Chapter 22:

Computed Tomography
Simulation Procedures
Patients treated with radiation therapy get involved to numerous procedures from
diagnosis to ongoing patient follow up. Before the procedure, simulation must be
done first. These determin the success rate of the procedure.
HISTORIC PERSPECTIVE
During the early days, simulation was performed on the treatment unit, and
accuracy was evaluated by poor quality film.

1. Virtual simulation was introduced, provided the ability to design the fields
without a conventional simulator and with better visualization of internal structures
by using 3D images on the computer.

2. Treatment planning computers were developed with more sophisticated

algorithms and faster computer speeds that could carry out 3D treatment planning
by using CT images

3. A true virtual simulator allowed for a CT scan to be acquired and a virtual

patient could be reconstructed from the CT images.
Simulation - is carried out by the radiation therapist under the supervision of the
radiation oncologist, a mockup of the procedure.

Localization - geometric definition of the position and extent of the tumor or

anatomic structures by reference of surface marks that can be used for treatment.

Verification is a final check to ensure that each of the planned treatment beams
does cover the tumor.

Radiopaque marker refers to a material with a high atomic number. It is usually

made of lead, copper, or solder wire.

Contrast media is a compound or agent used as an aid in visualizing internal

structures.
Separation refers to the measurement of the thickness of a patient along the
central axis (CA).

Field size involves the dimensions of a treatment field at the isocenter, which are
represented by width × length.

Digitally reconstructed radiograph is a two-dimensional image reconstructed from

CT data that shows a beam’s eye view of the treatment field.

Interfraction motion is the change in target position from one fraction to another.

Intrafraction motion is the change in target position during treatment delivery as

might occur in the thorax with respirations
Gross tumor volume indicates the gross palpable or visible tumor.

Clinical target volume indicates the gross palpable or visible tumor (GTV) and a
surrounding volume of tissue that may contain subclinical or microscopic disease.

Planning target volume indicates the CTV plus margins for geometric
uncertainties, such as patient motion, beam penumbra, and treatment setup
differences.

Internal target volume indicates the CTV plus and internal margin that accounts
for tumor motion.
Anatomic Body Planes
A review of the three major body planes helps in understanding the nature of 3D
localization. And the human body has three planes (coronal, sagittal, and axial).
Benefits of Computed Tomography Simulation
1. Accurate delineation of 3D volumes in the patient’s treatment position. The
ability to outline tumor volume and critical structures, also known as OAR, and
view these structures in three dimensions.

2. The isocenter can be placed quickly and accurately in any location.

3. A virtual patient provides flexibility to create or change any factor of the

treatment plan.

4. More information/data for measurements post-simulation

5. Cone down or boost fields can be accomplished without the patient present
(virtual simulation).
6. Beam’s eye view (BEV) display allows anatomy to be viewed from the perspective of the radiation
beam.

7. CT simulation allows field shaping electronically at the graphic display station.

8. Virtual simulation allows comparison of beams and construction of DRRs without the patient present.

9. CT simulation allows for downstream calculation and viewing of dose distribution based on patient
anatomy.

10. Virtual simulation confers the ability to mitigate intrafraction motion with 4D CT.

11. Simulation results in an easier procedure for the patient because of reduction in procedure time.

12. All information is archived digitally, which facilitates data recovery and streamlines storage.

13. CT exposure can be quantified and recorded.

Considerations of Computed Tomography
Simulation
Several things should be taken to consideration when doing CT simulation such
as CT aperture size, isocenter location, dose, and machine parameters.
COMPUTED TOMOGRAPHY SIMULATION PROCEDURES

Pre-Simulation Planning - Assessment of the procedures to be done and the

patient must be done.

Patient Positioning - This must be done with regards to the unit limits, and to the
patient’s age, weight, health, and anatomic part.

Patient Immobilization - This is critical to reduce errors and give accuracy for the
treatment.
Tips to ensure patient reproducibility and quality imaging:

1. The patient must be cooperative and relaxed. This can only occur with good
communication. Clearly explain the procedure to the patient.

2. Take extra care to construct an immobilization device to ensure accuracy.

Follow manufacturer recommendations for making the immobilization device.

3. Straighten the patient, re-straighten, and repeat the topogram (scout) if

necessary.
Special Procedure Immobilization
These are radiation beams directed in the brain. And the immobilization device
used is a frame fixed to the skull.

stereotactic body radiation therapy (SBRT) immobilization consists of an extended

vacuum bag molded specifically for each patient

More immobilization are used for specific procedures.

Room Preparation
This preparation saves time, with proper assessment, the therapist can prepare
the room in advance.
Explanation of Simulation Procedure
Proper explanation of the simulation procedure helps the patient understand what
will be done,This include:
Assessment, Communication and Education the Patient and Family.

The patient must also be informed of what to do during the simulation, and what to
do after the simulation
CONTRAST AGENTS
Contrast agents can be used during CT, this can be administered via 4 ways:
intravenous, oral, intrathecally, or intra-arteriorly.
Medical History
Before injecting Contrast agents, the medical history should be checked for
adverse reactions to contrast media.

Every contrast medium has risks when used.

Ionic Contrast media has high osmolality or number of particles / kg of water.

Higher osmolality contrast mediums pose higher risks for adverse reactions to it,
low osmolality contrast agents are preferred.
PATIENT POSITIONING IN THE COMPUTED TOMOGRAPHY SCANNER

The patient should be positioned carefully so that the area of interest/treatment is

in the center of the CT bore and scan field of view (SFOV). This will help to
eliminate image artifacts, provide the best image quality, and ensure the field of
view (FOV) encompasses the entire patient.
COMPUTED TOMOGRAPHY TOPOGRAMS
Topograms are first scans taken and are usually AP or lateral or both, Topograms
help ensure that the patient is properly positioned.
COMPUTED TOMOGRAPHY DATA ACQUISITION
Newer CT units today have spiral and axial scanning, and these greatly reduce
scan time. Most protocols use spiral scanning to reduce scan time and reconstruct
the image instantly.
METHODS OF SIMULATION WITH COMPUTED TOMOGRAPHY IMAGES

There are methods during the simulation in CT

These are Shift and No-Shift methods
Shift method
This method places reference marks on the patient and scan that location close to
the treatment isocenter. After the scan, the images are calculated, and the new
marks are shifted towards the new isocenters while removing the old marks.
No-shift method
In this method, after putting the marks and calculating them, the lasers will be
pointed to the isocenter, and will be used as the treatment marks without shifting
and using new markers.
PATIENT MARKING SYSTEM
Isocenter or field edge markings are used in simulations, and when the volume
has been determined, the computer calculates the isocenter. Several lasers help
in this process.
DOCUMENTING DATA
Data gathered during the simulation may be used for daily setups and must be
documented to use during the treatment.
USE OF FOUR-DIMENSIONAL COMPUTED TOMOGRAPHY IN VIRTUAL
SIMULATION

Most artifacts in CT have been identified as motion artifacts, specially from

breathing, breath hold have been used for this, but some patients can’t hold their
breath too long. Because of this, prospective axial scanning was used to let the
scanner take images during specific part of the respiration to let the patient
breathe freely.

After image taking, the images will be reconstructed and played in a movie-loop to
show tumor motion.

4D scans are used to generate treatment margins for the tumor extent.

New machines can let the patient breathe freely with lesser motion blur.
NUCLEAR MEDICINE
This relies on CT imaging to know about the tumor metabolic activity and function,
along to imaging the radionuclides injected in the patient.

The radioactive decay is recorded by a gamma camera which detects

Positron Emission Tomography
This was developed in the 1970s and was used to diagnose, stage, and follow up
tumors.

During a PET scan, patients are injected with 18-Fluoro-2-Deoxy-D-Glucose with

110min half-life.

FDG accumulates in parts with high glucose activity, usually disease sites.
Single-Photon Emission Computed Tomography
SPECT is another imaging modality that can aid in treatment planning and used to
assess lung perfusion and amount of functional lung tissue.
Magnetic Resonance Imaging
A non-invasive procedure that has better soft tissue contrast and resolution than
CT.
MRI is useful for defining tumor volume in the brain, head, neck, liver, pelvis,
prostate, and in sarcomas.

MRI data is fused with CT for treatment, because MRI cant give any information
about electron density to use for dose calculation.