Original Article

Investigation of tube voltage dependence on CT number and its

effect on dose calculation algorithms using thorax phantom in
Monaco treatment planning system for external beam radiation
therapy
Amit Saini1,2, V P Pandey3, Pankaj Kumar1,4, Avtar Singh1,2, Rajesh Pasricha5
1
Chitkara University Institute of Engineering and Technology, Chitkara University, Punjab, 2Department of Medical Physics, Tata Memorial Center, Homi Bhabha Cancer
Hospital, Sangrur, Punjab, 3Department of Medical Physics, Hind Institute of Medical Sciences, Safedabad, Barabanki, Uttar Pradesh, 4Centre for Liquid Crystal
Research, Chitkara University Research and Innovation Network, Chitkara University, Punjab, 5Department of Radiotherapy, All India Institute of Medical Sciences,
Bhopal, Madhya Pradesh, India

Abstract
Introduction: The accuracy of dose calculation algorithms depends on the electron density and computed tomography (CT) number of medium
scanned. Our study aimed to verify the impact of different CT scanning protocols on Hounsfield unit (HU) and effect on dose calculation
algorithms. Materials and Methods: CIRS thorax phantom with different density material plugs was scanned at varying tube voltages
from CT scanner and HU values were measured in treatment planning system (TPS). Calibration curves of electron density at different tube
voltages were plotted and used for dose calculation with different calculation algorithms at varying high energy megavoltage photon energies.
Results: Insignificant difference is obtained in electron density curves plotted at different tube voltages. The mean variation in HU values was
found at different tube voltages for bone, lung, and water are 896.75 (standard deviation [SD] 122.88), −799.25 (SD 5.74), and −17.5 (SD 0.57),
respectively. The estimated P values for change in HU values were 0.089, 0.258, and 0.121 for bone, lung, and water, respectively. Pencil
beam (PB) convolution and collapsed cone algorithms show no significant dose difference, i.e., <1% variation and Monte Carlo (MC) shows
maximum dose difference up to 1.4%. Conclusion: Third‑generation algorithms such as MC shows dependence on varying tube voltages in dose
calculation. Calibration curves plotted at different kVp in TPS advised to be chosen wisely to avoid any dosimetric errors in different medium.

Keywords: Collapsed cone convolution, Hounsfield unit, Monte Carlo, pencil beam convolution
Received on: 24‑12‑2020 Review completed on: 29-08-2021 Accepted on: 29‑08‑2021 Published on: 31.12.2021

Introduction surrounding normal tissues. Before using treatment planning

system (TPS) for clinical needs, a relation between CT numbers
Radiotherapy treatment process is very complex in nature
consisting of various steps and each step is prone to systematic
and random errors. Each component of chain influences Address for correspondence: Dr. V. P. Pandey,
the radiotherapy outcome and must be handled cautiously. Department of Medical Physics, Hind Institute of Medical Sciences,
After diagnosis, patients are advised to start the radiotherapy Safedabad, Barabanki, U.P, India
E-mail: aryanbarc@gmailcom,
procedure with computed tomography (CT) Simulation. CT is Dr. Pankaj Kumar
a vital diagnostic imaging modality that can produce images Chitkara University Institute of Engineering and Technology, Chitkara
of patient geometry in axial, sagittal, and coronal planes used University, Punjab, India
for radiation treatment planning. It provides high‑resolution Centre for Liquid Crystal Research, Chitkara University Research and
Innovation Network, Chitkara University, Punjab, India
transverse images and gives information about the Hounsfield E-mail: [Link]@[Link]
Units (HUs) and electron densities (ED) of medium scanned
which influences the delineation of target volumes and the
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Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
Access this article online remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
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How to cite this article: Saini A, Pandey VP, Kumar P, Singh A, Pasricha R.
DOI: Investigation of tube voltage dependence on CT number and its effect on dose
10.4103/jmp.JMP_124_20 calculation algorithms using thorax phantom in Monaco treatment planning
system for external beam radiation therapy. J Med Phys 2021;46:315-23.

© 2021 Journal of Medical Physics | Published by Wolters Kluwer - Medknow 315

 Saini, et al.: Effect of tube current on dose distribution

and relative electron density (RED) has to be established in the radiation therapy. Rana et al.[9] investigated the dose prediction
form of calibration curve as described by Schneider et al.[1] TPS accuracy of Acuros XB algorithm and anisotropic analytical
usually equipped with the standard calibration curve provided algorithm (AAA) for different field sizes and air gap thickness.
by the vendors to use in clinical environment but its usage The results from that study revealed that dose prediction
without validation may result into the dosimetric inaccuracy. errors are up to 3.8% for Acuros XB and up to 10.9% for
AAA, respectively. Furthermore, the study by Rana et al.[10]
Treatment planning workstation is important component in
demonstrated the limitation of dose calculation algorithms
the radiotherapy chain procedure. Many factors are present in
TPS which can influence the dosimetric treatment outcome and when treating a smaller size of tumor, especially when large
calibration curve is one such parameter present in the system. air gaps are created by immobilization devices.
In most clinics, only the calibration curve plotted at 120 kVp In the current study, the effect of different CT scanning
for all scans ignoring the potential benefit of dose and noise protocols, i.e., varying kVp settings on HU number variation
reduction with an applied tube voltage. Constantinou et al.[2] and their dosimetric impact on dose calculation in TPS
suggested having more than a standard 120kVp calibration using different algorithms, for example, MC, collapsed cone
curve, for example, an additional 80kVp curve for pediatric convolution and pencil beam (PB) were investigated using
patients which may potentially decreases the CT dose and CIRS thorax phantom.
offers a high contrast to noise ratio. Although having many
calibration curve increases the amount of workload and degree
of error are also increases.
Materials and Methods
CIRS thorax phantom
The accuracy of new generation dose calculation algorithms The CIRS Model 002 LFC (Norfolk, VA) intensity‑modulated
present in radiotherapy primarily depends on the electron density radiotherapy (IMRT) thorax phantom shown in Figure 1 were
obtained from CT data and calibration of CT‑HU to RED.[3] The used in the present study, which is designed to address the
CT number depends on the linear attenuation coefficient of the comparison of calculation algorithms TPS and complete system
material with the formula mentioned in equation (1): QA from CT imaging to dose verification. The 002 LFC is an
HUtissue = 1000 × ([µtissue‑µwater]/µwater)(1) elliptical in shape and properly represents an average human
torso in proportion, density, and two‑dimensional structure. It
Where HU is Hounsfield Unit (HU) and μ is the linear
measures 30 cm long × 30 cm wide ×20 cm thick. The phantom
attenuation coefficient of the medium.
is constructed of proprietary tissue equivalent epoxy materials.
The change in HU values due to kVp settings and geometric Linear attenuations of the simulated tissues are within 1% of
distribution of various tissue substitute materials has also actual attenuation for water and bone, and within 3% for lung
been studied by Nobha et al.[4] and found to be well within from 50 keV to 15 MeV. Tissue equivalent interchangeable rod
2%. The CT number of medium depends on the spectra of inserts accommodate ionization chambers allowing for point
CT scanner and CT‑RED curve may lead to determination dose measurements in multiple planes within the phantom
of material composition of medium. A slight change in CT shown in Figure 1. Adapter placement allows verification in
number may lead to relative change in electron density of the the most critical areas of the chest. One half of the phantom
medium and in turn leads to the variation in dose calculation. is divided into 12 sections, each 1 cm thick, to support
Accurate calculation of dose distribution in an inhomogeneous radiographic or Gafchromic film. Three kinds of materials
medium like human body is a complex phenomenon, especially are contained in this phantom to emulate different tissues
for tumors located in the lung. Till date, only the Monte in human body, including soft tissue, lung, and bone. Dose
Carlo (MC) method is considered to be the most accurate measurements can be performed by placing ionization chamber
algorithm for dose calculation, but it requires the greatest and Gafchromic film inside grooves provided in phantom.
processing time. Apart from MC method, all other methods
make different degrees of approximation and simplification Validation of kV and mAs in computed tomography
which lead to much faster calculation speed but also result scanner
in less accurate dose distribution compared with the MC kV and mAs stability was validated before starting the study.
calculation algorithm. The applied voltage was reported to be Stability of scanner was measured from the last 6 year readings
most relevant parameter leading to errors in the reconstructed to till now which are given below [Tables 1-3].
Hounsfield numbers of about 300 units for high density.[5] Plotting calibration curves
In previous studies, dose variation within 1% has been reported The relationship between the RED and CT number plotted in
when varying the kVp.[6] In addition, the HU measurements of TPS is known as calibration curve. In radiotherapy treatment
solid water and air had found to differ significantly between planning simulation, different kVp settings are used depending
scanners from different manufacturers. [7,8] The highest on the different body sections to be imaged. To calculate
variation was noted in case of high density materials and the mean HU values, the phantom was scanned using CT
CT scan at lowest kVp. Many authors have conducted the scanner (GE optima 580 w, USA) with the different kVp
evaluation of dose calculation algorithms for external beam protocols (tube voltage: 80 kVp, 100 kVp, 120 kVp, and 140

316 Journal of Medical Physics ¦ Volume 46 ¦ Issue 4 ¦ October-December 2021

 Saini, et al.: Effect of tube current on dose distribution

kVp with slice thickness of 2.5 mm) to acquire CT images. In

order to obtain the calibration curve, a CIRS phantom was used
at different tube voltages protocol scanning. The phantom was
placed on CT couch, leveling of the phantom was ensured. The
HU values obtained from the systems were plotted against RED
of the materials. Figure 2 illustrates CT‑RED calibration curves
obtained for different tube voltages from the Monaco TPS.
Formula used:
Mean Percentage Dose Difference
( Individual Value- Mean Value) ×100 (2)
Mean Value
Figure 1: CIRS thorax phantom
Treatment planning system dose calculation measurement
TPS was commissioned as per the standard guidelines of TRS
430. Several end‑to‑end tests were performed in phantom with CT numbers VS RED values for different tube
voltages measured by Monaco TPS
all photon energies to found out the percentage of variation 1500.0
in between chamber measured and TPS calculated dose are
given below. These values are baseline TPS data found during
commissioning of TPS. 1000.0

Measured HU Numbers
Table 4a shows the dose difference in TPS data and measured
data with Farmer type chamber, Fc‑65 for different calculation 500.0
algorithms in a homogeneous medium in central axis
measurement. All the percentage values obtained for MC,
Collapsed cone (CC), and PB were well within the tolerance 0.0
0.00 0.50 1.00 1.50 2.00
limit. At depth 10 cm, the full scattering condition is satisfied
and measurement showing the similarity in dose obtained as
-500.0 80 KV 100 KV
in planning system. For 6 mega voltage (MV) flattening filter
120 KV 140 KV
free (FFF) and 10MV FFF CC algorithm is not available into
the Monaco TPS, so no variation was found out. -1000.0
Relative Electron Densities (RED)
Table 4b shows the percentage variation in dose differences
calculated in an inhomogeneous medium through ionization
chamber and TPS for all energies in central axis measurement. Figure 2: Computed tomography to relative electron density calibration
The field sizes were chosen were 10 cm × 10 cm and curve obtained from Monaco treatment planning system
15 cm × 15 cm for evaluation in dose difference as field size
10 cm × 10 cm includes mostly water equivalent part of thorax
Phantom, whereas 15 cm × 15 cm includes both lungs partially
with dose measurement in water equivalent material.
In the present study, three different calculation algorithms
of the Monaco TPS (Version 5.11, Elekta AB, Stockholm,
Sweden) were evaluated. These three algorithms were MC,
Collapse Cone, and PB dose calculation engine. The acquired
CT images of CIRS Phantom were sent to the TPS through
digital Imaging and communication in medicine networking
system. Circular region of interest of diameter 1.5 cm was
defined on the CT images of the phantom and mean CT
numbers for different materials were obtained from TPS as
Figure 3: Computed tomography scan of thorax phantom with different
shown in Figure 3, using Monaco TPS Version 5.11, Elekta densities
AB, Stockholm, Sweden). Lungs, Bone, and water medium
were properly contoured, and the point of interest was marked
were performed with PB, CC, and MC algorithm on Monaco
kept same in all three calculations algorithm cases.
TPS version 5.11 with calculation grid size of 3 mm and
A single anterior beam plan using 6 MV, 10 MV. 15 MV, 6MV statistical uncertainty of 0.5%. Dosimetric comparison was
FFF and 10 MVFFF at gantry angle 0° with isocenter placed at performed in between for various CT to RED calibration
the center of the phantom for dose of 100 centiGray (cGy) was curves obtained from various tube voltages, i.e., 80 kVp, 100
planned and calculated as shown in Figure 4. Dose calculations kVp, 120 kVp, and 140kVp on Monaco TPS.

Journal of Medical Physics ¦ Volume 46 ¦ Issue 4 ¦ October-December 2021 317

 Saini, et al.: Effect of tube current on dose distribution

min f ( tubevoltage ) = Total Error - ∫ min f (Uncertainity ) 

∫ max max
(4)
In case of MC Calculation Algorithm, for any fixed grid size
and maximum uncertainty window of 0.5%, the equation will
become,

min f ( tubevoltage ) = Total Error - 0.5

∫ max  (5)
For FFF beam, CC algorithm calculation is not available in
TPS system and Calculation performed only for 6 MV, 10 MV,
and 15 MV flattened beam. In flattened and unflattened Beams,
dose calculation difference with the PB calculation algorithms
in different density medium at varying tube voltages were
found insignificant and <1%. Similarly, for flattened beams,
CC calculation algorithm shows <1% variation at varying
kVp scans in different medium. MC calculation algorithm
Figure 4: Axial plane of dose measurement in Monaco treatment planning
system with different density contours of lung, bone and water shows impact in dose calculations in different medium for
varying tube voltage scans at different photon energy which
is discussed below.
Results
Evaluation of variation in Hounsfield unit‑relative electron Monte Carlo dose calculation variation in different density
density calibration curves medium at varying tube voltages
Here, we have evaluated the variation in HU‑RED calibration Using equation no. 5, the actual error due to tube voltage
curves for different tube voltages used in CT scanning protocols. was evaluated making other parameters such as grid size
constant and the resultant error obtained is only due to the
In Table 5, the HU numbers of different materials for various tube voltage impact in dosimetric spectra. Table 6 shows the
kVp values on Monaco TPS were presented. The mean percentage variation evaluated for all beam energies in different
variation in HU values were found at different tube voltages density medium using MC calculation engine. The maximum
for bone, lung, and water are 896.75 (standard deviation [SD]: uncertainty introduced in a calculation window was subtracted
122.88), −799.25 (SD: 5.74), and −17.5 (SD: 0.57), from the total error obtained to get exactly the contribution
respectively. No significant difference was found between of error due to varying tube voltage. The percentage variation
the HU numbers obtained from different tube voltages. The in doses was <1% in all cases at different energy and density
estimated P values were 0.089, 0.258, and 0.121 for bone, medium except for 6FF and 6FFF beams whose values were
lung, and water, respectively. 1.2% and 1.4%, respectively, for high density medium of bone.
Maximum CT number difference was observed in bone.
However, the measured CT numbers for lung and water were Discussion
in agreement with one another with in 20 MU.
Computed tomography relative electron density calibration
Impact of different kVp on dose calculation algorithm curves
Dose calculated with the CT images on Monaco TPS for At all the points in a medium of contoured circular diameter,
different algorithms in four different contour of bone, different HU values were shown by the TPS. For the purpose
bilateral lungs, and water in cGy for a plan created for of simplicity and plotting, the curve mean values of all circular
100 cGy dose at the isocenter using 6 MV, 10 MV, 15 MV, medium were considered against the RED. The spectral
6FFF, and 10FFF from various tube voltages of 80 kVp, changes in scanning beam ultimately result into the changes
100 kVp, 120 kVp, and 140 kVp. Phantom CT scan with in the HU values of medium. The highest variation in CT
120 kVp scanning protocol was considered to be reference number was observed in bone material with respect to different
raw data for comparative analysis of dose in three different CT scanning protocols (tube voltages) than followed by lung
density contours created on CT images of the phantom, equivalent material and least in the water equivalent material.
and100 MU was delivered on different density cavities in In lung equivalent material, small CT number was observed
thorax phantom using 3 mm grid size and 0.5% statistical as the electron density is extremely low, thus, becomes more
uncertainty in dose calculation with 10 cm × 10 cm field sensitive to the imaging noise over variation in tube voltages,
size. causing more variation in HU values for air‑like materials. The
 (3) HU‑RED curves as shown in Figure 2 reflected no specific
min f ( tubevoltage ) + ∫ min f (Uncertainity )
Total Error = ∫ max max

difference in the curves obtained using HU and ED values

For any fixed grid size, G
from different tube voltages scans. A very small deviation
On rearranging above equation, the error contribution due to of curve is shown near to bone HU values. The reported HU
tube voltage difference may be obtained as: variations may be explained due to nonuniform beam filtration

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 Saini, et al.: Effect of tube current on dose distribution

Table 1: kVp stability of computed tomography scanner

Set 1st year 2nd year 3rd year 4th year 5th year 6th year SD Relative
kV measured kV measured kV measured kV measured kV measured kV measured kV SD (%)
80 81.05 80.7 80.28 80.74 80.97 79.34 0.579 80.51±0.72
100 99.22 99.5 99.92 99.82 99.86 98.48 0.503 99.63±0.50
120 119.33 120.33 119.62 120.05 120.87 118.83 0.667 119.83±0.55
140 139.5 140 140.82 141.3 141.82 139.15 0.959 140.43±0.68
ALL of the above results are within tolerance limit of±2 kV. SD: Standard deviation

Table 2: Coefficient of mA linearity was also found out from last 6 years
mA setting COL (1st year) COL (2nd year) COL (3rd year) COL (4th year) COL (5th year) COL (6th year)
100, 150, 200 0.0018 0.004 0.00024 0.0003 0.0014 0.0013
All of the above results are within tolerance limit=±0.1. COL: Coefficient of mA linearity

Table 3: Output constancy was also checked and found the coefficient of variation
kV setting mAs COV (1st year) COV (2nd year) COV (3rd year) COV (4th year) COV (5th year) COV (6th year)
80, 100, 120, 140 100 0.003 0.006 0.000663 0.000329 0.002156 0.039
All above results were within tolerance limit=±0.05. COV: Coefficient of variation

Table 4: Dose measurement in Homogeneous and CIRS Thorax Phantom

(a) TPS dose comparison in homogeneous phantom using Fc‑65 ionization chamber for cental axis measurement
Energy (MV) Chamber TPS dose (cGy) Percentage variation
dose (cGy)
PB CC MC PB CC MC
6 164.08 163.7 163.4 165.7 0.23 0.41 −0.987
10 175.38 173.9 174.3 174.5 0.84 0.62 0.50
15 183.95 185.4 184.9 183.9 −0.78 −0.51 0.027
6FFF 162.22 161.0 ‑ 162.2 0.75 ‑ 0.012
10FFF 174.52 172.9 ‑ 174.2 0.93 ‑ 0.18
(b) Dose measurement in water equivalent groove in CIRS thorax phantom and TPS
Field size Energy
6 MV (dose cGy) 10 MV (dose cGy) 15 MV (dose cGy) 6 MV FFF 10 MV FFF
(dose cGy) (dose cGy)
Algorithms Algorithms Algorithms Algorithms Algorithms
MC CC PB MC CC PB MC CC PB MC PB MC PB
10×10 91.8 90.3 90.7 96.1 93.9 94.4 100.8 98.6 99.4 91.5 89.7 96.2 94.2
Chamber dose 90.3 97.4 100.3 88.2 92.4
Percentage variation 1.66 0 0.44 −1.33 −3.6 −3.1 0.49 −1.69 −0.89 3.74 1.7 4.1 1.94
15×15 95.3 94.2 94.4 98.6 97.3 96.8 103.8 102.2 102.1 93.5 91.8 97.7 95.6
Chamber dose 94.91 100.91 103.71 92.64 95.32
Percentage variation 0.41 −0.75 −0.54 −2.29 −3.57 −4.07 0.087 −1.45 −1.55 0.92 −0.91 2.49 0.29
SAD setup, Depth=10 cm, FS=10 cm×10 cm, MU=200. MC: Monte carlo, PB: Pencil beam, CC: Collapsed cone, TPS: Treatment planning system, FFF:
Flattening filter free, CIRS: Computerized Imaging Reference Systems, SAD: Source to Axis Distance, FS: Field Size, MU: Monitor Units

of scanning beam passing different densities inserts. The CT planning system equipped with the standard calibration
number variation depends on the scanner‑specific factors such curves which could be used with some errors for clinical
as spectral energy, filtration of radiation, and reconstruction purposes, but it is always recommended to plot the curve of
algorithm used. Many researchers have reported large existing CT simulator for regular clinical usage. To reduce
deviations of HU values in high‑density material like Teflon.[11] any uncertainties during radiotherapy procedure protocol, it
According to the different guidelines, there are range of RED is recommended to validate the CT‑RED curves of the CT
values for air, soft–tissue, and bone, and different tolerances unit whose images would be used for clinical planning and
of HU values are reported for different materials.[12] Every treatment.

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 Saini, et al.: Effect of tube current on dose distribution

Dosimetric comparison of different calculation algorithms however, uses some approximations that make the model
versus tube voltage perform better under certain irradiation geometries (lung)
Monaco TPS showing variation in calculated doses with and worse in others such as with bone heterogeneities.[13‑15]
different dose calculation algorithms with respect to different This shows that MC simulation algorithm is a powerful tool
CT scanning protocols (tube voltages) in Tables 7 and 8. for quality assurance in radiotherapy as it is only calculation
Out of three algorithms, only MC shows the variation in the method that can account for all the physical phenomena
calculated doses at different tube voltages scan, whereas PB that take place in the interaction of radiation beams with
and CC show very negligible variations. This may be due to inhomogeneous media. MC can even describe the dose
the reason that MC calculation algorithm even takes care of deposition in the vicinity of high‑Z interfaces. Figure 4 clearly
small changes in electron density of the medium and includes shows the distribution of dose in different density materials by
in dose calculation. The PB and CC algorithms failed to MC calculation algorithm.
calculate dose variations very accurately and results very Table 6 clearly shows the maximum dose variation in different
small difference of <1% at different scanning protocols. The density materials with varying photon energies calculated
MC algorithm simulates the transport of millions of particles with MC calculation algorithms. This variation depicts the
and photons through matter. It utilizes the law of probability MC while calculating considers the electron density and
distribution of individual interactions of particles and photons. energy spectrum factors while performing three‑dimensional
The CC algorithm is a convolution superposition model‑based calculations in a medium. At higher energy, the scattering
engine. It consists of a convolution equation that separately distribution will be maximum in bone medium results in
considers the transport of primary photons and scattered maximum variation in dose calculation with varying electron
electrons. A point kernel convolution/superposition model density obtained at different tube voltages. For lower energy
accounts for inhomogeneity correction in patients. In CC in the low density medium, maximum variation is observed
algorithm, variations in lateral photon and electron transport due to consideration of scattering contribution with varying
are approximately modeled. In PB algorithm, the beam is electron density at different tube voltages. According to
divided into infinitesimal into narrow PBs and into the field Chen et al.,[16] MC method is considered to be the most
grid PBs is calculated altogether. Finally, the dose at any point accurate algorithm for dose calculation, but it requires the
is obtained by summation of the dose contribution of all PBs greatest processing time. Apart from MC, all other methods
into point of interest. However, in the PB algorithm, variations make different degrees of approximation and simplification
in photon transport and lateral electrons are not modeled. which lead to much faster calculation speed but also result
A patient’s body contains different densities, requiring a in less accurate dose distribution comparing with the
correction factor for each beam causing beam attenuation. The MC simulation.[17‑20] Variation of 1% was reported in the
PB algorithm is very fast due to its use of a one‑dimensional previous study on CATPHAN phantom for MC calculation
density correction, which does not accurately model the algorithm,[1] in contrast our study reveals maximum difference
distribution of secondary electrons in heterogeneous media. of 1.2%–1.4% when MC calculation algorithm is used which
The CC algorithm was developed to model the physical may be due to sufficient density materials availability in CIRS
processes involved instead of semi empirically tabulated phantom and the contribution of scattered beam and energy
measurements in water. The implementation of such a model, spectrum could be sufficiently dissipate in the medium. In
CATPHAN phantom, only different density materials of small
sizes are present which could provide insufficient scattering
Table 5: Mean Hounsfield unit values from Monaco contribution effect of different density. CIRS phantom mimics
treatment planning system for different tube voltages the torso of human body and suitable for the dose distribution
Density material 80 kVp 100 kVp 120 kVp 140 kVp study providing sufficient medium for incorporating scattering
Bone 1058 920 834 775 contribution.
Lung −791 −804 −800 −802 At different scanning protocol, the spectra of tube voltages
Water −17 −17 −18 −18 changes and offers different electron density to the medium.

Table 6: Actual error for different energy in density medium using Monte Carlo calculation at varying tube voltage using
0.5% uncertainty window
Energy (MV) Bone (%) Left lung (%) Right lung (%) Water (%)
6FF 1.2 0.37 0.37 0.53
6FFF 1.4 0.65 0.65 0.73
10FF 0.45 0.05 ‑ 0.12
10FFF 0.42 ‑ ‑ ‑
15FF 0.6 ‑ ‑ 0.3
FFF: Flattening filter free

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Table 7: Percentage dose variation calculated using beams for pencil beam convolution and collapsed cone convolution
algorithms at different tube voltages
Energy (MV) Density PB (cGy) SD Mean Maximum mean percentage
material dose difference
80 kVp 100 kVp 120 kVp 140 kVp
6FF Bone 73.7 74.5 74.1 73.7 0.38 74 0.67
Left lung 108.4 108.7 108.4 108.7 0.17 108.5 0.18
Right lung 108.8 108.9 108.6 109.1 0.21 108.8 0.27
Water 114.5 114.7 114.7 114.9 0.16 114.7 0.17
6FFF Bone 59.6 60.1 60 60.2 0.26 59.9 0.5
Left lung 76.6 76.7 76.6 76.8 0.09 76.7 0.13
Right lung 76.9 77 76.8 77.1 0.13 76.9 0.26
Water 92.9 93 93 93.2 0.12 93.0 0.21
10FF Bone 74.4 75 74.9 75.1 0.31 74.8 0.53
Left lung 106.7 106.8 106.7 106.9 0.09 106.8 0.09
Right lung 107 107 106.8 107.2 0.16 107 0.18
Water 112.2 112.4 112.4 112.6 0.16 112.4 0.18
10FFF Bone 58.4 58.9 58.8 59 0.26 58.8 0.68
Left lung 74.9 74.9 74.9 75 0.05 74.9 0.13
Right lung 75.1 75.1 75 75.3 0.12 75.1 0.26
Water 89.3 89.4 89.4 89.5 0.08 89.4 0.11
15FF Bone 76.9 77.5 77.3 77.6 0.31 77.3 0.52
Left lung 108.8 108.9 108.7 109 0.13 108.8 0.18
Right lung 109.1 109.1 108.9 109.3 0.16 109.1 0.18
Water 112.9 113 113 113.2 0.12 113.0 0.17
Energy (MV) Density CC (cGy) SD Mean Maximum mean percentage
material dose difference
80 kVp 100 kVp 120 kVp 140 kVp
6FF Bone 69.7 70.3 70.8 69.7 0.53 70.1 0.99
Left lung 109.1 109.2 109.5 109.6 0.24 109.3 0.27
Right lung 109.3 109.3 109.5 109.7 0.19 109.5 0.18
Water 115.8 116.2 116.2 116.5 0.28 116.2 0.34
6FFF Bone
Left lung
Right lung
Water
10FF Bone 73.1 73.6 74 74.3 0.52 73.75 0.88
Left lung 104.7 104.7 105 105 0.17 104.85 0.14
Right lung 105.1 105 105.3 105.4 0.18 105.2 0.19
Water 112.9 113.1 113.2 113.4 0.21 113.15 0.22
10FFF Bone
Left lung
Right lung
Water
15FF Bone 76.1 76.4 76.8 77 0.4 76.6 0.65
Left lung 106.6 106.6 106.9 106.8 0.15 106.7 0.18
Right lung 106.5 106.4 106.6 106.7 0.13 106.55 0.14
Water 114.1 114.3 114.3 114.5 0.16 114.3 0.17
PB: Pencil beam, CC: Collapsed cone, FFF: Flattening filter free, SD: Standard deviation

The circle of diameter chosen for study itself shows variation calculated for selected diameter’s for different algorithm
in value of HU at different points in a circular diameter, and depicts variation.[21]
for study purpose, the mean values were considered, and
curve of HU and RED was plotted, but in reality, every point Figures 5 and 6 show the expected behavior of beam
in a medium was offered different energy spectra by CT and energies 6ff and 6fff in different density materials at varying
results into different ED in a medium. The circular diameter tube voltages and depicts the maximum variation in bone
for different materials shows variation in electron density material due to scattering contribution and changes in energy
in a selected grid size for calculation and total dose when spectra. It is recommended to use the system cautiously

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 Saini, et al.: Effect of tube current on dose distribution

Table 8: Dose calculated using beams for Monte Carlo calculation algorithms at different tube voltages
Energy Density MC (cGy) SD Mean Maximum mean percentage
(MV) material dose difference
80 kVp 100 kVp 120 kVp 140 kVp
6FF Bone 69.2 70.3 70.8 71.2 0.86 70.4 1.7
Left lung 113.4 114.2 114.8 115.2 0.78 114.4 0.87
Right lung 113.6 114.4 114.9 115.4 0.78 114.6 0.87
Water 114.6 115.9 116.1 116.6 0.85 115.8 1.03
6FFF Bone 56.3 57.3 57.6 58.3 0.83 57.4 1.9
Left lung 77.1 77.9 78.2 78.8 0.71 78.0 1.15
Right lung 77.4 78.2 78.4 79.1 0.70 78.3 1.15
Water 92.1 93.4 93.3 94.2 0.86 93.25 1.23
10FF Bone 72.7 73.5 73.6 73.9 0.51 73.4 0.95
Left lung 109.2 109.9 109.9 110.1 0.39 109.8 0.55
Right lung 109.4 110.1 110.0 110.2 0.36 109.9 0.45
Water 112.5 113.5 113.2 113.5 0.47 113.2 0.62
10FFF Bone 53.6 54.0 54.4 54.5 0.41 54.1 0.92
Left lung 63.9 64.1 64.5 64.4 0.27 64.2 0.46
Right lung 64.2 64.4 64.7 64.7 0.24 64.5 0.46
Water 82.3 82.8 82.9 83.0 0.31 82.75 0.30
15FF Bone 75.2 76.0 76.6 76.5 0.64 76.07 1.1
Left lung 110.4 111.0 111.7 111.5 0.58 111.15 0.49
Right lung 110.5 111.2 111.8 111.5 0.55 111.25 0.49
Water 112.9 113.9 114.3 114.1 0.62 113.8 0.80
MC: Monte Carlo, FFF: Flattening filter free, SD: Standard deviation

6MV 6FFF
Max Percentage Variation

Max Percentage Variation

1.5 1.5

1 1

0.5 0.5

0 0
Bone Lt Lung Rt Lung Water
Bone Lt Lung Rt Lung Water
Density Material
Density Material

Figure 6: Maximum percentage variation of dose in different density

Figure 5: Maximum percentage variation of dose in different density materials for 6 mega voltage flattening filter free photon energy calculated
materials for 6 mega voltage photon energy calculated with 0.5% with 0.5% uncertainty Monte Carlo calculation algorithm
uncertainty Monte Carlo calculation algorithm
The study can be validated through other dosimeters such
as Thermoluminescent dosimeters, optically stimulated
when different tube voltage scan is used different from luminescence, three‑dimensional gel dosimeter, and MC
baseline calibration curve, and judiciously, the uncertainty Simulation method as in the present study only ionization
window level needs to be set for optimum result; otherwise, chamber‑based assessment has performed. Institutions using
there are chances to obtained wrong doses in clinical
third‑generation algorithms like MC shall use it cautiously
environment.
when for high‑end techniques such as intensity‑modulated
radiation therapy and volumetric‑modulated radiation therapy
Conclusion considering tube voltage effect on electron density. Every
We have found that different kVp setting shows no statistically center shall plot calibration curves of different tube voltages
significant variation in the measured HU values. The highest before using for dose calculation and same energy calibration
variation was observed in case of high‑density bone material curve shall be used on which simulation was performed.
at the lowest kVp tube voltage. PB and CC convolution TPS quality assurance needs to be performed with different
algorithms show <1% variation in dose distribution in all calibration curves of different tube voltage energy before
cases of varying tube voltage electron density obtained but using for clinical treatment with third‑generation calculation
MC calculation algorithm shows deviation up to 1.2%–1.4%. algorithms. In future, impact of tube voltage on gamma

322 Journal of Medical Physics ¦ Volume 46 ¦ Issue 4 ¦ October-December 2021

 Saini, et al.: Effect of tube current on dose distribution

index needs to be explored for MC calculation algorithm on 10. Rana S, Rogers K, Lee T, Reed D, Biggs C. Verification and dosimetric
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Financial support and sponsorship 11. Sharma DS, Sharma SD, Sanu KK, Saju S, Deshpande DD, Kannan S.
Nil. Performance evaluation of a dedicated computed tomography scanner
used for virtual simulation using in‑house fabricated CT phantoms.
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