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Improving radiotherapy planning in patients with metallic implants using the

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 Biomed. Phys. Eng. Express 1 (2015) 025206 doi:10.1088/2057-1976/1/2/025206

PAPER

Improving radiotherapy planning in patients with metallic implants

RECEIVED
30 March 2015
using the iterative metal artifact reduction (iMAR) algorithm
REVISED
7 July 2015
ACCEPTED FOR PUBLICATION
Esther Bär1,3, Andrea Schwahofer1,4, Stefan Kuchenbecker2 and Peter Häring1
13 July 2015 1
Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ) Im Neuenheimer Feld 280, D-69120
PUBLISHED Heidelberg, Germany
2
19 August 2015 Department of Medical Physics in Radiology, German Cancer Research Center (DKFZ) Im Neuenheimer Feld 280, D-69120 Heidelberg,
Germany
3
Current affiliation: Department of Medical Physics and Biomedical Engineering, University College London, Gower Street, WC1E6BT
London, UK
4
Current affiliation: Department of Radiotherapy and Oncology, Clinical Center Vivantes Neukölln Rudower Strasse 48, D-12351 Berlin,
Germany
E-mail: esther.baer.11@ucl.ac.uk.

Keywords: metal artifact reduction, metal implants, radiotherapy planning, iterative raw data reconstruction

Abstract
Metal artifacts in computed tomography (CT) images can cause important errors in dose calculation.
Algorithms developed to reduce these artifacts could improve these images but also introduce a bias in
tissues surrounding metallic implants. The purpose of this study is to validate a pre-commercial metal
artifact reduction tool for radiotherapy treatment planning. The performance of the iterative metal
artifact reduction (iMAR) algorithm developed by Siemens Healthcare is evaluated on a test platform.
A calibration phantom constituted of tissue-equivalent plastics is used to estimate the image bias from
artifact correction. Patient CT data with metal implants (seven dental fillings, one bilateral hip) are
reconstructed using weighted filtered backprojection and corrected using the iMAR algorithm.
Radiotherapy treatment plans are calculated and compared on corrected and uncorrected images
using the collapsed cone convolution dose algorithm implemented in RayStation (RaySearch).
Phantom scans show that iMAR reproduces CT numbers within ±44 HU for tissue equivalent
substitutes in 3.6 cm2 circular ROIs. The effect of this CT number difference on megavoltage photon
dose calculation is shown to be within ±1% dose error. Comparing patient plans from corrected and
uncorrected images, dose differences of up to ±5% are discovered in target volume and organs at risk,
depending on the treatment site. The iMAR algorithm resulted in improvement of image quality in
metal artifact affected CT images for radiotherapy planning. The technique reduces dose errors
significantly while keeping calculated doses in the surrounding tissues within a clinically acceptable
level in comparison to ground truth. Future work could aim at the improvement of benchmark
methods for a clinical environment.

1. Introduction artifacts [1]. These artifacts decrease image informa-

Planning of radiation therapy (RT) with modern
techniques relies on the simulation of the patient
anatomy and x-ray attenuation properties using com-
puted tomography (CT) images.
Metal implants cause artifacts on CT images.
Metal artifacts arise from photon starvation, beam
hardening and scatter. As a large number of photons is
attenuated within the metal, only few photons arrive at
the detector, resulting in beam hardening and scatter
tion in two ways. Firstly, the visibility of anatomical
structures is impaired. Secondly, the CT numbers on
the image are modified. CT numbers are used to deter-
mine electron densities, which are the most important
quantity for CT based treatment planning of RT.
Implants such as hip prostheses and dental fillings
cause severe image artifacts. On the one hand these
artifacts complicate the delineation of tumor and
organs at risk (OARs). When structures are obscured
by metal artifacts, the physician must rely on

© 2015 IOP Publishing Ltd

Biomed. Phys. Eng. Express 1 (2015) 025206
experience to delineate target and OARs [2]. On the
other hand, CT number accuracy is affected by metal
artifacts. This leads to incorrect assignments of elec-
tron density values, which results in errors in dose cal-
culation. With modern techniques like intensity
modulated radiation therapy (IMRT) or particle ther-
apy, high dose gradients can be achieved to increase
dose in the target volume and simultaneously spare
OARs [3]. Particularly in cases of pelvic and head and
neck tumors, metal artifacts can be adjacent to or even
included in the target volume or OAR. This leads to
inaccuracies in target delineation and dose calcula-
tion [4].
To prevent major errors in dose calculation, the
electron density of soft tissue is assigned manually to
the artifact affected region. This is time and resource
consuming, and decreases the quality of the treatment
as the benefit from highly precise radiotherapy techni-
ques is degraded. Another approach is to obtain mega-
voltage CT (MVCT) images. MVCT images are less
susceptible to metal artifacts [5]. However, the use of
MVCT is concerned with low soft tissue contrast and
additional patient dose [6].
Several techniques for metal artifact reduction
(MAR) are proposed in literature [7–10]. Dual energy
CT based monoenergetic imaging provides a method
to reduce artifacts from beam hardening [11]. CT data
are acquired from two different energies and a mono-
energetic extrapolation is performed. The result of this
extrapolation is a virtually monochromatic dataset,
which in principle is free of beam hardening artifacts
[7, 12, 13]. This method is widely used in radiology for
diagnosing regions of interest (ROIs) near metal clips
or titanium implants which only cause mild artifacts
[14]. However, the majority of radiotherapy cases with
metal artifacts in close proximity to target volume or
OARs are head and neck patients with dental fillings or
implants. These fillings are often made from Amal-
gam, which has a high mass density and produces
severe photon starvation artifacts. Metal artifacts can
be reduced, but not completely corrected with this
algorithm [15, 16].
Another technique for MAR is based on sinogram
inpainting, which was proposed by Kalender et al in
1987 [9]. It relies on the interpolation of missing data
within the sinogram data. In a first step, the metal is
identified in an uncorrected image. The metal-only
image is forward projected to find regions in the origi-
nal sinogram that need to be interpolated. The inter-
polated sinogram is then used to reconstruct the
corrected images using filtered backprojection.
Although this method effectively reduces metal arti-
facts, new artifacts are introduced, especially in the
region close to the implant. Meyer et al [17] proposed
to apply a normalization to the original sinogram
before interpolation to overcome this problem. This
normalized metal artifact reduction (NMAR)
approach has been investigated from a diagnostic
point of view, using CT data of patients with dental
2
E Bär et al
fillings. They concluded that ‘normalized MAR sig-
nificantly improves image quality in CT imaging ... in
patients with metallic dental hardware and revealed
tumors that were masked by artifacts’ [18]. The quality
of the artifact corrected image can be further
improved by including a technique called frequency
split (FSMAR) into the reconstruction process [19]. It
enhances the visibility of fine details that otherwise
might get lost during the inpainting step. Based on this
approach, the algorithm iterative metal artifact reduc-
tion (iMAR) was developed by Siemens (Siemens Sec-
tor Healthcare, Forchheim, Germany). A recent study
by Axente et al [20] presented a clinical evaluation of
iMAR for the application in radiotherapy.
The here presented study aims at a detailed clinical
evaluation of the iMAR algorithm for its application in
radiotherapy. Besides confirming the results found by
Axente et al, we extend the phantom study in two
points. Firstly, we investigated a number of different
metal inserts (aluminum, titanium, steel and tung-
sten) to mimic different clinical situations. Secondly,
we investigated the performance of iMAR in very close
proximity to the metal in both, patient and phantom.
An extensive elaboration of ROIs in patients was per-
formed using an approximate ground truth (GT).
Additionally, the dose differences between doses from
iMAR and conventionally reconstructed images are
evaluated closely using histograms.
2. Materials and methods
2.1. Phantom study
2.1.1. Data acquisition
The tissue characterization phantom Gammex 467
(Gammex, Middleton, WI, USA) was scanned with and
without metal inserts. The phantom itself has a
diameter of 32 cm and comprises 16 rod shaped
tissue substitutes of 5.6 cm length with a diameter of
2.8 cm. The phantom loading pattern is illustrated
in figure 1 and table 1. The following metal inserts
were introduced into the phantom: aluminum
(ρAl = 2.7 g cm−3), titanium (ρTi = 4.5 g cm−3), steel
(ρsteel = 7.9 g cm−3), tungsten ( ρ W = 19.3 g cm−3).
The metals were chosen to simulate materials with
densities used in typical medical applications such as
hip and dental implants. CT data was acquired using a
Siemens Somatom Flash (Siemens Sector Healthcare,
Forchheim, Germany) CT scanner at 120 kVp at a tube
current of 300 mAs. Reconstruction parameters were
chosen as: field of view (FoV) of 500 mm, slice
thickness of 2 mm and a B40f reconstruction kernel,
using weighted filtered back projection (WFBP) as
implemented in the Syngo software (version 2012b,
Siemens Sector Healthcare, Forchheim, Germany). In
a first scan, a metal free data set has been acquired
using a real water insert, serving as GT. This scan has
been repeated for each metal insert at the position of
real water (figure 1(a)). In a second scan, an image of
Biomed. Phys. Eng. Express 1 (2015) 025206
Figure 1. Configuration of the Gammex phantom tissue equivalent inserts for (a) single metal plugs of different material, placed at the
position of real water; and (b) two steel inserts. The position of the metal inserts is indicated by the shading. The ROIs for artifact
density evaluations are illustrated. The indices correspond to the indices in table 1.
Table 1. Inserts of the
Gammex phantom used
in this study. The indices
correspond to the indices
in figure 1.
Index Insert
1 Lung LN-300
2 Adipose
3 Breast
4 Real water
5 Solid water
6 Liver
7 Inner bone
8 B-200 bone
9 Cortical bone
the phantom with two steel inserts was acquired to
simulate the case of bilateral hip prostheses. The two
steel plugs were placed opposite to each other. Soft
tissue substitutes (adipose and liver) and an inner bone
substitute were chosen to fill the area between the two
steel plugs to mimic soft tissue contrast.
The raw data of each image set were reconstructed
using the iMAR algorithm, with exact same para-
meters as in previous reconstructions with WFBP. The
images reconstructed with iMAR and WFBP will be
shortened with iMAR and WFBP in the following.
2.1.2. CT number accuracy evaluation
The artifact density was measured within the largest
hypodense and hyperdense streak artifacts on each
image set. Directly next to the metallic insert two
1.6 cm2 circular regions of interest (ROI 1 and ROI 2,
see figure 1(a)) were placed to determine mean CT
number and standard deviation on WFBP, iMAR and
GT data. The ROIs were chosen as large as to cover the
hypodense/hyperdense areas next to the artifact,
enclosing only water equivalent material (expected CT
number: 0 HU). The CT number accuracy was deter-
mined within 3.6 cm2 circular ROIs inside eight tissue
equivalent substitutes as shown in figures 1(a) and (b).
CT numbers and standard deviations were determined
on WFBP and iMAR reconstructed data as well as on
3
E Bär et al
GT. In order to evaluate the improvement in CT
number representation with iMAR, the absolute CT
number difference between GT and WFBP or iMAR
was calculated
ΔHU = HUGT − HUiMAR WFBP . (1)
All CT numbers in this study are presented as mean
and standard deviation. To evaluate if the CT numbers
are improved significantly with iMAR in contrary to
WFBP, a statistical analysis was performed on the data
sets containing one metal insert. Further on, it is
evaluated if the iMAR reconstructed data can yield CT
numbers close to the GT. To show if the difference is
significant a Studentʼs t-test was applied to all investi-
gated tissue substitutes using a significance level
of p < 0.05.
2.1.3. Dosimetric evaluation
A static field treatment plan was calculated on the
image set containing two steel plugs. The single field
approach was chosen as it enables to evaluate dose
differences in the simplest and most straightforward
manner. It was shown by Jäkel et al [4] that dose
differences arising from one beam may be compen-
sated by the dose from another beam, when a multi-
beam approach is used. Treatment planning was
performed using the treatment planning system RayS-
tation (RaySearch Laboratories AB, Stockholm), ver-
sion 4.0. The field size was set to be 14 × 2 cm2 with a
photon energy of 6 MV and a gantry angle of 0°. The
dose resulting from 200 MU was calculated with a
collapsed cone convolution (CCC) algorithm on GT,
WFBP and iMAR reconstructed images. The dose
distributions were evaluated by calculating the dose
differences between the dose calculated on GT and the
dose calculated on WFBP or iMAR. In the transversal
plane, depth dose profiles were taken from either dose
distribution on the central axis and 50 mm off-axis. A
2D local gamma index analysis as implemented in Low
et al [21, 22] was performed to compare the dose
distributions, using PTW VeriSoft 5.1 (PTW, Frei-
burg, Germany). The distance to agreement was set to
Biomed. Phys. Eng. Express 1 (2015) 025206
Table 2. List of patients used for this study, includ-
ing indications.
Patient Indication
Head and neck 1 Non-Hodgkin lymphoma
Head and neck 2 Hypopharyngeal carcinoma
Head and neck 3 Carcinoma of the tongue
Head and neck 4 Carcinoma of the tonsils
Head and neck 5 Lymphoma of the nose
Head and neck 6 Oropharyngeal carcinoma
Head and neck 7 Metastasis of NSCLC
Hip 1 Prostate carcinoma
1 mm and the dose difference criterion was set to 1%,
and the low dose cut off was set to 20%.
2.2. Patient study
2.2.1. Data acquisition
CT images of seven patients selected for radiotherapy
were used, each with cancer in the head and neck
region (for indications see table 2). All head and neck
treatments were planned and conducted at the Ger-
man Cancer Research Center (DKFZ, Heidelberg,
Germany). All head and neck patients have dental
fillings or implants which produce artifacts over
several slices. Patients had their RT treatment planning
CT scan (tube voltage 120 kV, tube current 300 mAs,
slice thickness 2 mm, FoV 500 mm, reconstruction
kernel H30s). For each patient, two image data sets
with similar reconstruction parameters were recon-
structed, one conventional WFBP used for treatment
planning and one using the iMAR algorithm. A CT
scan of a patient with bilateral hip prosthesis
(tube voltage 120 kV, tube current 300 mAs, slice
thickness 2 mm, FoV 500 mm, reconstruction kernel
B40s) was used to simulate radiotherapy of a prostate
carcinoma.
2.2.2. Image quality analysis
For quantification of the CT number accuracy in
patients with dental fillings, CT numbers were deter-
mined in four 0.57 cm2 circular ROIs see figure (2)
within the CT datasets of the head and neck patients:
• ROI 1: within the most hypodense streak on the
cheek;
• ROI 2: within the most hypodense streak on the
tongue;
• ROI 3: within the most hyperdense streak on the
cheek;
• ROI 4: within the most hyperdense streak on the
tongue.
The measurements were performed on WFBP and
iMAR reconstructed images for all head and neck
patients. Furthermore reference values were estimated
in order to create a GT. Therefore ROIs of the same
4
E Bär et al
Figure 2. Illustration of the ROIs used to generate an
approximate ground truth in the patient cases.
size as ROIs 1-4 were placed into the same tissue at a
WFBP image slice that was not affected by artifacts.
For each patient the reference values were determined
individually since every patient has slightly different
anatomy.
2.2.3. Dosimetric evaluation
Radiotherapy plans were generated, optimized and
calculated on the WFBP reconstructed images using
the treatment planning system RayStation, version 4.0.
The final dose was calculated with a CCC algorithm.
All patient plans are created for 6 MV photon IMRT.
The resulting treatment plan was recalculated on the
iMAR reconstructed image set. For each patient, the
CT slice that is optically most affected by artifacts was
used for further investigation. The percentage differ-
ence between the two dose distributions was calculated
voxelwise and normalized to the prescribed dose for
each patient
WFBP Dose − iMAR Dose
DoseDiff[%] = · 100
WFBP Dose prescribed
(2)
The 3D gamma index analysis was performed to
evaluate dose differences between WFBP and iMAR
within the 50%, 80% and 90% isodose volumes,
using the software PTW VeriSoft 5.1. The distance
to agreement was set to 1 mm and the dose
difference criterion was set to 1%, using a 20% low
dose cut off.
3. Results
3.1. Phantom study: CT number accuracy
evaluation
Images representative for all phantom setups are
presented in figure 3. Results of the artifact density
Biomed. Phys. Eng. Express 1 (2015) 025206 E Bär et al

Figure 3. Top: original images without metal inserts, serving as ground truth. Middle: original images containing artifacts induced by
different metal inserts. Bottom: iMAR reconstructed images. (c = 40 HU, w = 350 HU).

Figure 4. CT numbers determined in ROI 1 and 2 for images with different metal plugs. The ground truth CT number (GT) is
displayed as a dashed line.

evaluation are shown in figure 4. CT numbers were
determined as described in section 2.1.2. The values
on the GT image are (−4.5 ± 30.9) HU in ROI 1 and
(−7.3 ± 38.1) HU in ROI 2. CT numbers determined
on the data set with aluminum insert are equal for
both, iMAR and WFBP reconstruction. For all other
data sets with metal inserts, the CT numbers in ROI 1
are represented well by iMAR (titanium: (−3.5 ±
35.1) HU, steel: (−17.6 ± 34.6) HU, tungsten (−8.0
± 35.4) HU). Results are slightly worse for ROI 2,
where iMAR overestimates the CT numbers within the
ROI (titanium: (66.6 ± 42.0) HU, steel: (68.5 ±
36.3) HU, tungsten (73.9 ± 45.3) HU).
Figure 5 displays the results of the CT number
accuracy evaluation. The column charts show that CT
number alteration due to artifacts is strongest in lung,
liver and cortical bone inserts. These inserts are also
visually most affected by artifacts, see figure 2. iMAR
improved CT number estimation for all investigated
tissue substitutes on the metal artifact affected images.
The largest CT number difference between iMAR and
GT is 43.5 HU, observed for the lung substitute in the
images containing steel. In the soft tissue region, the
CT numbers could be corrected to a level where they
are not significantly different from the GT, as shown in
table 3 (p < 0.05; ✓, p > 0.05; X).
In the WFBP image containing two steel inserts,
one observes CT number differences of up to
±351 HU, especially in inserts which are located
directly in the region between the inserts (adipose and
liver). Artifacts are corrected well with iMAR, within a
maximum CT number difference of ±33.9 HU (in
liver insert).

5
Biomed. Phys. Eng. Express 1 (2015) 025206 E Bär et al

Figure 5. The CT number differences to ground truth, following equation (1), determined for WFBP and iMAR images. Only absolute
values are displayed here.

Table 3. Results of the significance analysis. Differences in CT num- WFBP image is lower in regions of dark streaks
ber mean values over the investigated ROIs were tested according to
their statistical significance using Studentʼs t-test. Significant differ- compared to dose calculated on GT, with dose
ences between iMAR and ground truth are marked with a tick. differences of up to 5%. Comparing the dose calcu-
p < 0.05 Aluminum Titanium Steel Tungsten lated on the GT image with the dose on iMAR, small
dose differences are observed within the range of ±1%.
Lung ✓ ✓ ✓ ✓
The gamma analysis of GT versus WFBP dose revealed
Adipose ✓ ✓ ✓ ✓
Breast X X X X
62.1% passed dose points with the chosen criteria.
Solid water X X X X iMAR could improve that up to 85.7% passed dose
Liver X X X X points.
Inner bone X X ✓ X Profiles of the dose distributions were measured
B200 X ✓ ✓ ✓ on the central axis and 50 mm off axis. Figure 7 shows
Cortical bone X ✓ ✓ ✓
these profiles. A clear underdose of the WFBP dose in
the region of the dark streak can be observed on the
3.2. Phantom study: dosimetric evaluation central axis as well as off axis. However, the profiles
The calculated doses on GT, WFBP and iMAR images measured on the GT and on the iMAR reconstructed
are displayed in figure 6. The dose calculated on the images are almost equal.

6
Biomed. Phys. Eng. Express 1 (2015) 025206 E Bär et al

Figure 6. Dose distribution calculated on (a) the ground truth image, (b) the WFBP reconstructed image and (c) the iMAR
reconstructed image. Dose difference maps to ground truth determined on (d) WFBP and (e) iMAR data (c = 0 HU, w = 800 HU).

Figure 7. Depth dose profiles measured from the dose distributions. Top panel: central axis dose profile. Bottom panel: off axis dose
profile, 50 mm from central axis. The origin of the x-axis was set to the midpoint between the steel inserts, which corresponds to
10 cm depth in the phantom, marked by the Iso-point in figure 6.

3.3. Patient study: image quality
Results of the image quality analysis using the ROI
readout are presented in figure 8. The reference values
for ROIs 1-2 are tabulated in table 4. ROI 1 and 2 were
placed within the hypodense streaks. ROI 1: the mean
CT numbers determined on WFBP image for the
different patients are between −301 HU and −846 HU
over the whole patient cohort. With iMAR, mean CT
numbers in ROI 1 are within the range of ±94 HU
from the reference CT numbers. In the following, the
CT number difference from reference is discussed.
iMAR worked well especially for patients 7 (+5 HU)
and patient 2 (+22 HU). The least effect was detected
for patient 4 (−94 HU).
The CT numbers determined for ROI 2 on the
WFBP image are within the same range as for ROI 1.
iMAR corrected CT numbers for patients 1, 2, 3 and 6
within the range of ±50 HU. In Patients 3 and 5, iMAR

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Biomed. Phys. Eng. Express 1 (2015) 025206 E Bär et al

Figure 8. CT numbers for the four ROIs determined on WFBP and iMAR images in comparison to CT numbers determined in a
reference ROI, as described in section 2.2.2.

Table 4. Estimated reference CT numbers (mean) in In regions of bright streaks on the WFBP image,
HU for the patient ROIs, measured in slices which
were not affected by artifacts. the dose calculated on iMAR is higher. Accordingly, in
regions of dark streaks, the dose calculated on the
ROI 1 ROI 2 ROI 3 ROI 4 iMAR image is lower. This is demonstrated in the head
Pat 1 81 111 81 111 and neck patient of figure 10. The target volume (red
Pat 2 38 66 38 66 contour) in this case is directly located within an area
Pat 3 59 44 59 44 of very bright streak artifacts. This leads to a dose dif-
Pat 4 61 87 61 87 ference of up to −5% in the target and +5% in the sur-
Pat 5 28 108 28 108 rounding tissue when calculated on the WFBP image.
Pat 6 107 89 107 89
The dose difference in the prostate case is displayed in
Pat 7 27 72 27 72
figure 10. Maximal dose differences of −5% (seminal
vesicles, within bright region on WFBP) and +5%
(bladder and rectal wall, within dark region on WFBP)
underestimated CT numbers in ROI 2 (−340 HU for
were determined.
both patients). CT number for patient 7 is over-
The calculated gamma values for all seven head
estimated by iMAR (+172 HU).
and neck patients and the prostate patient are shown
ROI 3 and 4 were placed within the hyperdense
in table 5.
streaks. CT numbers determined for ROI 3 on
WFBP are within the range of 246–1697 HU.
With iMAR, ROI 3 in patients 4 and 6 is described very 4. Discussion
good (+35 HU and −41 HU, respectively). For all other
patients, iMAR corrected CT numbers within the 4.1. Phantom study
range of +130 HU. For ROI 4, iMAR correction was Intensities of metal artifacts were simulated to test the
very good for all patients except for patient 7, where the performance of the iMAR algorithm regarding geo-
CT number is still overestimated (+210 HU). metric and image quality reestablishment. The metal
inserts were distinguished in low-Z and high-Z (Z:
3.4. Patient study: dosimetric evaluation atomic number) implant materials. Titanium is a very
Dose difference column charts for all patients are commonly used material in trauma surgery (e.g.
displayed in figure 9. Dose differences within the screws for extremities and spinal cord). Steel is a very
patients vary from case to case. Maximal dose differ- common basic material for all kinds of endoprostheses
ences of up to ±20% can occur in single voxels. The (e.g. hip-, knee-, shoulder joints). Tungsten in turn
dose difference range in all patients in this study is has nearly the same physical density as gold, which is
± 5%. preferred for dental prostheses.

8
Biomed. Phys. Eng. Express 1 (2015) 025206 E Bär et al

Figure 9. Column charts of the voxelwise dose difference between doses calculated on iMAR and WFBP for the whole patient cohort.

Figure 10. Top panel: WFBP and iMAR reconstructed images of one head and neck patient, as well as the dose difference map between
WFBP and iMAR. The target volume is contoured in red. Bottom panel: WFBP and iMAR reconstructed images of the prostate
patient, (C = 40 HU, W = 350 HU).

Table 5. Percentage of evaluated points with γ < 1 within the 50%, Without metal implants present in the images, the
80% and 90% isodose volumes.
iMAR reconstruction algorithm yields the exact same
Patient Case Gamma 50% Gamma 80% Gamma 90% results than a standard WFBP reconstruction. No
negative or undesired effects occur. This was tested in
Head and neck 1 92.1 94.8 94.3
reconstructions of phantom and patient data sets
Head and neck 2 98.5 100.0 100.0
Head and neck 3 96.1 99.7 100.0
without metal inserts. However, the behavior of the
Head and neck 4 96.9 99.9 100.0 algorithm in the presence of metal and sharp tissue
Head and neck 5 99 99.8 100.0 boundaries such as soft tissue and air needs to be
Head and neck 6 96.9 100 99.9 investigated more closely.
Head and neck 7 95.1 95 94.2 In this pre-commercial release of the iMAR soft-
Hip 97.9 95.1 94.5 ware, the reconstruction parameters were set to

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Biomed. Phys. Eng. Express 1 (2015) 025206
Table 6. CT number difference that causes a 1% dose difference for a selected set of tissues.
Tissue Lung
CT number difference (HU) ± 61
correct strong metal artifacts arising from high-Z
metals such as alloy prostheses or severe artifacts from
dental fillings. This setup of reconstruction para-
meters detects only strong artifacts and was therefor
not able to recognize aluminum as an artifact introdu-
cing metal. It follows that the software did not correct
the artifacts from aluminum, hence the original WFBP
reconstructed data equals the corrected data. But high-
Z materials cause a nearly complete absorption of the
x-rays leading to missing information in the projec-
tion data, showing up as severe bright and dark streaks
in WFBP reconstructed image (see figure 2, second
row). The higher the metal density the stronger are the
artifacts.
The iMAR algorithm replaces this missing infor-
mation iteratively [17]. Hence the resulting image is
almost artifact free (see figure 2, third row). All tissue
equivalent inserts in the phantom can now be delim-
ited in their geometrical borders as in the GT images.
Differences of the CT numbers in the iMAR data com-
pared to the GT is given in figure 4. The highest devia-
tions of CT numbers after iMAR reconstruction are
observed for the cortical bone tissue substitute
with 41 HU (tungsten) and for the lung tissue sub-
stitute with 44 HU (steel). Thus we report higher abso-
lute CT number differences between iMAR and GT
than Axente et al [20], who claimed a CT number
accuracy of ±25 HU in the presence of multiple steel
inserts.
Our tolerance level for interpretation was set to
that CT number difference which would cause a 1%
error in dose calculation when converting HU in elec-
tron densities. These tolerance levels are listed in
table 6 for selected tissue equivalent subsitutes.
Finally it can be summarized that the CT numbers
of all tissue equivalent substitutes in the iMAR data
meet the required 1% tolerance level and hence it was
shown that iMAR can be useful to reconstruct metal
artifact affected CT images.
Furthermore, this is confirmed by the evaluation
of the dose distributions: the differences in dose dis-
tribution between GT and iMAR are negligible,
whereas up to ±5% had been revealed between GT
and WFBP.
The dose accuracy evaluation in the phantom
study revealed dose distribution differences between
GT and WFBP of up to −5% in the region of the dark
streak. The dose difference between GT and iMAR is
very small and only show small residual dose errors in
the field periphery. It can be followed from these
results that the dose calculated on the iMAR image is
closer to the true dose than the dose calculated on
WFBP image.
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E Bär et al
Adipose Water Liver Inner bone Cortical bone
± 79 ± 81 ± 83 ± 87 ± 117
Axente et al in their paper used the Acuros XB
(Varian Medical Systems Inc, Palo Alto, CA) determi-
nistic radiation transport method for dose calculation.
In our comparison, we used a CCC method. Han et al
[23] have performed an extensive comparison of these
two dose calculation algorithms. They concluded that
the algorithms are comparable to Monte Carlo dose
simulations and only show differences in bone, lung
and interface regions, where Acuros XB is slightly
superior to CCC. The here presented results of the
dosimetric analysis will thus be different from the
results presented in the paper from Axente et al. It is
subject to discussion whether these differences would
be clinically relevant. As to compare the influence of
the dose calculation algorithm, further analysis needs
to be performed applying the two different algorithms
to the same phantom setup and subsequent patient
cases.
The results found in this paper confirm the results
of Axenteʼs phantom study and provide com-
plementary information on how the algorithm per-
forms in close proximity to the metal insert. We also
investigated the performance of the algorithm in pre-
sence of different metals. We found that in all cases the
CT numbers reconstructed by iMAR result in a dose
difference less than 1% compared to GT.
4.2. Patient study
Patient images from WFBP and iMAR reconstruction
were compared. In all cases, the overall image quality
was improved with iMAR. Areas of bright or dark
streaks were filled with soft tissue. One of the head and
neck cases was chosen as example (figure 10(a)). In
this case, artifacts arise from dental fillings and affect
17 slices on the WFBP image. These artifacts do not
allow for precise differentiation of the buccal tissue,
master muscle, mandible and infiltrative metastasis.
With iMAR, the visibility of the metastasis and
surrounding tissues is improved. Residual artifacts are
visible on the depicted slice, especially between the
dental fillings itself and between fillings and tissues of
high density such as bone. These results are confirmed
by the remaining head and neck cases.
Figure 10(b) illustrates the image quality of the
pelvis case (bilateral hip prostheses). On the usual
WFBP reconstructed image the area between the pros-
theses is hardly visible. Important anatomical struc-
tures are not discernible, such as the borders of the
prostate and seminal glands as well as the caudal
bladder wall and ventral rectal wall. Based on this lack
of anatomical information in the WFBP image, RT
with highly conformal techniques like IMRT is ques-
tionable. On the iMAR reconstructed image in
Biomed. Phys. Eng. Express 1 (2015) 025206
contrast, details of these anatomical structures are very
well discernible. However, borders between tissues
seem to be smeared out on the iMAR reconstructed
image, as shown in figure 10(b) exemplarily in the
ventral bladder wall.
The CT number accuracy evaluation in the patient
case shows similar findings to the phantom case. The
comparison of iMAR and WFBP images (figure 8)
shows the improvement of HU representation in all
investigated ROIs. Although artifacts are highly
reduced and residual artifacts are very mild with
iMAR, it is noticeable that especially in the patient
cases the boundaries between soft tissues are slightly
blurred. The reason therefor are missing projections.
As illustrated by Meyer et al, ‘Inpainting-based meth-
ods for MAR consider those parts of the projection
data that are affected by metal (the so-called metal
trace or metal shadow) as completely unreliable’ [19].
These projections without any useful image informa-
tion are filled by interpolation between neighboring
projections, leading to unsharp boarders in the recon-
structed image.
The evaluation of dose differences of IMRT
plans calculated on WFBP and iMAR needs to be
considered for each patient case. Based on the
dosimetric evaluation in the phantom, the dose
distributions resulting from iMAR images can be
considered as the true dose distributions. Addition-
ally, our phantom studies and the approximate GT
in the patient cases indicate that iMAR is very close
to the truth. Using uncorrected WFBP images is
the current standard method in radiotherapy plan-
ning. In this study, dose differences between iMAR
and WFBP are pointed out. Although there are
indications that iMAR is very close to the truth,
this study does not make a statement about which
of the strategies offers the most realistic representa-
tion of patient anatomy and dose distributions.
However, from the phantom study and the CT
number analysis in the patient cases, one can con-
clude that iMAR reliably reconstructs soft tissue
HU in presence and proximity of metal implants.
Further studies need to be performed to investigate
the performance of the algorithm in presence of
tissue heterogeneities and high tissue gradients such
as bone-adipose or soft tissue-lung boundaries. The
here presented dosimetric study focuses on head
and neck radiotherapy patients. The majority of
patients with head and neck cancer have dental fill-
ings or implants that impair tumor and OAR visi-
bility. While Axente et al show one patient data set
per anatomical location of the metal implant, we
closely investigated the influence of artifacts from
dental implants on the dose distribution, based on
histograms. In the majority of patients we observe
relevant dose differences in the range of ±5%, with
single voxel exceptions of up to 20%. Dose differ-
ences of these dimensions are critical for treatment
outcome [24].
11
E Bär et al
5. Conclusion
This study investigated the novel CT algorithm iMAR
for MAR in terms of improvements in radiotherapy
planning. A phantom trial showed that geometry and
CT number accuracy can be re-established with iMAR
as if there were no metal artifacts, independent of the
density of the introduced metal substitute.
Differences in dose calculations for radiotherapy
planning on metal artifact affected CT image could be
amounted to a range of 5%, with maximal values
of 20% in single voxels. Considering dose distribu-
tions calculated on iMAR close to the truth, these
errors stay undiscovered in metal artifact affected CT
images.
It is essential to provide algorithms like iMAR for
clinical routine. The application will help avoiding
misinterpretation of dose distributions in RT
planning.
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