4
CHAPTER
Multidetector
Computed Tomography
Ashley S. Shaw and Adrian K. Dixon
Computed tomography: a brief history
Technical overview of MDCT
Image reconstruction and analysis
Clinical applications of MDCT
Whole body MDCT in asymptomatic adults
Radiation dose considerations
Radiotherapy
Future directions
COMPUTED TOMOGRAPHY: A BRIEF HISTORY
The first CT machine used for clinical purposes, developed
by the late Sir Godfrey Hounsfield, was installed at the Atkin-
son Morley Hospital, London, in the early 1970s1. Each axial
image of the head took several minutes to acquire and days to
reconstruct at the EMI laboratories. Over the next decade, CT
machines became faster as the processing power of comput-
ers improved. In the mid-1980s, the development of slip-ring
technology enabled continuous revolution of the X-ray unit,
which reduced the acquisition time and allowed helical data to
be acquired2. Since the late 1990s, the focus of development has
been on reducing the size of the detectors in order that they
could be arranged in multiple rows along the z-axis.This permits
the acquisition of multiple slices simultaneously, thus reducing
acquisition time yet further. At the time of writing, state of the
art CT systems have up to 64 rows of detectors, allowing up to
4 cm to be imaged per revolution, a revolution time around 0.4 s,
and with a resolution of approximately 0.4 mm.
TECHNICAL OVERVIEW OF MDCT
Before multidetector CT, imaging protocols and patient
throughput were frequently limited by the time taken for the
tube to cool between exposures. Refinements in tube design
now ensure that multiple phases of imaging can be performed
without overheating, as the tube cools faster than the through-
put of patients. These design improvements also allow increas-
ingly complex studies of small structures, which require the
focal spot to be kept to an absolute minimum even when the
mA is increased. For example, one manufacturer offers a focal
spot measuring 0.60.9 mm, depending on the mA used.
The X-rays are detected by various forms of detector. A
ceramic scintillator, for example, absorbs the X-rays and pro-
duces visible light. This stimulates a photodiode to produce an
electrical signal from which the image can be constructed. In
order to reach the spatial resolution, detectors have become
smaller (typically around 0.6 mm), more sensitive (allowing
some dose reduction) and react faster (allowing increased gan-
try rotation speeds). In short, the smaller each detector is, the
smaller the possible collimation, whereas the wider the bank of
detectors, the greater the potential coverage per rotation. Some
manufacturers arrange detectors of varying width such that
the smallest are positioned centrally and the largest positioned
peripherally, whereas others use identically sized detectors
across the array.The majority of machines in use are characterized
by the number of detectors (e.g. 16-, 40- or 64-slice) and use a
single focal spot on the tube. By contrast, one 64-slice machine
has a 32-detector array with two rapidly alternating focal spots
in the tube. In effect, this produces overlapping projections that
are acquired and processed simultaneously.
The end result of these advances is that the latest technology
from all manufacturers is able to produce isotropic images with
sub-mm resolution in all planes with ever-increasing rapidity.
IMAGE RECONSTRUCTION AND ANALYSIS
The rapid acquisition of such large datasets has necessitated
a change in radiologists approach to CT reporting. As a bare
minimum, both thick and thin section axial images should be
produced and stored. Images need to be viewedwon a worksta-
tion capable of producing images in all planes, with the ability
to change window level and width.
When viewing images, our experience has shown that, in
addition to standard lung or soft tissue windows, review of the
data on bone windows (preferably in the sagittal plane) often
demonstrates unsuspected abnormalities (Fig. 4.1).The optimal
80 SECTION 1 IMAGING TECHNIQUES AND GENERAL ISSUES

slice thickness will depend on the clinical question posed.

Figure 4.1 Sagittal MPR imaged on bone windows, demonstrating
multiple sclerotic lesions throughout the vertebrae in a patient presenting
with lymphoma.
Cardiac imaging, for example, will require sub-mm images,
whereas renal calculi will be reliably visualized on images
up to 3 mm thick, and the detection of lung nodules can be
enhanced by scrolling through overlapping 10 mm images
(allowing differentiation from branching blood vessels).
For 3D viewing of datasets, there are four principal post-
processing techniques: multiplanar reconstructions (MPR),
maximum intensity projection (MIP), surface shaded display
(SSD) and volume rendered (VR) images (Fig. 4.2). MPR
and associated curved planar reconstruction (CPR)simply
allows the image to be viewed in any plane chosen, including
a curved plane with CPR (Fig. 4.3). MIP displays the highest
attenuation voxels in an image only, thus allowing visualization
of structures (usually vessels) not in a single plane. However,
visualization of arterial wall calcification can be difficult and
vessels near to bony structures may be obscured. SSD gives 3D
representations of the anatomy in grey scale, but is prone to
noise and artefacts. VR allows visualization of the vessels dis-
tinct from the surrounding anatomy and is of particular value
in cerebral angiography, where the vessels pass through and lie
in close proximity to the skull base.
Computer aided detection (CAD) of lung nodules is
currently under development by a number of groups. Prelimi-
nary results indicate that, while more nodules can be detected,

Figure 4.2 (A) Coronal MPR demonstrating renal cell carcinoma at the lower pole of the left kidney extending to the hilum. (B) Coronal MIP
demonstrating renal cell carcinoma at the lower pole of the left kidney extending to the hilum. (C) Coronal SSD demonstrating renal cell carcinoma at
the lower pole of the left kidney extending to the hilum. (D) Coronal VR demonstrating renal cell carcinoma at the lower pole of the left kidney extending
to the hilum.
 CHAPTER 4 MULTIDETECTOR COMPUTED TOMOGRAPHY 81

Dynamic perfusion CT (PCT)5 evaluates regional blood

flow within the brain by serially imaging a limited area follow-
ing the infusion of intravenous contrast medium.The resulting
images give a computerized map of relative cerebral blood
flow, mean transit time and cerebral blood volumes, albeit
with limited coverage of the brain (Fig. 4.4)6. In the context
of patients presenting with acute stroke, PCT is significantly
more accurate than non-enhanced CT in detecting stroke

Figure 4.3 CPR demonstrating a normal calibre right coronary

artery.

there is a significant rise in the number of false-positive

nodules. Although not current routine clinical practice, CAD
may become a useful prompt in the evaluation of resectable
metastases and on lung cancer screening programmes (should
they prove to be of clinical value).

CLINICAL APPLICATIONS OF MDCT

Neuroradiology
In many areas, CT has been superseded by magnetic resonance
imaging (MRI) for the evaluation of neurological disease as
it gives superior differentiation of the soft tissues. However,
CT remains the initial imaging investigation for many patients,
particularly those presenting following trauma or with acute
neurological syndromes.
Digital subtraction angiography (DSA) has long been
regarded as the gold standard for detection of an intracranial
aneurysm. Single row detector helical CT could not acquire
data sufficiently quickly to obtain reliable diagnostic angio-
graphic studies. MDCT has been shown to be highly accurate
in the detection of aneurysms, with a sensitivity of over
96% and specificity of 100% on a 16-detector row ma-
chine, identical to the DSA results3. Even for small aneu-
rysms (< 3 mm), sensitivity remained over 90%. This has led
to a significant change in neuroradiological and neurosurgical
practice, enabling treatment to be planned from 3D images at
a workstation, with a consequent reduction in the number of
diagnostic angiograms performed. Furthermore, it is now pos-
sible to perform multiple phases of vascular imaging within
Figure 4.4 (A) Unenhanced CT of the head in a patient presenting
the brain, obtaining both an arterial and a venous phase4. with acute aphasia. (B) Cerebral perfusion map demonstrating delayed
This may provide additional information in patients with an perfusion in the left middle cerebral artery territory. Images courtesy of
arteriovenous malformation, but needs further evaluation. Rosie Farmer, Addenbrookes Hospital, Cambridge, UK.
82 SECTION 1 IMAGING TECHNIQUES AND GENERAL ISSUES

(7586% versus 66%), the extent of stroke (94% versus 43%),

and has a high interobserver agreement7. This may prove to be
of clinical use in those patients in whom thrombolysis or other
novel therapies are being considered. Potentially, the technique
can differentiate the ischaemic penumbra from infarcted tissue,
identifying patients who would benefit from revascularization
and those in whom unnecessary treatment could be avoided.
The data obtained from this technique are very similar to that
obtained with perfusion and diffusion-weighted MRI but CT
is considerably easier in the acute situation. It is likely that
routine clinical use will be guided by developments in therapy
for acute stroke. Similarly, the use of perfusion CT follow-
ing severe head trauma has been reported to yield indepen-
dent prognostic information regarding functional outcome8,
although again this is not part of current routine clinical prac-
tice.

Cardiac
The rapid acquisition times and increased spatial resolution of
MDCT probably holds the greatest potential for cardiac imag-
ing. Imaging of the coronary arteries with CT has two major
components: unenhanced coronary artery calcium scoring
and contrast-enhanced coronary artery angiography. Elec-
tron-beam CT (EBCT) has been used for coronary calcium
scoring for approximately two decades and is a highly sensitive
method of detecting coronary artery atherosclerosis. A number
of authors have shown there to be a high correlation between
EBCT and MDCT. However, there is a well-recognized high
interscan, interobserver and intraobserver variability and the
consensus of the American Heart Association/American Col-
lege of Cardiology is that the incremental value of calcium
scores over traditional risk assessments has not been proven
and that its use could only be justified in selected groups at
intermediate risk9.
CT coronary angiography is typically performed in a single
breath-hold, with ECG gating, during a rapid ( 5 ml/s) infu-
sion of iodinated contrast material (Fig. 4.5). The sensitivity
and specificity of 16-detector row CT for detection of 50%
luminal stenosis is around 90%10,11, although a significant pro-
portion of the arteries (12%)11 were not demonstrated suffi-
ciently well to be evaluated. However, the negative predictive
value (NPV) of a normal study is reported to be 95%12 and
thus could be potentially used to exclude cardiac disease in
patients with chest pain.There are, of course, limitations: prob-
lems occur in patients with arrhythmias (e.g. atrial fibrillation),
the heart rate should ideally be 60 beats per minute or below13,
and beta-blockers may be necessary for optimal imaging.
In order to detect a 1020% change in stenosis, imaging will
require an isotropic spatial resolution of 0.3 mm and an acqui-
sition time of approximately 0.1 stechnical specifications
that, as detailed above, are becoming possible with double tube
64-slice systems CT. It is anticipated that this development
will further enhance the accuracy and reproducibility of coro-
nary artery angiography and, importantly, give an overview
of cardiac morphology and function. By using all the data
during the various phases of the cardiac cycle, cine loops can
provide ejection fractions and other objective measurements.
Figure 4.5 VR image of the heart depicting the coronary arteries.
Assessment of perfusion can be made on delayed imaging.The
potential impact of noninvasive coronary imaging on clinical
practice is clearly enormous, and will depend on the results
achieved with newer MDCT technology.
Thoracic
The imaging of patients with suspected pulmonary venous
thromboembolism (PE) had, for many years, relied on either
ventilationperfusion (VQ) studies or pulmonary angiogra-
phy. However, once CT became sufficiently fast to image the
thorax with thin collimation ( 2 mm) in a single breath-hold,
CT pulmonary angiography (CTPA) rapidly became the test
of choice for many clinicians. Indeed, the number of patients
referred for CT with suspected PE has increased dramatically
since its introduction. This is likely to be due to increased
awareness of the diagnosis in combination with easy access to
an accurate noninvasive study.
VQ studies expose the patient to a significantly lower
radiation dose than CTPA, but have a number of drawbacks.
There is a significant proportion in which the result will be
indeterminate due to cardiorespiratory disease or an abnormal
radiograph14. Once these are taken into account, the overall
radiation burden to the population is only slightly (approxi-
mately 4%) higher using CTPA for all15. Moreover, the greater
specificity of a positive CTPA, compared with a high prob-
ability of PE, gives the clinician greater confidence in the
diagnosis.
The negative predictive value of a CTPA for PE is 99.4% in
patients at 3-month follow-up, with a mortality attributable to
PE within this time period of 0.01%16. The current generation
of MDCT machines produces consistently high quality images
of the pulmonary arteries down to the subsegmental level. How-
ever, the clinical significance of tiny peripheral emboli is unclear

as they may not affect outcome17. Consequently, CTPA is now
widely considered to be the equal of pulmonary angiography in
terms of accuracy without the associated risks.
Imaging of the venous system 2 min postinjection from the
iliac crests to the popliteal fossa has been advocated by several
groups for all patients undergoing CTPA. The evidence sug-
gests that 20% of patients with a negative CTPA will have
venous thrombosis in the legs18. However, it is difficult to
justify replacing a highly accurate, noninvasive and radiation-
free test (ultrasound) with CT, particularly as the gonads are
unavoidably included in the imaging.
Vascular
The high resolution and speed afforded by MDCT has a num-
ber of potential applications in the assessment of the vascular
system elsewhere. The increased speed allows a pure arterial
phase study to be obtained; however, the faster the machine,
the less forgiving it is. It is imperative that all such studies are
either triggered by the arrival of contrast medium at a defined
site or are based on a test bolus. In our practice, unenhanced
and arterial-phase images are acquired. This aids detection of
intramural haematoma or haemorrhage in acute patients and
differentiates calcification from endoleak in treated patients.
The commonest vascular application clinically is the assess-
ment of aortic aneurysms, both before and after treatment.The
enhanced resolution, particularly in the z-axis, together with
multiplanar reconstruction (Fig. 4.6), allows accurate planning
of endovascular or surgical repair. Following endovascular
aneurysm repair (EVAR), MDCT is regarded by the Society
of Interventional Radiology (SIR) as the gold standard for
monitoring the aorta. Particular attention should be paid to
the presence of any fractures or kinking of the stent on the
unenhanced study. Following intravenous contrast medium,
Figure 4.6 Colour volume rendered image of the aorta
demonstrating an infrarenal aneurysm extending down to the bifurcation.
CHAPTER 4 MULTIDETECTOR COMPUTED TOMOGRAPHY 83
the presence of an endoleak will be seen as contrast medium
within the aorta tracking into the thrombus and implies failure
of the stent graft. Enlargement of the aneurysmal sac with-
out an apparent endoleak is termed endotension. Visceral
infarction, particularly involving the kidneys, should also be
apparent on the arterial study.
When using MDCT to investigate patients with peripheral
vascular disease, it is important to appreciate that the flow rate
down both normal and atherosclerotic peripheral vessels can
be highly variable. Consequently, it is our practice to perform
two test bolus studies: one in the lower aorta and a second in
the popliteal fossa. We then subtract the time delay between
the two and set the table speed accordingly. Post-processing of
the data can be time consuming and the images in the distal
vessels can be variable, as with all forms of peripheral vascular
imaging. In our experience, the results from 16-detector row
and above are comparable with magnetic resonance angiogra-
phy (MRA) and have the advantage of providing bony land-
marks to help treatment planning. Both of these techniques
yield a 3D dataset, unlike conventional arteriography, and have
the advantage of being noninvasive. It would seem likely that
the role of MDCT in this field will grow in coming years,
with arteriography increasingly reserved for therapeutic cases.
Trauma
Accurate assessment of the cervical spine is of critical impor-
tance in trauma cases: the consequences of missing a significant
injury are potentially devastating. The reported accuracy of
plain radiographic studies is highly variable, but approximately
1020% of significant cervical spine injuries will be missed
through a combination of suboptimal radiographs, interpreta-
tion error and absence of radiographic signs19. In the obtunded
patient, these problems are compounded by the absence of any
clinical information from physical examination. Single detec-
tor row CT is superior to plain radiography, but the relatively
poor resolution in the z-axis could prove problematic in iden-
tifying fractures in the axial plane. MDCT has overcome this
with increased speed and resolution, such that the entire cervi-
cal spine can now be imaged and viewed in any plane within
a matter of seconds. The sensitivity, specificity and NPV of
MDCT are reported to be 98.1%, 98.8% and 99.7%, respec-
tively, with many major trauma centres now using MDCT as
the primary imaging method for evaluating the cervical spine
in the obtunded trauma patient20,21.
Imaging of the thorax and abdomen following trauma is
usually performed with MDCT; ultrasound may be of use in
confirming the presence of a haemoperitoneum in the unsta-
ble patient before laparotomy, but cannot reliably assess the full
extent of solid organ or GI tract injuries. In addition to the
non-enhanced imaging, the speed of image acquisition with
MDCT allows the radiologist to perform each phase of the
study at an appropriate delay following intravenous enhance-
ment. The thorax should be imaged in the arterial phase, as
deceleration injuries may lead to shearing injuries of the aorta
(most commonly occurring at the isthmus, just distal to the
origin of the left subclavian artery). The abdomen should ide-
ally be imaged in the arterial and portal venous phases, in order
84 SECTION 1 IMAGING TECHNIQUES AND GENERAL ISSUES
that both vascular injuries (dissection, pseudoaneurysm, avul-
sion) and parenchymal injuries may be assessed. The pelvis is
usually imaged in the portal venous phase. The sensitivity and
specificity of CT for detecting bowel and mesenteric injury
are approximately 80%22, while for solid organ injuries these
approach 100%.
Gastrointestinal
CT colonography (CTC) has been extensively investigated
over the past decade, with the ultimate goal of providing an
accurate, minimally invasive screening test for detecting colonic
polyps before they become frankly malignant. The evolution
of MDCT has enabled the development of CTC. Current
best practice involves thin collimation ( 3 mm) and low dose
imaging of the insufflated colon in both prone and supine
positions following either purgative or faecal tagging with
multiple doses of oral contrast media for 4872 h23. The use of
intravenous hyoscine is recommended by some authors.
Reporting is usually, though not always, performed from
the axial and MPR images with 3D endoluminal fly-through
views used for problem solving. However, the precise tech-
niques employed are as variable as the results achieved, which
range from as low as 59% sensitivity for polyps > 10 mm24 to
93% (outperforming colonoscopy) in the detection of polyps
> 8 mm25. CTC outperforms double contrast barium enema
(DCBE) in all studies. The clinical significance of missed and
diminutive polyps has also been questioned, given the slow
progression of polyps over time26. Moreover, there is wide
variation in the reporting of polyps even among expert read-
ers27, illustrating that this truly is a technique in evolution from
a technical perspective, with a steep learning curve for the
radiologist.
Multicentre trials are currently underway in the USA
(ACRIN) and the UK (SIGGAR 1) to evaluate the use of
CTC in the context of a screening programme, but at present
the majority view is that colonoscopy should be viewed as the
gold standard, with CTC likely to replace the DCBE in the
future. Again CAD techniques are under evaluation.
Hepatobiliary
The use of multiple phases of contrast-enhanced imaging has
probably had the greatest impact in liver imaging, which is
reflected in the extensive US, CT and MR literature on the
subject. The detection and characterization of focal liver lesions
is largely based on patterns of vascular enhancement, with the
hypervascular lesionshepatocellular carcinoma (HCC), regen-
erative nodules, focal nodular hyperplasia and adenomain
particular providing diagnostic dilemmas. In order to optimize
contrast enhancement, our practice is to trigger the CT study
from the arrival of contrast in the abdominal aorta. CT-based
surveillance programmes for early detection of HCC with cir-
rhosis consist of an arterial and portal venous phase study at the
very least, with many centres also obtaining unenhanced images.
Both early and late arterial phase imaging can be performed, but
no additional benefit for this has yet been shown.
In living related liver transplantation, MDCT may be used
to determine liver volumes and is increasingly utilized for
identifying the arterial and venous anatomy of the donor for
surgical planning. Following transplantation, we have found
MDCT to be particularly useful in evaluating the vascular
supply to the graft in cases of suspected ischaemia where US is
nondiagnostic (Fig. 4.7).
Genitourinary
The evaluation of a patient presenting with haematuria may
involve intravenous urography, ultrasound, CT or MRI in com-
bination with cystoscopy. Increasingly, MDCT is being used as
the primary imaging investigation as it has a high sensitivity for
detecting malignant lesions, calculi and traumatic injuries. The
other major causes (infection, coagulopathy, instrumentation)
may be diagnosed on clinical history and blood and urine test-
ing.The technique employed should encompass an unenhanced
study (to detect calculi), a nephrographic phase (approximately
100 s, to assess the renal parenchyma) and an excretory phase
(810 min, to assess the ureters). The latter two stages may be
combined by giving the intravenous contrast medium in two
parts, 810 min apart, and then imaging 100 s after the second
dose. This will significantly reduce the radiation dose to the
patient. As MDCT may not depict flat tumours of the bladder
wall, cystoscopy must not be omitted.
The increased anatomical resolution and multiplanar
reconstructions possible with MDCT have enabled its use for
surgical planning. In particular, urologists are able to accurately
assess whether resection of a malignant lesion requires partial
or complete nephrectomy, whilst potential organ donors may
be noninvasively evaluated with an accurate depiction of the
renal vasculature.
Paediatric
Imaging children with CT poses a number of problems. It
requires cooperation with instructions and the need to remain
still, requires a high degree of spatial resolution to depict
smaller organs and their vessels and exposes patients to a rela-
tively high dose of radiation. Some hold that around 1 per
Figure 4.7 Coronal MIP image demonstrating hepatic artery
thrombosis with collateral arteries in a patient following liver
transplantation.

12002000 patients undergoing CT might develop cancer
because of the effects of the CT radiation, and these risks are
greater in children28.
Advances in MDCT have led to a significant reduction in
acquisition time, which has been shown to reduce the need for
sedation of paediatric patients29. Simultaneously, it has become
possible to reduce the collimation below 1 mm, dramatically
improving the resolution, and thereby not only aiding the
diagnosis but also enabling accurate assessment of congenital
abnormalities and surgical planning, particularly in patients
with malignancy. Unlike in adult patients, imaging in differ-
ent vascular phases is discouraged because of radiation issues.
Therefore it is important to select a single optimal imaging
sequence whenever possible (e.g. in a Wilms tumour, the late
arterial phase will also opacify the renal veins and upper IVC).
Optimizing an MDCT study for a paediatric patient should
also include reducing the radiation dose as much as is pos-
sible while maintaining diagnostic quality. Reducing the kV
and/or mAs will significantly reduce the dose to the patient30,
and this can now be modulated automatically during imaging
on newer machines, giving a constant image signal-to-noise
ratio throughout the study. Additionally, increasing the pitch
reduces the radiation dose significantly without loss of diag-
nostic quality30.
WHOLE BODY MDCT IN ASYMPTOMATIC
ADULTS
Whole body CT imaging of asymptomatic patients is con-
troversial, yet is becoming commonplace in several countries,
particularly the United States. Clearly, the potential benefits
of identifying early stage malignant lesions or coronary heart
disease with one noninvasive test could be enormous, but as
yet the case for whole body CT screening is far from proven.
When considering these studies, it should be borne in mind
that a single CT examination cannot be optimized for looking
at all organs at once. Consequently, the sensitivity and speci-
ficity of a whole-body study is likely to be significantly lower
than with the dedicated organ-specific studies currently being
evaluated. Inevitably, further follow-up investigations will be
required for incidental findings, resulting in anxiety and distress
for the patient and occasionally lead to morbidity and mortality.
Moreover, the radiation dose is nontrivial. A recent publica-
tion exploring the hypothetical situation of a 45-year-old man
undergoing annual screening CT until the age of 75 calculated
the overall estimated lifetime attributable risk of cancer mor-
tality to be approximately 1.9% (1 in 50)31. This combination
of high cost, low specificity and high risk indicates that it is
unlikely that whole body CT screening would be of benefit
to the population. In the UK, such CT examinations are not
recommended by the National Screening Committee32.
RADIATION DOSE CONSIDERATIONS
In the late 1980s, CT represented approximately 2% of radio-
logical investigations and 20% of the collective dose to the
CHAPTER 4 MULTIDETECTOR COMPUTED TOMOGRAPHY 85
population. In 20032004, it is estimated that this has increased
to 9%, with the dose from CT contributing around half of all
radiation from medical exposures33. Since 1997, CT has been
designated a high-dose procedure by the European Union,
along with interventional radiology and radiotherapy.
The reasons for this expansion in practice have been out-
lined above, with MDCT able to perform increasingly complex
diagnostic procedures noninvasively and, in some instances,
requiring multiple phases of imaging. Furthermore, unlike
conventional plain radiography, where the radiation dose from
each exposure is to some extent regulated by automatic detec-
tors (increasing the dose will result in an overexposed, dark
radiograph of little diagnostic value), increasing the exposure
factors (and patient dose) for a CT study will provide the user
with higher quality images. More difficult to assess is the effect
that an increasingly litigious society has had on the practice of
medicine and in particular the number of requests for studies
to rule out underlying tumour, pulmonary embolism, etc.,
even when these are clinically unlikely.
The responsibility for reducing patient dose should be
shouldered by all parties. The referring clinician should ensure
that the radiologist is given full clinical information to ensure
that CT is indeed the most appropriate test. The radiologist
should ensure that each study is justified, that the imaging pro-
tocols are optimized to answer the clinical question and that
the dose to the patient follows the ALARA (as low as reason-
ably achievable) principle. CT manufacturers also play a key
role in this area through the continued development of dose
modulation and the installation of low-dose preset protocols.
In order to maximize patient safety, it is essential that all these
issues are addressed in each case.
RADIOTHERAPY
Over the past decade, significant advances have been made in
the planning and delivery of radiotherapy. The introduction of
MDCT enabled the oncologist to map the extent of tumour in
three planes, allowing accurate dose planning of irregular shapes
while minimizing the dose to the surrounding normal tissues.
This 3D conformal radiotherapy (CRT) results in a significant
reduction in side-effects. However, there were limitations in
corrections that could be made to the delivered dose. More
recently, intensity modulated radiotherapy (IMRT) has been
developed, whereby each radiation beam is divided into 1-cm2
beamlets, each delivering a different prescribed dose. This has
reduced even further the dose delivered to the surrounding
normal tissues through increasing accuracy of delivery.
Current research in radiotherapy includes the development
of techniques to account for movement during radiotherapy,
particularly respiration, with 4D CRT. Moreover, techniques
are being developed which take account of the changes to the
patient and tumour (weight loss and tumour shrinkage) that
occur during a course of radiotherapy, so-called adaptive radio-
therapy. It is anticipated that both of these will again further the
accuracy of radiotherapy with more precise dose delivery and
reduced side-effects. The increasing use of functional imaging
of tumours with 18FDG-PET is also beginning to impact on
86 SECTION 1 IMAGING TECHNIQUES AND GENERAL ISSUES
radiotherapy planning. The co-registration of anatomical and
physiological images using CT-PET has resulted in significant
advances in lung tumour radiotherapy in particular, as it is
now possible to differentiate between the central obstructing
tumour and distal collapse.
FUTURE DIRECTIONS
The gantry speeds and coverage currently achieved in MDCT
are more than adequate for almost all clinical applications. The
most notable exception, cardiac imaging, will undoubtedly drive
manufacturers to produce yet faster machines with greater cover-
age until high-quality,real-time images are achieved, which could
potentially directly replace all diagnostic coronary angiography.
A significant improvement in resolution will be more difficult
to achieve using the current technology with up to 64 banks of
detectors.This would require significant improvements in detec-
tor efficiency and size reduction. However, the next generation
of CT machines may instead employ flat panel detectors. Early
reports of prototype machines indicate that spatial resolution is
greatly improved, with isotropic voxels of the order of 0.25 mm,
with coverage of approximately 20 cm in the z-axis per revolu-
tion. However, contrast resolution is relatively poor and data
acquisition is still slow on these machines at present. One of the
most important potential applications for such high-resolution
studies, in addition to those described above, would be imaging
of the breast. Early reports indicate that the technique is fea-
sible at a dose comparable to that from 2-view mammography,
with the added advantages of better tumour localization and
potentially better detection of tumours. The tumour detection
and dose characteristics will clearly be of greater importance
than the speed of data acquisition for breast work, but increased
speed will be crucial for cardiac applications.
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