 mm were
was aligned using the DORADOnova 3 laser system, and clearly discernible for both CT simulators as shown in Fig.
scanned with 120 kV, 200 mAs, and a slice thickness of 1.25 1c, d, respectively. Thus, the CT simulators passed the
mm. The accuracy of the laser system was analyzed using spatial resolution assessment. The slice thicknesses for the
the tumorLOC program (Philips Medical System). aluminum strip were 8.9 mm and 9.1 mm, for CT SIM1 and
CT SIM2, respectively. All testing parameters were within
Results the required tolerance level (Fig. 1e).

1. Verification of scan parameters and computed 3. Hounsfield unit curves and verification of laser
tomography dose index position

The scan parameters set by users were correctly mea- The phantom manufacturer provided the physical den-
sured, showing average discrepancies of –1.28% and sity as well as the electron density for the designated mate-
–1.67% in kV, and –0.39% and –1.06% in mAs, for the first rials. The average HU values for each ROI according to the
CT simulator (CT SIM1) and the second CT simulator (CT material were comparable for both scanners. A relatively
SIM2), respectively. As shown in Table 1, the results of the large HU difference for the lung inhale insert (3.2 HU) and
scan parameter verification were tolerable for both CT sim- at the trabecular bone insert (3.3 HU) was observed, and
ulators as they were within the tolerance levels of ±7% and the complete results are summarized in Table 3. The aver-
±10% for kVp and mAs, respectively. The CTDI measure- age of HU values corresponding to each relative electron
ments are provided in Table 2. The head and body CTDIs density (RED) were imported into the treatment planning
for each chamber position were all within the tolerance system. The laser position was verified in three directions
limit for both CT simulators. as shown in Fig. 2. The difference between the laser posi-
tion and the groove center shown in the images was less
2. Image quality than 0.1 mm for both scanners.

As shown in Fig. 1b, the HU of water, the noise level,

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164 Hyun Joon An, et al：ATP and Commissioning of CT Simulator

a b c

Fig. 2. (a) Wilke phantom, (b) an axial slice, and (c) a coronal slice. The deviations between laser position and groove position in the
images are marked.

Discussion dose calculations as megavoltage photon beams interact

primarily with Compton scattering.3,20) Although CT num-
The accreditation procedure for the newly installed CT bers are defined as being proportional to the linear attenu-
simulators was performed by reviewers in KIAMI. All test ation coefficient, individual scanners exhibit inaccura-
items were identified as acceptable for both scanners. cies.6,21) Therefore, the HU corresponding to each material
CTDI is often not recommended as a surrogate for patient should be measured for a given scanner, which is generally
doses as it does not consider an actual body size or com- established during the commissioning stage.6) Notably, the
10,11,15-17)
position. Despite this, CTDI measurement is crucial consistency of HU for a given tissue should be monitored
because it is applied when estimating a more precise dose because changes in HU will result in changes in dose dis-
16,17)
estimate such as size-specific dose estimates. As men- tribution.6,22) Typically, HU value changes of ±20 HU for soft
tioned above, the tolerance levels for CTDIvol suggested by tissue and ±50 HU for lung and bone are known to lead to
the ACR accreditation program are 80 mGy and 30 mGy for 1% changes in dose distribution.22) The two newly installed
a head and a body phantom, respectively. By applying the CT simulators showed consistent HU values showing a
CTDIvol=1/3×CTDIcenter+2/3×CTDIperiphery formula, the CT- maximum difference of 3.3 HU. Since this difference is neg-
DIsvol in KIAMI were 35.73 mGy and 19.96 mGy for a head ligible when considering the tolerance for HU consistency,
and a body phantom, respectively. In our head phantom a single CT calibration curve by averaging two HUs was ap-
measurements, the measured CTDIsvol were 22.26 mGy and plied in the treatment planning system.
23.70 mGy for CT SIM1 and CT SIM2, respectively. Fur- In short, installation, acceptance testing, and commis-
thermore, for body phantom measurements, the CTDIsvol sioning of the new CT simulators were performed. Al-
were 12.30 mGy and 12.99 mGy for CT SIM1 and CT SIM2, though the acceptance testing and commissioning of the
respectively. All measurements were within strict tolerance CT simulators were tolerable, periodic quality assurance
levels. should be performed by medical physicists.5,6) The overall
HU uniformity, noise level, and homogeneity were also system should be appropriately monitored to rigorously
within required tolerance levels. The acceptance criteria maintain the CT simulators in the radiation oncology de-
for noise level provided by KIAMI changed from 8 HU to 7 partment.
HU in 2007. Noise level is known to dominate overall image
quality, thus the detectability of a lesion is mainly affected Conclusions
by noise level.18,19) According to existing literature regarding
image quality in multiple CT scanners, higher noise levels The clinical use of the newly installed CT simulators was
9,14)
resulted in lower contrast-to-noise ratio. Therefore, the validated by performing image quality evaluation and dose
application of stricter criteria for noise level is reasonable. measurements. Both CT simulators showed comparable
A CT calibration curve—that is, the relationship between performance and are acceptable for clinical use.
HU values and their corresponding RED—is necessary in

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Progress in Medical Physics Vol. 30, No. 4, December 2019 165

Acknowledgements criteria for computed tomography. European Commis-

sion. 1999.
This work was supported by the National Research Foun- 9. Park HJ, Jung SE, Lee YJ, Cho WI, Do KH, Kim SH, et al.
dation of Korea (NRF) grant funded by the Korean govern- The relationship between subjective and objective param-
ment (NRF-2019R1F1A1041944). eters in CT phantom image evaluation. Korean J Radiol.
2009;10:490-495.
Conflicts of Interest 10. Deak PD, Smal Y, Kalender WA. Multisection CT protocols:
sex- and age-specific conversion factors used to determine
The authors have no conflicts of interest to declare. effective dose from dose-length product. Radiology. 2010;
257:158-166.
Availability of Data and Materials 11. McCollough CH, Leng S, Yu L, Cody DD, Boone JM, Mc-
Nitt-Gray MF. CT dose index and patient dose: they are not
All relevant data are within the paper and its Supporting the same thing. Radiology. 2011;259:311-316.
Information files. 12. Chun M, Choi YH, Kim JH. Automated measurement of CT
noise in patient images with a novel structure coherence
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