II.
Technology and Implementation
Chapter 5
CT SIMULATION
TIM FOX, PHD, ELIZABETH BUTKER, MS, ERIC ELDER, PHD
Over the past decade, many radiation oncology depart-
ments have incorporated the modern computed tomog-
raphy (CT) simulator into their treatment process. In fact,
many clinics are moving away from conventional simula-
tors altogether and are relying primarily on CT simulators.
Commercial CT simulators are available that combine
many of the functions of an image-based, three-dimen-
sional treatment planning system and a conventional sim-
ulator.1–18 These systems attempt to integrate as much of
the planning process as possible using exact anatomic infor-
mation of the patient obtained at the time of CT scanning.
The software used in conjunction with a CT simulator pro-
vides virtual representations of the patient and the geo-
metric capabilities of a treatment machine. Often CT
simulation is referred to as virtual simulation, and the two
terms tend to be used interchangeably.1
The initial concept of the CT simulator was to emu-
late the conventional simulation process on a contiguous
CT data set representing the patient. This idea was first
proposed by Goitein and colleagues as beam’s eye view
(BEV) planning.15 In BEV treatment planning, relevant
segmented critical structures from CT contours are pro-
jected to a plane beyond the patient from the vantage
point of the radiation source to ensure appropriate three-
dimensional target coverage. This concept was further
developed by Sherouse and colleagues, who introduced
a system that could work like a simulator but used digi-
tal information derived from the patient imaging data
set.11–13 A patient treatment simulation could be com-
pleted on a virtual patient model with digitally recon-
structed radiographs (DRRs). A DRR is simply a virtual
radiographic projection of the CT data in a BEV and is
analogous to the conventional simulation film. The DRR
allows for verification of the treatment field using con-
ventional port film techniques. Therefore, the simulation
process can be completed in a virtual domain without
having the patient in the simulator room. This method
83
not only improves the accuracy of target localization but
also provides flexibility for radiation oncologists to com-
plete the simulation process at a time that is more con-
ducive to their schedule.
Intensity-modulated radiation therapy (IMRT) treat-
ment planning uses dose-volume constraints as part of the
optimization methods during the plan creation phase. CT
simulation allows the anatomic segmentation of the tar-
get volumes and critical structures for IMRT planning.
In addition to CT imaging, other imaging modalities, such
as magnetic resonance imaging (MRI), positron emis-
sion tomography (PET), single-photon emission computed
tomography (SPECT), or another CT scan, can be regis-
tered with the CT simulation scan to provide more anatom-
ic or functional information during the process (see Chapter
8, “PET-CT in IMRT Planning”).
The American Association of Physicists in Medicine
(AAPM) created Task Group Report 66 (TG-66), “Quality
Assurance for Computed-Tomography Simulators and the
Computed Tomography-Simulation Process,” which pro-
vides the medical physicist with a framework and guid-
ance for the establishment of a comprehensive quality
assurance (QA) program for CT scanners used for CT sim-
ulation, CT simulation software, and the CT simulation
process.1 A section is provided in this chapter that high-
lights the main tests to perform for a typical radiation
oncology department. For detailed information, the read-
er is encouraged to review this report.
Technology and Process
A CT simulator consists of three main components: a CT
scanner with a flat tabletop, an integrated laser marking
system, and virtual simulation and visualization software.
All three components form the package for simulating
the treatment of an individual patient. The CT simula-
tion scanner table must have a flat top similar to that of
84 / Intensity-Modulated Radiation Therapy

radiation therapy (RT) treatment machines (Figure 5-1).

Even though the general shape of the CT simulation and
treatment machine tables may be similar, the treatment
machine table usually has components, such as remov-
able panels and table support components, that are not
reproduced on the simulator table. As described in the
AAPM TG-66 report, treatment policies and planning tar-
get volumes should account for these differences.1 Besides
the flat tabletop, the scanners used for CT simulation are
usually equipped with external patient marking or posi-
tioning lasers, which can be fixed or mobile. Mobile lasers
allow easier marking of patients. In particular, the sagit-
tal laser should be mobile because CT tables do not move
in the lateral direction, and it allows marking away from
the patient’s midline.
Today, most devices used for CT simulation are capa- FIGURE 5-1. An AcQSim (Philips Medical Systems, Cleveland, OH)
CT simulator equipped with a flat couch top to mimic the Varian (Varian
ble of both conventional and spiral CT scanning for image
Medical Systems, Palo Alto, CA) Exact Couch Top on a CL2100 EX. The
acquisition. Conventional CT (sometimes called axial scan-
external laser system, used for marking the patient, is located outside
ning) acquires data one slice at a time. Alternatively, spiral the scanner.
or helical CT, which became available in the late 1980s, allows
data to be acquired while the table translates and the x-ray
tube gantry rotates simultaneously. The path of the tube
forms a helical pattern around the patient. The spiral mode CT Scanning, Positioning, and Immobilization
is preferred for CT simulation owing to faster scan times. The CT simulation scan is similar to a conventional diag-
Besides image acquisition techniques, the use of mul- nostic scan. However, the radiation oncology requirements
tislice CT scanners has been recently adopted in CT sim- must specify information in regard to patient positioning
ulation, allowing projection data from multiple slices to be and immobilization, treatment-specific scan protocols, use
acquired simultaneously.19–23 These multislice scanners use of contrast, and placement of localization marks on the
multiple rows of detectors to acquire image studies faster patient’s skin. It is highly recommended that procedures and
than single-slice scanners. In addition, the tube heat load- protocols be developed for most treatment sites to ensure
ing for a particular patient volume is lower for multislice consistency during the CT simulation process. In IMRT, one
than for single-slice scanners. Multislice technology can be of the most critical issues is patient positioning and immo-
especially beneficial for simulation of tumors in the tho- bilization. All cranial patients, including patients with head
rax because breathing artifacts can be minimized. This tech- and neck cancer, should use a head support system with a
nology is also valuable for simulation of respiratory-gated head mask or cast. For other regions of the body, either a
treatments. Vac-Lok Bag (MED-TEC, Orange City, IA) or an Alpha
Most conventional CT scanners use a 70 cm bore open- Cradle (Smithers Medical Products, North Canton, OH)
ing. This has been a weakness for CT simulation because should be used. The use of a reliable and reproducible fixa-
patient positioning may be compromised with a small open- tion system for the patient is important and should verify
ing. Currently, two manufacturers (GE Healthcare and
Philips Medical Systems) offer a CT scanner with an 85 cm TABLE 5-1. Technical Options for Commercial Computed
bore opening, designed specifically for radiation oncology Tomography Simulation Systems
purposes. The larger opening allows for greater flexibility CT Simulator Manufacturer
in patient positioning and use of immobilization devices.24
These large-bore scanners also have an increased scan field GE Healthcare Siemens Philips Medical
Features Systems
of view, 60 cm compared with 48 cm on most 70 cm bore
units. The large-bore scanner image quality is generally Spiral CT option Yes Yes Yes
comparable to that of 70 cm units; however, some degra- Multislice CT option Yes Yes Yes
Flat tabletop option Yes Yes Yes
dation in high-contrast resolution and image noise has Bore size 85 cm 70 cm 85 cm
been observed. The various systems offered by the com- SFOV size 60 cm 48 cm 60 cm
mercial vendors are summarized in Table 5-1. Data transfer DICOM-RT DICOM-RT DICOM-RT
The CT simulation process has been divided into three Software platform Advantage Sim Virtual Simulation AcQSim
major categories by the AAPM TG-66 report.1 Methods for 4D simulation Yes Future product Future product
simulating specific anatomic sites have been described by CT = computed tomography; 4D = four-dimensional; DICOM = Digital Imaging
several authors and are discussed here.3,4,6,16–18 Communications in Medicine; RT = radiation therapy; SFOV = scan field of view.
 CT Simulation / 85

that patient movement is minimized during the CT simu-
lation process.3 The immobilization device should ideally
register or fix to the treatment table. Using an immobiliza-
tion device that is registered to the table, the record-and-
verify system can monitor treatment table coordinates with
tight tolerance limits. Contrast agents may also be used to
improve visualization of the patient’s normal (and abnor-
mal) anatomy and may be desirable for certain situations.
However, for heterogeneity-based calculations in IMRT plan-
ning, contrast can cause dose distribution errors owing to
artificial CT numbers and corresponding tissue densities.
During CT simulation, patients are scanned using pre-
set oncology-specific protocols for each treatment site.
These protocols are designed to optimize both the transax-
ial CT and the DRR image quality. The imaging parame-
ters include kilovolts peak, milliamperes, slice thickness,
slice spacing, and total scan time. A small slice thickness
and spacing are desirable for producing high-quality DRRs.
In addition to the scan protocols, scan limits should be
specified by the physician and should encompass a volume
large enough to create DRRs with enough anatomic infor-
mation. The AAPM TG-66 report recommends that the
scan volume should be at least 5 cm or greater in the supe-
rior and inferior directions from the anticipated treatment
volumes and that larger scanning regions may be necessary
for special situations.1
Treatment Planning and CT Simulation
Beam placement and treatment design are performed using
virtual simulation software. The virtual simulation process
typically consists of contouring the target and normal struc-
tures, placement of the treatment isocenter and beams,
design of treatment portal shapes, generation of DRRs, and
documentation. However, for IMRT planning, the design
of treatment portal shapes is not performed at this time
because an intensity map is created to deliver a nonuni-
form dose distribution from each treatment field. DRRs
are created by the virtual simulation software but are main-
ly used for visual comparison and alignment of anatomic
sites (Figure 5-2). Thus, CT simulation for IMRT planning
relies more on anatomic segmentation and localization of
the isocenter for treatment setup.

FIGURE 5-2. Philips virtual simulator software (AcQSim, Philips Medical Systems, Cleveland, OH). The large window shows a digitally reconstructed
radiograph (DRR) from an anterior view. The contours drawn on individual axial slices are superimposed on this DRR. Other views are axial, sagit-
tal, and coronal computed tomography slices through various planes intersecting the isocenter. (To view a color version of this image, please refer
to the CD-ROM.)
86 / Intensity-Modulated Radiation Therapy

The treatment planning portion of the CT simulation

process. Once the plan has been completed, the patient is
process begins with target and normal structure delineation.
set up on the conventional simulator for treatment plan
Other imaging studies (diagnostic CT, MRI, PET) may be
verification. Thus, the conventional simulator is being used
registered to the planning CT scan to provide information
for the final step of the planning process, which does not
for improved target and normal tissue delineation.After delin-
take dedicated time on the treatment machine. In certain
eation of the target volumes, a treatment isocenter is creat-
cases, the fluoroscopic mode of the conventional simula-
ed either manually or automatically in the CT study. The
tor can also be used for verifying intrafraction motion of
automated isocenter placement is performed by the software
the target volume or critical structures. This can be impor-
by computing the center of the mass of the target volume.
tant for treatment sites in the thorax and abdomen, for
After the isocenter has been identified in the virtual simula-
example, owing to the inability of the CT simulation process
tion software, these coordinates must be transferred to the
to display breathing motion.
external laser marking system for localizing on the patient’s
Table 5-2 provides a representative step-by-step outline
skin. These marks are required to ensure a daily reproducible
of a typical CT simulation process for a specific body site.
setup at the treatment machine. There are two methods for
This table provides a checklist for verifying the steps used
localization of the marks on the patient, which are described
in their CT simulation process, as well as identifying the
as either final isocenter marking or reference point marking.1
roles of different clinical team members. In a well-designed
When a final isocenter is marked, the patient is scanned,
CT simulation process for IMRT planning and delivery, all
and the physician or physicist determines the isocenter loca-
of these steps appear to be relatively seamless and the dura-
tion on the digital images while the patient remains on the
tion of the entire process relatively short.
CT scanner table. This requires that the target volume be
delineated during this time by a clinician. Once the isocen- TABLE 5-2. CT Simulation Step-by-Step Process for Intensity-
ter has been determined, these coordinates are transferred Modulated Radiation Therapy
to the external laser system. The marks are then placed on Description Personnel
the patient and are used for patient positioning on the first
1. Patient enters room and the immobilization device Therapist
day of treatment at the linear accelerator. is constructed
The reference point method is typically used when the 2. Position patient on CT table in treatment position Therapist
radiation oncologist is not available during the simulation 3. Acquire AP and lateral scout images of patient to Therapist
process.1,3 Prior to the scan procedure, the physician instructs ensure correct patient position
4. Place preliminary alignment marks on patient using Therapist
the radiation therapist where to place a set of reference marks
lasers
on the patient. These are marked on the patient, and 5. Record CT couch position of preliminary lasers Therapist
radiopaque markers are placed on the skin. After the scan, 6. Choose appropriate scanning protocol Therapist
the patient can leave, and images are transferred to the vir- 7. Set CT scan limits to include region superior and Therapist
tual simulation workstation. Subsequently, the treatment inferior to treatment volume
8. Administer prescribed contrast: eg, IV, oral, urethral, Therapist
isocenter coordinates are determined after the target vol-
rectal
umes are delineated. The distances in three directions 9. Place external markers if desired on scars, tattoos, Therapist
between the initial reference marks and the final treatment palpable mass, etc.
isocenter (referred to as shifts) are then calculated. On the 10. Scan patient Therapist
first day of treatment, the patient is aligned to the initial ref- 11. Transfer data to virtual simulation workstation Therapist
12. Localize, compute, and lock in isocenter Therapist
erence marks using the treatment machine’s lasers and then
and physician
shifted to the CT simulation isocenter using the calculated 13. Mark isocenter on patient using long laser lines in Therapist and/
shifts. Initial reference marks are then removed, and the three orthogonal planes or physician
isocenter localization marks are placed on the patient. This 14. Patient leaves CT suite Therapist
process is conducive to IMRT planning because the isocen- 15. Contour all critical organs for dose-volume Dosimetrist
constraints
ter is often determined by the planning system.
16. Beam placement for treatment plan design Dosimetrist
and physician
Treatment Setup 17. Print hard copy of DRRs Dosimetrist
On the treatment machine, the patient is set up according 18. Transfer data to treatment planning Dosimetrist
to instructions created from the CT simulation software. 19. Plan patient via computer-aided optimization Dosimetrist
and physicist
Port films are acquired and are compared with CT simu-
20. Verify patient setup according to plan Therapist and
lation DRRs. In some cases, the patient may undergo treat- physician
ment setup verification on a conventional simulator prior 21. Perform routine QA to ensure accurate localization Physicist
to treatment. Some radiation oncology departments use ofport films
both a conventional simulator and a CT simulator during AP = anterior-posterior; CT = computed tomography; DRR = digitally
the planning process. The CT simulator is used for the ini- reconstructed radiograph; IMRT = intensity-modulated radiation therapy; IV =
tial CT scan, virtual simulation, and treatment planning intravenous; QA = quality assurance.

Integration of CT Simulators with
IMRT Planning Systems
Traditionally, radiology departments have implemented
image acquisition, archive, and distribution systems in clin-
ical diagnostic environments, referred to as picture archive
and communication systems (PACS). However, radiation
oncology departments have different needs and data than
radiology departments. Thus, PACS for radiation oncolo-
gy or radiation oncology information systems (ROIS) have
been developed for handling the tasks of storing and shar-
ing image, patient, and machine data.25 A ROIS is a system
for acquiring, transmitting, storing, and operating on images
and image-related information specifically used in radia-
tion oncology. The technical data objects used in CT sim-
ulation are three-dimensional image sets, anatomic volumes,
target volumes, and treatment plan parameters (including
multileaf collimator [MLC] settings). Anatomic and tar-
get volumes are the outlined contours of various organs
and tumors used for visualization on DRRs and CT images.
Treatment parameters are the machine settings for each
individual treatment field, including the gantry angle, col-
limator angle, collimator jaw settings, and couch angle. CT
simulation data may contain all or part of these technical
data objects used for ROIS.
The ROIS data may be transmitted to both radiation
treatment planning systems and record-and-verify data-
base systems for sharing and reuse of these data. The com-
munication system used for transmitting, converting, and
associating medical imaging data is the Digital Imaging
and Communications in Medicine (DICOM) standard.26
This standard describes the methods of formatting and
exchanging images and associated information. DICOM
relies on industry standard network connections and effec-
tively addresses the communication of digital images from
CT simulation systems to various data systems. Over the
past 5 years, an extension to DICOM was developed for RT
objects, referred to as DICOM-RT. This extension handles
the technical data objects in radiation oncology, such as
anatomic contours, DRR images, treatment planning data,
and dose distribution data. Many CT simulator and treat-
ment planning vendors have begun to adopt DICOM-RT
for ensuring a cost-effective solution for sharing techni-
cal data in a radiation oncology department. The DICOM-
RT objects used for CT simulation are as follows:
• CT images. These are images taken during the CT sim-
ulation procedure consisting of transaxial CT slices.
• RT structure sets. These consists of contours of anatom-
ic structures that have been segmented by physicians,
dosimetrists, and/or physicists. Target volumes and
normal structures are represented by these objects.
• RT images. DRRs that are created by the CT simula-
tion software are stored in this data object.
• RT plans. Treatment plans that consist of treatment fields
CT Simulation / 87
(RT beams) are represented by this DICOM object.
Static and dynamic MLCs can be stored with an RT plan.
Dynamic MLCs used to represent IMRT treatment fields
can support both step-and-shoot and sliding windows
for data formats.
After the data have been transferred from CT simulation
to IMRT treatment planning, the physicist and dosimetrist
will generate the optimal IMRT plan for the patient. If the
planning system needs to use any software features of the
CT simulation software, the treatment planning system can
transmit the DICOM-RT objects back to the CT simulation
system. However, this process rarely happens because most
treatment planning systems provide the same functionali-
ty of virtual simulation. Typically, once the IMRT plan is
complete, the transfer of the treatment plan from the IMRT
planning system to a record-and-verify system is performed
for treatment verification and delivery.
Data transfer and communications among disparate tech-
nical systems were once a difficult feat to accomplish. However,
the use of DICOM-RT has provided a more open standard
for efficiently sharing data within the radiation oncology soft-
ware systems. Most modern CT simulator vendors support
the use of DICOM-RT, as reflected in Table 5-1.
CT Simulation QA
AAPM TG-66 provides a comprehensive QA program for
CT scanners used for CT simulation, CT simulation soft-
ware, and the CT simulation process.1 Depending on the
CT scanner location and primary use, acceptance testing,
commissioning, and QA can be the responsibility of the
therapy physicist, the diagnostic physicist, or a joint respon-
sibility. The commissioning and periodic QA of the accom-
panying software and the QA of the CT simulation process
are always the responsibility of the therapy physicist. AAPM
TG-66 establishes a set of QA procedures that are applic-
able to scanners used for CT simulation regardless of their
location and primary purpose. The report breaks the QA
tests into three main areas: QA for CT scanners used for
CT simulation, QA for CT simulation software, and eval-
uation of the CT simulation process.
QA for CT Scanners Used for Simulation
The TG-66 report addresses QA procedures for the CT
scanners to ensure consistent operation and a successful
CT simulation process. One of the important performance
components for daily and monthly testing of the CT scan-
ner is the external laser marking system. These laser sys-
tems are used to position the patient in the correct treatment
position and place positioning marks on the patient. The
accuracy of the lasers affects the reproducibility of patient
positioning from the CT scanner to the treatment delivery
machine.
88 / Intensity-Modulated Radiation Therapy

Table 5-3 summarizes the laser QA tests recommended QA for CT Simulation Software
by the TG-66 report, including the frequency of the test and
In addition to the CT scanner QA, TG-66 discusses testing
acceptable tolerance limits.1 The external laser marking sys-
features of the CT simulation software for verifying its accu-
tem for the CT scanner consists of three separate compo-
racy. The QA program should verify the following features:
nents: gantry lasers, wall-mounted lasers, and an overhead
image input test, structure delineation, multimodality image
mobile sagittal laser. Besides the laser marking system, the
registration, machine definition, isocenter calculation and
other electromechanical components, such as the couch and
movement, and image reconstruction. One of the final prod-
tabletop, gantry tilt, and scan localization from the scout
ucts from the CT simulation process is the generation of
image, should be part of a comprehensive QA program.
DRRs used for verifying the patient’s position at the treat-
Table 5-4 summarizes the TG-66 recommendations for eval-
ment machine. The use of poor-quality DRRs can affect the
uating the image quality of CT simulators.
patient positioning process owing to the inability to visu-
alize anatomic details. The choice of slice thickness and spac-
ing will affect the spatial resolution and image quality of the
DRR. Figure 5-3 shows DRRs scanned with 10, 5, 2.5, and
TABLE 5-3. American Association of Physicists in Medicine 1.25 mm slice spacing using a pelvic phantom, respective-
Task Group Report 66 Test Specifications for External Laser ly. These figures illustrate the relationship between poor
Marking System DRR spatial resolution and slice spacing. Figure 5-3A depicts
Performance Parameter Frequency Tolerance Limits a blurred and poor DRR image using 10 mm slice spacing.
Alignment of gantry lasers with Daily ± 2 mm
Figure 5-3B and Figure 5-3C indicate improved DRRs with
the center of imaging plane smaller slice spacing of 5 and 2.5 mm, respectively. Figure
Orientation of gantry lasers with Monthly and after ± 2 mm over the
5-3D shows a DRR with excellent detail using 1.25 mm slice
respect to the imaging plane laser adjustments length of laser spacing. From these images, the use of 10 mm slice spacing
projection would be inadequate for proper DRR images. The use of
Spacing of lateral wall lasers Monthly and after ± 2 mm 1.25 mm slice spacing for DRRs may not show enough visu-
with respect to lateral gantry laser adjustments al improvement compared with the 2.5 mm slice spacing to
lasers and scan plane warrant using it for routine clinical scanning. A clinic should
Orientation of wall lasers with Monthly and after ± 2 mm over the perform a similar test to determine the acceptable slice thick-
respect to the imaging plane laser adjustments length of laser ness and slice spacing to use for DRR generation.
projection
Orientation of the ceiling laser Monthly and after ± 2 mm over the
with respect to the imaging laser adjustments length of laser
plane projection

Adapted from Mutic S et al.1

TABLE 5-4. American Association of Physicists in Medicine

Task Group Report 66 Test Specifications for Image Quality
Evaluation
Performance Parameter Frequency Tolerance Limits

CT number accuracy Daily, monthly, annually Water: 0 ± 5 HU

Image noise Daily Manufacturer’s
specifications
In-plane spatial integrity Daily, monthly ± 1 mm
Field uniformity Monthly, annually ± 5 HU
Electron density Annually Commissioning results
and manufacturer’s
specifications
Spatial resolution Annually Manufacturer’s
specifications
FIGURE 5-3. Digitally reconstructed radiographs of a pelvic phantom
Contrast resolution Annually Manufacturer’s using various slice thicknesses to illustrate the effect of slice thickness
specifications on image quality: (A) 10 mm slice thickness; (B) 5 mm slice thickness;
Adapted from Mutic S et al.1 (C) 2.5 mm slice thickness; and (D) 1.25 mm slice thickness. (To view a
HU = Houndsfield unit. color version of this image, please refer to the CD-ROM.)

Evaluation of CT Simulation Process
After testing the CT scanner components and virtual simula-
tion software, the overall simulation process should be eval-
uated by the clinical team members.A CT simulation program
should include a written set of procedures and be reviewed
annually by the clinical staff. Procedures should be written for
each treatment site to identify the scan protocol, scan limits,
contrast, special instructions, and possible beam arrangements.
Emerging Technologies
A new method of CT simulation is evolving known as four-
dimensional CT simulation (three dimensions + time = four
dimensions). In four-dimensional CT simulation, retrospective
gating of the CT simulation data is performed using the
patient’s respiratory breathing cycle. GE Medical Systems
(Waukesha, WI) and Varian Medical Systems (Palo Alto, CA)
have developed a system using the Real-Time Position Monitor
(RPM) respiratory gating system (Varian Medical Systems)
with a multislice CT scanner for analyzing and incorporat-
ing intrafraction motion management using tomographic
data sets. The system provides retrospective gating of the
tomographic data set by taking three-dimensional data sets
at specific time intervals to create a time-dependent four-
dimensional CT imaging study. The use of this four-
dimensional imaging set allows one to accurately define the
target and its trajectory with respect to normal anatomy and
critical structures. This type of CT simulation tool can then
be used with the respiratory gating system at the treatment
machine to gate the beam delivery with the patient’s breath-
ing cycle. The use of four-dimensional CT simulation makes
it possible to acquire CT scans that provide new information
on the motion of tumors and critical structures. As this tech-
nology emerges within radiation oncology departments,
IMRT treatment planning systems may begin to incorporate
the dimension of time into the planning process.
In addition to CT simulation, some departments are
using magnetic resonance scanners with virtual simulation
software to create magnetic resonance simulation systems.
Typically, CT scans have been used to provide a tomographic
data map of the patient’s anatomy. If MRI was incorpo-
rated for improved soft tissue delineation, the MRI set was
often registered to the CT image data for the virtual sim-
ulation process. One reason for using CT data has been
its use for heterogeneity information in the treatment plan-
ning process. Another reason is that portal films at the treat-
ment machine are matched to DRRs for treatment
verification of geometric patient setups. However, there are
some areas in which magnetic resonance simulation may
be used as the main imaging data set in a department. A
magnetic resonance simulator consists of a magnetic res-
onance scanner with a flat tabletop along with an exter-
nal laser marking system. Because this technology is
relatively new, its clinical role has yet to be defined.
CT Simulation / 89
Conclusion
As with other components of IMRT planning and deliv-
ery, CT simulation is an evolving process. Much of the vir-
tual simulation software is being incorporated into
treatment planning systems, making it more difficult to
distinguish between CT simulation and treatment plan-
ning. The overlap of these systems with seamless com-
munication of data provides powerful tools to clinicians in
visualizing the patient’s anatomy. With IMRT treatment
planning, anatomic segmentation and dose-volume con-
straints drive the final solution for the patient, which places
more importance on accurate and precise delineation of
anatomy. The medical physicist in RT must take on more
responsibility for ensuring that an adequate QA process
has been implemented for the CT simulation system and
process. As new treatment planning and delivery systems
are developed, the process of CT simulation will evolve and
adapt to provide the clinician with accurate representations
of patient anatomy.
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