COMPUTED TOMOGRAPHY

DEFINITION BRIEF HISTORY

COMPUTED TOMOGRAPHY 1930’S – ALLESANDRO VALLEBONA

 Creation of a cross-sectional tomographic  Proposed a method to represent a single
section of the body with a rotating fan beam, slice of the body on the radiographic film
a detector array and computed (TOPOGRAPHY)
reconstruction
 Other Names: Computed Axial 1970 – GODFREY NEWBOID HOUNSFIELD
Tomography (CAT), Computed Transaxial  First demonstrated the CT technique
Tomography (CTAT), Computed
Reconstruction Tomography (CRT), Digital 1972-1974
Axial Tomography (DAT), Body Section  First clinical CT scanners were installed
Roentgenography
 Greek Word: “Tomos” = slice/section; 1979
“Graphia” = describing  Hounsfield & Allan Mcleod Cormack
shared the Nobel Prize in Physics
CT SCANNER
 Consists of an x-ray source emitting finely 1980
collimated x-ray beam and a single detector  CT scan machine became widely available
both moving synchronously in a translate or
rotate mode or a combination of both EMI SCANNER
 1st CT scan machine
 180 translation/1o rotation
INTRODUCTION
ACTA
COMPUTERS  1st CT system that could make images of any
 Used Binary System part of the body
 Did not require water tank
BINARY DIGIT/BIT
 Can code for 2 values or 2 shades of gray
which correspond to white and black PRINCIPLES OF OPERATION
 8 bits=1 byte
 2 bytes=1 word CONVENTIONAL/AXIAL TOMOGRAPHY
 16 bits=1 word  Plane of the image is parallel to the long
axis of the body
STORAGE REQUIREMNENT  Produces sagittal and coronal images
 Kilobytes, megabytes, gigabyte or terabytes
COMPUTED TOMOGRAPHY
 Plane of image is perpendicular to the long
axis of the body
 Produces a transverse image
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 COMPUTED TOMOGRAPHY

CT IMAGE 2ND GENERATION

 A transaxial/transverse image  Has a narrow fan beam and multiple
detectors
TRANSLATION/SWEEP
 It refers to movement of source-detector 3RD GENERATION
assembly across the patient  Has a wide fan beam
 Results in a projection
 Projection: represents the attenuation 4TH GENERATION
pattern of patient profile  Equipped with a detector ring
 Detector signal: has a dynamic range of 12
bits (4096 gray levels) 5TH GENERATION
 The electron beam tomography CT
PROJECTION
 An intensity profile 6TH GENERATION
 The helical (or spiral) CT scanner
ALGORITHM
 Computer-adapted mathematical calculation 7TH GENERATION
applied to raw date during image  The multi-detector row CT.
reconstruction
SEVEN GENERATIONS
RECONSTRUCTION
 Creation of an image from date FIRST GENERATION
 A demonstration project
RECONSTRUCTION TIME  Characteristic: translate/rotate (Bushong )
 Time needed for the computer to present a or rotate/translate (Reveldez)
digital image after an examination has been  X-ray Beam Shape: pencil beam
computed  Detector: single detector
 Time between the end of imaging and the  Imaging Time: 5-minute imaging time
appearance of an image
SECOND GENERATION
 Characteristic: translate/rotate (Bushong )
GENERATIONS OF COMPUTED or rotate/translate (Reveldez)
TOMOGRAPHY  X-ray Beam Shape: narrow fan beam
 Detector: multiple detector (5-30)
GENERATION OVERVIEW  Imaging Time: 30 seconds
 Advantage: speed
1ST GENERATION o Rationale: consist of multiple
 Has a pencil beam and one detector detectors
 Disadvantages:
o Increased scattered radiation

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 COMPUTED TOMOGRAPHY

o Increased radiation intensity toward rotation of the x-ray source, proving a self-
the edges of the beam calibrating system. Third generation system are
 Compensation: used of bow- calibrated only once every few hours.
tie filter
 Bow-tie Filter: equalize the radiation FIFTH GENERATION (early 1980’s)
intensity that reaches the detector array  Electron beam CT
 Ultrafast CT scanner
THIRD GENERATION  X-ray tube rotation is mechanical
 Characteristic: rotate/rotate  No moving parts
 X-ray Beam Shape: wide fan beam  Electron Gun: produces a focused electron
 Detector: curvilinear detector array (30) beam that generates a rotating x-ray fan
 Imaging Time: <1 second beam after being steered along tungsten
 Advantages: target rings
o Better x-ray beam collimation
o Decreased scattered radiation SIXTH GENERATION (early 1990’s)
o Good image reconstruction  Helical/Spiral CT
 Disadvantage: ring artifacts  Volumetric scanners
o Compensation: software connected  Introduced by Will Kalender and Kazuhiro
image reconstruction algorithm Katada
 Uses slip ring technology
NOTE: Third generation designs have the  Excels in 3D multiplanar reformation
advantage that thin tungsten SEPTA can be place  Slip Ring: electromechanical device that
between each detector in the array and focused on conduct electricity and electric signals
the x-ray source to REJECT SCATTERED through rings and brushes across a rotating
RADIATION surface onto a fixed surface

FOURTH GENERATION SEVENTH GENERATION

 Characteristic: rotate/stationary  64-Slice CT
 X-ray Beam Shape: wide fan beam  Multiple detector array
 Detector: fixed circular detector array IMAGING SYSTEM DESIGN
(4000) with detector ring
 Imaging Time: <1 second 3 MAJOR COMPONENTS
 Advantage: no ring artifacts 1.) Gantry
 Disadvantage: 2.) Operating Console
o Increased patient dose 3.) Computer
o High cost
GANTRY
NOTE: The detectors are no longer coupled to the  Largest component
x-ray source and hence cannot make used of
focused SEPTA to reject scattered radiation.
However, detectors are calibrated twice during each
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 COMPUTED TOMOGRAPHY

 Subsystems: x-ray tube, detector array, high and change them to electronic
voltage generator, patient couch and signals
mechanical support o Low or no after glow
 A brief, persistent flash of
X-RAY TUBE scintillation that must be
 Special requirements: taken into account &
o Power capacity: must be high subtracted before image
 >120 kVp reconstruction
 400 mA o High scatter suppression
o High speed rotors: for heat o High stability
dissipation  Allows a system to be used
o Anode heat capacity: 7 MHU without interruption of
(Spiral CT) frequent calibration
o Heat storage capacity: 8 MHU o Types:
o Anode cooling rates: 1MHU/min o Gas-filled detector – previously used
o Focal spot size: small o Scintillation & solid-state detectors –
 Takenote: CT scanners recently used
designed for high spatial o Gas detector:
resolution imaging not for o Basis: ionization of gas
direct projection imaging o Three types:
o Limiting characteristics:  Ionization chamber
 Focal spot design: must be  Proportional counter
robust or strong  Geiger-Muller counter
 Heat dissipation o Characteristics:
o X-ray tube life: approx. 5000  Excellent stability
exposures (Conventional CT)  Large dynamic range
 Focal-Spot Cooling Algorithms:  Low quantum efficiency
o Design to predict the focal spot o Scintillation detector:
thermal state o Characteristic: high x-ray detection
o To adjust the mA setting accordingly efficiency (90%)
 Reduces patient dose
DETECTORY ARRAY  Allows faster imaging time
o The entire collection of detectors  Improves image quality
o Group of detectors o Crystals used: Sodium iodide
o The image receptor in CT o Replaced by:
o Detector: absorbs radiation and converts it  Bismuth germinate (BGO)
to electrical signal  Cesium iodide (CsI)
o Optimal Characteristics: o Current crystal of choice:
o High detector efficiency  Cadmium tungstate (CdWO4)
 The ability of the detector to  Special ceramics
capture transmitted photons
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 COMPUTED TOMOGRAPHY

o Photodiode: converts light into electrical  Value <1: non ideal detector system
signal o Result: increased in patient dose to
o Characteristics: maintain image quality
 Small,
 Cheap CAPTURE EFFICIENCY
 Does not require power  Refers to the ability with which the detector
supply obtains photons that have passed through the
patient
THREE IMPORTANT FACTORS
CONTRIBUTING TO DETECTOR ABSORPTION EFFICIENCY
EFFICIENCY  Refers to the number of photons absorbed
by the detector
1.) GEOMETRIC EFFICIENCY  Depends on: physical properties of the
 The area of the detectors sensitive to detector face
radiation as a fraction of the total exposed o Thickness
area o Material
 The amount of space occupied by the
detector collimator plates relative to the RESPONSE TIME
surface area of the detector  The time required for the signal from the
2.) QUANTUM EFFICIENCY detector to return to zero after stimulation of
 The fraction of incident x-rays on the the detector by x-ray radiation so that it is
detector that are absorbed and contribute to ready to detect another x-ray event
the measured signal  A function of the detector design

3.) CONVERSION EFFICIENCY DYNAMIC RANGE

 The ability to accurately convert absorbed x-  The ratio of the maximum signal measured
ray signal to electrical signal to the minimum signal the detectors can
measure
OVERALL/DOSE EFFICIENCY
 The product of geometric, quantum and DATA ACQUISITON SYSTEM (DAS)
conversion efficiency  Computer-controlled electronic amplifier
 The product of the following factors and switching device
o Stopping power of the detector  Where signal from each radiation detector is
material connected
o Scintillator efficiency (in solid-state  Consists of:
types) o Preamplifier
o Charge collection efficiency (in o Integrator
xenon types) o Multiplexer
o Geometric efficiency o Logarithmic
o Scatter rejection o Amplifier
 Normal value: b/n 0.45-0.85 o Analog-to-digital converter
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 COMPUTED TOMOGRAPHY

 Patient dose
HIGH VOLTAGE GENERATOR  Predetector/Post Patient Collimator
o High frequency power o Restricts the x-ray beam viewed by
o High voltage step-up transformer the detector array
o Power: 50 kW o Purpose:
o Accommodates higher x-ray tube rotor  To decrease scattered
speeds radiation
o Accommodates instantaneous power surges  To improved contrast
characteristic of pulsed system o Determines:
 Slice thickness
PATIENT COUCH  Sensitivity profile
o Supports the patient comfortably
o Construction: low-Z material (Carbon OPERATING CONSOLE
fiber)  Contains meters and controls
o Rationale: it does not interfere with o For selection of proper imaging
x-ray beam transmission & patient technique factors
imaging o For proper mechanical movement of
o Features: should be the gantry and patient couch
o Smoothly and accurately motor o For the use of computer commands
driven  Allow image reconstruction
 Rationale: precise and transfer
positioning is possible  2-3 operating consoles
o Capable of automatic indexing o 2 for CT radiologic technologists
 Rationale: operator does not  1st: To operate imaging
have to enter the room system
between each scan  2nd: to post-process images
for filming and filing
COLLIMATION o 1 for physician
 Restricts the volume of tissue irradiated  To view the images
 Purpose:  To manipulate contrast, size
o Reduces patient dose & general visual appearance
o Improved image contrast  Accepts the reconstructed
 Types: post patient & prepatient collimator image from operator’s
 Prepatient Collimator console
o Limits the area of the patient that  Displays reconstructed image
intercepts the useful beam for viewing and diagnosis
o Mounted on the x-ray tube housing  Two monitors:
or adjacent to it o 1st: provided for operator
o Purpose: to decrease patient dose  To annotate patient data on
o Determines: the image (e.g. hospital
 Dose profile
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 COMPUTED TOMOGRAPHY

identification, name, patient  Central Processing Unit (CPU): performs

number, age, gender) calculations and logical operations under
 To provide identification for control of software instruction
each image (e.g. number, o Heart of the computer
technique, couch position)
nd
o 2 : allows the operator to view the  Special requirements:
resulting image before transferring it o Controlled environment
to hard copy or physician’s viewing o Relative Humidity: <30%
console o Temperature: <20oC
 Technique factors: o High humidity and temperature:
o kVp: <120 contribute to computer failure
o mA: 400 (maximum)
 varied according to SLIP-RING TECHNOLOGY
 patient thickness to reduce  Slip ring: electromechanical device that
patient dose conducts electricity and electrical signals
o Slice thickness: 0.5-5 mm through rings and brushes
 Physician’s work station: allows the o Allows the gantry to rotate
physician continuously without interruption
o To call up any previous image o Made MSCT possible
o To manipulate image to optimize  Brushes: transmit power to the gantry
diagnostic information components
 Scan time: length of time required per scan o Composition: silver graphite alloy
 Used as sliding contact
COMPUTER o Replacement of brushes:
 Unique subsystem of the CT imaging system  Every year
 Microprocessor & primary memory: heart  During preventive
of the computer maintenance
o Determine reconstruction time
 Array processors:
o Mostly used in CT instead of IMAGE CHARACTERISTICS
microprocessors
o Rationale: IMAGING MATRIX
 Does many calculations  Layout of cells in rows and columns
 Faster than microprocessors  Original EMI: 80x80 matrix
(<1 sec reconstruction time) o 6000 cells of information
 Computer memories: ROM & RAM  Current system: 512x512 matrix
 Random access memory: temporary o 262,144 cells of information
memory that stores information while  Pixel: a picture element
software is used o Each cell of information
 Read only memory: for storage data only o Two-dimensional
and cannot be overwritten  Pixel Size = FOV ÷ matrix size
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 COMPUTED TOMOGRAPHY

 Voxel: a volume element Blood 20

o The tissue volume CSF 15
 Voxel (mm3) = pixel size (mm2) x slice Water 0
thickness (mm) Fat -100
Lungs -200
 CT number/Hounsfield unit: the numeric
Air -1000
information contained in each pixel
 Matrix: rows and columns of pixels
displayed on a digital image
IMAGE RECONSTRUCTION
 Field of view (FOV): the diameter of image
reconstruction
FILTER BACK PROJECTION
o FOV increased, fixed matrix size
 Process by which an image is acquired
 Result: increase/larger pixel
during CT and stored in computer memory
size
is reconstructed
o Fixed FOV, increase matrix size
 Filter: refers to mathematical function
 Result: decrease/smaller
pixel size
MULTIPLANAR REFORMATION (MPR)
 A method for generating coronal, sagittal, or
oblique images from the original axial image
data
CT NUMBER/HOUNSFIELD UNIT (HU)
 MSCT: excels in 3D MPR
 Used to assess the nature of tissue
 3D MPR Algorithm: most frequently used
 HU: scale of CT number
 Range: -1000 – +3000
THREE 3D MPR ALGORITHMS
 Formula: CT Number = k (µt-µw/ µw)
o k: constant that determines the scale
1.) MAXIMUM INTENSITY PROJECTION
factor for the range of CT number
(MIP)
o µt: attenuation coefficient of the
 Reconstruct an image by selecting the
tissue in the pixel under analysis
highest value pixels along the arbitrary line
o µw: x-ray attenuation coefficient of
 Widely used in CT Angiography
water
2.) SHADED SURFACE DISPLAY (SSD)
 Computer-aided technique that identifies
CT NUMBER FOR VARIOUS TISSUES
narrow range of values as belonging to the
APPROXIMATE CT
TISSUES object to be imaged
NUMBER
Dense bone 3000 3.) SHADED VOLUME DISPLAY (SVD)
Bone 1000  Very sensitive to the operator-selected pixel
Liver 40-60 range
Muscle 50  Previously: applied to bone imaging
White matter 45  Recently: applied to virtual colonoscopy
Gray matter 40
Kidney 30
IMAGE QUALITY
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 COMPUTED TOMOGRAPHY

SPATIAL FREQUENCY
FIVE PRINCIPAL CHARACTERISTICS OF  Used to describe CT spatial resolution
CT IMAGE  Low SF: represents large objects
1.) Spatial resolution  High SF: represents small objects
2.) Contrast resolution
3.) Noise EDGE RESPONSE FUNCTION (ERF)
4.) Linearity  Mathematical expression of the ability of the
5.) Uniformity CT scanner to reproduced a high-contrast
edge with accuracy
SPATIAL RESOLUTION
 Ability to image small object that have high MODULATION TRANSFER FUNCTION
subject contrast (MTF)
 Expressed in: linepairs/millimeter (lp/mm)  Mathematical expression for measuring
 A function of pixel size resolution
 Takenote: SR for a CT image is limited to  The ratio of the image to the object as a
the size of the pixel function of spatial frequency
 Image reconstruction and postprocessing  Used to describe CT spatial resolution
tasks: powerful way to affect SR  MTF = 1: faithfully represents the object
 Formula: SR (cm) = ½ {1/SF (lp/cm)}  MTF = 0: image is blank and contain no
information
FACTORS AFFECTING/INFLUENCING  MTF = intermediate values: intermediate
SPATIAL RESOLUTION levels of fidelity
1.) Pixel size
2.) Slice thickness CHARACTERISTICS OF CT IMAGING
3.) Voxel size SYSTEM CONTRIBUTING TO IMAGE
4.) Design of prepatient and predetector collimators DEGRADATION
5.) Detector size 1.) Collimation
2.) Detector size and concentration
EFFECT IN SPATIAL 3.) Mechanical/electrical gantry control
FACTORS
RESOLUTION 4.) Reconstruction algorithm
Thick slice thickness Poor SR
Thin slice thickness Better SR
IMAGE FIDELITY
Large pixel size Poor SR
 Measured by determining the optical density
Small pixel size Better SR
Large voxel size Poor SR along the axis of the image
Small voxel size Better SR
Large detector size Poor SR LIMITING RESOLUTION
Small detector size Better SR  Spatial frequency at MTF equal to 0.1

LINE PAIR IMPORTANT MEASURES OF IMAGING

 One bar and its interspace of equal width SYSTEM PERFORMANCE
1.) Artifacts generation
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 COMPUTED TOMOGRAPHY

2.) Contrast resolution Equal 0

3.) Spatial resolution Large variation High
Small variation Low
CONTRAST RESOLUTION
 The ability to distinguish one soft tissue FACTORS AFFECTING NOISE
from another without regard for size or 1.) kVp and filtration
shape 2.) Pixel size
 Takenote: CR is superior to CT 3.) Slice thickness
o Rationale: better x-ray beam 4.) Detector efficiency
collimation 5.) Patient dose – primary control of noise
 Ability to image low-contrast objects:
o Limited by: LINEARITY
 Size and uniformity of the  Describes the amount to which the CT
object number of a material is exactly proportional
 Noise of the system to the density of this material (in Hounsfield
units)
X-RAY ABSORPTION IN TISSUE  Evaluation test: five-pin performance test
 Determined by the mass density of the body object
part  Frequency: daily
 Characterized by x-ray linear attenuation UNIFORMITY
coefficient  The consistency of the CT numbers of an
image of a homogeneous material across the
X-RAY LINEAR ATTENUATION scan field
COEFFICIENT
 A function of x-ray energy and atomic SPATIAL UNIFORMITY
number of the tissue  Constancy of pixel values in all region of the
reconstructed image
NOISE  Evaluation test: plotting the CT number in
 The percentage standard deviation of a histogram/line graph
large number of pixels obtained from a  Acceptable value: +/- 2 mean value
water bath image (Standard Deviation)
 The variation in CT number above or below
the average values
 Appears as graininess MULTISLICE SPIRAL CT IMAGING
 Takenote: the resolution of low-contrast PRINCIPLES
objects is limited by the noise of the CT
imaging system ADVANTAGE OF MSCT
o Evaluation test: 20-cm water bath  Increases the volume of tissue that can be
o Frequency: daily imaged at a given time

PIXEL VALUE NOISE

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 COMPUTED TOMOGRAPHY

o Rationale: it has the ability to image  Z-axis location and

a larger volume of tissue in a single reconstruction width can be
breath-hold selected after imaging
 Helpful in:  CTA Pitch: <1:1
o CT Angiography  Pitch >1:1:
o Radiation therapy treatment o Decreases Z-axis resolution
o Imaging uncooperative patients o Rationale: a wide section sensitivity
profile
INTERPOLATION ALGORITHMS
 A special computer program VOLUME IMAGING
 1st interpolation algorithm: used 360o  Formula:
linear interpolation o TISSUE IMAGED = Beam width x
o Disadvantage: caused prominent Pitch x Imaging time
blurring of the reconstructed image  For 360o gantry rotation/sec
 Solution for blurring: 180o linear o TISSUE IMAGED = (Beam width
interpolation x Pitch x Imaging time) ÷ gantry
o Results: rotation
 Improved Z-axis resolution  If gantry rotation is not
 Improved sagittal and coronal 360o/sec
reformatted views
o It allows imaging at a pitch <1 SENSITIVITY PROFILE
 Interpolation:  Full Width at Half Maximum (FWHM):
o Estimation of value between two o The width of sensitivity profile at
known values one half of its maximum value
o A mathematical method of creating
missing data  If MSCT pitch=1:1:
 Extrapolation: estimation of value beyond o Sensitivity profile: 10% wider than
the range of known values conventional CT
 Data interpolation: performed by  If MSCT pitch=2:1:
interpolation algorithm o Sensitivity profile: 40% wider than
conventional CT
PITCH/SPIRAL PITCH
 The relationship between patient couch
movement and x-ray beam width IMAGING TECHNIQUES
 Spiral Pitch Ratio:
o PITCH = Couch movement each TWO PRINCIPAL DISTINGUISHING
360o ÷ Beam width FEATURES OF MSCT
 MSCT Pitch: 1 1.) Several parallel detector arrays
o Rationale: 2.) Quickly energizing
 Multiple slices are obtained
MULTISLICE DETECTOR ARRAY
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 COMPUTED TOMOGRAPHY

 Early 1990’s: initial demonstration of dual- Improved lesion -Reconstructs at

slice imaging detection arbitrary z-axis intervals
 Recently: 320 slice imaging -Reconstructs at
overlapping z-axis
 Wider slice imaging: Reduced partial
interval
o Better contrast resolution (at same volume
-Reconstructs small than
mA setting) image interval
 Rationale: detected signal is -Date obtained during
larger peak of enhancement
Optimized IV contrast
o Slight decrease in spatial resolution -Reduces volume of
 Rationale: increased voxel contrast agent
size Multiplanar images -Higher quality
improved reconstruction
 Smaller detector size: better spatial
resolution
FEATURES OF MSCT
DUAL SOURCE MSCT
LIMITATIONS RATIONALE
 Has two x-ray tubes & two detector arrays -bigger x-ray tubes
 Principal advantage: speed Increased image noise
needed
 Imaging time: 80 ms Reduced z-axis
-increases with pitch
resolution
DATA ACQUISITION RATE Increased processing -more data, more images
time needed
 Slice Acquisition Rate (SAR): one measure
of the efficiency of the MSCT imaging
system
 Formula:
COMPUTED TOMOGRAPHY QUALITY
o SAR = Slice acquired/360o ÷
CONTROL
Rotation time
NOISE AND UNIFORMITY
Z-AXIS COVERAGE (Z)
 Assessment test: 20-cm water bath
 Formulas:
 Frequency: weekly
o Z = (N/R) x W x T x B
 Acceptable tolerance:
o Z = SAR x W x T x B
o Water: w/in +/- HU of 0
 N: number of slice acquired
o Uniformity: not > +/- 10 HU from
 R: rotation time
center of periphery
 W: slice width
 Assessment in quantitative CT: the
 T: time
following should be changed
 B: pitch o CT scan parameters
o Slice thickness
FEATURES OF MSCT o Reconstruction diameter
ADVANTAGES RATIONALE o Reconstruction algorithm
-Removes respiratory
No motion artifacts
misregistration
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 COMPUTED TOMOGRAPHY

LINEARITY  Intended slice thickness of <5 mm: 0.5

 Assessment test: five-pin insert mm acceptable tolerance
performance
 Frequency: semiannually COUCH INCREMENTATION
 Analysis: should show relationship b/n the  Assessment test: noting the position of the
HU and electron density couch with tape measure & straightedge on
 Acceptable tolerance: the couch rails
o Correlation coefficient: at least  Frequency: monthly
0.96% or 2 standard deviation  Acceptable tolerance: w/in +/- 2 mm
 Assessment in quantitative CT: requires
precise determination of the value of tissue LASER LOCALIZER
in HU  For patient positioning
 Assessment test: specially designed test
GAMMEX 464 objects
 CT test object  Frequency: semiannually
 Used to evaluate noise, spatial and contrast
resolution, linearity and uniformity PATIENT DOSE
 Specified as CT dose index (CTDI)
SPATIAL RESOLUTION  High resolution: high patient dose
 Most important component of QC program  Monitored by: specially designed pencil
 Assessment test: imaging a wire/edge/hole ionization chamber/TLD
array/bar pattern  Frequency: semiannually
 Frequency: semiannually  Acceptable tolerance:
 Acceptable tolerance: w/in manufacture’s o Fixed technique: patient dose not
specifications vary from > +/- 10%
 Should follow replacement of the tube
CONTRAST RESOLUTION
 Assessment test: low-contrast test objects
with built-in analytic schemes CT SCAN ARTIFACTS
 Frequency: semiannually
 Acceptable tolerance: ARTIFACTS
o CT resolving power: should be 5  Systematic discrepancy in CT numbers/HU
mm objects at 0.5% contrast  Unintended optical density on a radiograph
 More common in CT than in conventional
radiographs
SLICE THICKNESS/SENSITIVITY PROFILE
 Types:
 Assessment test: ramp, a spiral or a step o Streaking - due to an inconsistency
wedged (specially designed test objects) in a single measurement
 Frequency: semiannually o Shading – due to a group of
 Acceptable tolerance: w/in 1 mm of the channels or views deviating
intended slice thickness gradually from the true measurement

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 COMPUTED TOMOGRAPHY

o Rings – due to errors in an Patient positioning

individual detector calibration Gantry tilting
o Distortion – due to helical Appropriate FOV selection
reconstruction Appropriate bowtie filter
 Four categories: Most commonly
Bone and metal implants
o Physics-based artifacts occur
 Caused: physical processes
involved in the acquisition of CUPPING ARTIFACT
CT data Beam is hardened more
o Patient-based artifacts in the middle portion of
 Caused: Description
an object than those in
 Patient movement the edges
 Presence of metallic Caused Beam hardening
materials The middle of the
o Scanner-based artifacts, Effect image appear darker
 Caused: imperfections in than the periphery
scanner function Beam hardening
o Helical and multisection artifacts Avoidance
correction
 Caused: image
reconstruction process.

PHYSICS-BASED ARTIFACTS STREAK AND DARK BAND ARTIFACTS

 Beam hardening artifact Description
Appear between two
o Cupping artifact dense objects
o Streak artifact Metals (bullets,
 Partial volume pacemaker, dental
 Photon starvation fillings)
 Undersampling Caused Beam hardening
Poisson noise
BEAM-HARDENING ARTIFACT Patient motion
Edge effects
Increased mean energy of
Description the x-ray beam when it High CT number on the
Effect
passes through object image
Polychromatic nature of the Beam hardening
Caused Avoidance
x-ray beam correction
Cupping artifact Bony regions of the
Appearance of dark bands Most commonly occur body
or streak Used of contrast media
Effect
(b/n metal or bone)
Pseeudoenhancement of PARTIAL VOLUME ARTIFACTS
renal cysts Distortion of signal
BUILT-IN FEATURES: Description intensity from an
Filtration anatomy
Calibration correction Anatomy that doesn’t lie
Avoidance
Beam hardening correction Caused totally within the slice
software thickness
BY OPERATOR:
14
 COMPUTED TOMOGRAPHY

Averaging the linear

attenuation coefficient in METAL ARTIFACTS
Effect a voxel that is Presence of metal object
heterogenous in Caused
in the scan field
composition Incomplete attenuation
Thin slice selection Effect profile
Avoidance
Thin slice incrementation Severe streaking artifacts
Most critical region Posterior cranial fossa Asked patient to remove
metallic objects
PHOTON STARVATION ARTIFACTS Use gantry angulation
Potential source of Avoidance
Description (for nonremovable items)
streaking artifacts Increased kVp
High x-ray attenuation Thin slice thickness
Caused Highly attenuating
structures
MOTION ARTIFACTS
Insufficient x-ray Patient motion
photons reaching the Caused
Effect (involuntary & voluntary)
detector
Effect Misregistration artifacts
Very noise projections
By the operator:
Increase tube current
Use of positioning aids
Use of adaptive
Immobilization
Avoidance filtration
Sedation (infant)
Automatic tube current
Short scan time
modulation
Instruct patient to hold
Avoidance
UNDER SAMPLING ARTIFACTS breath
By built-in features:
Two large an interval
Description Overscan & underscan
between projections
modes
Misregistration by the
Software correction
computer of information
Caused Cardiac gating
relating to sharp edges
and small objects
View aliasing (fine INCOMPLETE PROJECTION
stripes appearance) Presence of anatomy
Effect lying outside the scan
Ray aliasing (stripes Description
appearance) field produces severe
For view aliasing: artifacts
Slower rotation speed Portion of anatomy lies
Caused
Avoidance For ray aliasing: outside the field of view
Quarter-detector shift Incomplete information
Flying focal spot of the anatomy by the
Effect computer
Generation of streaking
PATIENT-BASED ARTIFACTS and shading artifacts
 Metallic materials Position patient so that
 Patient motion Avoidance no parts lying outside
 Incomplete projection the scan field
15
 COMPUTED TOMOGRAPHY

sagittal reformats seen

with helical and
SCANNER-BASED ARTIFACTS multidetector row CT
 Ring artifacts Increased number of
section acquired per
RING ARTIFACTS rotation
Caused
Artifacts seen in third Wider collimation
Description Increase number of
generation CT scanner
Faulty detector detector rows
Caused Detector out of Artifacts similar to those
Effect
calibration caused by partial volume
Consistently erroneous Employing cone beam
Avoidance
reading at each angular reconstruction
Effect
position
Circular artifact ZEBRA ARTIFACTS
Detector calibration Periodic stripes of more
Selecting correct scan or less noise at the image
Avoidance FOV Description periphery seen on
(by using calibration coronal or sagittal
date) reformats
HELICAL AND MULTISECTION CT Caused Helical interpolation
ARTIFACTS Alternating high and low
 Cone beam effect (Helical) Effect
noise on image
 Stair-step artifacts (MSCT) Employing cone beam
Avoidance
 Zebra or windmill artifacts (MSCT) reconstruction

CONE BEAM EFFECT

The x-ray beam becomes -THE END-
Description cone-shaped rather than “There are no secrets to success. It is the result of
fan-shaped
preparation, hard work learning from failure”
Increased number of
05/29/14
section acquired per
rotation
Caused
Wider collimation
Increase number of
detector rows
Fundamental deficit in
Effect
the acquired data
To acquire a more
complete data set
Avoidance
Employing cone beam
reconstruction

STAIR STEP ARTIFACTS

Description Serrations on coronal or
16
 MAGNETIC RESONANCE IMAGING

DEFINITION MRI
 Provides sectional images
MAGNETIC RESONANCE IMAGING  No superimposition of structures
 A computer-based cross-sectional imaging  Clearly demonstrates structures even
modality without contrast media
 The use of magnetic field and radio waves to  Can resolved relatively small contrast
obtain a mathematically reconstructed image differences among tissue
 Originally called: Nuclear Magnetic  Contrast depends on the interaction of
Resonance matter with electromagnetic forces

ADVANTAGES OF MRI CONVENTIONAL

 Best low contrast resolution  Provides “flat” image
o Main advantage  Structures are superimposed
o Rationale:  Contrast media is required to clearly
 X-ray attenuation coefficient distinguished one anatomic structure or
in soft tissue – differ by <1% organ from one another
(in same tissue)  Limited in its ability to distinguish types of
 Spin density & T1 – differ by tissue
20-30% (in same tissue)  Cannot detect small attenuation changes
 T2 – differ by 40% (in same  Can only distinguish air, fat, bone, soft
tissue) tissue, and metal
 No ionizing radiation
 Contrast depends on differences of x-ray
 Direct multiplanar imaging attenuation
 No bone or air artifact
 Direct flow measurements BRIEF HISTORY
 Totally noninvasive
 Contrast media not required 1940’s
 Felix Bloch and Edward Purcell first
MRI CONTRAINDICATION discovered the properties of magnetic
 Cardiac pacemaker resonance
 Aneurysm clips  MRI spectroscopy: technique they used for
 Claustrophobia analysis of complex molecular structures
 Metallic fragments in the eye and dynamic chemical processes
 Cochlear implants 1952
 Internal drug infusion pumps  Bloch and Purcell shared a Nobel Prize in
 Neurostimulators Physics
 Bone growth stimulators 1971
 Raymond Damadian showed that the
MRI VS CONVENTIONAL RADIOGRAPHY relaxation time of water in a tumor differed

1
 MAGNETIC RESONANCE IMAGING

from the relaxation time of water in normal DIFFUSION

tissue  Spontaneous random motion of molecules in
 Investigated excised rat tissue a medium
 He reported that there were significant
differences between normal rat tissues and FAT SUPPRESSED IMAGES
tumors  Fat tissue in the image is made to be of a
1973 lower, darker signal intensity
 Paul Lauterbur published the first cross-
sectional image of objects (two water-filled FREE INDUCTION DECAY
capillary tubes) obtained with MRI  Signal emitted by tissue after RF excitation
technique
1975
 Damadian obtained the first animal images GATING
1970s  Technique used in reducing motion artifacts
 MRI was progressing rapidly
1978 GRADIENT ECHO
 The first human head scans were obtained  Fast pulse sequence
 Followed by first human body scans  Often used with 3D imaging to generate T2-
weighted images
INDOMITABLE
 Original name of the first MRI machine GRADIENT MAGNETIC FIELD
 A change in the intensity of a magnetic field
DEFINITION OF TERMS in space
ANTENNA  Unit: mT/cm
 Device for transmitting or receiving radio
wave GYROMAGNETIC RATIO
ARTIFACTS  A constant, specific ratio for each nucleus
 Spurious finding in or distortion of an image  Half-life in MRI
ATTENUATION  Unit: MHz/T
 Reduction in energy or amount of a beam of  Hydrogen: 43 MHz/T
radiation when it passes through tissue or o Most abundant element in the body
other substances (60%)
COIL
 Single or multiple loops of wire designed to INVERSE RECOVERY
produce a magnetic field from current  Standard pulse sequence available in most
flowing through the wire MRI imagers
CLAUSTROPHOBIA  Used for T1-weighted images
 The fear of having no escape and being in
closed or small spaces or rooms LARMOR FREQUENCY
CRYOGENIC
 Relating to extremely low temperature
2
 MAGNETIC RESONANCE IMAGING

 The frequency at which a nucleus precesses  Returning to equilibrium

in the magnetic field
 Unit: MHz RELAXATION TIME
 The time required for return
MAGNETIC MOMENT
 A force created when magnetic dipole is in a RESONANCE
magnetic field  Transfer of vibrating energy from one
 The inherent magnetism system to another
 Unit: T

SPECIFIC ABSORPTION RATE (SAR)

MAGNETIZATION  The power absorbed during RF irradiation
 The large-scale macroscopic magnetic  Unit: W/kg
moment resulting from many nuclear
magnetic moments SPIN DENSITY (SD)
 Concentration of hydrogen nuclei in tissue
NET MAGNETIZATION  Principal determinants of MRI signal
 Magnetic moments of individual hydrogen
nuclei aligned in the external magnetic field T1 RELAXATION TIME
 Spin-lattice relaxation time
PERFUSION  Longitudinal relaxation time
 Flow of blood through vessels of an organ or  Decrease in signal: 63% of maximum value
anatomic structure
T2 RELAXATION TIME
PRECESSION  Spin-spin relaxation time
 The wobble of the rotational axis of a  Transverse relaxation time
spinning body about a stationary axis  Decrease in signal: 37% of maximum value
 Describes a cone
 Rate of precision: increases as MF strength TESLA
increase  SI unit of magnetic field strength
 1T = 10,000 G
RADIO FREQUENCY (RF)
 Electromagnetic radiation having a PHYSICAL PRINCIPLES
frequencies from 0.3kHz to 300 GHz
 RF range in MRI: 1-100 MHz SIGNAL PRODUCTION
 MRI depends on the properties of the
RAW DATA nucleus
 Information obtained by radio reception of  Hydrogen nuclei: element used in most
the MRI signal as stored by a computer MRI
o Rationale:
RELAXATION
3
 MAGNETIC RESONANCE IMAGING

 Strongest nuclear magnets FAST SPIN-ECHO

 Create the strongest MRI  Known as rapid acquisition recalled echo
signal
 Most common element in the FLUID ATTENUATED INVERSION
body RECOVER (FLAIR)
 Suppresses signal from cerebrospinal fluid
PULSE SEQUENCES (CSF)
 Most applicable in the brain
SPIN ECHO SEQUENCE o For seizures disorders
 Classic imaging sequences o For spinal cord injuries
 Most widely use pulse suquence SHORT TAU INVERSION RECOVERY
 Used with timing parameters to yield T1-  Suppresses signal from fat
weighted images
 Also provide pro ton-density weighted FAST SPIN-LATTICE RELAXATION RATE
images  Short T1
 Time consuming  Produces high MRI signal in T1-weighted
 Slow patient “throughput” or productivity images

INVERSE RECOVERY SLOW SPIN-SPIN RELAXATION RATE

 A sequence that accentuates T1 information  Long T2
 Time consuming  Produces high MRI signal in T2-
 Slow patient “throughput” or productivity weighted images

FAT SAT FUNDAMENTAL CONCEPTS

 Pulse sequence used to saturate fat
3 PRINCIPAL INDEPENDENT
FAT SUPPRESSED IMAGES PARAMETERS
 Used to minimize the high signal intensity  Spin density
from fat tissue overwhelming small signal  T1
intensity in the tissue of interest  T2

GRADIENT ECHO FUNDAMENTAL PARTICLES

 Oldest imaging sequence CHARACTERISTICS
 Most common type of faster imaging  Charge
sequence  Spin

FAST GRADIENT ECHO CLASSIC MECHANICS

 Fast gradient imaging technique  Describes the motion of large object
 Good wherever there is turbulent flow
QUANTUM MECHANICS

4
 MAGNETIC RESONANCE IMAGING

 Describes the motion of atoms and their PROPERTIES THAT INLUENCES IMAGE
constituents APPEARANCE
 Nuclear/spin density
MAGNETIC DIPOLE  Relaxation times – T1 and T2
 Small magnet created by the electron orbit  Flow phenomena

LARMOR EQUATION SPIN DENSITY

 Formula: ω = γBo  An indication of hydrogen concentration
o ω = Larmor frequency or frequency  Strength of signal is proportional to the
of precession (MHz) number of nuclei
o γ = gyromagnetic ration (MHz/T)
 constant value
o Bo = strength of external MF (T) T1 RELAXATION TIME
 Spins begin to precess at smaller and smaller
RESULTS OF RF ENERGY ABSORPTION BY angle (out of plane)
NUCLEI  The return of net magnetization along the Z
 Nuclei will turn upside down or flip axis to its normal equilibrium state
(energized or excited)  A characteristic of tissue itself
 Nuclei are caused to precess in phase
T2 RELAXATION TIME
EQUILIBRIUM MAGNETIZATION VECTOR  Spins begin to precess out of phase with
(M0) each other
 Amplitude of the net magnetization vector at  Exponential loss of signal caused by
equilibrium dephasing in the XY plane
 Factors that determine the amplitude:  Always less than or equal to T1 relaxation
o Spin density time
o Gyromagnetic ratio
o Strength of the external magnetic T1-WEIGHTED IMAGES (T1W)
field  Useful for showing anatomical detail
 Larger M0:
o More intense MRI signal T2-WEIGHTED IMAGES (T2W)
o Brighter MR image  Useful for showing pathology

FOURIER TRANSFORM FLOW PHENOMENA

 Used to generate the spectrum of free  Weak MRI signals: moving substances
induction decay (NMR spectrum) (e.g. blood)
 Essential to most imaging techniques  High MRI signals: stagnant (immobile)
blood (blood clot)
NMR PARAMETERS o Short T1 and long T2

5
 MAGNETIC RESONANCE IMAGING

IMAGING PRINCIPLES o Magnetic tape or optical disk

 For permanent storage and retrieval
GRADIENT MAGNETIC FIELD
 A magnetic field that changes in strength in MRI GANTRY
a given direction  Contains magnets, shim coils, gradient coils
 The only difference between NMR and RF transceiver coils
spectrometer and MR imager  Power supply:
 Functions: o High current power for magnet
o Used to localized MRI signal o Precision power for secondary coils
o Used for slice selection
o Used for encoding the location of CT GANTRY
MRI signal  Contains x-ray tube and detectors
 Power supply: high voltage generator
GRADIENT COILS IMAGING MAGNETS
 Current-carrying coils designed to produce a
desired gradient magnetic field MAGNET
BACK PROJECTION RECONSTRUCTION  Major component of MRI system
 The earliest and easiest to understand
THREE GROUPS
2D FOURIER TRANSFORMATION  Permanent
 Recently used technique  Resistive
 Requires a rigorous mathematical  Superconducting
development
PERMANENT MAGNET
MR EQUIPMENT AND IMAGES  The simplest in design and least expensive
to operate
OPERATING CONSOLE  Material: bricklike ceramics
 Used to control the computer o Inexpensive
 Laser or multiimage camera: used to print o Easy to magnetize
the image o Light weight
 Advantages:
COMPUTER ROOM o Low capital cost
 Houses the electronics o Low operating cost
o For transmitting the radiowave pulse o Negligible fringe file
sequences  Disadvantages:
o For receiving and analyzing the o Limited field strength (0.3 T)
MRI signal o Fixed field strength
 Storage of raw data/computer- o Very heavy
constructed images:
o Computer disk RESISTIVE MAGNET (0.15 T)
 For temporary storage  Magnets have finite resistance
6
 MAGNETIC RESONANCE IMAGING

o Rationale: conductor used in coils is SHIM COILS

not a perfect conductor  30 individual windings
 Can be turned off but requires continuous  For improving the homogeneity of the main
power and water cooling magnetic field
 Uses 4 large coils  Prevent degradation of image quality
 Advantages:  Shimming the magnet: the process
o Low capital cost
o Easy coil maintenance GRADIENT COILS
o Negligible fringe field  Produces gradient magnetic field
 Disadvantages:  3 coils:
o High power consumption o Z gradient coils – for transaxial slice
o Water cooling required o X gradient coils – for coronal slice
o Significant fringe field o Y gradient coils – for sagittal slice
SUPERCONDUCTING MAGNET  Frequency-encoding gradient: X gradient
 A magnet containing coils made from a  Phase-encoding gradient: Y gradient
superconducting metal alloy
 Requires no continuous power source but RF COILS/PROBE
more difficult to maintain  Transceiver coils
 No electrical resistance  Used for transmitting RF signals and/or
 Dewar: a double-walled flask of metal with receiving MR signal
vacuum between the walls  RF probe/Probe Assembly:
 Uses cryogens: o A rigid unit consisting of antenna col
o Cooling agents and support material (plastic, fiber
o Used to optimized superconductivity glass, insulators)
o Liquid nitrogen o Functions:
 97 K  Maintain the coil in its
 Filled in outermost chamber intended shape
o Liquid helium  Protect the coil from damage
 47 K o Location:
 Filled in innermost chamber  Inside the gradient coils
 Advantages:  Closest to the patient
o High field strength (2 T)
o High field homogeinity COILS
o Lower power consumption
 Disadvantages: RF COILS
o High capital cost  Antenna of the MRI system
o High cryogen cost
o Intense fringe field SURFACE COILS
 Simplest design of coil
SECONDARY COILS  Applications: spines, shoulders, TMJs,
small body parts
7
 MAGNETIC RESONANCE IMAGING

 Endocavitary Coil:  Polyvinyl chloride (PVC): structural

o Used for imaging the rectum concrete slab or walls
o Used for imaging the wall of the  Lighting: should be direct current
cavity
 Neurovascular Coil: FARADAY CAGE/RF SHIELD
o Used for imaging the brain and neck  A wire-mesh shield enclosing the MR
imager
PAIRED SADDLE COIL  Used to attenuate extraneous sources of RF
 Commonly used for knee imaging
 Used for X and Y gradient coils FRINGE MAGNETIC FIELD
 Magnetic field outside the patient aperture
 Must be considered in the design of MRI
facility
HELMHOLTZ PAIR COIL  Problems in fringe MF:
 Consists of two circular coils parallel to o Can interfere with the proper
each other operation of mechanical and
 Used for Z gradient coils electronic equipment
 Used as RF coils for pelvis and cervical o Any large mass of ferromagnetic
imaging material can distort the homogeneity
of the imaging volume by interacting
BIRD CAGE COIL with fringe MF
 Provides best RF homogeneity of all the RF  Takenote: distortion of fringe MF by a
coils ferromagnetic object will cause a
 Commonly used as transceiver coil for head compensating distortion of the imaging
imaging volume
 Occasionally used for extremity imaging
MR IMAGES
FACILITY DESIGN
FACTORS INFLUENCING SPATIAL
EXAMINATION ROOM DESIGN RESOLUTION
 Room must be shielded against Effect in Spatial
Factors
Resolution
o Radio interference
Increase slice thickness Low
o Fringe magnetic fields
Decrease slice thickness High
 Only nonmagnetic materials are used for Increase data collection High
the structure and finish Decrease data collection Low
 Must have electric filters Increase MRI signal
High
o Rationale: to remove interfering acquisition
frequencies Decrease MRI signal
Low
 Plumbing: should be PVC or copper acquisition
Increase MRI signal
High
strength
8
 MAGNETIC RESONANCE IMAGING

Decrease MRI signal o Rationale: to minimize the

Low
strength unsharpness caused by involuntary
and voluntary motion
SLICE THICKNESS
 Important in visualization of pathology BIOLOGICAL HAZARDS
 Large slice thickness:
o Provide less grainy images MRI MAGNETIC FIELDS
o Can’t visualize small pathologic  Exhibit threshold dose-response relationship
lesions
 Small slice thickness: THREE PHYSICAL FIELDS THAT MIGHT
o Provide more grainy images SUSPECT OF PRODUCING BIOLOGICAL
o Can visualize small pathologic lesion RESPONSE
1.) Strong static magnetic field (B0)
 Unit: Tesla (T)
CONTRAST RESOLUTION  Affects:
 Low contrast resolution structures o Membrane permeability
 Most tissues: <1% difference o Enzymes kinetics
 MR parameters and biologic tissues: o Nerve conduction
>30% difference 2.) Time-varying gradient magnetic field (B1)
 Gray and white matter: 30-40% difference  Unit: Tesla/second (T/s)
 Null regions: total loss of contrast  Affects:
o Rationale: improper RF pulse o Visual phosphenes
selection o Bone healing
o Cardiac fibrillation
APPEARANCE OF NORMAL TISSUES 3.) RF emission
SPIN  Unit: Watts/kilogram (W/kg)
TISSUES T1 T2
DENSITY  Causes tissue heating
Fat and
High/white Short/white Long/white  Heat: the principal result of the interaction
skin between RF field and tissue
Very Very
Bone Low/black
long/black long/black  Heating: expressed as specific absorption
White rate (SAR)
High/white Short/white Long/gray
matter o Unit: W/kg
Gray
High/white Long/gray Long/gray
matter MAXIMUM PERMISSIBLE DOSE (MPD)
Very Very Very
CSF  Not correct for MRI
high/white long/gray long/black

PHYSICAL HAZARDS
EXAMINATION TIME
 Keep as short as possible
STRONG MAGNETIC FIELDS
 Physical Precautions:

9
 MAGNETIC RESONANCE IMAGING

o Avoid any objects made from metal

or iron inside the examination room GATING
o Patient must be free from metallic  Technique used to organize the signal
objects even internally  Technique used for improving image quality
o Warnings signs are necessary  Used to reduce motion artifacts from the
beating heart
QUENCHING  The moving object is “frozen” at that phase
 The events that occur when the liquid of its motion, reducing image blurring
cryogens that cool the magnet coils boil off
rapidly ARTIFACTS
 Caused:
o Activation of the magnet STOP IMAGE ARTIFACT
button  A structure not normally present but visible
o A fault in the magnet itself as a result of a limitation or malfunction in
 Results the hardware or software of MRI device
o Helium escaping very rapidly from
the cryogen bath
o A loud bang or thundering or hissing MAGIC ANGLE ARTIFACT
or rushing sound with the cold gas Increase of the T2 time;
Description
expulsion bright signal in tendons
o Patient asphyxiation and frostbite Angle about 55o to the
Cause
 If quench does occur: main magnetic field
o RT should evacuate immediately Solution Angle not about 55o
o It takes 72 hrs to ramp magnet up to
full magnetic potential PARTIAL VOLUME ARTIFACT
Loss of contrast between
Description
two adjacent tissues
CONTRAST MEDIA Insufficient resolution
Cause
 Gadolinium-containing compounds Solution Thinner slices
 Gadolinium: a metal with paramagnetic
effect METAL ARTIFACT
o Lower toxicity Magnetic susceptibility
Same as
o Few side effects and clip artifact
 Teslascan: a new manganese-based Description
Signal dropouts; bright
paramagnetic liver contrast agent spots; spatial distortion
o Used in detection, characterization, Cause Field inhomogeneity
Remove the metal; don’t
localization and evaluation of lesions
take a gradient echo
in the liver Solution
sequence; take a short
 Feridex: an iron oxide mixture and the only echo time
supramagnetic contrast agents available
o Used to detect and diagnose liver MOTION ARTIFACT
lesions Same as Phase encoded motion;
10
 MAGNETIC RESONANCE IMAGING

phase effect; instability;

smearing artifacts ALIASING ARTIFACT
Description Blurring and ghosting Backfolding, phase
Movement of the Same as wrapping & wrap
Cause
imaged object around artifacts
Compensation Description Image wrap around
Solution techniques; more Anatomy extends out of
averages; antispasmodic Cause the FOV within the
plane of the image
HERRINGBONE ARTIFACT Large FOV;
RF noise; Interference; Solution oversampling; foldover
Same as suppression
crisscross
Description Static on the image
Electromagnetic ZEBRA STRIPES ARTIFACT
Cause
emissions Same as Zero fill artifact
Shielding; eliminate the Zebra stripes or other
Solution Description
factor of disturbance anomalies
Cause Signal changes
RF OVERFLOW/DATA CLIPPING Surface coil; change the
Solution
ARTIFACT sequence
Description Image non-uniform
Cause Signal too intense ZIPPER ARTIFACT
Manually decrease of Same as Star artifact
Solution
the receiver gain Bands through image
Description
center
SHADY ARTIFACT Hardware or software
Cause
Localized problems
Description inhomogeneous Large FOV;
Solution
brightness oversampling
Cause Various causes
Check correct
Solution positioning; call the -THE END-
service “There are no secrets to success. It is the result of
preparation, hard work learning from failure”
SLICE OVERLAP ARTIFACT 06/18/14
Description Slice overlap
Cause Loss of signal
Solution Saturation

STAIRCASE ARTIFACT
Description Staircase like nuance
Slices too thick; no
Cause
overlapping
Solution Overlapping slices

11
 PATHOLOGY

A. CHEST  EFFECT: difficulty in emptying the lungs of

ASPIRATION air
 A mechanical obstruction
 CAUSED BY: foreign objects are CYSTIC FIBROSIS
swallowed/aspirated into air passages of  Most common inherited diseases
bronchial tree  Secretion of heavy mucus cause progressive
 Most common in small children clogging of bronchi and bronchioles
 TREATMENT: Heimlich maneuver  CAUSED BY: faulty genes in chromosomes
No.7
ATELECTASIS
 Collapse of all or a portion of a lung DYSPNEA
 CAUSED BY: obstruction of the bronchus  A sensation of difficulty in breathing
or puncture or “blowout” of an air  Most common in older persons
passageway  CAUSED BY:
o Physical exertion
BRONCHIECTASIS o Restrictive/obstructive defects within
 Irreversible dilation or widening of bronchi the lungs or airways
or bronchioles o Pulmonary edema
 CAUSED BY: repeated pulmonary infection
or obstruction EMPHYSEMA
 EFFECTS:  Irreversible and chronic lung disease
o Increased mucous production  Air spaces in the alveoli become greatly
o Coughing up sputum enlarge
 CAUSED BY:
BRONCHITIS o Smoking
 Excessive mucous secretion into the bronchi o Long-term dust inhalation
 CAUSED BY: cigarette smoking  RESULTS:
 EFFECTS: o Alveolar wall destruction
o Cough o Loss of alveolar elasticity
o Shortness of breath  EFFECTS:
o Seriously labored breathing
CHRONIC OBSTRUCTIVE PULMONARY o Serious impedance of gas exchange
DISEASE (COPD) within the lungs
 A persistent obstruction of the airways
 CAUSED BY: PLEURAL EFFUSION/HYDROTHORAX
o Smoking  Abnormal accumulation of fluid in the
o Emphysema pleural cavity
o Chronic bronchitis  TYPES: empyema and hemothorax

1
 PATHOLOGY

EMPYEMA  CAUSED BY: Streptococcus pneumonia

 Accumulation of pus in the pleural cavity
 CAUSED BY: VIRAL/INTERSTITIAL PNEUMONIA
o Chest wounds  Inflammation of the alveoli and connecting
o Obstruction of bronchi lung structures
o Ruptured lung abscess
o Pneumonia PNEUMOTHORAX
 Accumulation of air in the pleural space
HEMOTHORAX  CAUSED BY:
 Accumulation of blood in the pleural cavity o Trauma
 CAUSED BY: trauma/injury o Pathologic conditions
 EFFECTS:
PLURISY o Partial or complete collapse of lungs
 Inflammation of the pleura surrounding the o Severe shortness of breath
lungs o Chest pain
 CAUSED BY:
o Virus or bacterium PULMONARY EDEMA
o Visceral and parietal pleura  Excess fluid in the lungs
“rubbing” during respiration  CAUSED BY: coronary artery disease
o Pneumonia
o Trauma to the chest RESPIRATORY DISTRESS SYNDROME
 EFFECT: severe pain  Hyaline Membrane Disease in infant
 Adult Respiratory Distress Syndrome in
PNEUMONIA/PNEUMONITIS adult
 Inflammation of the lungs  The alveoli and capillaries of the lung are
 TYPES: aspiration pneumonia, injured or infected
bronchopneumonia, lobar pneumonia and  CAUSED BY:
viral/visceral pneumonia o Lack of lung development
 EFFECT:
ASPIRATION PNEUMONIA o Leakage in fluid and blood into the
 CAUSED BY: aspiration of foreign objects spaces between alveoli
or food in the lungs
 RESULT: irritation of the bronchi TUBERCULOSIS
 EFFECT: edema  A contagious disease
 CAUSED BY: Mycobacterium tuberculosis
BRONCHOPNEUMONIA  TYPES: primary and reactivation/secondary
 CAUSED BY: Streptococcus or
Staphylococcus bacteria PRIMARY TUBERCULOSIS
 It occurs in persons who have never had the
LOBAR PNEUMONIA disease before
 Confined to one or two lobes of the lungs
2
 PATHOLOGY

 INDICATORS: DYNAMIC (with power or force)/MECHANICAL

o Hilar enlargement BOWEL OBSTRUCTION
o Enlarged mediastinal lymph nodes  Complete or nearly complete blockage of
the flow of intestinal contents
REACTIVATION/SECONDARY  EFFECTS:
TUBERCULOSIS o Fibrous adhesions
 Develops in adult  Fibrous band of tissue
 INDICATORS: interrelates with the intestine,
o Irregular calcification in the upper creating a blockage
lobes bilaterally  Most common cause of
o Upward retraction of the hila mechanical obstruction
o Crohn’s disease
OCCUPATIONAL LUNG DISEASE  Chronic inflammation of
ANTHRACOSIS intestinal wall
 Black lung pneumoconiosis  CAUSE: unknown
 CAUSED BY: deposits of coal dust  EFFECT: bowel obstruction
 Most common in young
ASBESTOSIS adults
 CAUSED BY: inhalation of asbestos dust o Intussusception
(fibers)  Telescoping of a section of
 EFFECT: pulmonary fibrosis bowel into another loop
 Most common in ileum
SILICOSIS  Most common in children
 CAUSED BY: inhalation of silica (quartz) o Volvulus
dust  Twisting of a loop of
intestine
B. ABDOMEN  TREATMENT: surgery
ASCITES
ILEUS
 Abnormal accumulation of fluid in the
peritoneal cavity  Non-mechanical bowel obstruction
 CAUSED BY:  TYPES:
o Cirrhosis of the liver o Adynamic Ileus
o Metastatic disease to the peritoneal  Without power or force
cavity  CAUSED BY: peritonitis
o Paralytic Ileus
PNEUMOPERITONEUM  Paralysis
 CAUSED BY: lack of
 Free air or gas in the peritoneal cavity
intestinal motility
 CAUSED BY:
 Most common in postoperative patients
o Gastric or duodenal ulcer
o Trauma

3
 PATHOLOGY

ULCERATIVE COLITIS COLLE’S FRACTURE

 Chronic disease involving inflammation of  Transverse fracture of distal radius with
the colon posterior displacement
 Most common in young adults
 Most frequently involves rectosigmoid colon SMITH’S FRACTURE
 Reverse Colle’s Fracture
C. UPPERLIMB  Transverse fracture of distal radius with
BONE METASTASES anterior displacement
 Transfer of disease or cancerous lesion from
one organ or part JOINT EFFUSION
 Most common bone malignant tumors  Accumulation of fluid in the joint cavity
 CAUSED BY:
BURSITIS o Fracture
 Inflammation of the bursae o Dislocation
 EFFECTS: o Soft tissue damage
o Pain o Inflammation
o Limited joint movement
OSTEOARTHRITIS
CARPAL TUNNEL SYNDROME  Degenerative Joint Disease
 Common painful disorder of the wrist and  Noninflammatory joint disease characterized
hand by gradual deterioration of articular cartilage
 CAUSED BY: compression of the median  Most common type of arthritis
nerve
 Most commonly in middle-aged women OSTEOMYELITIS
 Local or generalized infection of bone or
FRACTURES bone marrow
 Break in the structure of bone  CAUSED BY:
 CAUSED BY: direct or indirect force o Bacteria introduced by trauma or
surgery
BARTON’S FRACTURE o Diabetic foot ulcer
 Fracture and dislocation of posterior lip of
distal radius OSTEOPETROSIS
 Hereditary diseased marked by abnormally
BENNETT’S FRACTURE dense bone
 Fracture of the base of the first metacarpal  CAUSED BY: fracture of affected bone
bone
OSTEOPOROSIS
BOXER’S FRACTURE  Reduction in the quantity of bone or atrophy
 Transverse fracture of the fifth metacarpal of skeletal tissue
neck  Most common in postmenopausal women
and elderly men
4
 PATHOLOGY

PAGET’S DISEASE BENIGN BONE/CARTILIGINOUS TUMORS

 Osteitis Deformans ENCHONDROMA
 Most common chronic skeletal diseases  Slow-growing benign cartilaginous tumor
 CAUSE: unknown  Most commonly found in small bones of the
 Most common in men older than age 40 hand and feet of adolescents and young
adults
RHEUMATOID ARTHRITIS
 Chronic systemic disease with inflammatory OSTEOCHONDROMA/EXOSTOSIS
changes throughout the body’s connective  Most common type of benign bone tumor
tissue  Most common in persons aged 10-20 years
 Most common in women  Most common at the knee

SKIER’S THUMB D. HUMERUS AND SHOULDER

 Sprain or tear in the ulnar collateral ligament ACROMIOCLAVICULAR JOINT SEPARATION
of the thumb  Partial or complete tear of the AC and/or
 CAUSED BY: injury coracoclavicular ligaments
 CAUSED BY: trauma to upper shoulder
MALIGNANT BONE TUMORS region
MULTIPLE MYELOMA
 Tumors that occur in various parts of the ACROMIOCLAVICULAR DISLOCATION
body, arising from bone marrow or marrow  Superior displacement of distal clavicle
plasma cells  CAUSED BY: fall
 Most common of the primary cancerous
bone tumors BANKART LESION
 an injury of the anteroinferior aspect of the
OSTEOGENIC SARCOMA/OSTEOSARCOMA glenoid labrum
 The second most common type of primary  CAUSED BY: anterior dislocation of the
cancerous bone tumor proximal humerus
 Most common in persons aged 10-20 years
 May develop in older persons with Paget’s BURSITIS
disease  Inflammation of the bursae

EWING’S SARCOMA HILL-SACHS DEFECT

 A common primary malignant bone tumor  A compression fracture of the articular
 Most common in children and young adults surface of the posterolateral aspect of the
humeral head
CHONDROSARCOMA  CAUSED BY: anterior dislocation of
 A slow-growing malignant tumor of the humeral head
cartilage

5
 PATHOLOGY

IDIOPATHIC CHRONIC ADHESIVE ENCHONDROMA

CAPSULITIS/FROZEN SHOULDER  Slow-growing benign cartilaginous tumor
 A disability of the shoulder joint  Most often in small bones of the hands and
 CAUSED BY: chronic inflammation in or feet in adolescents and young adults
around the joint
EWING’S SARCOMA
IMPINGEMENT SYNDROME  Common primary malignant bone tumor
 Impingement of the greater tuberosity and  Most common in children and young adults
on the coracoacromial ligamentous and  SYMPTOMS: low-grade fever and pain
osseous arch
EXOSTOSIS/OSTEOCHONDROMA
SUPRASPINATUS MUSCLE IMPINGEMENT  Benign, neoplastic bone lesion
 Most common injury of the rotator cuff  CAUSED BY: consolidated overproduction
 CAUSED BY: subacromial bone spur of bone at a joint

SHOULDER DISLOCATION GOUT

 Traumatic removal of humeral head from  A form of arthritis
the glenoid cavity  Excessive uric acid in the blood
 Common initial attacks occur in the first
TENDONITIS MTP joint
 Inflammation condition in the tendon  Most common in men

F. LOWER LIMB LISFRANC JOINT INJURY

BONE CYST  Sprains or dislocations-fractures of the bases
 Benign, neoplastic bone lesions filled with of the first and second metatarsals
clear fluid  CAUSED BY:
 Most common near the knee joint in o Motor vehicle crashes
children and adolescence o Twisting falls
o Falls from high places

CHONDROMALACIA PATELLAE/RUNNER’S MULTIPLE MYELOMA

KNEE  Tumor arises from the bone marrow or
 Softening of the cartilage under the patella marrow plasma cells
 Most common in cyclists and runners  Most common type of primary cancerous
bone tumor
CHONDROSARCOMAS
 Malignant tumors of the cartilage OSGOOD-SCHLATTER DISEASE
 Most common in the pelvis and long bones  Inflammation of the bone and cartilage of
of men older than 45 years the anterior proximal tibia
 Most common in boys ages 10-15

6
 PATHOLOGY

 CAUSED BY: large patellar tendon AVULSION/EVULSION FRACTURES OF THE

detaches part of the tibial tuberosity PELVIS
 Fractures experience after a sudden, forceful
OSTEOCLASTOMAS/GIANT CELL TUMORS or unbalanced contraction of the tendinous
 Benign lesions that occur in the proximal and muscular attachment
tibia or distal femur after epiphyseal closure  Most common in athlete adolescents
 Typically occur in the long bones of young
adults DEVELOPMENT DYSPLASIA OF THE
HIP/CONGENITAL DISLOCATION OF THE HIP
OSTEOID OSTEOMAS  CAUSED BY: conditions present at birth
 Benign bone lesions
 Most common in teenagers or young adults LEGG-CALVE-PERTHES DISEASE
 SYMPTOMS: localized pain that typically  Most common type of aseptic or ischemic
worsens at night necrosis
 Lesions typically involve one hip (head and
OSTEOMALACIA/RICKETS neck of femur)
 Bone softening  Most common in boys ages 5-10 years
 CAUSED BY: deficiency of calcium,
phosphorus and/or vitamin D PELVIC RING FRACTURES
 Rickets in children  CAUSED BY: severe blow or trauma to one
 Osteomalacia in adults side of the pelvis
 RESULT: fracture site away from the site of
REITER SYNDROME primary trauma
 Bony erosion at the Achilles tendon
insertion on the posterosuperior margin of PROXIMAL FEMUR (HIP) FRACTURES
the calcaneus  CAUSED BY: weakening or collapse of
 Affects the sacroiliac joints and lower limbs weight-bearing joints
of young men  Most common in older adults or geriatric
 CHARACTERISTIC: arthritis, urethritis and patients with osteoporosis or avascular
conjunctivitis necrosis
 CAUSED BY:
o Infection of the GI tract SLIPPED CAPITAL FEMORAL EPIPHYSIS
o Sexually transmitted disease  Epiphysis appears shorter and the epiphyseal
plate wider with smaller margins
G. FEMUR AND PELVIC GIRDLE  Most common in persons ages 10-16 years
ANKYLOSING SPONDYLITIS
 Rheumatoid arthritis variant involving the H. CERVICAL AND THORACIC SPINE
sacroiliac joints and spine CLAY SHOVELER’S FRACTURE
 Most common in males  Avulsion fractures on the spinous processes
of C6 through T1
 CAUSED BY: hyperflexion of the neck
7
 PATHOLOGY

KYPHOSIS
COMPRESSION FRACTURE  Abnormal or exaggerated convex curvature
 Collapse of the anterior edge of the vertebral of the thoracic spine
body, changing its shape into a wedge  CAUSED BY: compression fractures of the
instead of block anterior edges of the vertebral bodies in
 CAUSED BY: osteoporotic patients
o Osteoporosis  RESULTS:
o Severe kyphosis caused by other o Stooped posture
diseases o Reduced height
o Injury of the spinal cord
LORDOSIS
HANGMAN’S FRACTURE  Abnormal or exaggerated concave lumbar
 Fracture extends through pedicles of C2 curvature
with or without subluxation of C2 upon C3  CAUSED BY:
 CAUSED BY: extreme hyperextension of o Pregnancy
the neck o Obesity
o Poor posture
JEFFERSON’S FRACTURE o Rickets or tuberculosis of the spine
 Comminuted fracture of anterior and
posterior arches of C1 SCOLIOSIS
 CAUSED BY:  Abnormal or exaggerated lateral curvature
o Landing on one’s head of the spine
o Landing on one’s feet  Most common in children ages 10-14 years
 Most common in girls
ODONTOID FRACTURE
 Fracture involving the dens and can extend SCHEUERMANN’S DISEASE
into the lateral masses or arches of C1  Osteochondritis involving one or more of
the verterbrae
TEARDROP BURST FRACTURE  RESULTS IN: abnormal spine curvature of
 Compression with hyperflexion in the kyphosis and scoliosis
cervical region  Most common in boys

HERNIATED NUCLEUS PULPOSUS TRANSITIONAL VERTEBRA

 Herniated lumbar disc/Slipped disk  Vertebra takes on a characteristic of the
 CAUSED BY: protrusion of nucleus adjacent region of the spine
pulposus (soft inner part) of an invertebral  Most often occurs in the lumbosacral region
disk through the annulus (fibrous cartilage  It also involves the cervical and lumbar ribs
outer layer) in the spinal canal

8
 PATHOLOGY

I. LUMBAR, SACRUM AND COCCYX  CAUSED BY:

CHANCE FRACTURE o Blunt trauma
 Fracture through the vertebral body and o Pulmonary injury
posterior elements (spinous processes,
pedicles, facets, transverse processes) STERNAL FRACTURE
 CAUSED BY: hyperflexion force  CAUSED BY: blunt trauma
METASTASES
 Primary malignant neoplasms that spread to CONGENITAL ANOMALIES
distant sites via blood and lymphatics PECTUS CARINATUM
 Pigeon breast
SPINA BIFIDA  Anterior protrusion of the lower sternum and
 Congenital condition in which posterior xiphoid process
aspects of the vertebrae fail to develop
 Most often at L5 PECTUS EXCAVATUM
 Funnel chest
SPONDYLOLISTHESIS  Characterized by a depressed sternum
 Forward movement of one vertebra in
relation to another K. SKULL
 CAUSED BY: SKULL FRACTURE
o Developmental defect in the pars  Disruptions in the discontinuity of bones of
interarticularis the skull
o Spondylolysis
o Severe osteoarthritis LINEAR FRACTURE
 It appears as jagged or irregular lucent lines
SPONDYLOLYSIS that lie at right angles to the axis of the bone
 Dissolution of a vertebra
 CAUSED BY: DEPRESSED FRACTURE
o Aplasia (lack of development) of the  Ping-pong fracture
vertebral arch  A fragment of bone that is separated and
o Separation of the pars interarticularis depressed into the cranial cavity
 Most common at L4 or L5
BASAL SKULL FRACTURE
J: BONY THORAX– STERNUM AND RIBS  Fracture through the dense inner structures
RIB FRACTURE of the temporal bone
 CAUSED BY:
o Trauma MULTIPLE MYELOMA
o Underlying pathology  It consists of one or more tumors that
originate in the bone marrow
FLAIL CHEST  Skull is the common site
 Fracture of the adjacent ribs into two or
more places
9
 PATHOLOGY

PITUITARY ADENOMAS
 Tumors of the pituitary gland
 FINDINGS:
o Enlargement of the sella turcica
o Erosion of the dorsum sellae

MASTOIDITIS
 Bacterial infection of the mastoid process
 Mastoid air cells are replaced with a fluid-
filled abscess
 RESULTS IN: hearing loss

ACOUSTIC NEUROMA
 Benign tumor of the auditory nerve sheath
originates in the internal auditory canal
 SYMPTOMS:
o Hearing loss
o Dizziness
o Loss of balance

CHOLESTEATOMA
 Benign cyst-like mass or tumor
 Most common in the middle ear or mastoid
region

POLYP
 Growth arises from a mucous membrane and
projects into a cavity
 CAUSES: chronic sinusitis

OTOSCLEROSIS
 Hereditary disease involving excessive
spongy bone formation of the middle and
inner ear
 Most common cause of hearing loss in
adults without ear drum damage

-THE END-
“Board Exam is a matter of preparation. If you
FAIL to prepare, you PREPARE to fail”
05/25/14
10
Radiation Therapy/ Radiation Oncology
-medical use of ionizing radiation as part of cancer treatment
-treatment of malignant cancer and may be used as the primary therapy or common to combine with
surgery, chemotherapy, hormone therapy or three.
- To kill a malignant tumor or to render them permanently incapable of further cell division.

RADIATION ONCOLOGY TEAM

1. Radiation Oncologist – Doctor of medicine specializing in use of ionizing radiation in the

treatment of disease.
- Makes most of the decision regarding the cancer patient’s treatment.
- Prescribes the quantity of radiation and determines the anatomic regions to
be treated
2. Medical Physicist – responsible for calibration and maintenance of the radiation-producing
equipment.
- Advises the physician about dosage calculations and complex treatment
techniques.
3. Medical Dosimetrist – devises a plan for delivering the treatments in a manner to best meet the
physician’s goals of irradiating the tumor while protecting vital normal structures.
4. Radiation Therapist – Responsible for obtaining radiographs or CT scans that localize the area to
be treated, administering the treatments, keeping accurate records of the dose delivered each
day, and monitoring the patient’s physical well-being.
 Educating Patients about potential radiation side effects and assisting patients with the
management of these side effects are often the responsibilities of the Oncology Nurse.

TYPES OF TREATMENT INTENT

1. CURATIVE TREATMENT
a. Adjuvant – (Additive) given to destroy left-over microscopic cells that may
be present after the known tumor is removed by surgery.
 Is given to prevent a possible cancer reoccurrence.
b. Neo Adjuvant – (primary) given prior to the surgical procedure.
 may be given to attempt to shrink the cancer so that the
surgical procedure may not need to be as extensive.
2. PROPHYLACTIC TREATMENT – (Preventive) to shrink any cancerous tumors and/or stop the
cancer from growing and spreading.
3. PALLIATIVE TREATMENT – may be used to relieve symptoms caused by the cancer at an
advance stage, extends the quality of life of the patient.

TYPES OF CANCER TREATMENT

1. SURGERY – used for small tumors.

2. CHEMOTHERAPY – uses drug. Prevents cancer cell production.
3. BIOLOGIC THERAPY – immunotherapy
4. HORMONE THERAPY – prevent of release of hormones consumed by cancer cells.
5. HYPERTHERMIA – least used
6. RADIATION THERAPY –

SUMMARIZED BY: MINZHU YAP, RXT, RRT

 FACTORS FOR TREATMENT

1. TUMOR TYPE
2. TUMOR LOCATION
3. STAGE
4. GENERAL HEALTH OF THE PATIENT

CANCER – a malignant tumor that expands by invasion or systemically by metastasis.

- A disease process that involves an unregulated, uncontrolled replication of cells.

METASTASIS – spread of cancer from primary tumor to sites elsewhere in the body.

THREE PATHWAYS OF MALIGNANT NEOPLASM

1. SEEDING - The spread of a malignancy into body cavities can occur via penetrating the surface of
the peritoneal, pleural, pericardial, or subarachnoid spaces.
2. LYMPHATIC SPREAD - Lymphatic spread allows the transport of tumor cells to lymph nodes and
ultimately, to other parts of the body. This is the most common route of metastasis
for carcinomas.
3. HEMATOGENOUS SPREAD - This is typical route of metastasis for sarcomas, but it is also the
favored route for certain types of carcinoma, such as those originating in the kidney (renal cell
carcinoma). Because of their thinner walls, veins are more frequently invaded than are arteries,
and metastasis tends to follow the pattern of venous flow.

REMISSION - Stage or period of absence of cancer.

TYPES OF REMISSION
1. COMPLETE REMISSION – all signs and symptoms of Ca are gone.
2. PARTIAL REMISSION – the malignant tumor shrunk, but does not disappear.

 CURED – FREE OF SIGNS AND SYMPTOMS FOR FIVE (5) YEARS.

 SECOND PRIMARY CANCER – PATIENT IS DIAGNOSED WITH NEW CANCER THAT’S COMPLETELY
UNRELATED WITH THE PREVIOUS CANCER.

RECURRENCE - return of cancer after treatment and after a period of time during which the cancer
cannot be detected.

TYPES OF RECURRENCE
1. LOCAL – Ca returns at the original site.
2. REGIONAL - Ca returns at a lymph node or tissue located near the previous Ca.
3. DISTANT – at a farther site.

3 MAJOR SUBTYPES OF CANCER

1. CARCINOMA – originating from epithelial tissue.

2. SARCOMA – originating from connective tissue.
3. LYPHOMA – involves blood forming tissue.

SUMMARIZED BY: MINZHU YAP, RXT, RRT

CANCER RISK FACTORS
1. EXTERNAL
 EXPOSURE TO CHEMICALS
 VIRUSES
 IONIZING RADIATION
2. INTERNAL
 HORMONES
 GENETIC MUTATTION
 DISORDERS OF THE IMMUNE SYSTEM

GENERAL CANCER SYMPTOMS

 UNEXPECTED WEIGHT LOSS – about 10 lbs.
 FEVER
 FATIGUE
 PAIN
 SKIN CHANGES
 CHANGE IN BOWEL/BLADDER FUNCTION
 UNHEALING SORE

BIOPSY - medical removal of tissue from living subject to determine presence or extent of disease.

TYPES OF BIOPSY
1. SURGICAL – a surgical procedure done at the o.r.
2. EXCISIONAL – entire lump removed
3. INCISIONAL – small sample tissue
4. FINE NEEDLE ASPIRATION – sample fluid
5. CORE NEEDLE – small solid sample

CLASSIFICATION OF TUMOR
 GRADING
 STAGING
 TNM SYSTEM
T – tumor
N – has spread to NODES
M – meT1Ntastasis, has spread to other organs.

CLASSIFICATION DESCRIPTION OF TUMOR

STAGE 0,
Occult lesion; no evidence clinically
T0N0M0
STAGE I, Small lesion confined to organ of origin with no evidence of vascular or lymphatic
T1N0M0 spread or metastasis
STAGE II, Tumor of less than 5cm. invading surrounding tissue and first-station lymph nodes
T2N1M0 but no evidence of metastasis
STAGE III, Extensive lesion greater than 5cm. with fixation to deeper structure and with bone
T3N2M0 and lymph invasion but no evidence of metastasis
STAGE IV,
More extensive lesion than above or with distant metastasis.
T4N3M1

SUMMARIZED BY: MINZHU YAP, RXT, RRT

TUMOR LOCALIZATION SIMULATION

STEP 1. PATIENT IMMOBILIZATION

STEP 2. TUMOR TARGET VOLUME CENTER (ISOCENTRIC DEFINITION)
STEP 3. COMPUTE PLANNING AND TREATMENT DELIVERY
STEP 4. PLANNING IMPORTANT TREATMENT ACTION VERIFICATION

 TREATMENT PLANNING – determines the volume of tissue that needs to be encompassed

within the radiation field.

IMMOBILIZATION DEVICES
1. THERMOPLASTIC MASK – (HEAD)made up of thermoplastic. When heated and placed on
patient, molds in shape.
2. ALPHA CRADLE – (HEAD AND EXTREMETIES) made of 2 chemicals that can be mixed together
to form a styro-like material that may take shape of the patient.

THREE TYPES OF RADIATION THERAPY

1. EBRT,XBRT OR TELETHERAPY
– for external beam treatment, the patient lies underneath machine that emits
radiation or generates a beam of x-rays
- long distance treatment

a. Superficial Machine – treating lesions on or near the surface of the skin.

- 50-70 cm. SSD
- 50-120 kVp
b. Orthovoltage – moderately superficial tissues
- 50-70 cm. SSD
- 250 kVp
c. Betatron – electron accelerator that uses magnetic induction to accelerate electrons in circular
path; also capable of producing photons.
- By Kerst in 1941
d. Cobalt 60 – artificially produced isotope formed in a nuclear reactor
- 1st skin-sparring machine80cm.
- Replaced orthovoltage in 1950’s
- SSD AT
- Unit known as “work horse”
- 1st RadThera unit to rotate 360° around a patient
- From Cobalt 59
- Emits two gamma ray beams with 1.17 and 1.33 MeV
e. Linac - accelerates electron in a straight line or linear path
- By Widroe in1925
- SSD AT 100cm.

SUMMARIZED BY: MINZHU YAP, RXT, RRT

 Types of treatment for LinAc

 2DXRT – Conventional External Beam RadioTherapy

 3DCRT – 3 Dimensional Conformal RadioTherapy
- Multi-leaf collimator
- Cerrobend blocks – fixed heavy custom made wedge filter dedicated for
each patient.
 4DXRT (IGRT) – Image-guided real time RadioTherapy
 IMRT – Intensity Modulation RadioTherapy
 STEREOTACTIC RADIOSURGERY – gamma knifes
 PARTICLE THERAPY –

2. BRACHYTHERAPY (SEALED SOURCE)

- A technique in which the radioactive material is placed within the patient.

Types of BrachyTherapy

 Mould Technique – placement of Radioactive source on or in close proximity to the lesion

 Intracavitary – Placement of Radioactive source in a body cavity
 Interstitial – Placement of Radioactive directly into the tumor site and adjacent tissue.

Two Brachytherapy Systems

 LDR (Low Dose Rate)

- 40-500 cGy/hr.
- 3-4 days
 HDR (High Dose Rate)
- Greater than 1200 cGy/hr.
- 10-20 mins.

3. SYSTEMIC RADIOISOTOPE THERAPY (UNSEALED SOURCE)

- Delivered through infusion
- Or ingestion

CLINICAL APPLICATIONS

1. LARYNGEAL CANCER
- Megavoltage radiation
- 6300 t0 6500 cGy over a 6-week period
- Delivered thru 5x5 or 6x6 opposed lateral fields
- Cobalt 60 4MV Photons
2. EPIGLOTTIS
- 120-125 cGy BID

SUMMARIZED BY: MINZHU YAP, RXT, RRT

 - Post op: 4000-4500 cGy

3. SUBGLOTTIS
- 4500 cGy
4. SKIN CANCER
- Superficial radiation
- 4000-5000 cGy in a 3-4 weeks period
- 2-3 cm. in size
5. MEDULLOBLASTOMA
- 4500 cGy (brain)
- 3500-4500 cgY (spinal cord)
6. LUNG CANCER
- 5000-6000 CgY OF 10 MeV
7. PROSTATE
- Megavoltage beam of 10 MV
- 7600 cGy
8. ORAL CAVITY
- 6000 cGy in 4weeks
- orthovoltage
9. CERVICAL
- 4500-5000 cGy in 5 weeks.
10. HODGKIN’S DISEASE
- 3000-4000 cGy
- megavoltage
11. BREAST
- 5000 cGy in 5 weeks

 Hotspot – an area of excessive radiation dose.

SUMMARIZED BY: MINZHU YAP, RXT, RRT