SOMATOM

Issue no.11

SESSIONS

Contents

Computed Tomography for

Oncology Care
Page 4

CASE 1–4:
Clinical Studies of CT with PET
Page 6

CASE 5–6:
Clinical Studies of CT with
Angiographic Interventions
Page 18

CASE 7:
Clinical Study of CT-guided
Radiation Therapy
Page 22

CASE 8:
Clinical Study of CT
in Therapy Planning
Page 24

Virtual Simulation
Page 26
SOMATOM SESSIONS 11
From the Editor
This is the eleventh issue of Siemens SOMATOM® Sessions.
We feature CT in oncology care, namely clinical applications
in combination with the other modalities such as Angio-
graphy, Radiation Therapy (RT) and Positron Emission
Tomography (PET).
This issue also presents you with clinical case studies for
each application.
To order copies of the past issue or submit your registration
for receiving future issues, please visit our Web site at:
http: // www.siemensmedical.com / somatomsessions
As always, we appreciate your suggestions and comments.
Xiaoyan Chen, M.D., MBA Roselle Anderson
Editor of SOMATOM Sessions Guest editor of this issue
2
The information in this document contains general descriptions of the tech-
nical options available, which do not always have to be present in individual
cases. The required features should therefore be specified in each individual
case at the time of closing the contract.
The information presented in the case report is for illustration only and is not
intended to be relied upon by the reader for instruction as to the practice of
medicine. Any health care practitioner reading this information is reminded
that they must use their own learning,training and expertise in dealing with
their individual patients.This material does not substitute for that duty and is
not intended by Siemens Medical Solutions Inc., to be used for any purpose
in that regard.
The drugs and doses mentioned herein were specified to the best of our
knowledge.We assume no responsibility whatsoever for the correctness of
this information.Variations may prove necessary for individual patients.
The treating physician bears the sole responsibility for all of the parameters
selected.
Contents

Computed Tomography for Oncology Care Page 4 CASE 5:

Diagnosis of Hepatocellular
CASE 1: Carcinoma Page 18
Diagnosis of Gastrointestinal
Stromal Tumor with Multiple Metastases Page 6 CASE 6:
Diagnosis and Interventions of
CASE 2: Bladder Cancer Page 20
Diagnosis of Non-Small Cell Lung Cancer
with Multiple Metastases Page 10 CASE 7:
Image Guided Radiation Therapy of Prostate
CASE 3: Cancer Using a Novel Combination of
Therapy Monitoring in the Treatment CT and Linear Accelerator, the PRIMATOM Page 22
of Hepatic Metastasis with Radiofrequency
Ablation Page 14 CASE 8:
CT imaging in Radiation Therapy Page 24
CASE 4:
Diagnosis of Recurrent Virtual Simulation Page 26
Non-Hodgkin’s Lymphoma Page 16
SOMATOM SESSIONS 11

Computed Tomography for Oncology Care

SINCE THE EARLY DAYS of Computed Tomography – dat- biograph™ – CT + PET

ing back to the early 1970s – medical engineering has been
pushing the limits of this technology. Today, we boast
shorter scan times than ever before; increased detail reso-
lution; sophisticated image post-processing capabilities;
greater ease of use with the common syngo user interface;
and efficient networking solutions.
The biograph system combines two technologies – Com-
puted Tomography and Positron Emission Tomography
(PET) [Fig. 1]. It provides both anatomical and functional
information by image acquisition and fusion from both
modalities. Please refer to cases 1– 4 for clinical examples.

Routinely, much of the focus of clinical work with CT has

been for the visualization and staging of malignancy. In
fact, it is estimated today that over 50% of all examinations
are performed to help the physician either confirm the
presence or absence of lesions like tumors. Other applica-
tions such as low-dose CT exams for the early visualization
of pulmonary nodules and CT-guided interventions are also
performed clinically. The merging of CT and PET technolo-
gies brings oncology imaging to unprecedented levels,
helping to reduce the PET examination times and providing
functional images with morphological landmarks. And as
advanced techniques such as Intensity Modulated Radia-
tion Therapy (IMRT) become more widespread in the ther-
apy arena, CT is gaining presence as the modality of choice
for simulation of radiation treatments. In the following
brief overview, we would like to introduce you to some of
the clinical applications of CT as a crucial modality in the
continuum of oncology care.
[ 1 ] biograph system

4
Miyabi®– CT + Angiography
The Miyabi system combines two modalities – a CT scanner
with sliding gantry and an Angiography system
[Fig. 2]. It can be used to aid the physician in the visualiza-
tion of lesions like tumors and also for performing safe and
effective interventional treatments. Please refer to cases
5 & 6 for clinical examples.
[ 2 ] MIYABI system
PRIMATOM™ – CT +
PRIMUS® Linear Accelerator
The PRIMATOM system combines two modalities – a CT
scanner with Sliding Gantry™ and a Radiation Therapy
delivery system [Fig. 3]. It is used for accurate verification
of tumor location prior to treatment delivery, as well as for
precise simulation on the therapy table. Please refer to case
7 for a clinical example.
[ 3 ] PRIMATOM system
In the pages that follow, we offer a glimpse of how
Siemens SOMATOM CT scanners are being used in
diverse applications and configurations in the oncology
arena today. We invite you to join us for an interesting
read.
5
SOMATOM SESSIONS 11

Case1: Diagnosis of Gastrointestinal Stromal Tumor

with Multiple Metastases
PATIENT HISTORY EXAMINATION PROTOCOLS
A 48-year-old male patient had been diagnosed with CT examination
hepatic metastases of an unknown primary tumor. Biopsy Scanned body regions Thorax, abdomen, pelvis
of the hepatic lesions revealed metastases from a gastro- Arm positioning Raised above head
intestinal stromal tumor. CT imaging of the abdomen as mAs 140
well as endoscopy of the stomach and the colon had not kV 120
been able to define the primary lesion. A dual-modality Slice width 5 mm
Table feed / rotation 8 mm
PET-CT examination was scheduled for further evaluation.
Pitch 1.6
Rotation time 800 ms
Increment 2.5 mm
DIAGNOSIS Scanning direction Craniocaudal
Oral contrast material 1000 ml barium
Examinations with a combined PET/ CT scanner, the bio- (1.5 g / 100 ml)
graph, revealed a hypodense 2.5 x 2.5 cm lesion at the i.v. contrast material 1.80 ml at 3 ml / s
2.60 ml at 2 ml / s
lesser curvature of the stomach [Fig.1] with pathologically
increased tracer uptake (SUV 9.1). Adjacent to the gastric
lesion a pathologically enlarged lymph node (1.5 cm on CT)
was found to present with increased FDG utilization. Fur- PET examination
thermore, multiple hepatic metastases with pathologically Tracer 350 MBq FDG
increased glucose metabolism (SUV 9.9) were verified Scanned body regions Thorax, abdomen, pelvis
[Fig. 1 and 2]. On thoracic imaging bilateral pulmonary Arm positioning Raised above head
lesions of up to 0.7 cm in size were found, but no increased Number of bed positions 5
tracer uptake was demonstrated [Fig. 3]. Scan time / bed position 5 minutes
Reconstruction algorithms Iterative (FORE and AWOSEM),
Diagnosis: Gastrointestinal stromal tumor of the stomach’s
2 iterations and 8 subsets;
lesser curvature with local lymph node metastasis as well Data filtered (FWHM 3.2 mm)
as multiple hepatic and pulmonary metastases. Data scatter corrected
Reconstructed slice width 5 mm
Scanning direction Caudocranial

6
A B

C [ 1 ] Axial images of the primary tumor (arrow) at the

lesser curvature of the stomach on CT (A), fused PET/ CT
(B), and PET images (C) with adjacent lymph node
metastasis and hepatic metastases.

7
SOMATOM SESSIONS 11

A B

C [ 2 ] Coronal view of CT (A), fused PET/ CT (B), and PET

images (C) of the primary tumor and hepatic metastases.
Evaluation of the PET images alone may have led to
misinterpretation of the primary tumor as just another
hepatic metastasis.

8

A B
C [ 3 ] Pulmonary metastasis without signs of FDG uptake.
COMMENTS
Dual-modality PET/ CT was able to define a lesion at the
lesser curvature of the stomach as the primary tumor.
The diagnosis was verified on biopsy. Initially, the tumor of
the lesser curvature had not been visualized by CT or
endoscopy. CT was negative because the hypodense lesion
may have been mistaken for parts of a bowel loop.
Endoscopy was negative because the tumor originated
from the outer parts of the gastric wall and was there-
fore not visible from inside the stomach. Compared to CT
alone, PET/ CT was able to define the primary tumor. Com-
pared to PET alone, the area of focal tracer uptake in the
epigastrium could accurately be attributed to a lesion at
the stomach’s lesser curvature and an adjacent lymph
node. On plain PET imaging the primary tumor with the
CASE 1: Clinical studies of CT with PET
PET image (C) was acquired in shallow breathing.
(A) shows axial view of CT image and (B) shows fused
PET/ CT image.
adjacent lymph node metastasis would, probably, have
been mistaken for just another hepatic metastasis [see
Fig. 2]. Considering the pulmonary lesions another benefit
of combined PET/ CT over PET imaging becomes obvious.
Small pulmonary lesions may not demonstrate tracer
uptake as PET images are acquired in shallow breathing
which leads to smearing in visualization of FDG uptake.
The integration of CT accurately demonstrated pulmonary
metastases and, therefore, increased diagnostic yield over
PET alone.
9
SOMATOM SESSIONS 11

Case 2: Diagnosis of Non-Small Cell Lung Cancer

with Multiple Metastases
PATIENT HISTORY EXAMINATION PROTOCOLS
45-year-old male patient with histologically proven non- CT examination
small cell lung cancer (NSCLC) in the apex of the left upper Scanned body regions Head, neck, thorax,
pulmonary lobe. CT imaging of the thorax had revealed abdomen, pelvis
mediastinal lesions suspected of lymph node metastases Arm positioning Split protocol:
1. Beside trunk for head
as well as pulmonary lesions of up to 2.5 cm in diameter in and neck
the right lung. PET/ CT imaging was carried out for tumor 2. Raised above head for thorax
staging. to pelvis
mAs 140
kV 120
Slice width 5 mm
EXPLANATION FOR Table feed/rotation 8 mm
SPLIT PROTOCOL Pitch 1.6
Rotation time 800 ms
To improve image quality by minimizing artefacts from the Increment 2,5 mm
arms in the field of view, combined PET/ CT was acquired in Scanning direction Craniocaudal
two steps in this patient. First a PET/ CT of the thorax, ab- Oral contrast material 1000 ml barium
(1,5 g / 100 ml)
domen and pelvis was carried out followed by another PET/ i.v. contrast material Head / neck: 70 ml at 2 ml / s
CT covering the head and neck. Between examinations the Thorax – pelvis: 50 ml at
patient’s arms were repositioned to be outside the field of 3 ml / s; 50 ml at 2 ml / s

view.

DIAGNOSIS PET examination

Tracer 350 MBq FDG
The primary tumor in the left apex of the lung was clearly Scanned body regions Head, neck, thorax,
visible on FDG-PET/ CT as a region of inhomogeneous abdomen, pelvis
contrast enhancement on CT with pathologically increased Arm positioning Split protocol:
1. Beside trunk for head
tracer uptake on PET [SUV 8.0; Fig. 1]. In addition focal FDG and neck
uptake could be demonstrated in mediastinal lymph nodes 2. Raised above head for thorax
to pelvis
[Fig. 2] as well as in the pulmonary lesions on the right side
Number of bed positions 7
[Fig. 3]. An area of focal tracer uptake was, furthermore,
Scan time / bed position 4 minutes
demonstrated in projection on the pelvis. This hot spot Reconstruction algorithms Iterative (FORE and AWOSEM)
could be accurately attributed to the right pubic bone. The 2 iterations and 8 subsets
corresponding CT images revealed only mild sclerosis of Data filtered (FWHM 3.2 mm);
Data scatter corrected
the bone without typical signs of osseous destruction
Reconstructed slice width 5 mm
[Fig.4]. Diagnosis: NSCLC of the left pulmonary apex with Scanning direction Caudocranial in both
mediastinal lymph node metastases, pulmonary metas- examinations
tases and a right pubic bone metastasis.

10
 A A

B B

C C

[ 1 ] Partially necrotic non-small cell lung cancer [ 2 ] CT (A), PET/ CT (B), and PET (C) images of an
of the left pulmonary apex as demonstrated on CT (A), infracarinal lymph node metastasis from NSCLC.
fused (B), and PET (C) images.

11
SOMATOM SESSIONS 11

A A

B B

C C

[ 3 ] Right pulmonary metastasis from NSCLC.
Only mild FDG uptake is mainly attributed to smearing
due to respiratory motion.
Also note a mediastinal lymph node metastasis.
[ 4 ] Bone metastasis in the right pubic bone.
CT (A) demonstrated only mild sclerosis while PET (C)
shows pathologically increased focal tracer uptake.
On fused images focal tracer uptake can be accurately
attributed to the lesion in question.

12
 CASE 2: Diagnosis of Non-Small Cell Lung Cancer with Multiple Metastases

[ 5 ] biograph system

COMMENTS
Dual-modality PET/ CT is a useful tool for tumor staging.
The application of a whole-body protocol (head to upper
thigh) is required to ensure visualization of distant meta-
stases. In this case, the bone metastasis would have been
missed if scanning had been limited to the thorax. The ben-
efit of the combined approach over CT alone is demon-
strated by the visualization of the bone metastasis which is
characterized by only mild sclerosis on conventional CT
imaging. The acquisition of a fully diagnostic CT compo-
nent is, however, of importance, as there are tumors that
do not show increased glucose metabolism, or metastases
from a tumor may express FDG-uptake characteristics dif-
ferent from the primary lesion. A fully diagnostic, contrast-
enhanced CT can be of great value in these cases.

13
SOMATOM SESSIONS 11

Case 3: Therapy Monitoring in the Treatment

of Hepatic Metastasis with Radiofrequency Ablation
PATIENT HISTORY EXAMINATION PROTOCOLS
66-year-old male patient with recurrent hepatic metastasis CT examination
from colorectal carcinoma in segment 4 of the liver. Scanned body regions Liver
The patient had undergone resection of the rectum and Arm positioning Raised above head
resection of a solitary hepatic metastasis in segment mAs 140
4 one year prior. Radiofrequency ablation was carried out kV 120
for treatment of metastatic recurrence. A combined Slice width 5 mm
Table feed/rotation 8 mm
PET /CT examination was scheduled before and after
Pitch 1.6
radiofrequency ablation to determine the therapeutic
Rotation time 800 ms
effectiveness. Increment 2.5 mm
Scanning direction Craniocaudal
Oral contrast material none
DIAGNOSIS AND FOLLOW-UP i.v. contrast material 100 ml at 3 ml / s
Delay 70 seconds

Dual-modality PET/ CT imaging revealed an ill-defined

hypodense lesion in the area of prior resection in segment
4 of the liver [Fig. 1A]. Fused images demonstrated patho- PET examination
logically increased tracer uptake of the lesion as a sign of Tracer 350 MBq FDG
metastatic recurrence [Fig. 1B and C]. Radiofrequency Scanned body regions Liver
ablation was carried out featuring an ablative device with Arm positioning Raised above head
3 cm distal tip exposure (Cool-Tip™, Radionics, Burlington, Number of bed positions 2
MA, USA) over a time period of 20 minutes. No compli- Scan time / bed position 5 minutes
Reconstruction algorithms Iterative (FORE and
cations occurred. In the 4 weeks following radiofrequency
AWOSEM); 2 iterations and
treatment the patient had another PET/ CT scan to deter- 8 subsets; Data filtered
mine the effectiveness of the RF-ablation procedure. Figure (FWHM 3.2 mm)
Data scatter corrected
2A demonstrates the thermo-induced hepatic necrosis on
Reconstructed slice width 5 mm
plain CT imaging. Fused images showed a small area of Scanning direction Caudocranial
decreased glucose metabolism in the necrotic region
[Fig. 2B and C]. There is no increased FDG uptake visible in
the periphery of the necrotic lesion. Complete necrosis of
the metastasis was demonstrated by PET/ CT.

COMMENTS
Follow-up examinations to evaluate the effectiveness of
tumor therapy are frequently compromised by the inability
to differentiate viable tumor areas from therapy-induced
necrosis on CT imaging. As demonstrated in this case, com-
bined PET/ CT can accurately evaluate metabolism in liver
tissue adjacent to the necrotic area to exclude residual or
recurrent viable tumor.

14
 A A

B B

C C

[ 1 ] CT (A), fused PET/ CT (B), and PET (C) images of [ 2 ] Successful treatment of recurrent hepatic metastasis
recurrent hepatic metastasis from colorectal carcinoma by radiofrequency ablation.
one year after resection. Images prior to radiofrequency PET/ CT demonstrated tumor-free margins of the
ablation. ablated area 4 weeks post-intervention.

15
SOMATOM SESSIONS 11

Case 4: Diagnosis of Recurrent

Non-Hodgkin’s Lymphoma
PATIENT HISTORY EXAMINATION PROTOCOLS
51-year-old male patient who had undergone multiple CT examination
cycles of chemotherapy for non-Hodgkin’s lymphoma with Scanned body regions Head, neck, thorax, abdomen,
mediastinal, pulmonary, and cerebral involvement. A PET / pelvis
CT staging examination was carried out 6 months after ter- Arm positioning Beside trunk
mination of therapy. The patient had been disease-free mAs 140
kV 120
over the past 6 months.
Slice width 5 mm
Table feed / rotation 8 mm
Pitch 1.6
DIAGNOSIS Rotation time 800 ms
Increment 2.5 mm
Combined PET/ CT imaging revealed focal FDG (SUV 4.3) Scanning direction Craniocaudal
uptake in the left axilla [Fig. 1 and 2] which could be accu- Oral contrast material none
rately co-registered with a lymph node. The lymph node i.v. contrast material 1.80 ml at 3 ml / s
2.60 ml at 2 ml / s
was determined to be 1.3 cm in size on CT imaging. From
PET/ CT findings recurrence of non-Hodgkin’s lymphoma
was diagnosed and diagnosis was verified histologically PET examination
after lymph node excision. Tracer 350 MBq FDG
Scanned body regions Head, neck, thorax,
abdomen, pelvis
Arm positioning Beside trunk
COMMENTS Number of bed positions 7
Scan time / bed position 5 minutes
By demonstrating focal tracer uptake within a lymph node,
Reconstruction algorithms Iterative (FORE and
combined PET/ CT improves differential diagnosis of benign AWOSEM); 2 iterations and
and malignant diseases. FDG-PET/ CT will play an important 8 subsets; Data filtered
(FWHM 3.2 mm)
role in tumor follow-up with emphasis on early diagnosis of Data scatter corrected
tumor recurrence.

16
 A B C

[ 1 ] Coronal CT (A), fused PET/ CT (B), and PET (C) images of a patient with recurrence of
non-Hodgkin’s lymphoma in the left axilla.

A B

C [ 2 ] Accurate co-registration of CT and PET images (B)

demonstrates FDG uptake in a lymph node suspected for
recurrence of non-Hodgkin’s lymphoma.

17
SOMATOM SESSIONS 11

Case 5: Diagnosis of Hepatocellular Carcinoma

PATIENT HISTORY
A 65-year-old male patient had a history of chronic hepati-
tis C. Hypoechoic lesion was visualized in the right lobe of
the liver by ultrasonography. Serum PIVKA-II level was
elevated, which is well known as a tumor marker of hepa-
tocellular carcinoma (HCC). Dynamic arterial phase CT
scan showed high attenuation area in the liver (segment
eight / tumor size: 3.5 x 3 cm).

DIAGNOSIS
Angiography was performed for preoperative examination
[Fig. 1 and 2]. In addition to hepatic angiography, the pa-
tient underwent CT during arterioportography (CTAP) and
CT during hepatic arteriography (CTA) using the Angio-CT
system “MIYABI” [Fig. 3]. The tumor was manifested as a
solitary perfusion defect of portal venous flow on CTAP and
no other portal perfusion defect was seen in the liver. On [ 1 ] Angiography performed through the common
CTA,the tumor was depicted as a hypervascular lesion. Par- hepatic artery.
tial hepatic lobectomy was performed and histological
examination of the tumor showed moderately differenti-
ated HCC.

COMMENTS
CT during arteriography with the Angio-CT system
“MIYABI“ provides useful information about tumor visuali-
zation and drug distribution. In this case, such information
helps to determine surgery plan. Patients with severe liver
dysfunction may not tolerate an operation or transcatheter
arterial chemoembolization (TACE) covering a wide area.
To reduce damage of normal liver tissue, superselective
TACE is necessary. MIYABI enables us to identify whether
drug infusion area contains whole area of the tumor with
minimal surrounding liver tissue.
The Angio-CT system “MIYABI” is useful not only for diag-
nosing tumor but also for performing safe and effective
interventional treatments.
According to our experience, syngo viewer is very useful
for the comparison of images between different phases [ 2 ] Angiography performed superselectively through the
[Fig. 3]. It is very easy to identify even very small lesions. right hepatic artery.
The “stack mode” is ideal for ICT image viewing.

18
[ 4 ] Image comparison between different phases with
syngo viewer in “Stack” mode – simultaneous image
scrolling within different segments – an easy, useful and
ideal way of ICT image viewing.

LU: plain CT

RU: CTAP (portal venous phase, through superior

mesenteric artery)

LL: CTA (early arterial phase, through hepatic artery)

RL: CTA (later arterial phase, through hepatic artery)

19
SOMATOM SESSIONS 11

Case 6: Diagnosis and Interventions

of Bladder Cancer
PATIENT HISTORY
An 83-year-old male patient presented with hematuria.
Computed Tomography (CT) revealed a tumor arising in
the bladder wall [Fig. 4]. Left hydroureter was seen due to
tumor invasion. Transurethral partial resection of the blad-
der tumor was performed and the histopathological diag-
nosis was transitional cell carcinoma.

INTERVENTIONAL TREATMENT
Transcatheter arterial chemoembolization was performed.
The contralateral internal iliac artery was catheterized with
a 4-F cobra type catheter [Fig. 2]. Using a coaxial tech-
nique, a microcatheter was introduced into bladder artery
superselectively [Fig. 3]. Then, CT images during super-
selective bladder arteriography were acquired with the
Angio-CT system “MIYABI”, and the tumor included in
the enhanced areas was confirmed [Fig. 5]. CDDP (50 mg /
body) was infused through this feeding artery, which was [ 1 ] Angio-CT system, MIYABI
subsequently embolized with gelatine sponge.

COMMENTS
The advantages of this treatment are its abilities to expose
tumor to a highly concentrated anticancer agent and to
avoid unexpected normal tissue damages. Because
patients with bladder cancer are generally elderly and
usually have severe arteriosclerosis, and because many
arterial variants exist around the bladder, superselective
bladder arteriography is technically difficult. In such cases,
the Angio-CT system “MIYABI” helps us to determine
the final position of the catheter tip for safe and effective
treatment.

[ 4 ] Axial CT image revealed a tumor arising in the

bladder wall.

20
[ 2 ] Contralateral internal iliac artery was catheterized [ 3 ] Using a coaxial technique, a microcatheter was
with a 4-F cobra type catheter. Image shows the feeding introduced into bladder artery superselectively.
artery of the tumor (arrow). Image shows the feeding artery of the tumor (arrow).

[ 5 ] CT images acquired during superselective bladder arteriography confirmed the tumor was
included in the enhanced areas.

21
SOMATOM SESSIONS 11

Case 7: Image Guided Radiation Therapy of

Prostate Cancer Using a Novel Combination of CT and
Linear Accelerator, the PRIMATOM

The PRIMATOM system is a unique combination of a
Siemens PRIMUS® linear accelerator and Siemens
SOMATOM CT* technologies. Using the PRIMATOM,
daily CT localization can be performed prior to each
radiation treatment, thus reducing significantly the
extrinsic and intrinsic uncertainties that are associated
with patient set up and organ motion, respectively. We
illustrate this principle in the radiation treatment of a
very common cancer in men, prostate cancer.
PATIENT HISTORY
A 73-year-old white male with prostate cancer was
referred to radiation therapy. The patient consented to the
use of the PRIMATOM because of the extreme precision of
the radiation beams. The imaging property of the
PRIMATOM directs the radiation beams to the target
(prostate) while sparing radiation dose to the adjacent
normal tissues.
enable corrections of these daily movements of the
prostate and rectum. The treatment table is then rotated
180 degrees back to the treatment position. Treatment on
the PRIMUS follows this position verification.
DIAGNOSIS AND COMMENT
The PRIMATOM provides a platform for extreme precision
in the radiation treatment of cancer. Here, the prostate
is used as an example of such treatment, but the principle
applies to cancers in any parts of the body. Image Guided
Radiation Therapy using the PRIMATOM allows “no misses”
and thus, can lead to delivery of higher doses to the tumor
while minimizing unwanted radiation to the adjacent nor-
mal tissues. With ever better imaging technologies such as
PET/ CT or other radiological advances, the PRIMATOM
could provide a platform for even more precise radiation
treatments.

EXAMINATION PROTOCOLS
For PRIMATOM treatment of the prostate, the patient is set
up on the treatment couch, with radio-opaque markers
placed over skin marks that delineate the central axis
planes. The treatment couch is rotated 180 degrees for PRI-
MATOM CT scanning. The patient is scanned by way of a
SOMATOM Plus 4 with Sliding Gantry, a movable CT scan-
ner on a pair of horizontal rails. The exact position of the
prostate and rectum are identified and localized. These
positions are then compared to the original simulated posi-
tions. Daily variations of the prostate gland and rectum
outlines from the original contour determine the daily
movement of the prostate gland in the anterior-posterior,
left-right, and cephalic-caudal directions. Similar variations
of the rectum determine the daily anterior-posterior move- [ 1 ] The PRIMATOM installation at Morristown Memorial
ment of the rectum. Deriving a new isocenter and then Hospital, Morristown, New Jersey, USA.
shifting the treatment isocenter to this new position

22
 CTV Dose coverage for 5 mm margin of PTV with prostate
movement 10 mm relative to original field

% Volume
120

Treatment Planning Day 1 100

80

60

40

20

0
40 50 60 70 80 90 100 110

Day 2 Day 3 % Dose Level

0 mm
10 mm

[ 3 ] Variation of radiation dose to the target with respect

to set up and organ movements. In a hypothetical case,
if the allowed margin of set up and organ movement is
5 mm, then a 10 mm movement of the prostate gland
would lead to insufficient dose to the prostate target (red
Day 4 Day 5 line). The green line assumes that there is no movement.

[ 2 ] Daily movement of the prostate over 5 consecutive

treatment days. The prostate is outlined in red, while the
rectum is outlined in green. As can be seen in the figures,
the prostate and rectum are dynamic structures that take
on different positions with respect to the bony landmarks.

* The PRIMATOM solution is available with the following models of

SOMATOM CT scanners (with Sliding Gantry option): SOMATOM Balance,
SOMATOM Emotion, SOMATOM Emotion Duo, SOMATOM Sensation 4
and refurbished SOMATOM Plus 4.
An existing PRIMUS, PRIMART or MEVATRON linear accelerator room
can be upgraded with a SOMATOM CT Sliding Gantry for the
PRIMATOM solution. Contact your Siemens therapy representative
for more information.

23
SOMATOM SESSIONS 11

Case 8: CT Imaging in Radiotherapy Planning

PATIENT HISTORY The patient is positioned supine and is scanned from

the level of the external auditory meatus to the level of the
A 22-year-old male patient with cystic fibrosis had under- greater trochanter. Landmarks are tattooed on the
gone bilateral lung transplantation. Although receiving patient to correlate with the scanned images. The images
anti-rejection drug therapy, his lung function was deterio- from the CT scan are transferred to the planning station
rating and he developed bronchiolitis obliterans (EXOMIO) and 3 separate fields are planned. These are
syndrome1. Chronic lung allograft rejection resulting in splenic / para aortic field, mantle field and pelvic/inguinal
sustained decline in lung function is the most common field. Specific gaps are calculated between the fields to
cause of late death after lung transplantation. It was avoid areas of overlap in underlying tissues.
decided to treat him with Total Nodal Irradiation (TNI) to try Treatment consists of parallel opposed fields given
to stabilise his condition2. twice weekly with a mid plane dose of 0.8 Gy to a total
of 8 Gy. The blood count is monitored throughout the
treatment4.
EXAMINATION PROTOCOLS According to our experience, the SOMATOM Emotion Duo
has the following advantages for radiotherapy planning:
Scanner Emotion Duo
Scan area Head / Chest / Abdo / Pelvis
3 Speed
Scan length 862 mm Prior to the use of the Emotion Duo, patients for TNI
Scan time 58.4 s were planned on the Simulator and this imaging procedure
Scan direction Craniocaudal would take at least one hour. However, using the
kV 130 SOMATOM Emotion Duo, the patient was on the CT couch
Effective mAs 79 mAs (+ CARE Dose)
for less than 10 minutes.
Rotation time 0.8 s
The scan was 862 mm in length and this was covered in
Slice collimation 4 mm
Slice width 5 mm less than one minute, due to the sub-second rotation time.
Table feed / rotation 12 mm This is a big advantage over single slice spiral scanning,
Pitch 3 where such a scan would take between 2 – 3 minutes.
Reconstruction increment 5 mm This short examination time also reduces the artefacts
Kernel B 40 s produced from breathing and movement. The patient was
CTDIw 8.5 mGy allowed to breathe gently throughout the scan in order to
reproduce the treatment conditions.
Multislice sub-second CT, as used in the SOMATOM
Comments Emotion Duo, allows scanning of longer ranges without
compromise in slice thickness and therefore image
CTNI is used for transplant rejection in patients who resolution. This is due to the SureView concept, whereby
demonstrate severe or repetitive immunologic response the slice you select is the slice you get, independent of
despite anti-rejection drug therapy. This could lead to fatal pitch. This enables a longer range to be planned using an
loss of graft. The aim of TNI is to reduce the incidence of increased feed per rotation with no compromise in the slice
recurrent rejection and decrease the amount of circling thickness that is reconstructed.
lymphocytes3. The treatment fields include most of the
body’s lymphatic tissue. Supra diaphragmatically these are
the cervical, axillary, supraclavicular, mediastinal and pul-
monary hilar lymph node groups and the thymus gland.
Sub diaphragmatically these are the para aortic, iliac,
inguinal and femoral lymph node groups and the spleen.

24
 A C

B D

[ 1 ] Coronal MPR [ 2 ] (A) Axial head, top of the range (B) Axillary level
(C) Splenic level (D) Femoral level, bottom of range

3 Accuracy REFERENCES
The use of the CT images for planning also enables the 1 Tamm M. et al; Bronchiolitis Obliterans Syndrome following heart lung
spleen to be visualised with greater accuracy than on transplantation Transplant International 1996; 9 Supplement 1: S.299 – 302.

the simulated radiographs, thus allowing more precise 2 Diamond D.A. et al Efficacy of total lymphoid irradiation for chronic
planning of this treatment field. The ability of multislice CT allograft rejection following bilateral lung tranplantation Int. Journal
to acquire 5 mm slices throughout the volume produces Radiation Oncology-Biology-Physics 1998 July 1; 41(4): S. 795 – 800.

high quality digital radiographs on the planning system,

again allowing precise placement of the treatment fields.
3 Workflow
The syngo platform allows the user to automatically trans-
fer images to the planning station as they are recon-
structed, which saves valuable time in a busy department.
3 Wolden S. et al; Long term results of total lymphoid irradiation
in the treatment of cardiac allograft rejection Int. Journal Radiation
Oncology-Biology-Physics 1997; Vol 39 (5): S. 935 – 960.
4 Yang F. E. et al: Analysis of weekly complete blood counts in patients
receiving standard fractionated partial body radiation therapy Int. Journal
Radiation Oncology-Biology-Physics 1995, Oct 15; 33 (3): S. 617– 620.

25
SOMATOM SESSIONS 11
Virtual Simulation
[ 1 ] Marking of Isocenter-Coordinates for Laser System
RADIATION TREATMENT PLANNING (RTP) has tradition-
ally been performed with the help of conventional X-ray
simulation systems, providing beam geometry that
matches that of the linear accelerator. The radiographs
are then used by physicists or dosimetrists to establish the
margins of the area to be treated, and prescribe the radia-
tion dose.
Although this technique is still in widespread use today,
Virtual Simulation – using CT or in some cases MR images
– offers detail, software image manipulation and recon-
struction, and substantial increase in patient throughput
not known on conventional simulators. For example, CT
26
imaging offers virtual fluoroscopy and 3D Beam Design,
supporting more complex radiation treatments.
Accurate virtual simulation begins with the acquisition of
thin-slice, high-resolution images. Choose from Siemens
SOMATOM family of CT scanners, covering the spectrum of
workflow needs and techniques. Through the DICOM inter-
face, Siemens CT image sets are compatible with the treat-
ment planning systems of RTP vendors such as ADAC,
NOMOS, CMS and MEDINTEC.
Siemens syngo-based Virtual Simulation* uses Siemens
imaging expertise, advanced data processing, and the
syngo software platform to provide a comprehensive * The information about this product is being provided for planning
oncology workflow solution. The application is designed to purposes. The product is pending 510(k) review, and is not yet commercially
available.
accurately model all structures, radiation beams and linear
accelerator parameters – and to produce high-quality Digi-
tal Reconstructed Radiographs (DRRs), Multiplanar Refor-
mats (MPRs), Maximum Intensity Projections (MIPs) and
Surface Shaded Displays (SSDs). A full suite of automatic /
manual contour and edit tools enables streamlined con-
touring of image data – with real-time display – while inter-
active 3D capabilities enable viewing of and navigation
through the generated structures. syngo brings fast pro-
cessing, image fusion, innovative filming tools, DICOM-RT
compliance, and any easy-to-use interface common to all
Siemens medical imaging modalities.

[ 2 ] PET/ CT tumor visualization

27
[ 3 ] Planning target definition

[ 4 ] Tissue definition [ 5 ] Beam placement, Room’s-Eye-View

28
SOMATOM SESSIONS 11

IMPRESSUM

Published by International Distribution

CT Marketing Xiaoyan Chen, M.D., MBA Stefan Schaller, Ph.D.

Siemens AG CT Concepts CT Concepts
Medical Solutions
Siemens AG, Medical Solutions Siemensstrasse 1
Siemensstrasse 1
Siemensstrasse 1 91301 Forchheim, Germany
91301 Forchheim, Germany
91301 Forchheim, Germany Phone +49-9191-18-8160
Phone +49-9191-18-9652 Fax +49-9191-18-9996
Fax +49-9191-18-9996 eMail stefan.schaller@siemens.com
eMail xiao_yan.chen@siemens.com

Anil Gupta
CT Marketing

Siemens AG, Medical Solutions

Siemensstrasse 1
91301 Forchheim, Germany
Phone +49-9191-18-8121
Fax +49-9191-18-9998
eMail anil.gupta@siemens.com

THIS ISSUE’S AUTHORS

Computed Tomography for Case 1– 4 Case 7

Oncology Care
Gerald Antoch, M.D. James R. Wong1, Lisa Grimm1,
Virtual Simulation Joerg F. Debatin, M.D., MBA Reva Oren1, Allan Scher1,
Department of Diagnostic and Chester Wilson1, Ian Altas1,
Roselle Anderson
Interventional Radiology Albert Fung1, Peter Schiff3,
Marketing Communications
University Hospital Essen Michal Chow1 and Minoru Uematsu2
Siemens Medical Solutions USA, Inc.
Hufelandstrasse 55 1
Oncology Care Systems Department of Radiation Oncology,
45122 Essen
4040 Nelson Avenue Morristown Memorial Hospital/Atlantic Health
Germany
Concord, CA 94520 System, NJ, USA;
2
USA Andreas Bockisch, M.D., PhD National Defense Medical College, Namiki,
Department of Nuclear Medicine Tokorozawa, Japan;
3
University Hospital Essen Department of Radiation Oncology,
Hufelandstrasse 55 The New York Presbyterian Hospital, NY, USA
45122 Essen
Germany Case 8

Susan Dixon, Damien Parr

Case 5–6
CT Scanning Dept.
Nakajima Takahito, M.D. Northern Centre for Cancer Treatment
Keigo Endo, M.D. Newcastle General Hospital
Jun Aoki, M.D. Newcastle-upon-Tyne NE4 6BE
Gunma University Hospital UK
Shouwa Town, 3-39-15
Sue Taylor
Maebashi City
CT Applications Specialist
Gunma Prefecture,
Siemens Medical Solutions
371-8511, Japan
UK
SOMATOM SESSIONS 11

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