The influence of bowtie filtration on cone-beam CT image quality

N. Mail, D. J. Moseley, J. H. Siewerdsen, and D. A. Jaffray

Citation: Medical Physics 36, 22 (2009); doi: 10.1118/1.3017470

View online: http://dx.doi.org/10.1118/1.3017470
View Table of Contents: http://scitation.aip.org/content/aapm/journal/medphys/36/1?ver=pdfcov
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The influence of bowtie filtration on cone-beam CT image quality
N. Mail
Radiation Medicine Program, Princess Margaret Hospital, Toronto, Ontario M5G 2M9, Canada
and Ontario Cancer Institute, University Health Network, Toronto, Ontario M5G 2M9, Canada
D. J. Moseley
Radiation Medicine Program, Princess Margaret Hospital, Toronto, Ontario M5G 2M9, Canada;
Ontario Cancer Institute, University Health Network, Toronto, Ontario M5G 2M9, Canada;
and Department of Radiation Oncology, University of Toronto, Toronto, Ontario M5G 2M9, Canada
J. H. Siewerdsen and D. A. Jaffraya兲
Radiation Medicine Program, Princess Margaret Hospital, Toronto, Ontario M5G 2M9, Canada;
Ontario Cancer Institute, University Health Network, Toronto, Ontario M5G 2M9, Canada;
and Department of Radiation Oncology and Department of Medical Biophysics, University of Toronto,
Toronto, Ontario M5G 2M9, Canada
共Received 20 February 2008; revised 10 October 2008; accepted for publication 11 October 2008;
published 4 December 2008兲
The large variation of x-ray fluence at the detector in cone-beam CT 共CBCT兲 poses a significant
challenge to detectors’ limited dynamic range, resulting in the loss of skinline as well as reduction
of CT number accuracy, contrast-to-noise ratio, and image uniformity. The authors investigate the
performance of a bowtie filter implemented in a system for image-guided radiation therapy 共Elekta
oncology system, XVI兲 as a compensator for improved image quality through fluence modulation,
reduction in x-ray scatter, and reduction in patient dose. Dose measurements with and without the
bowtie filter were performed on a CTDI Dose phantom and an empirical fit was made to calculate
dose for any radial distance from the central axis of the phantom. Regardless of patient size, shape,
anatomical site, and field of view, the bowtie filter results in an overall improvement in CT number
accuracy, image uniformity, low-contrast detectability, and imaging dose. The implemented bowtie
filter offers a significant improvement in imaging performance and is compatible with the current
clinical system for image-guided radiation therapy. © 2009 American Association of Physicists in
Medicine. 关DOI: 10.1118/1.3017470兴

Key words: bowtie filter, Elekta synergy CBCT system, image quality, dose

I. INTRODUCTION Previously, beam shaping x-ray filters or compensators

Cone-beam computed tomography 共CBCT兲 systems are em-
ployed in radiation therapy to provide information regarding
daily target and normal tissue localization during the course
of fractionated radiation treatment. CBCT allows radiation to
be directed at tumors with greater accuracy and precision
than was previously possible. However, improving CBCT
image quality further will allow more precise dose delivery
to the tumor. Precision in tumor localization and reduction in
setup error is based on image quality of CBCT system. How-
ever, flat-panel detectors used in CBCT have limited dy-
namic range compared to CT. These limitations are exposed
by the large variation of x-ray fluence at the detector across
the imaged field-of-view. It is often the case that the tech-
niques used overwhelm the signal range of the detector at the
periphery of the patient, leading to a loss of information in
projections and artifacts in reconstruction due to the trunca-
tion of anatomy. As a result, effects include the loss of skin-
line and reduction in CT number accuracy, contrast, and im-
age uniformity. The purpose of this study is to investigate the
relative advantages and limitations of a bowtie filter for im-
proving image quality of a commercially used CBCT Elekta
Synergy System. The implementation of a bowtie filter in
CBCT offers the method of addressing the issue of x-ray flux
variation across the detector.
have been used in computed tomography 共CT兲 to modify the
distribution of x-ray flux across the field of view. Compen-
sator filters have been used in CT for beam hardening1–5 and
reduction6–8 in dose to the patient. These compensators have
been used in CBCT for scatter9–11 and heel12 compensation.
Initially, compensators have been used to improve the detect-
ability in film radiographs with the delivery of more uniform
fluence at the film.13
Bowtie filters potentially play a larger role in scatter,
beam hardening, uniform fluence across the detector, and
dose reduction. Quantitative investigations are performed on
the Elekta Synergy radiotherapy image-guidance system.
These investigations provides quantitative evidence of
bowtie filter for improving skinline, image uniformity, CT
number accuracy, contrast, and reduction in streak artifacts
and patient dose.
II. MATERIALS AND METHODS
II.A. Cone-beam CT system
Investigations of bowtie filter use in CBCT were per-
formed on Elekta oncology system shown in Fig. 1共a兲. The
x-ray source uses a rotating anode x-ray tube 共DunleeD604,
IL兲 with maximum potential of 150 kVp, 14 deg tungsten

22 Med. Phys. 36 „1…, January 2009 0094-2405/2009/36„1…/22/11/$25.00 © 2009 Am. Assoc. Phys. Med. 22
23 Mail et al.: The influence of bowtie filtration on cone-beam CT image quality 23

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FIG. 1. 共a兲 A photograph of the cone-beam CT Elekta Synergy CBCT system. 共b兲 A schematic of the CBCT offset geometry at angle 0 deg and medium FOV.
共c兲 Schematic of the CBCT offset geometry and medium FOV after 180 deg rotation.

target, and 0.8 mm focal spot. The detector used was the
RID1640-Al1 共Perkin Elmer, Wiesbaden, Germany兲 indirect-
detection flat-panel imager with a 1024⫻ 1024 array of
0.4 mm⫻ 0.4 mm pixels and a 0.55 mm thick CsI:Tl x-ray
converter. The geometry of the system was configured to
have a source-to-isocenter distance of 100 cm and source-to-
detector distance of 153.6 cm.
The x-ray tube and flat-panel imager were placed orthogo-
nally to the treatment head and its EPID imaging device. The
kV system shares a common axis of rotation with the MV
treatment source. The kV beam is 425⫻ 425 mm2 incident
on the flat-panel detector. Images can be acquired with three
different fields-of-view 共FOV兲; small, medium, and large.
The difference between the three is the edge to the kV central
beam, which is 138 mm for the small FOV, 213 mm for the
medium FOV, and 262 mm for the large field of view. Dur-
ing 360 deg rotations the system acquires approximately 650
projection images. The size of the flat-panel detector is 410
⫻ 410 mm2 and is located at a fixed source to detector dis-
tance, resulting in limited FOVs along the x and z direction.
An offset scanning geometry was used, in which the imager
was shifted laterally 10 cm and a corresponding asymmetric
beam, defined by an M20 collimator, was utilized to scan a
larger FOV. This offset geometry 关Fig. 1共b兲兴 was used to
provide the optimum image sets, in terms of quality and
reconstructed FOV. The Feldkamp algorithm for 3D filtered

35
(a) (b)

85mm 25
Thickness (mm)

15
117mm

-5
-10 15 40 65 90 115 140
Length (mm)

FIG. 2. 共a兲 Photograph of the Elekta designed bowtie filter. 共b兲 Bowtie thickness measured with needle gauge as a function of length.

Medical Physics, Vol. 36, No. 1, January 2009

24 Mail et al.: The influence of bowtie filtration on cone-beam CT image quality 24

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FIG. 3. 共a兲 A schematic diagram of the CTDI body phantom. 共b兲 Percentage of dose reduction with bowtie filter is plotted as a function of radial distance from
the phantom center. Symbol represents measured data and solid line theoretical fit. 共c兲 Circular 共Catphan兲 phantom with an irregular annulus 共human torso兲.

back-projection algorithm was used for CBCT reconstruc-
tion, with a Hann reconstruction filter. The total recon-
structed volume used in this work was 410⫻ 410
⫻ 264 mm3 with voxel size of 1 ⫻ 1 ⫻ 1 mm3.
II.B. Bowtie filter
An aluminum bowtie filter 共Elekta, Filter Cassette Assem-
bly, F1兲 was employed for all the tests described here. This
F1 filter was inserted in the filter tray 30 cm from the x-ray
source on an Elekta Synergy XVI unit. For the medium FOV,
a cassette of M20 collimator was inserted between the x-ray
tube and F1 filter shown in Fig. 2共a兲. There are various pos-
sible designs for bowtie filters implemented on Elekta Syn-
ergy XVI systems. Bowtie filters could potentially be opti-
mized based on a variety of imaging tasks while accounting
for tradeoffs between image quality and patient dose. The
design of the bowtie filter used here is based on patient size,
dose, nominal x-ray energy, and material.
The bowtie filter used in this study 关Fig. 2共a兲兴 has no
modulation in the z direction. The filter used for this work
was built based on the objective of achieving uniform flu-
ence through a cylindrical water phantom of diameter
300 mm measured at 120 kVp. The manufacturing material
was aluminum of size 85⫻ 135 mm2. The bowtie filter thick-
ness measured with a needle gauge as a function of length is
shown in Fig. 2共b兲. The filter was rigidly mounted in the
cassette with a 1 mm thick acrylic covering protecting it
from physical damage or scratching.
II.C. Dosimetry measurements
Dose measurements were made with and without a bowtie
filter, such that the scanning geometry, phantom size, beam
quality, and mAs/projections were the same for both cases.
The phantom 共shown in Fig. 3共a兲兴 was a PMMA CTDI do-
simetry phantom with diameter of 320 mm and thickness of
150 mm 共RTI Electronics, Mölndal, Sweden兲. Two low-
density polyethylene 共LDPE兲 blocks 共32⫻ 32⫻ 15 cm3兲
were placed superior and inferior to the acrylic phantom to
simulate scattered dose. The center of the phantom was
placed at the machine isocenter position. This specially de-
signed phantom allows for accurate positioning of radiation
detectors. A 0.6 cc farmer-type ion chamber 共NE 2571,
Nuclear Associates兲 and Fluke 3504 electrometer at atmo-
spheric pressure 756.2 共mmHg兲 and room temperature
22 ° C was used for dose measurements. The dose was mea-
sured at five different radial positions of the phantom, start-
ing from the phantom center to the skin. A total of five
CBCT scans were obtained, with and without a bowtie filter
at 120 kVp and 1.6 mAs per projection 共⬃660 projections兲.
The ratio of doses with and without bowtie was modeled for
all the radial positions of the phantom’s center to periphery.
This model contained four fitting coefficients and is very
useful to compute the dose reduction attributed to the bowtie
at any radial position of the CTDI phantom.
II.D. Scatter-to-primary ratio measurements
Scatter-to-primary ratio was measured for imaging condi-
tions with and without the bowtie filter using a beam-blocker
method.9 The SPR can be defined as
S
SPR = , 共1兲
P
where S is the energy integrated signal of the scattered ra-
diation measured as the average of a 10⫻ 10 pixel2 area on

Medical Physics, Vol. 36, No. 1, January 2009

25 Mail et al.: The influence of bowtie filtration on cone-beam CT image quality
the FPI, and P is the signal from the primary radiation. The
same CBCT system/geometry was used as discussed in Sec.
II A. The SPR measurements were performed at the center
and edge of the projection image for the circular and irregu-
lar 关posterior-anterior 共PA兲 view兴 phantoms. A 10⫻ 10
⫻ 4 mm3 lead block was placed on the central axis before the
phantom on the side facing the source. The scatter account-
ing for shadowing a part of the phantom by the blocker was
not included for this SPR data. Twenty 共20兲 images of the
circular and irregular phantoms were acquired with and with-
out the bowtie filter at the tube voltage of 120 kVp and ex-
posures 1.0 and 1.6 mAs, respectively. The SPR measure-
ments were performed on an irregular phantom at equivalent
patient dose techniques 共0.1 mGy/exposure兲 for with and
without the bowtie filter. This required an exposure of
1.6 mAs/projection 共bowtie filter兲 as compared to
1.0 mAs/projection 共without bowtie filter兲 at 120 kVp. The
same procedure was used for the SPR measurements at the
phantom’s edge except the block was moved from the center
to the edge of the phantom’s projection.
II.E. CBCT image quality: Phantom study
The Catphan 500 共The Phantom Laboratory, Salem, NY兲
was employed in these investigations. Experiments were per-
formed with the Catphan 500 phantom alone 共referred to as
“circular phantom”兲 and with the Catphan 500 phantom in-
serted in an irregular annulus 关referred to as “irregular phan-
tom;” Fig. 3共c兲兴 shaped to reflect a humanoid torso. Two
types of configurations were used to evaluate overall CBCT
image quality with and without a bowtie filter. The phantom
was positioned at the center of the imaging field of view with
the help of room lasers. A photograph of the cone-beam CT
system is shown in Fig. 1共a兲. Image acquisition proceeded
with gantry rotation over 360 deg for all the cases during
which approximately 660 planar images were acquired at the
medium FOV. Images of the circular phantom, with and
without bowtie filter, were acquired under the same imaging
conditions at 120 kVp and tube current 40 mA and exposure
time 20 ms per projection. Similarly, images of the irregular
phantom with and without bowtie were acquired under the
same imaging conditions at 120 kVp and tube current 40 mA
and exposure time 40 ms, respectively. The CBCT recon-
struction algorithm includes a scatter correction technique as
described by Boellaard et al.14 The irregular phantom was
scanned using a conventional helical CT scanner 共Discovery
ST 16 slice, GE Healthcare, Milwaukee, WI兲 at 120 kVp and
300 mAs. The total number of CT reconstructed slices were
264 with each slice thickness of 1 mm and voxel size of 1
⫻ 1 ⫻ 1 mm3. The CT number for both CBCT and CT im-
ages was defined as CT# = 关共␮object − ␮water兲 / ␮water兴
⫻ 1000 HU, where ␮object and ␮water are the linear attenua-
tion coefficients for the object and water, respectively. Quan-
titative comparison of image quality based on skinline recov-
ery, CT number accuracy, CT number uniformity, spatial
resolution, and contrast-to-noise ratio were evaluated using
the circular phantom tests performed in acquisitions with and
Medical Physics, Vol. 36, No. 1, January 2009
25
without the bowtie filter. Imaging metrics were also per-
formed on images generated on a conventional CT scanner.
II.E.1. Uniformity
The uniformity measurements were performed on the cir-
cular and irregular phantoms. The circular phantom contains
a uniform, water-equivalent portion 共CTP486兲 with CT num-
ber 共HU兲 within −10 and +10 HU at standard scanning pro-
tocols. The CBCT images were analyzed in Matlab. Five
ROIs of size 10⫻ 10 mm2 were selected in CBCT images of
the phantom—one at the center and four at peripheral posi-
tions symmetrically around the center, each within the cen-
tral axial plane. The spatial nonuniformity 共SNU兲 was de-
fined as
VVmax − VVmin
SNU = ⫻ 100, 共2兲
1000
where VVmax and VVmin are the maximum and minimum
mean voxel values, respectively, within each ROI.
II.E.2. Skinline artifacts/Reduction in CT number at
skin zone
In CBCT images, the reduction in CT number 共RCTN兲 at
the skin zone is attributed to the detector saturation near the
object periphery. Measurements were performed on circular
and irregular phantoms. The reduction in CT number 共de-
noted ⌬CT#兲 was measured using 3 ROIs at skin depths 5,
10, and 20 mm. The size of each ROI was 4 ⫻ 4 mm2. The
average reduction in CT 共RCTN兲 was calculated as
HUCT − HUCBCT
RCTN = ⫻ 100, 共3兲
HUCT
where HUCT and HUCBCT are the mean voxel values for a
given ROI measured in helical CT and CBCT images, re-
spectively.
II.E.3. CT number accuracy and linearity
The CT number accuracy and linearity measurements
were performed on circular and irregular phantoms. The
phantom contains seven different cylindrical contrast inserts
共12 mm diameter, CTP 404兲 with known electron densities
and CT numbers. The mean HU value was measured for each
contrast insert. The CBCT images were converted into polar
coordinates for convenient analysis. A 2D ROI size was ap-
proximately 4 ⫻ 4 mm2 covering approximately 16 voxels
and was confined to within the contrast inserts. For conven-
tional CT images, the 2D ROI size was 4 ⫻ 4 mm2. The
voxel values in helical CT images of the phantom defined the
true CT number.
II.E.4. Contrast-to-noise ratio
CNR measurements were performed using the circular
and irregular phantoms 共CTP 404 module兲, including poly-
styrene 共PS, −100 HU兲 and low-density polyethylene
共LDPE, −35 HU兲 inserts of 12 mm diameter. Contrast-to-
noise ratio 共CNR兲 measurements were performed on circular
26 Mail et al.: The influence of bowtie filtration on cone-beam CT image quality 26

TABLE I. The scatter, primary, and scatter-to-primary ratios behind the center and edge of the circular 共Cat-
Phan500兲 phantom using lead strip of size 10⫻ 10⫻ 3.5 mm3.

Scatter at Primary at Scatter at Primary at

phantom phantom phantom phantom Scatter-to- Scatter-to-
Scanning center center periphery periphery primary ratio primary ratio
techniques 共ADU兲 共ADU兲 共ADU兲 共ADU兲 at center at edge

Bowtie 302 801 602 6594 0.377⫾ 0.02 0.092⫾ 0.02

120 kVp/ 0.8 mAs
Without bowtie 630 1212 1301 12 730 0.519⫾ 0.03 0.102⫾ 0.02
120 kVp/ 1.6 mAs

and irregular phantoms. For each individual phantom, the
imaging conditions including kVp, exposure time, and tube
current were the same, with and without the bowtie filter.
ROIs of size 4 ⫻ 4 mm2 共⬃4 ⫻ 4 voxels兲 within each insert
were used to measure the mean and standard deviation
共noise兲 in HU value. The mean HU value was measured for
each contrast insert. The CNR 共signal difference divided by
average noise兲 values was calculated as
关HU共LDPE兲 − HU共PS兲兴
CNR = 2 ⫻ , 共4兲
Noise共LDPE兲 + Noise共PS兲
where HU共LDPE兲 and HU共PS兲 are the mean voxel values in
LDPE and PS, respectively, and Noise共LDPE兲 and
Noise共PS兲 are the standard deviation in voxel values in
LDPE and PS, respectively.
II.F. Patient study
CBCT image quality measurements including uniformity
and skinline reconstruction were performed on ten gyneco-
logical patients. But only one patient is reported here be-
cause there were no significant differences from patient to
patient. Images were acquired with and without a bowtie
filter at 120 kVp and 1.6 mAs 共⬃650 projections acquired
across 360 deg. The same CBCT system geometry and pro-
cedure was used as explained in the phantom study section.
CBCT reconstructions with and without bowtie filter were
analyzed quantitatively 共difference images兲 and qualitatively
共examination by a radiation oncologist兲. Of specific interest
in these studies were the gynecological patient contrast and
the reduction in CT number 共cupping artifact兲 from the skin-
line to the center of the image.

II.E.5. Spatial resolution and modulation transfer

function
The MTF measurements were performed on circular and
irregular phantoms using the CTP528 module, which con-
tains a radial high contrast spatial resolution bar pattern rang-
ing from 1 through 21 line pair per cm. A bar pattern may be
considered resolved if the bars can be perceived with some
discernible spacing or lowering density among them. The
radial design eliminates the possibility of streaking artifacts
from other test objects. A circular pattern of pixels 共passing
through the bar patterns兲 was taken to obtain square-wave
response function 共SWRF兲. The amplitude response at vari-
ous spatial frequencies was analyzed between 1 and
21 lp/ cm. The MTF of the system was determined by decon-
volving out the SWRF.15
III. RESULTS AND DISCUSSIONS
III.A. Dose measurements for kV CBCT
The uncertainty of the ion chamber measurements was
determined 共standard deviation/mean value兲 to be with in
⫾0.55%. The dose reduction 共define in methods兲 with
bowtie filter as a function of radial distance from the phan-
tom center is shown in Fig. 3共b兲. It shows the achievable
decrease in dose at the center and periphery of the body
phantom with the bowtie used in this study. Dose reductions
by 25% and 43% were found at phantom center and skin
depth of 1 cm, respectively. It may be noted that the increase
in dose reduction was consistent and followed a Lorentzian
peak function 共LPF兲. A theoretical fit represented by a solid
line is shown in Fig. 3共b兲. Dose reduction with a bowtie as a

TABLE II. The scatter, primary, and scatter to primary ratios behind the center and edge of the irregular
共Cat-Irreg兲 phantom using lead strip of size 10⫻ 10⫻ 3.5 mm3.

Scatter at Primary at Scatter at Primary at Scatter to

phantom phantom phantom phantom primary Scatter to
Scanning center center periphery periphery ratio at primary
techniques 共ADU兲 共ADU兲 共ADU兲 共ADU兲 center ratio at edge

Bowtie 1011 2280 2539 20 427 0.443⫾ 0.03 0.124⫾ 0.01

120 kVp/ 1.6 mAs
Without bowtie 2125 3221 4240 31 921 0.661⫾ 0.03 0.133⫾ 0.01
120 kVp/ 1.6 mAs
Without bowtie 1328 2059 2625 1937 0.645⫾ 0.025 0.132⫾ 0.01
120 kVp/ 1.0 mAs

Medical Physics, Vol. 36, No. 1, January 2009

27 Mail et al.: The influence of bowtie filtration on cone-beam CT image quality
!" )"
" III.C.1. Uniformity and skinline
&""
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" bowtie filter are shown in Figs. 4共a兲 and 4共b兲, respectively.
&""
45 6789:
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FIG. 4. Trans-axial images of uniform water portion of a circular phantom
共Catphan兲 acquired 共a兲 without 共window level −130 to 150 HU and 共b兲 with
bowtie filter 共window level: −130 to 150 HU兲. 共c兲 Profiles through the uni-
form water portion of the circular phantom with and without bowtie; the
profile position is indicated by a dotted line in image.
function of the radial distance, X, from the center of the
dosimetry phantom was calculated using an LPF function:
2AB
D共X兲 = D0 + , 共5兲
4␲共X − C兲 + B2
where D0 is the intercept and A, B, and C are the fitting
coefficients. The values of the intercept and fitting coeffi-
cients are listed in Fig. 3共b兲. With the help of Eq. 共5兲, the
dose reduction with the bowtie filter can be calculated for
any radial distance within the body phantom. Also this em-
pirical fit will assist in the design for an optimum bowtie
filter.
III.B. Scatter-to-primary ratio
The SPR at the center of each phantom is higher than the
SPR measured at the edges. But the absolute scatter signal is
higher at the edges of both phantoms including circular and
irregular. The SPR values for the circular and irregular phan-
toms for with and without bowtie filter are listed in Tables I
and II, respectively. It shows that the scatter signal at the
phantom’s edge is higher than the primary signal at the cen-
ter for the case without the bowtie filter. The absolute scatter
signal at the edges of both phantoms is almost two times less
than without the bowtie filter. This high absolute scatter sig-
nal strongly affects the SPR behind the center of the phantom
and hence image quality. Also, the SPR values at the center
and edge are higher for the irregular phantom because of the
size and excessive fluence at the edge that creates high scat-
ter and affects the SPR at the center 共throughout the image兲.
The bowtie filter shapes and modulates the beam to reduce
Medical Physics, Vol. 36, No. 1, January 2009
27
the unwanted signal at the object’s periphery and hence im-
proves the SPR behind the phantom’s center and prevents
detector saturation at the skin zone.
III.C. CBCT image quality: Phantom study
Trans-axial CBCT images of a uniform water-equivalent
portion of the circular phantom acquired without and with
Profiles through the images are shown in Fig. 4共c兲; the pro-
file position is indicated by a dotted line in the image. Image
关Fig. 4共a兲兴 and its profile both show severe reduction in CT
number near the skin zone, which reduces as a function of
skin depth. This is due to the signal range of the detector
共saturation兲 at the periphery of the phantom, leading to a loss
of information in projections that creates a skinline artifact in
the reconstruction. Approximately 15% of average reduction
in CT number was measured at 1 cm skin depth. The CBCT
image with the bowtie filter 关Fig. 4共b兲兴 and its profile 关Fig.
4共c兲兴 demonstrate significant improvement in the recovery of
CT number at the skin zone compared to the nominal case.
Almost 100% of the CT number is restored at 1 cm skin
depth. The bowtie filter improves image uniformity by 共i兲
flattening of the fluence profile at the detector 共thereby re-
ducing the dynamic range requirement and preventing detec-
tor saturation at the skinline兲 and 共ii兲 attenuates more fluence
at the edge of the field which reduces the primary beam on
the periphery of the phantom, which, in turn reduces scatter
throughout the image. The reduction in scatter throughout
the image has the greatest advantage in the center of the
image where the bowtie has minimally affected the primary
fluence. The mean spatial non-uniformity, as defined in Eq.
共2兲, was 2.1% and 9.8% for image acquired with and without
a bowtie filter, respectively. The higher non-uniformity num-
ber as defined in Eq. 共2兲 means poorer uniformity.
Trans-axial CBCT images of irregular phantom acquired
without and with bowtie filter are shown in Figs. 5共a兲 and
5共b兲, respectively, at the same window/level. The difference
image 共image without bowtie subtracted from the image ac-
quired with bowtie兲 is shown in Fig. 5共c兲. Profiles through
the reconstructed slices of CBCT images are compared with
helical CT in Fig. 5共d兲, with the bowtie filter case providing
an improvement in edge definition. The images and profiles
show a severe reduction of CT number near the skin zone in
the nominal CBCT image. Since the irregular phantom is
larger in size than the circular phantom, a higher exposure is
required for sufficient signal behind the center of the object,
resulting in increased pixel saturation near the phantom pe-
riphery, which is the main source of CT number reduction at
the skinline. Even with the bowtie filter case, there is still
some missing skin on the right shoulder of the image profile
in Fig. 5共d兲. This is due to the detector lag and ghosting
effects. As the object is irregularly shaped, the projected lo-
cation of skinline relative to previous projections causes an
accumulated lag signal that degrades the reconstruction and
results in reduction in CT number in the skinline zone. The
gantry rotates clockwise around an irregular phantom, which
28 Mail et al.: The influence of bowtie filtration on cone-beam CT image quality 28

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FIG. 5. Trans-axial CBCT images of irregular 共Cat-Irreg兲 phantom 共a兲 without 共window level: −350 to 500 HU兲 and 共b兲 with bowtie filter 共window level:
−350 to 500 HU兲. 共c兲 The difference of image 共b兲 and 共a兲. 共d兲 Profiles through the uniform water portion of the irregular phantom. 共e兲 The right shoulder of
共d兲 is magnified to see the missing skinline more clearly. 共f兲 Reduction in CT number 共RCTN兲 at several skin depths for with and without bowtie filter.

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FIG. 6. Trans-axial images of circular phantom with several contrast inserts acquired 共a兲 without 共window level −800 to 500 HU兲 and 共b兲 with bowtie filter
共window level −800 to 500 HU兲. 共c兲 The same image shown in 共a兲, but transformed into polar coordinate 共window level −800 to 500 HU兲. 共d兲 Profiles
through the image 共c兲 with several inserts are compared with CT and without bowtie filter. 共e兲 The difference between the measured CT and CBCT number
plotted as a function of Ideal CT number for several inserts. The empty circle and filled square symbols represent CT number error with and without bowtie.
A gray solid line represents a linear fit to bowtie data.

Medical Physics, Vol. 36, No. 1, January 2009

29 Mail et al.: The influence of bowtie filtration on cone-beam CT image quality 29

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FIG. 7. Trans-axial CBCT images of irregular 共CatគIrreg兲 with several inserts, 共a兲 without bowtie 共window level −350 to 500 HU兲 and 共b兲 with bowtie filter
共window level −350 to 500 HU兲. 共c兲 The difference of image 共b兲 and 共a兲. 共d兲 The same image in 共a兲 but converted into polar coordinates 共window level
−700 to 300 HU兲. 共e兲 The same image in 共b兲 but converted into polar coordinates to make it simple for analysis such as CT number accuracy and streaking
artifacts 共window level −700 to 300 HU兲. 共f兲 The measured CT number plotted as a function of ideal CT number for several inserts.

causes lag on the right side of the image. Mail et al.16 quan-
titatively explained this lag effect in CBCT images of irregu-
lar phantom acquired with and without bowtie filter. Even
without a bowtie filter, the reduction in CT number at the
skinline is worse on the right shoulder than the left in Fig.
5共d兲, due to the lag and ghosting.16 This clearly explains the
bowtie case where the reduction in CT number at the skinline
on the right shoulder in Fig. 5共d兲 is due to lag and ghosting16
共not due to the compatibility of the bowtie filter for an ir-
regular shaped phantom兲. The shoulder on the right hand side
of Fig. 5共d兲 is magnified in Fig. 5共e兲 to illustrate the reduced
signal at the periphery. The mean reduction in the CT num-
ber at the skin region, as defined in Eq. 共3兲, is quantitatively
shown in Fig. 5共f兲 for three different skin depths for both
cases. The mean signal losses for skin depths of 5, 10, and
20 mm were found 35.1%, 25.15%, and 20.12%, respec-
tively, in cases without bowtie filter images. These numbers
in bowtie cases were measured 13.8%, 12.5%, and 11%.
The spatial non-uniformities of the irregular phantom
without and with bowtie filter 关Figs. 5共a兲 and 5共b兲兴 were
calculated to be 4.1% and 5.7%, respectively. Profiles in Fig.
5共d兲 show that the CT and CBCT images with the bowtie
filter have similar uniformity within the circular phantom
region.
spectively. For convenient analysis, the image in Fig. 6共b兲
was transformed into polar coordinate in Fig. 6共c兲. A profile
through several inserts, indicated by a dotted line in image, is
shown in Fig. 6共d兲. The dotted, solid black, and gray solid
lines represent CT and CBCT with and without bowtie filter
image profiles, respectively. This signal profile shows that
CBCT image acquired with a bowtie filter is comparable to
helical CT. The comparison of CT number accuracy and lin-
earity for circular phantom, without and with the bowtie fil-
ter, is shown in Fig. 6共e兲, where the difference of measured
CT number to CBCT is plotted versus the ideal CT number.
The CBCT with bowtie filter demonstrated a clear improve-
ment in CT number accuracy and an increase in image con-
trast compared to the nominal cases. For the nominal case,
inaccuracy in CT number is related to the assumption that the
detected signal is all primary fluence. Scattered fluence
clearly violates this assumption. Reducing scatter will lead to
more accurate CT numbers by allowing accurate inversion of
TABLE III. Comparison of the CT number accuracy and linearity using three
different techniques in terms of slope, intercept 共at ideal CT# water兲, and R2
values.
Techniques Slope R2 Intercept

III.C.2. CT number accuracy and linearity CT 0.98 0.995 4

Bowtie 0.85 0.99 43
The central slice images of a circular phantom without Without bowtie 0.71 0.98 −3
and with bowtie filter are shown in Figs. 6共a兲 and 6共b兲, re-

Medical Physics, Vol. 36, No. 1, January 2009

30 Mail et al.: The influence of bowtie filtration on cone-beam CT image quality
Beer’s law. It should be noted that other invalid assumptions
共e.g., beam hardening兲 can lead to inaccuracies in CT num-
ber as well. The improvement in CT number accuracy with
the bowtie filter is primarily attributed to the scatter reduc-
tion 共with improved beam-hardening and non-uniformity
also contributing to improved CT number accuracy兲 through-
out the image and particularly near the phantom’s periphery.
This reduction in scatter reduces the scatter to primary ratio
and hence improves CT number accuracy. The CT number
accuracies with and without a bowtie filter were found to be
⫾21 and ⫾68 HU, respectively.
Central slice images of the irregular phantom with and
without a bowtie filter are shown in Figs. 7共a兲 and 7共b兲,
respectively. These images were then transformed into polar
coordinates to make the image analysis simple. The trans-
formed polar coordinate images are shown in Figs. 7共d兲 and
7共e兲. In Fig. 7共f兲, the measured CT number for Catphan
phantom within irregular annulus is plotted versus the ideal
CT number. The measurements performed with a bowtie fil-
ter showed greater linear CT number accuracy than nominal.
The mean CT number obtained from a conventional CT im-
age showed reasonably good agreement with the expected
CT numbers. Detailed comparisons of the CT number accu-
racy and linearity in terms of slope, R2 values, and intercepts
are shown in Table III. The slope of the fitting line and in-
tercept values are reasonably improved. The CT number ac-
curacy for the helical CT and CBCT acquired with a bowtie
is higher than the nominal CBCT images. This is because of
the influence of scatter radiation in nominal CBCT, which is
more severe as compared to that of a fan beam geometry. In
general, x-ray scatter reduces image contrast, increases im-
age noise, and may introduce reconstruction error into
CBCT.
III.C.3. Contrast-to-noise ratio and streak artifacts
CNR measurements were performed on Catphan and ir-
regular phantoms 共contrast inserts, LDPE and Polystyrene兲.
For Catphan phantom, the CNR, as defined in Eq. 共4兲, was
measured as 4.51⫾ 0.43 and 3.58⫾ 0.35, with and without a
bowtie filter, respectively 共an improvement by a factor of 1.3
at fixed mAs兲. The improvement is likely due primarily to
reduced scatter 共with improved beam-hardening and non-
uniformity also contributing to improved CNR兲. The CNR
values for the irregular phantom were found to be
4.22⫾ 0.41 and 2.24⫾ 0.32, with and without bowtie cases,
respectively 共at equivalent mAs兲. The improvement in CNR
is found to be much greater for the irregular than circular
phantom. A primarily possible approach is that for the with-
out bowtie case, the amount of scatter in the irregular phan-
tom is higher than in the circular phantom, particularly at the
phantom’s peripheries. The CNR in the nominal case is sig-
nificantly reduced for the irregular phantom than for the cir-
cular phantom, while this reduction is very small in the case
of the bowtie filter. This is because of the scatter compensa-
tion. Comparing images acquired at equivalent patient dose
Medical Physics, Vol. 36, No. 1, January 2009
30
1
0.8 Bowtie
without bowtie
0.6
MTF
0.4
0.2
0
0 1 2 3 4 5 6 7 8 9 10 11
-1
Line pairs (cm )
FIG. 8. Measured MTF performed on irregular phantoms using the CTP528
module 共Catphan500兲 plotted as a function of line pairs with and without
bowtie filter.
共⬃0.1 mGy/exposure兲, the comparison of CNR improves
even further, giving a CNR of 4.22⫾ 0.41 for the bowtie,
compared to 1.61⫾ 0.3 without a bowtie.
The central slices of irregular phantom converted into po-
lar coordinates with and without the bowtie filter are shown
in Figs. 7共e兲 and 7共d兲, respectively. The streaking artifacts
are more visible around the high-density inserts in the polar
coordinate image acquired without the bowtie filter. These
streaking artifacts appear due to scatter and beam
hardening.17 Beam hardening and scatter effects are worse
because of the large size and irregular shape of the phantom
and the presence of high contrast objects. The image in Fig.
7共e兲 acquired with a bowtie filter is almost free of streaking
artifacts. The scatter compensation reduces streaking arti-
facts and improves CNR. The bowtie filter reduces beam
hardening effects by minimizing the range of variation in
x-ray energies presented to the detector. For example, con-
sidering the PA projection of the irregular phantom, the mean
energy of the x-ray beam is 75 keV at the center of the
detector 共path length 320 mm acrylic兲 and 64 keV near the
periphery 共path length 100 mm acrylic兲. With a bowtie filter,
however, the range in energy is reduced to 76 keV at the
center and 76 keV at the periphery. Beam-hardening artifacts
are therefore expected to be mitigated significantly by the
bowtie filter.
III.C.4. Spatial resolution and modulation transfer
function
The spatial resolutions 共for 50% MTF兲 of the circular
phantom’s images acquired with and without a bowtie filter
were measured as 2.3⫾ 0.11 and 2.2⫾ 0.1 lp/ cm, respec-
tively. The MTF is essentially equivalent with or without a
bowtie filter, with the curves of Fig. 8 showing consistent
shape between the two cases. For the irregular phantom, the
spatial resolutions 共for 50% MTF兲 were measured as
2.1⫾ 0.08 and 2.0⫾ 0.06 lp/ cm with and without a bowtie,
respectively. The measured MTFs for with and without the
bowtie filter have the same values within the error bar.
31 Mail et al.: The influence of bowtie filtration on cone-beam CT image quality
!" !"
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FIG. 9. CBCT images of gynecological patient 共window level −500 to 500 HU兲 共a兲 without bowtie and 共b兲 with bowtie 共window level −500 to 500 HU兲.
Profiles through the region of interest, indicated by a solid line. 共d兲 A portion of 共c兲, indicated by a rectangular box, is magnified to illustrate signal loss more
clearly at skinline zone.
III.D. Patient study
CBCT images of a gynecological patient acquired without
and with a bowtie filter are shown with the same window
level in Figs. 9共a兲 and 9共b兲, respectively. Profiles through the
images are shown in Fig. 9共c兲. Moderate improvements in
uniformity and skinline reconstruction are seen with the
bowtie filter. Improvement in skinline reconstruction is
clearly shown in Fig. 9共d兲, which is the magnified portion
indicated on the right of Fig. 9共c兲. The black spots in the
images are a brachytherapy applicator used as a fiducial
marker. The image in Fig. 9共a兲 demonstrates less clarity due
to high scatter-to-primary ratio while the image in Fig. 9共b兲
demonstrates clarity due to reduction in scatter-to-primary
with the bowtie filter.
IV. DISCUSSIONS
A fixed, shaped filter has been used to selectively attenu-
ate x rays at the periphery of the exposed field-of-view to
compensate for the patient profile. The filter reduces the dy-
namic range demands on the detector during a CBCT scan.
The resulting flux on the detector is relatively uniform across
the detector and does not result in saturation in regions be-
yond the skinline. Further, the reduction of the excessive
fluence near the skin zone with a bowtie filter reduces the
absolute scatter signal at the object’s edge. This reduction in
the absolute scatter signal improves the SPR behind the cen-
ter of the phantom and hence image quality. The influence of
the bowtie filter on both dose and image quality was evalu-
ated. The application of the bowtie filter for circular and
irregular phantoms resulted in an improvement in image
quality and reduction/alteration in the dose distribution
within the patient. Figure 3共b兲 demonstrates that the applica-
Medical Physics, Vol. 36, No. 1, January 2009
31
)" )"
""
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&%"
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?>;<*,
<%"
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tion of the bowtie filter results in a reduction in dose by 43%
at the skinline and 26% at the phantom center. Assessment of
contrast-to-noise performance demonstrated an improvement
when the bowtie filter is employed. This was specifically
observed in the large sized phantom 共irregular phantom兲
where scatter is increased. Overall, the bowtie improves CT
number accuracy and image uniformity. This improvement is
attributed to the scatter reduction, beam hardening reduction,
and flatness of fluence at the detector.
The selection/design of a bowtie filter is challenging and
will always be less than ideal. It is not likely to be optimum
given that a subject being imaged is significantly less than
uniform, not exactly cylindrical in shape, and not necessarily
centrally located in the x-ray beam. In such cases, it is pos-
sible for one or more disjointed regions of saturation to occur
or conversely to over-filter the x-ray flux and unnecessarily
create regions of very low signal. Regardless of compro-
mises associated with patient size, shape, anatomical site,
and field of view, the use of a simple bowtie filter results in
an overall improvement in the quality of CBCT images.
V. CONCLUSION
The implemented bowtie filter shows reduction in scatter-
to-primary ratio for the circular and irregular phantoms. The
bowtie filter shows an improvement in image quality includ-
ing uniformity, CT number accuracy, contrast-to-noise ratio,
and skinline reconstruction of the circular and irregular
phantoms. The implementation of a bowtie filer also reduced
streaking artifacts in CBCT images of an irregular phantom
compared to nominal. The implemented bowtie filter demon-
strated an improvement in skinline reconstruction and unifor-
mity in images of gynecological patients. This compensator
32 Mail et al.: The influence of bowtie filtration on cone-beam CT image quality
is static and makes many compromises for anatomical imag-
ing site, patient size, and imaged field of view. The ideal
compensator would optimize the fluence profile to account
for numerous properties of the patient and imaging system.
The investigated performance of the bowtie filter on image
quality of CBCT will create confidence in clinical implemen-
tation of bowtie filters.
a兲
Author to whom correspondence should be addressed. Address for cor-
respondence: Radiation Physics, Radiation Medicine Program, Princess
Margaret Hospital, 610 University Avenue, Toronto, Ontario M5G 2M9,
Canada. Telephone: 416-946-4501 X5384; Fax: 416-946-6566; Elec-
tronic mail: david.jaffray@rmp.uhn.on.ca
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