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Metal artifacts in computed tomography for radiation therapy planning: dosimetric effects and
impact of metal artifact reduction
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2017 Phys. Med. Biol. 62 R49
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Institute of Physics and Engineering in Medicine Physics in Medicine & Biology
Phys. Med. Biol. 62 (2017) R49–R80 https://doi.org/10.1088/1361-6560/aa5293
Topical Review
Metal artifacts in computed tomography

for radiation therapy planning: dosimetric
effects and impact of metal artifact
reduction
Drosoula Giantsoudi1, Bruno De Man2, Joost Verburg1,
Alexei Trofimov1, Yannan Jin2, Ge Wang3, Lars Gjesteby3
and Harald Paganetti1
1
Department of Radiation Oncology, Massachusetts General Hospital and Harvard
Medical School, Boston, MA, United States of America
2
General Electric Global Research Center, Niskayuna, NY, United States of America
3
Biomedical Imaging Center, Department of Biomedical Engineering, Rensselaer
Polytechnic Institute, Troy, NY, United States of America
E-mail: dgiantsoudi@mgh.harvard.edu
Received 3 August 2016, revised 20 October 2016

Accepted for publication 8 December 2016
Published 21 March 2017
Abstract
A significant and increasing number of patients receiving radiation therapy
present with metal objects close to, or even within, the treatment area,
resulting in artifacts in computed tomography (CT) imaging, which is the
most commonly used imaging method for treatment planning in radiation
therapy. In the presence of metal implants, such as dental fillings in treatment
of head-and-neck tumors, spinal stabilization implants in spinal or paraspinal
treatment or hip replacements in prostate cancer treatments, the extreme
photon absorption by the metal object leads to prominent image artifacts.
Although current CT scanners include a series of correction steps for beam
hardening, scattered radiation and noisy measurements, when metal implants
exist within or close to the treatment area, these corrections do not suffice. CT
metal artifacts affect negatively the treatment planning of radiation therapy
either by causing difficulties to delineate the target volume or by reducing
the dose calculation accuracy. Various metal artifact reduction (MAR)
methods have been explored in terms of improvement of organ delineation
and dose calculation in radiation therapy treatment planning, depending on
the type of radiation treatment and location of the metal implant and treatment
site. Including a brief description of the available CT MAR methods that
have been applied in radiation therapy, this article attempts to provide a
comprehensive review on the dosimetric effect of the presence of CT metal
1361-6560/17/080R49+32$33.00 © 2017 Institute of Physics and Engineering in Medicine Printed in the UK R49
Phys. Med. Biol. 62 (2017) R49 Topical Review
artifacts in treatment planning, as reported in the literature, and the potential

improvement suggested by different MAR approaches. The impact of artifacts
on the treatment planning and delivery accuracy is discussed in the context of
different modalities, such as photon external beam, brachytherapy and particle
therapy, as well as by type and location of metal implants.
Keywords: computed tomography, metal artifacts, dose effect, radiation

therapy, metal artifact reduction
(Some figures may appear in colour only in the online journal)
1. Introduction
Radiation therapy is one of the primary methods of cancer treatment worldwide with com-
puted tomography (CT) being the most commonly used imaging method for treatment plan-
ning. The treatment planning process in radiation therapy typically requires accurate organ
delineation, including the tumor volume and sensitive structures expected to be within or
close to the treatment area, voxel-based dose calculation and optimization of beam intensities
and/or orientations for external beam radiotherapy, or source location for brachytherapy. The
accuracy and resolution of the CT image set used for treatment planning is crucial, since the
lack of it can greatly affect all of these processes. Errors in the image reconstruction process
may lead to erroneous definition of the target volume with adverse effects such as tumor recur-
rence, in case of underestimation, or increased radiation toxicity, in the case of overestimation
of the target volume with unnecessary inclusion of healthy tissues within the treatment area.
Inaccuracies in the Hounsfield Unit (HU) values result in error in electron density or stop-
ping power estimate, which may significantly affect the dose calculation and optimization
processes.
Advances in orthopedic surgery have resulted in significant increase in the number of
patients receiving metal implants. In the United States for example, the number of total hip
replacements among patients aged 45 and over doubled in ten years, from 2000 to 2010
(Wolford et al 2015). Considering that, according to statistical data from the American
national cancer institute reporting, approximately 14% of men are diagnosed with prostate
cancer at some point during their lifetime and that radiation therapy is a primary cancer treat-
ment method worldwide, the number of patients affected by CT metal artifacts due to hip
replacement in prostate radiation therapy is expected to increase significantly in the years to
follow. Apart from the increasing number of prostate cancer patients with a hip prosthesis and
the more common cases of gold or amalgam tooth fillings in head-and-neck patients, rods and
screws are commonly present in spinal and para-spinal irradiations, since they are necessary
for spinal stabilization after surgical removal of spinal tumors before irradiation. In treatment
sites such as head-and-neck tumors more than one type of metal implants may be present, such
as dental fillings and metal rods for stabilization of the cervical spine.
In the presence of metal implants in the field of view of a CT scanner, image artifacts are
created due to three main effects: beam hardening, scatter and noise (De Man et al 1999,
Barrett and Keat 2004). Polychromatic x-ray beams are used by CT scanners and the lower
energy photons are more easily absorbed by matter, especially the high atomic number metal-
lic implants. As a result, the average beam energy increases—the beam hardens—and the
physics of transmission change. In extreme situations, involving large size, high density or
high atomic number metal objects, increased photon absorption may lead to photon starva-
tion, meaning insufficient number of photons, comparable to or lower than the noise level,
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reaching the detectors. The signal at these detectors is typically dominated by Compton scat-
tered x-rays. Compton scatter is the dominant type of interaction in CT. Scattering occurs
throughout the patient, the path of the corresponding x-rays is altered and they hit the detector
off the centerline of the incident beam. The combination of beam hardening and added scat-
tered radiation in the measurements of the metal implant leads to dark streaks in the image
along the axis of greatest attenuation, while the metal shows up as white. Another important
effect is noise which contributes to artifacts in CT, especially when the photon flux reaching
the detectors is significantly reduced due to strong attenuation. Photon detection assumes a
Poisson distribution of photon flux, so low photon counts cause higher statistical errors, which
present as thin dark and bright streaks in the image.
Current CT scanners include a series of correction steps for beam hardening, scattered
radiation and noisy measurements. However, these correction steps are usually based on sim-
plified physics models not accounting for cases of extreme density inhomogeneities. When
high-density materials, such as metal implants, exist within or close to the treatment area,
these corrections do not suffice, since they are not optimized to efficiently manage the extreme
photon absorption by the metal object, leading to prominent artifacts. In the case of common
implants, such as dental fillings, spinal stabilization implants or hip replacements, dark and
bright starburst-streaking artifacts are generated, which degrade the capabilities of CT images
to provide correct information about the HU and electron density of structures. Accurate organ
delineation may become extremely challenging and erroneous electron density values are
obtained, which can significantly compromise the calculation accuracy of dose distributions.
In addition to streaking artifacts, the HU value of metal implants tend to saturate and this
effect may become detrimental especially in particle therapy since the HU saturation results
in inaccurate estimate of relative stopping power compromising the range and dose calcul
ation accuracy. For large sized implants, such as hip replacements, or materials of high atomic
number (high-Z ), such as gold, the attenuation of the photon beam is so strong that almost
no photons reach the detector (photon starvation) resulting in incomplete or missing data in
the projection domain. The dynamic range of the CT scanner then stretches to its lower limit
and, when it is back projected into the image, two major effects occur: (a) lower CT numbers
are produced for the implants, since a relatively lower attenuation is registered and (b) noise
is associated with the artifacts, in the form of bright borders surrounding them (Coolens and
Childs 2003).
To compensate for these effects numerous efforts have been made to develop metal artifact
reduction (MAR) methods and algorithms. Their effectiveness has been explored in terms of
improvement of organ delineation and dose calculation accuracy in radiation therapy treat-
ment planning, for different types of radiation treatment modalities, metal implant locations
and treatment sites. This review focuses on the dosimetric effect of CT metal artifacts in treat-
ment planning and the potential improvement suggested by different MAR algorithms.
Section 2 presents a brief description of the main principles of MAR algorithms that have
been suggested. Sections 3–5 present the dosimetric effect of metal artifacts on CT-based
radiation therapy treatment planning. Since different radiation therapy modalities and treat-
ment sites may require specific treatment planning techniques and algorithms, which can be
affected by the presence of CT metal artifacts in different ways, the available literature was
reviewed based on the referred treatment modality, type and location of the metal implants
and treatment sites.
Section 3 focuses on the dosimetric effect of CT artifacts on treatment planning and
delivery of external photon beam radiation therapy. This section is further divided in four
sub-sections based on the most common metal implants and the treatment sites where they
are encountered: section 3.1 focuses on pelvic implants (hip prostheses) in the treatment of
R51
prostate cancer, section 3.2 on dental implants in the treatment planning of head-and-neck and
brain tumors, section 3.3 on spinal implants in the treatment of spinal tumors, and section 3.4
on Onyx embolization for the treatment of arteriovenous malformations (AVM).
Section 4 reports on the dosimetric effect of metal artifacts encountered in brachyther-
apy treatment of various treatment sites: intracavitary applicator treatment of gynecological
(GYN) cancers and the effect of the CT artifacts caused by the metallic applicators, artifacts
of permanent implants for low dose rate (LDR) lung and prostate brachytherapy treatments.
Section 5 summarizes the effect of CT artifacts on the dosimetry for particle therapy,
including proton therapy, for the treatment sites that are mostly affected by this issue.
Analyzing the findings of numerous publications on this topic, the importance of an
improved, automated MAR method becomes apparent. The necessary requirements for a CT
MAR method to be effective for the purpose of accurate organ delineation and dose calcul
ation is also discussed in the section 6 of this review, while the conclusions of this review are
summarized in the final section 7.
2. CT MAR algorithms in radiation therapy treatment planning
A variety of methods to reduce metal artifacts in CT have been suggested and are described
in the literature (Glover 1981, Kalender et al 1987, Prince and Willsky 1990, Zhao et al 2000,
De Man et al 2001, Bazalova et al 2007, Oehler et al 2008, Lemmens et al 2009, Meyer et al
2010, Veldkamp et al 2010, Xu et al 2011, Yazdi et al 2011, Zhang et al 2011, Verburg and
Seco 2012). Most methods can generally be categorized into two major groups: (a) sinogram
completion methods and (b) model-based iterative algorithms.
With the sinogram (or projection) completion methods areas of data corrupted by the pres-
ence of the metal, are identified in the sinogram space. That data are then treated as miss-
ing and is replaced using interpolation routines based on the uncorrupted sinogram regions.
CT image reconstruction, typically a filtered back projection (FBP) type algorithm, is then
applied. These interpolation-based approaches may achieve significant MAR at the site of
metallic implants. However, full removal of projections performed by these approaches is
associated with loss of information and inaccuracies in the estimated completion data may
lead to additional artifacts in the reconstructed images or loss of spatial resolution. Part of the
lost data may include the exact location of edges between the high-density metal and regular-
density soft tissues or bone, rendering the contouring of metal structures challenging and
estimation of their size highly inaccurate. A first example of a sinogram completion method
applied to CT image MAR is the algorithm suggested by Kalender et al (1987), consisting of
the following steps: the CT image is initially reconstructed from the original distorted data
and the metallic implants are segmented in the image domain. The metal mask is re-projected
to determine the metal shadow in the projection data. Linear interpolation is used to fill in the
missing data. After optional addition of noise to the interpolated data, the updated image is
reconstructed from the modified projection set. A more advanced approach, the normalized
metal artifact reduction (NMAR) algorithm, has been used in several studies. Its main princi-
ple, as introduced by Meyer et al (2010), is presented schematically in figure 1. Similar to the
previous algorithm, the uncorrected image is first reconstructed from the original sinogram.
By using appropriate threshold levels the image of the metal is obtained. Along with the
metal image, a prior image is also computed by segmentation of soft tissue and bone based
on the original uncorrected image. The sinograms of both the metal and prior images are then
obtained by forward projection, and the original sinogram is normalized by dividing it by the
sinogram of the prior. The missing data in the shadow of the metal object are estimated by
R52
Figure 1. Scheme of NMAR (Reproduced with permission from Meyer et al 2010).
interpolation in the normalized sinogram. Finally, the normalized sinogram is multiplied by

the sinogram of the prior image again to get denormalized and the corrected image is recon-
structed. To maintain the size and the edges of the metal implant, both methods described
above reinsert the metal image from the originally reconstructed image in the final corrected
image. In addition, to improve the edge information of surrounding bone structures the appli-
cation of a frequency split metal artifact reduction (FSMAR) algorithms was introduced by
Meyer et al (2012).
As an alternative approach to the sinogram completion methods, model-based iterative
algorithms function under the assumption that most artifacts arise because some data are miss-
ing or deviate from the model used for the data acquisition. Utilizing prior knowledge of the
imaging physics, the measurement statistics and the image statistics, iterative reconstruction
is applied to better interpret the measured projection data. Compared to FBP-based recon-
struction algorithms, the more complex models used by the iterative methods can improve the
accuracy of the reconstructed images, at the cost, however, of increased computation time.
Furthermore, the performance of this method is subject to the level of the accuracy of the
physics models utilized and the prior knowledge of the shape and location of the object. A
simplified schematic of the basic principle of an iterative approach is presented in figure 2.
Starting from an initial—often blank—image, the corresponding sinogram is calculated and
compared to the measured sinogram. The sinogram error is calculated, transformed back to
the image domain and subtracted from the current reconstruction. This process is repeated a
number of times until an objective function—a function of the sinogram error—is optimized,
indicating that a good reconstruction is obtained.
Figure 3 presents an example of a MAR algorithm, combining the principles of both the
sinogram completion and iterative algorithm, based on a commercially available MAR algo-
rithm (O-MAR, Philips Healthcare (PhilipsHealthcare 2012)). This algorithm was chosen to
be briefly presented in this section as an example of a commercially available solution because
R53
Figure 2. General iterative reconstruction scheme. Starting from the current

reconstruction, a sinogram is calculated. A measure for the sinogram error is transformed
to the image domain. The reconstruction is updated in a way that reduces the sinogram
error.
Figure 3. Schematic diagram of iterative algorithm.
it was evaluated by several studies referenced in this review. However, we should point out
that all major CT vendors such as General Electric, Siemens and Toshiba also offer various
MAR solutions. O-MAR is mainly focused on reducing the artifacts from orthopedic metal
implants and its implementation is an iterative loop where the output correction image is
subtracted from the original input image, however, including steps based on a sinogram com-
pletion method. Similarly to the NMAR algorithm, the first step is to produce a metal-only
image by applying a threshold. In addition to the metal only image, a tissue classified image
R54
is also created by segmenting the input image into tissue and non-tissue pixels. The sinogram
data of all three images, the input, the tissue classified and the metal-only, are then produced
by forward projection. An error sinogram is then calculated by subtracting the tissue classified
sinogram from the original image. The metal sinogram data are utilized as mask to remove the
non-metal data points from the error sinogram. Finally this error sinogram data are backpro-
jected to derive the correction image which will be subtracted from the input image and the
process can be repeated.
Although most MAR methods result in improved image quality in clinical scans, there are
cases where their efficiency is limited. In sinogram completion methods, the metal projection
data are discarded, leading to loss of spatial resolution (Boas and Fleischmann 2011). While
the main metal artifacts are mostly reduced, new artifacts may also be introduced by both
sinogram completion, such as linear interpolation technique, and iterative approaches, such as
selective algebraic reconstruction technique (Boas and Fleischmann 2011, Yazdi et al 2011).
Sinogram completion methods are more likely to result in additional artifacts or image that are
worse than the original. The main distinction between the two types of algorithms is whether
the projections through the metal implant(s) are disregarded or attempts are made to use the
data by correctly modeling the physics. The level of efficiency for each technique may differ
significantly between simulated data and actual clinical scans and for most methods depends
greatly on the type of the implant, the metal’s effective atomic number and size. Accounting
for a priori knowledge of the composition of the implant material a significant improvement
can be achieved (Verburg and Seco 2012). In diagnostic imaging, where efforts focus in reduc-
ing x-ray radiation dose, increased noise poses an additional challenge potentially making
metal artifacts more evident. An elaborate review on MAR algorithms is available in a recent
publication by Gjesteby et al (2016).
3. External photon beam treatment
3.1. Pelvic implants (hip prostheses)
The dosimetric effect of artifacts in conventional kilovoltage CT (kVCT) imaging caused

by metal hip replacements is a significant concern most commonly during CT-imaging for
treatment planning of radiation therapy for prostate cancer. When a unilateral prosthesis
exists, non-standard beam angles and planning techniques may be employed to overcome the
dosimetric inaccuracies caused by beams irradiating through the hip replacement, where con-
siderable artifacts are usually present. Due to the size of these implants, photon starvation is
common, resulting in missing data in the projection domain and stretching the dynamic range
of the CT scanner to its lower limit. The CT number for the implants is then underestimated
and bright borders are observed surrounding them (Coolens and Childs 2003).
In an extensive review on the dosimetric considerations for patients with a hip prosthesis
undergoing pelvic irradiation by the Task Group 63 of the American Association of Physicists
in Medicine (AAPM), the physics behind the beam attenuation and perturbation due to the
prosthesis and resulting dosimetric effects are outlined (Reft et al 2003). However the poten-
tial effects of the corresponding CT artifact to the dose calculation accuracy is only briefly
mentioned. One of the first studies on the effect of metal implants was published by Ding and
Yu (2001) and focused mostly on the dose perturbations due to the presence of metal implants.
They compared the inhomogeneity correction algorithms of a commercial analytical 3D treat-
ment planning system (TPS) (CADPLAN) to Monte Carlo (MC) in a homogeneous pelvic
phantom with hip prostheses simulated as metal bars. The study concluded that the analytical
calculation algorithm seriously underestimated the attenuation of hip prostheses due to its
R55
limitation in assigning the electron density of the prostheses. As a result, if no dose correction
factors are applied to the analytical algorithm, the dose to the target was overestimated by 14%
and 5% for a typical four-field box and an eight-field technique respectively. Smaller discrep-
ancies are expected however with modern TPS that allow assigning the electron density for
metals, such as titanium or gold.
In the case of a unilateral hip prosthesis, deviating from the standard beam arrangement
and selecting beam directions to avoid irradiating through the prosthesis and/or areas of arti-
facts may be a solution. However, this is not always an option in the case of bilateral prosthe-
sis because the constraints on beam geometry could compromise target volume coverage and
increase the dose to organs at risk (OARs). For these cases, in order to minimize any dosimetric
effects due to metal artifacts, an effective MAR method is desired. A case study by Su et al
(2005) revealed that if no MAR algorithm is applied, intensity modulated radiation therapy
(IMRT), treatments are more robust than non-modulated three-dimensional conformal radia-
tion therapy (3D-CRT). They used the Corvus system (NOMOS Corp., Cranberry Township,
PA) for IMRT planning and delivery with 5-field initial plan and 7-field coplanar boost plan,
with non-uniformly spaced gantry positions for all beams and inhomogeneity corrections for
both plans. It was demonstrated that better sparing of the bladder and the rectum was achieved
with the IMRT plan when non-standard beam directions were necessary due to the presence of
the metal implant and artifacts. However the IMRT plan was more inhomogeneous, as expected,
with a larger part of the target volume receiving more than 105% of the prescription dose.
Before any advanced MAR algorithm was applied in clinical routine, the use of extended
CT-scale was suggested as a method to reduce the effect of hip replacement artifacts in struc-
ture delineation accuracy (Coolens and Childs 2003, Glide-Hurst et al 2013). The basic prin-
ciple of the method, developed by Klotz et al (1990), dictates that by scaling down the CT
numbers by a factor of 10, the range of 12 bit CT numbers can be increased from 4096 HU
to 40 960 HU, with a CT-scale expanding from −10 240 HU to 30 710 HU. In a standard
CT-scale, metals with CT numbers of about 20 000–30 000 HU can produce artifacts of sev-
eral thousand HU and both hip implant and artifact can exceed its limits. By scaling the CT
numbers, although some loss in contrast resolution was observed, differentiating between the
metal and its surroundings was more plausible, preserving the detailed geometric informa-
tion and allowing for the metallic objects to be outlined correctly. To investigate whether the
extended CT range can be used to determine the composition of artificial hips in radiotherapy
patients, Coolens and Childs (2003) evaluated two CT-calibrations methods, one based on
material substitution (Henson 1983) and the other a stoichiometric calibration. Although none
of these calibration methods was proven accurate enough to predict electron densities of the
hip replacement materials, the extended CT range was shown successful in distinguishing
between implant densities and determining the physical dimensions to ±2 mm.
In a more recent study Glide-Hurst et al (2013) investigated the use of extended CT-to-
electron-density (CT-ED) curves coupled with an iterative type MAR algorithm. They com-
pared 12- to 16- bit image reconstructions, with and without the use of the commercially
available algorithm O-MAR (Philips HealthCare System 2012), of a pelvic phantom with
embedded cerrobend rods and of solid water with embedded stainless steel rods. MC dose
calculations showed discrepancies of 6.4% downstream of the cerrobend rod between the two
images (12- and 16- bit images), and absolute film dosimetry. Comparisons between calculated
dose distributions were performed using gamma analysis, which is a criterion combining both
concepts of the dose difference between a calculated dose distribution and a reference one,
and the distance to agreement (DTA) criterion, which is the distance between a dose point in
the reference distribution and the nearest point in the second distribution having the same dose
(Low et al 1998). The gamma analysis downstream of a stainless steel showed that the 16-bit
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Figure 4. Prostate cancer patient with bilateral hip replacement. Slice selection
was based on the largest dose discrepancy between 16- and 12-bit MAR corrected
datasets. (Top row) CT datasets and (Middle row) corresponding planar dose, with
dose calculated using fixed monitor units for 12-bit CT, MAR-corrected 12-bit CT,
16-bit CT, MAR-corrected 16-bit CT, and difference map for MAR-corrected 16-bit
versus 12-bit. Legends indicate dose in Gy. (Bottom row) Gamma analysis (2%/2 mm)
between datasets, with scale indicating gamma index (unitless quantity) (Reproduced
with permission from Glide-Hurst et al 2013).
calculated dose, with and without MAR, agreed better with film results compared to 12-bit
reconstructions. The impact of the 16-bit reconstruction improvement was significant in the
cases where beams were directly traversing a metal implant, such as in prostate cancer cases
with bilateral hip prostheses, but was diminished when the beams were not directly travers-
ing metal (figure 4). Evaluating the effect of the OMAR algorithm, Glide-Hurst et al found
negligible differences between CT numbers with and without the correction, demonstrating
that applying the OMAR correction did not alter the CT numbers of high-Z material. Gamma
analysis between the dose distributions based on the MAR-corrected and uncorrected images
showed high passing rages for both 12- and 16-bit reconstructions (93.5% versus 95.3%).
A different approach was chosen by Keall et al (2003) who created a reference image set
with a metal implant by virtually adding iron hip prostheses in a non-prosthesis original CT
of a prostate patient and calculated the corresponding sinogram based on this reference image
(figure 5). A comparison was then performed between two reconstruction methods: filtered
back-projection (FBP) and the iterative deblurring method (IDB) (Wang et al 1996, Robertson
et al 1997) in terms of image quality and calculated dose. Due to the over-simplified model
used for the sinogram calculation, assuming a noise-free detector and a mono-energetic pho-
ton beam with no scattered radiation, FBP image reconstruction resulted in minimal streaking
artifacts. No significant dose differences were noticed between dose distributions calculated
on the differently reconstructed images compared to the image set without the hip prosthesis.
A later study by Bazalova et al (2007), on which a MC method was used to simulate a CT
scanner and specifically evaluate the effect of scatter and beam hardening on the metal streak-
ing artifacts, showed significant discrepancies between the MC calculated doses (EGSnrc/
R57
Figure 5. Schematic diagram of the methodology by Keall et al (2003, Reproduced

with permission from Elsevier).
DOSXYZnrc) for the original and the artifact-corrected CT images. A projection completion
MAR algorithm, based on previous work by Roeske et al (2003) and Yazdia et al (2005),
was used in this study, along with extended CT-scale and assignment of a density of 8.055 g
cm−3, corresponding to steel, to all voxels with HU value of 3095. Using a known phantom
geometry as reference image, dose calculations errors exceeding 25% were noted for a 6 MV
photon beam in the original, uncorrected, CT images without using the extended calibration.
These discrepancies decreased to less than 2% in artifact-corrected images when the extended
calibration was used. Significant discrepancies in dose calculations were also observed for a
five 18 MV photon beam plan between the original and artifact-corrected geometry.
Wei et al (2006) investigated the dosimetric effect of CT metal artifacts for a variety of
treatment modalities, utilizing the smoothing-plus-scaling MAR algorithm for hip replace-
ment, previously developed by the same group (Wei et al 2004). The principle of this artifact
suppression technique, as originally proposed by Chen et al (2002), relies on scaling down the
projection profile peaks caused by the metal objects. The improved version by Wei et al (2004)
introduced a smoothing technique of the bone pixels to avoid bone artifacts introduced by the
original one. Dose distributions for 6 MV and 18 MV four-field plans for a prostate patient
with bilateral hip-replacement were compared based on artifact-contaminated and artifact-
suppressed image sets. Figure 6 (Wei et al 2006) presents the qualitative comparison between
the dose distributions. Based on the significantly more irregular shape of the 170 cGy and 180
cGy isodose lines, the target coverage is compromised when using the artifact-contaminated
images for both energies with the 18 MV plan being less affected compared to the 6 MV plan.
Based on dose distributions calculated by the analytical calculation algorithm of the TPS
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Figure 6. Isodose curves for four-beam 6 MV ((a) and (b)) and 18 MV ((c) and (d))
treatment plans based on an artifact-contaminated image ((a) and (c)) and an artifact-
suppressed image ((b) and (d)) (Reproduced from Wei et al 2006. Institute of Physics
and Engineering in Medicine. All rights reserved).
(Pinnacle3 system), they concluded that in the absence of any CT MAR method, turning off
the inhomogeneity correction when performing dose calculations may reduce the dosimetric
errors.
The use of megavoltage CT (MVCT) instead of the conventional kVCT imaging, alone or
in combination with appropriate MAR algorithms, has been suggested by several studies as
an artifact-suppression method. In a case report by Alongi et al (2011) for a prostate cancer
patient with bilateral femoral prostheses MVCT-image-based treatment planning was used
for a helical tomotherapy unit (HiArt). Sufficient morphological information of the pelvic
anatomy for radical prostate treatment planning was available and the patient completed the
planned treatment without severe side effects recorded at 90 d after the end of treatment.
While only a case study, this report demonstrated the feasibility of the method. Tomotherapy
treatment planning comparison based on kVCT, hybrid kVCT/MVCT and MVCT image sets
for prostate cancer patients with bilateral hip prostheses showed that D35 for the bladder was
8% higher in plans based on MVCT and 7% higher in plans based on hybrid images, com-
pared to the kVCT-based plans. Further, D35% for the rectum was 3% higher for both MVCT
and hybrid-based plans (Chapman et al 2014). For a water phantom with a hip prosthesis,
kVCT-based plan with O-MAR correction showed better dose agreement with measurement
than without the correction, however the best agreement was observed for the hybrid plans
(within 1%).
When combining a NMAR algorithm with MVCT images to correct the original kVCT
images of phantoms with bilateral steel inserts, Paudel et al (2013, 2014) showed up to 15.5%
discrepancies between the dose distribution on the corrected image compared to the original
one (figure 7). The use of MVCT-NMAR algorithm was found superior in terms of image qual-
ity to the commercial orthopedic MAR algorithm. Using MVCT-NMAR corrected images in
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Figure 7. Comparisons of dose distributions for 6 MV 5 × 10 cm2 parallel-opposed

fields calculated on (a) the reference image, (b) the image corrected using an IMPACT
corrected MVCT prior, (c) the image corrected using a FBP reconstructed MCVT prior,
and (d) the image corrected using a kVCT prior. The prescription for both the fields is
280 MU. The image window width/level is 1500/0 HU (Reproduced with permission
from Paudel et al 2013).
Table 1. For the relative hot or cold dose on OARs, unspecified normal tissue, and TVs when recomputed
on the reference data set (SAR-MVC) (Reproduced from Kim et al 2006, with permission from Elsevier).
OARs (Gy) TVs (Gy)
Metal artifact Parotids CTVs
correction Spinal
method Right Left Ave. cord GTV CTV1 CTV2 Ave.
UC Ave. 0.94 1.09 1.01 0.04 −0.76 −1.88 −2.12 −2.00
Std. 0.47 0.65 0.27 0.06 0.38 1.77 2.62 2.20
% Vol. 28.72 25.72 27.22 49.79 11.21 20.93 17.11 19.02
HUC Ave. 0.84 0.92 1.05 0.56 −0.76 −1.04 −0.74 −0.89
Std. 0.59 0.52 0.57 0.25 0.51 0.65 0.74 0.58
% Vol. 50.30 47.54 49.42 52.36 35.30 25.95 25.42 25.69
SCC Ave. 1.17 1.04 1.11 0.45 −0.64 −1.38 −1.16 −1.27
Std. 0.36 0.35 0.34 0.51 −0.73 −0.38 −0.81 −0.58
% Vol. 33.96 27.22 30.59 54.75 2.28 −13.76 −7.22 −10.49
MVC Ave. 0.32 0.29 0.30 0.38 −0.71 −0.83 −0.76 −0.76
Std. 0.25 0.28 0.25 0.34 0.59 0.45 0.49 0.47
% Vol. 45.02 37.69 41.36 38.89 36.54 21.34 27.57 24.45
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TomoTherapy treatment plans without directional blocks for a prostate cancer patient resulted
in potential for significant dose reduction outside the planning target volume (PTV) (59.2 Gy
to 52.5 Gy in pubic bone).
3.2. CT artifacts from dental implants
Compared to the material and the geometry of metal implants for hip replacement, dental metal
implants, although of smaller dimensions, are composed of materials of higher atomic num-
ber Z. Furthermore, clusters of dental implants are very commonly found in head-and-neck
patients’ CT images. The combination of high-Z materials and extended clusters of dental
implants can then result in prominent streaking artifacts due to missing projection data caused
by the close to complete photon absorption by the implant. Although in the case of CT artifacts
caused by a hip replacement implant avoidance of the prosthesis might be possible by selected
appropriate beam directions, this is not an option for most cases where artifacts are caused
by dental fillings. Especially for oral cavity treatment, unacceptably high upstream dose to
OARs, due to backscatter from dental filling material (DFM), and target under-coverage due to
attenuation from DMF, render the dose calculation accuracy significantly challenging.
The dosimetric impact of CT artifacts due to dental implants in head-and-neck IMRT was
studied by Kim et al (2006). They utilized IMRT plans based on five planning CT image data
sets, including the uncorrected and corrected images using projection completion methods
proposed by Olive et al (2004): (a) uncorrected (UC), (b) homogeneous uncorrected (HUC),
where all pixels identified by the tissue class model (Olive et al 2004) as soft tissue, bone or
metal were set to the electron density of water, (c) sinogram completion corrected (SCC),
where only segments identified as ‘corrupted’ were cut out and replaced by respective model
segments before reconstruction, (d) minimum value corrected (MVC), where all pixels identi-
fied as soft tissue, bone, or metal were adjusted to the minimum HU of water, and (e) MVC
subsequently corrected with a streak artifacts reduction algorithm (SAR-MVC), where the
HU of the pixels in the streaks resulting from the presence of metal were replaced as much as
possible by the HU of the soft tissue class or bone class. Image set (e) was used as the refer-
ence. IMRT plans created for (a)–(d) image sets were projected onto the reference data set
(e) and the dose distribution was recalculated and compared to dose distribution from IMRT
plan optimized using image set (e). Their results are shown in table 1, indicating that the dose
in small structures, such as the parotids, was less affected by the presence of dental metal
artifacts than in larger structures, like the clinical target volumes (CTVs) (CTV1 and CTV2).
However, small differences were observed on average for all structures.
In a following study by Kim and Tome (2007), the impact of dental metal artifacts on IMRT
dose distributions was investigated in terms of tumor control probability (TCP) and normal
tissue complication probability (NTCP). With reference to the IMRT plan optimized based on
the SAR_MVC image set (e), the larger increase in NTCP for the spared parotid gland and the
spinal cord (3.2% and 2.0% respectively) was estimated from the treatment plan optimized on
the original CT data-set (UC), accompanied by a 1.3% decrease in TCP. Corresponding devia-
tions for the plans generated based on the MVC CT data were significantly lower. The disad-
vantage of this study was that no measurements were performed to verify the dose calculation
accuracy or the level of MAR methods’ efficiency with reference to a ground truth image
such as a known phantom geometry. Later studies by other groups report higher level of dose
discrepancies, although it is generally accepted that the dosimetric effect of metal artifacts
diminishes with increasing number of IMRT beams.
The presence of the DFM and its effect on dose calculation in RapidArc treatment planning
was assessed in a phantom-based study by Mail et al (2012). They reported percent depth dose
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Figure 8. RapidArc plans of a head and neck patient, with dose calculated on (a) an
uncorrected CT image, (b) corrected image with an application of 10 HU mask; (c) dose
profiles of the treatment plans in (a) and (b) along the red line in (a) (Reproduced with
permission from Mail et al 2013).
(PDD) data in the site of DFM measured with Gafchromic EBT2 film and a parallel-plate (PP)
ion chamber. In order to investigate the effect of the CT artifacts, in addition to the original
artifact-contaminated CT image, two CT image sets were created by replacing the streaking
artifact regions with a mask of 10 HU and then adding a 2 cm thick 6000 HU virtual filter
to compensate for beam attenuation. A following study by the same group (Mail et al 2013)
reported updated data on the phantom study and applied the artifact suppression method in
treatment planning for patients. Both studies reported significant backscatter from the DFM
for a single, parallel-opposed fields, and RapidArc treatment technique. For a single-field
treatment technique, measurements revealed a 22% increase in backscatter dose upstream
from DFM compared to that without the DFM, while the downstream dose was decreased
by 14%, compromising target coverage. The calculated PTV dose, based on the original
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uncorrected CT image set, differed from the delivered by 13%. The application of the 10 HU
mask and virtual filter reduced the deviations between the calculated and delivered (measured)
doses to 2%, showing potential in improving dose homogeneity in the PTV. The use of a vir-
tual filter around the teeth during the planning phase reduces the target underdosage issue in
the phantom. The effect of the method applied for a patient is shown in figure 8. Comparison
of dose profiles shows the smoother dose distribution predicted by the dose calculation algo-
rithm when the 10 HU mask is applied (figure 8(c)).
A similar phantom-based study was performed by Maerz et al (2015). They created IMRT
and volumetric modulated arc therapy (VMAT) plans using both uncorrected and corrected CT
data of phantoms consisting of homogeneous water equivalent material surrounding gold or
Wirobond® (cobalt-chrome metal-to-ceramic alloy) dental implants. Dose calculations were
performed with both pencil beam and collapsed cone algorithms and compared to Gafchromic
film measurements. Deviations of ±11% between the measurement and original CT-based
calculated data were observed. Corrected CT data, using a simple bulk density correction
method, by setting the mass density of uniform water to ρ = 1 g cm−3, led to higher accuracy
of dose calculations. VMAT was found to be preferable over IMRT for patients with metallic
implants, since the continuous dose delivery in VMAT leads to a blurring of the inhomogene-
ity in dose distribution caused by the implants resulting in better dose agreement of the VMAT
optimized plans to the measurements.
When using a MAR method based on monoenergetic extrapolation with a dual energy
CT (DECT) scanner, Schwahofer et al (2015) observed only minor reductions of artifacts in
the images with aluminum and titanium at a scan extrapolated to a mono-energy of 105 keV
and practically no artifact reduction for higher material densities. Dose uncertainties in the
order of 10–20% were observed for both corrected and uncorrected image sets. In a study by
Kwon et al (2015) based on 11 patients and a custom-built phantom with metal bead inserts,
the dental implant CT artifact effect on dose calculation was investigated with and without
the OMAR (Philips) correction method. When patients were scanned and treated with closed
mouth (8/11) little significant difference was recorded in dose distributions. In agreement with
the study by Maerz et al (2015), the small dosimetric effect in these cases can be attributed
to the use of VMAT as the treatment planning method, in which the continuous dose delivery
during wide angle rotational treatment averages out the dose inhomogeneities. However this
was not the case for the three patients treated with opened mouth. These patients included
cases where targets such as the tongue and the tonsil were close to the air cavity and conse-
quently were irradiated in that cavity region. Since the air is represented by the lower limit of
CT HU, the streak artifacts in the air cavities cause increasing HU numbers. These artifacts
can make the mouth appear closed, functioning as a dose build-up region during radiation dose
calculation and predict a higher dose in the air cavity in the calculated result. As a result, larger
discrepancies were observed between OMAR and non-OMAR image based dose calculation,
with corresponding gamma passing rates (1%/1 mm) decreased by 3.5%–9% compared to the
average passing rate for the other 8 patients. The calculated dose on the OMAR image was
found closer to the real delivered dose on a radiochromic film.
3.3. Spinal implants
Although relatively low-Z materials, such as steel, are typically used in manufacturing spinal
implants, the CT-artifacts produced by their presence may be detrimental for the image resolu-
tion and ability to define structures or accurate electron density of voxels in the slices where
the implants are present. These structures are often very complex in geometry. A combination
of stainless steel rods and/or a spinal fusion cage is the most common instrumentation used to
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Figure 9. Diagnostic kVCT scan (a) and MVCT scan (b) on the TomoTherapy Hi-Art
system for a patient with metal implants in the spine (Reproduced with permission from
Rong et al 2011. CC BY 3.0).
stabilize the spinal column after a laminectomy, which is usually part of the treatment course
for spinal tumors prior to radiation treatment. The radiation target volume is commonly located
within or adjacent to the metal implant, of which the CT-artifacts render the delineation of the
target and OARs extremely challenging. Streak artifacts may occupy the regions surrounding
the implants and extend along multiple CT slices. Specifically when laminectomy of multiple
vertebrae was necessary, large part of information on electron density of tissues of interest is
corrupted causing the potential of significant dose calculation errors.
In a patient study for palliative spine treatment, Rong et al (2010) reported that the metal
artifacts due to stainless steel spine-stabilizing rods was too severe for treatment planning
based on a regular kilovoltage (kV) CT image, despite attempts to correct using density over-
ride. A MVCT image of the patient was used instead, acquired by a TomoTherapy Hi-Art unit
(TomoTherapy Inc., Madison, WI). The artifacts were not completely eliminated in the MVCT
image but were substantially reduced in comparison to kVCT (figure 9). A dose verification
measurement of the plan on the tomotherapy ‘cheese’ phantom with high and low density
plugs showed a good agreement between ion chamber/film measurements with a 3%/3 mm
gamma criterion, suggesting that this can be an option for treatment planning of similar cases,
provided that the output stability of the imaging system is verified and the soft tissue resolu-
tion allows for tumor and OARs delineation.
In a phantom study by Son et al (2012) the dose calculation accuracy was compared among
kVCT extended-scaled kVCT and MVCT image based plans, with reference to corresponding
measurements (ion chamber and Gafchromic film). The authors used both a reference phantom
without any metal implants and a phantom including titanium implants in realistic positions
according to a spinal posterior/posteriolateral fusion. Compared to the reference phantom, the
dose calculation accuracy at the center of the phantom, between the titanium implants, was
compromised by an average of 2%, with no clear dependence on the image set or radiation
treatment system (Siemens ARTISTE, TomoTherapy Hi-Art and Accuray Cyberknife) used
for the dose calculation and delivery. A decrease in the dose calculation accuracy was reported
while moving closer to the surface of the titanium implants, suggesting that the distance of
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the structures of interest (target or OARs) to the implants should be taken under consideration
when assigning dose constraints in treatment planning. These deviations were less significant
when MVCT was used for the dose calculation, concluding that the use of MVCT for planning
could be advisable for these cases.
The limitations of analytical dose calculation algorithms, when CT artifacts from titanium
rods exist, seem to be at least partially waived when density override and an extended CT-to-
density look-up table are used to include the titanium density (Wang et al 2013). Using MC
calculations (BEAMnrc/DOSXYZnrc (Rogers et al 2001, Walters et al 2005)) as a reference,
the accuracy of an analytical (Pinnacle3) dose calculation was evaluated for various 6MV
photon small field (2 × 2 to 5 × 5 cm2) irradiations of a 5 mm diameter titanium rod in water.
Although at depths more than 1 cm past the rod the analytical algorithm matched MC when
titanium density of 4.5 g cm−3 was used, the backscattering dose at the water-rod interface was
significantly underestimated. In multi-beam IMRT cases of spinal stereotactic radiosurgery
treatment, the dosimetric effect of assigning 4.5 instead of 1.82 g cm−3 (top density: cortical
bone) to titanium implants ranged from minimal effect to 2% dose difference affecting 15%
target volume in the study.
In an effort to study the impact of beam hardening and photon starvation effects on dose,
Spadea et al (2014) compared MC dose distributions calculated based on original (uncor-
rected) and artifact-corrected datasets from actual patient cases. They utilized a MAR method
suggested by Verburg and Seco (2012). Although dose discrepancies of 20–25% were observed
for the uncorrected images in the regions surrounding high-Z materials, such as gold dental
fillings or platinum wire used for an artery embolization, no significant differences between
the uncorrected and artifact-suppressed dataset were found for low-Z materials such as spinal
titanium implants.
3.4. AVM following embolization with Onyx
AVM of the brain are focal abnormal conglomerations of dilated arteries and veins within
brain parenchyma, in which abnormal arteriovenous shunting is present due to loss of normal
vascular organization at the subarteriolar level and a lack of a capillary bed. Depending on
the size, location in the brain and flow-related characteristics, therapeutic options may include
microsurgery, endovascular embolization, stereotactic radiosurgery or a combination of these
modalities. If endovascular embolization is followed by stereotactic radiosurgery, depend-
ing on the embolic agent used, CT imaging artifacts may occur that can distort the image
quality and dose calculation accuracy of the radiosurgery planning process. Onyx (ev3, Inc.,
Irvine, CA) is a biocompatible liquid embolic agent that is used in the treatment of AVM with
advantageous properties. Its composition includes suspended micronized tantalum powder
to facilitate the embolization procedure by providing contrast for visualization under fluo-
roscopy. This high-Z element (Z = 73) is the source of streaking artifacts, due to increased
photoelectric absorption, leading to photon starvation and significantly deteriorating the CT
image quality after embolization.
Measurements of attenuation and interface effects of two types of Onyx embolization
materials (Roberts et al 2012) revealed that effects on dose distributions of a MV therapeutic
beam should be dosimetrically negligible for effective thicknesses of less than 8 mm. The
measured interface effects are also small, particularly at 6 MV. However large areas of high-
density artifacts and low-density artifacts can cause errors in dose calculations and need to
be identified and resolved during planning. Figure 10 displays the effect of Onyx artifacts
on dose calculation for stereotactic radiosurgery, based on different heterogeneity correction
methods (Shtraus et al 2010). Having first measured the difference in attenuation of water
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Figure 10. Isodose comparisons among 3 dose calculation methods in a patient

with Onyx empolization. The images reflect the differences resulting from assigning
differing relative electron density (RED) values to the respective volumes. The three
columns show the axial, sagittal and coronal views respectively. (IA)–(IC): Regular
heterogeneity correction. (IIA)–(IIC): Completely homogeneous calculation (without
heterogeneity corrections). (IIIA)–(IIIC): Heterogeneity corrections with assigned
densities. Actual delivery resembles the lower panel: (IIIA)–(IIIC) (Reproduced from
Shtraus et al 2010, © Springer Science + Business Media, LLC. 2010, with permission
of Springer).
in comparison to the Onyx for beam energy of 6 MV, and approximated to 3%, Shtraus et al
suggested a modified heterogeneity corrections method, by assigning individual electron den-
sities to the normal brain, bone and Onyx, based on the actual attenuation measured. Without
this manually introduced correction, dose calculation may be unreliable and have dire conse-
quences for patients receiving high doses of radiotherapy.
4. Brachytherapy treatment
There are two main causes of CT artifacts in brachytherapy treatment. In LDR brachytherapy
it’s the metallic composition of the permanent implanted radioactive sources that causes beam
hardening during CT imaging for the post-implant position and dose verification process.
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In intracavitary brachytherapy (ICB) treatment, most commonly for GYN malignancies,

the planning CT is performed after the brachytherapy applicators are inserted in the patient.
Image artifacts produced by the metal applicators significantly delayed the widespread adop-
tion of CT-based brachytherapy treatment planning. In addition, due to the physics principles
in brachytherapy treatment techniques, most commonly the treatment dose is delivered within
areas of homogeneous tissue composition. Subsequently, even when CT imaging is used for
organ and tumor delineation and source guidance, heterogeneity corrections are not taken into
consideration for the vast majority of brachytherapy treatment cases, since the potential dosi-
metric inaccuracies due to the artifacts would cancel the dosimetric benefit of heterogeneity
corrections in tissues.
4.1. Intracavitary applicator treatment for GYN
The instrumentation causing the most significant artifact in GYN brachytherapy is the metal
components of shielded ovoids, the cylindrical structures that are placed against the entrance
of the cervix to facilitate lateral irradiation of the vagina and cervix, while shielding the
bladder and other OARs from unnecessary dose. Traditionally, treatment planning for ICB
treatment for GYN cases was based on a set of orthogonal x-ray films, which were used to
reconstruct the individual source locations and normal tissue dose calculation points, based
on the Manchester system (Tod and Meredith 1953), or dose distribution to the target volume,
based on the GYN dosimetry system recommended by the ICRU (ICRU 1985). For this treat-
ment site and technique, the dosimetric effect of CT image artifacts is practically equated with
the dosimetric differences between orthogonal-film- and CT-image-based treatment planning.
Applying a projection-interpolation MAR algorithm (Roeske et al 2003) or a hybrid
approach—combination of projection-based image segmentation and separate reconstruc-
tion of metal and non-metal images (Xia et al 2005)—to images containing the ICB applica-
tors, reconstructed images contained virtually no artifacts and allowed for CT-based planning
(Roeske et al 2003). Delineating the bladder and rectum boundaries to be used in conjunction
with 3D dose calculations showed a factor of two larger maximum dose to the bladder and
rectum compared to doses obtained using orthogonal films. The improvement in dose calcul
ation accuracy for these cases may become even more significant, if a global transformation
of CT images could be used to estimate the dose from whole pelvic radiation therapy (WPRT)
combined with brachytherapy.
As a different approach, Wagner et al (2009) suggested tomotherapy MVCT-based LDR
brachytherapy treatment planning for cervical carcinoma to minimize the reconstruction arti-
facts of kVCT images near high-Z materials, such as the metal brachytherapy applicators.
In a phantom study, the ICRU rectal point dose did not differ significantly between three-
dimensional (3D) CT-based and two-dimensional (2D) planning. However the ICRU blad-
der point dose was significantly lower than the DB2cc (minimal dose received by the 2 cm3
of bladder receiving the highest doses), with mean difference being 291 cGy ± 444 cGy.
Although MVCT soft tissue image resolution suffered compared to the ideal kVCT image,
in terms of discerning the posterior vaginal wall, the use of MVCT imaging for clinical LDR
GYN brachytherapy significantly improved the dosimetric accuracy of treatment planning.
To avoid the effects of metal artifacts in CT imaging by the brachytherapy applicators,
the use of magnetic resonance imaging (MRI) in image guided brachytherapy (IGBT) is
currently recommended by most international guidance groups—including but not limited
to the American Brachytherapy Society (ABS), Groupe Européen de Curiethérapie and
the European SocieTy for Radiotherapy & Oncology (GEC-ESTRO) and Royal College of
Radiologists (RCR)—on IGBT for GYN cancers (Board of the Faculty of Clinical Oncology
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2009, Dimopoulos et al 2012, Viswanathan et al 2015). Appropriate, MRI-compatible brachy-

therapy applicators are used in this case.
4.2. Lung brachytherapy
One lung brachytherapy technique includes creating an implant during the surgical procedure
by weaving strands of 125I seeds into a vicryl mesh, which is then sutured over the resection
staple line. The goal is to deliver 100 Gy at 5–7 mm along the central axis of the resection
margin. This process is followed by CT imaging in an effort to identify the seed positions and
verify the dose distribution according to TG-43 based calculations (Nath et al 1995, Rivard
et al 2004, 2007), assuming seeds in homogeneous water and no interseed attenuation. In
low energy brachytherapy, for photon energies of approximately 20–30 keV, the photoelectric
effect determines a substantial proportion of interactions, with cross section being propor-
tional to the fifth power of atomic number. Subsequently, MC-based dose calculations for this
brachytherapy technique are sensitive to the conversion of CT image pixel values to atomic
composition.
To estimate the level of dosimetric effect from CT artifacts on MC dose calculations for
lung brachytherapy treatment, Sutherland et al (2014) studied the differences among dose
distributions based on five different image sets: (a) uncorrected, artifact-contaminated origi-
nal CT image, (b) corrected image based on simple threshold replacement technique (STR),
where in a 1 × 1 × 1 cm3 cube centered around each seed position any voxel number greater
than or equal to 88 HU was replaced with a CT number of −200 HU, (c) corrected based
on fan beam virtual sinogram (Sutherland et al 2012), (d) corrected by applying a median
filter, where each voxel value is compared with a 3D local median value and replaced with
an adjacent voxel value if it differs by 0.25 times the standard deviation, and (e) corrected
using a combination of fan beam virtual sinogram method and STR (fan + STR). The radio-
nuclide photon spectra were found to be a significant factor affecting dose differences among
various MAR techniques, with largest differences observed for 103Pd seeds and smallest for
131
Cs seeds. When applying lung-constrained tissue assignment schemes to metallic artifact
corrected images, improved dose accuracy for permanent implant lung brachytherapy was
achieved. Dose metrics, such as D90, increase dramatically with the use of MAR methods,
with the fan + STR method showing the largest discrepancies compared to the uncorrected
image set: dose calculations based on the uncorrected image set seem to underestimate D90
by up to 69% for the 125I seeds, 107% for 103Pd seeds and 46% for 131Cs seeds. Application of
an artifact-suppression method in the presence of permanent brachytherapy seed implant for
lung treatment was crucial for the dose calculation accuracy.
4.3. Prostate LDR brachytherapy
Similarly to lung LDR brachytherapy, prostate permanent implant brachytherapy with 125I
seeds requires CT-based seed localization and dose calculation as part of the post-implant
dosimetry verification process. However, the permanently implanted seeds can cause signifi-
cant artifacts on the CT image set to be used for the post-implant dose verification, having
potential dosimetric effects if the voxel HU number is to be corresponded to electron density
information and used by the dose calculation algorithm. Figure 11 depicts a MAR algorithm
suggested by Takahashi et al (2006) to be applied in CT images acquired after permanent
implant brachytherapy with 125I seeds. The first step of their suggested method, utilizing raw
projection data as acquired by the CT scanner, was to obtain an image containing only the
125
I seeds by applying a CT number threshold (figure 11(b)). The sinograms of the CT image
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Figure 11. Scheme of MAR method suggested by Takahashi et al (2006, © Japan

Radiological Society 2006, reproduced with permission of Springer). The white stripes
highlighted by arrows represent the projection data of 125I seeds that caused metal
artifacts.
with seeds and of the seeds-only image (figures 11(c) and (d)) were then obtained by inverse
Radon transform (Lindgren and Rattey 1981). The sinogram without 125I seeds (figure 11(e))
was then provided by subtracting the projection data of the metal image from that of the origi-
nal one and the corrected image was reconstructed by Radon transform using this sinogram.
Significant image improvement was achieved, greatly facilitating the identification accuracy
of number and orientation of the seeds, showing potential for decreasing the time required and
improving the accuracy of post-implant dosimetry verification process.
5. Proton and heavy ion therapy
In proton and heavy radiation therapy CT numbers are used to determine the stopping power
of tissues in the beam path, which are required for calculation of dose distributions and range
of proton or heavy ion beams. Artifacts can therefore result in errors in the estimated range,
affecting the target coverage and sparing of the OARs. In clinical treatment plans, manual
modification of proton stopping power may be applied in an effort to reduce these errors
(Staab et al 2011), however the accuracy of such corrections is uncertain, since the artifact-
contaminated images may not allow to clearly determine the anatomy and tissue densities. The
level of ion range uncertainties based on an artifact-contaminated CT image set also depends
on the material composition and geometry of the metal implant creating the artifacts. Phantom
studies indicated that the underestimation of ion range due to artifacts alone may amount to
3% for dental fillings and up to 5% and 18% for hip prostheses made of titanium and steel
respectively (Jäkel and Reiss 2007). Since the size of the metal inserts cannot be determined
correctly in the artifact-contaminated image, a potential range correction in metal also leads
to large uncertainties.
In the case of small-diameter metallic objects, such as screws, employing MVCT-based
calibration to derive relative proton stopping power in the implant did not affect significantly
the values of calculated range (De Marzi et al 2013). However calculations based on MVCT
images were more accurate in predicting the dose distribution in the distal part of the dose
curve, probably due to the absence of streak artifacts. In the site of spine-stabilizing screws in
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Figure 12. Dose calculations of a posterior–anterior proton beam passing through

titanium hardware in the lumbar spine. The dashed line near the end-of-range of the
beam is drawn to guide the eye. Doses below 0.1 Gy (RBE) are not shown. CT window
level: 40 HU and window width: 400 HU.
the clinical case of proton treatment of a spine chordoma, MVCT-based estimation of proton
stopping power resulted in a minor difference of calculated range between −0.4 and 1.5 mm,
compared to the kVCT image, depending on the beam direction. However, Ainsley and Yeager
(2014) emphasized that when different calibration methods of CT scanners are explored for
proton therapy, one should be cautious of using metals in the calibration procedure since they
can strongly influence the result of the fitting procedure, especially in the high HU region and
they proposed that metallic plugs be avoided when performing the calibration.
5.1. Titanium rod implants in the treatment of spinal bone tumors
Clinical studies of chordoma patients who received proton therapy showed significant associa-
tion of reduced tumor control (Staab et al 2011) or increased local recurrence (Delaney et al
2009) when titanium-based surgical stabilization was involved. Investigating the dosimetric
effect of the presence of metal implants to these cases, Verburg and Seco (2013) performed
a systematic study to assess the dosimetric impact of CT titanium artifacts when surgical
titanium rods implants for spinal tumors are present during proton therapy, based on both
phantom and patient data. Dose recalculations on phantom geometries, with accurate knowl-
edge of the detailed geometry, revealed range errors between 1 mm and 10 mm, depending on
the proton beam orientation. When the beam was oriented perpendicular to several bright and
dark streak artifacts, the dose calculation was almost unaffected, because errors due to several
light and dark streak artifacts cancel out. For proton beams passing through the metal implant,
and the bright artifacts surrounding it, or beams parallel to the metal artifact, larger range dis-
crepancies of 5–10 mm were observed. Studying the effect on patient treatment plans, metal
artifacts resulted in proton field range errors up to 6 mm distal to regions affected by CT
artifacts. MC simulations revealed dose differences of more than 10% in the high-dose area
(figure 12), but since these errors are mostly local in nature, the large number of fields limits
the impact on target coverage to a small decrease of dose homogeneity. GafChromic film
measurements in an anthropomorphic phantom by Dietlicher et al (2014), revealed that when
manual artifact correction method of HU assignment was applied, dose calculations agreed
well with measurements for both single field uniform dose (SFUD) and intensity modulated
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Figure 13. Comparison between the dose calculations based on artifact-contaminated

(top left) and artifact-suppressed (top right) CT images and corresponding dose volume
histograms (bottom). For both dose calculations, the same range and modulation was
used, as optimized for the artifact-contaminated image set (Reproduced from Wei et al
2006. Institute of Physics and Engineering in Medicine. All rights reserved).
proton therapy (IMPT) plans. Without artifact corrections up to 18% of measured points failed
the gamma criterion for the SFUD plan.
5.2. Hip prostheses in the treatment of prostate cancer
Studying the effect of CT artifacts from bilateral hip prostheses on dose distributions and
treatment planning for a variety of treatment modalities, Wei et al (2006) demonstrated that
without any artifact-suppression method, a hypothetical treatment target volume, resembling
a prostate treatment located in between the hip prostheses and treated by a single anterior–
posterior proton beam, would be severely underdosed (figure 13). For the same target vol-
ume, proton beam range and modulation calculations based on the artifact-suppressed images
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differed by 13 mm and 9 mm respectively from those generated based on the artifact-contam-

inated CT images. Similar results were observed by Newhauser et al (2008), where streak-
induced range errors of 5–12 mm were present in uncorrected kVCT-based patient plans for
prostate treatment with single or bilateral hip prostheses. Appropriate calibration of TPSs to
simultaneously accommodate kV- and MVCT image sets for proton calculation can improve
the dose calculation accuracy when the kVCT image is used for soft-tissue contouring and
the prostheses are contoured in the MVCT images leading to a co-registered set of kVCT and
MVCT images.
Differences in calculated proton beam penetration for the artifact-contaminated and arti-
fact-suppressed image sets of water phantoms with a hip prosthesis were quantified using
water equivalent thickness (WET) based on stopping power data by Andersson et al (2014).
Images without metal objects were used as reference data for the analysis of artifact-affected
regions outside the metal objects in both the uncorrected and the corrected (O-MAR algo-
rithm) images. Relative to the reference image set, significant differences in WET of up to
2.0 cm were calculated for the uncorrected case, while for the O-MAR corrected images this
difference was reduced to up to 0.4 cm.
5.3. Artifacts present in head-and-neck treatments
Due to the complexity of cranial structures and the variety of possible diseases and treatment
techniques, different surgical implants might be the source of CT-artifacts affecting the dosi-
metric accuracy and treatment planning of proton therapy for cranial or head-and-neck treat-
ments. These may range from the most common dental fillings to artifacts caused by titanium
mesh cranial implants or metal frame used for sterotactic radiosurgery planning and patient
setup. The presence of more than one type of implants, simultaneously affecting the image
quality, is not uncommon.
Studying the effect of titanium mesh cranial implants for a mesh thickness of 0.6 mm on
passive-scattering proton, Lin et al (2014) observed a minimal range reduction of 0.5 ± 0.1 mm
for a beam perpendicular to the Ti-mesh or when the incident angle was at 60°. The corre
sponding dosimetric effect was minimal. In a more extended study (Park et al 2015) based on
four clinical cases with a variety of sources of artifacts (dental fillings, surgical clips or head
frame used for patient localization), a MRI-based MAR method was used for improvement of
proton range calculation accuracy. The corrupted CT data were replaced by mapping CT HU
from a nearby artifact-free slice, using a co-registered MRI. Absolute proton range errors of
2.4 and 1.7 cm, estimated for the uncorrected CT-image sets were reduced to less than 2 mm
in both cases.
6. Discussion
The increasing number of patients receiving metal implants and the fact that CT is still the
preferred imaging method used in radiation therapy, one of the primary cancer treatment
method worldwide, renders the issue of CT metal artifacts of significant clinical importance.
Depending on the treatment site and delivery method, the dosimetric effect of metal artifacts
becomes more significant in 3D conformal radiation compared to IMRT or VMAT delivery
techniques and when smaller number of beams is used in the treatment plan. The dosimetric
errors decrease when larger number of treatment beams is utilized and especially in VMAT
delivery technique where the continuous dose leads to a blurring of the inhomogeneity in
dose distribution caused by the implants. In contrary the effect of artifacts on dose calculation
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accuracy can be more significant in particle therapy due to the strong dependence of the par-
ticle dose calculation algorithm on the HU number.
6.1. External beam radiation therapy
Metal implants used in hip prostheses can pose a significant issue in external radiation therapy
of prostate cancer. CT metal artifacts in the form of streaks become significant due to rela-
tively large diameter of the metal implant causing photon starvation under standard scanning
techniques. For a 6 MV beam traversing the hip replacement, ignoring the attenuation due to
the high-density material can result to a dosimetric error in the order of 15–25% at the target.
Assigning the correct density to the metal in the analytical dose calculation process reduces
the effect, however significant dosimetric errors can still be observed, especially in the cases
of bilateral hip replacement where a dark area is observed in the CT images between the two
implants due to photon starvation. The estimated error varies greatly depending on the beam
energy and number of beams used in a plan. IMRT technique was shown superior to 3D-CRT
treatment, especially for cases of bilateral hip replacement where achieving sufficient dose
sparing of the OARs (bladder and rectum) becomes more challenging and non-standard beam
directions are necessary. The dosimetric error due to uncorrected metal artifacts decreases for
increasing number of beams and beam energy, but it still remains significant in the order of 5%
or higher in the target volume. Utilizing MVCT, when available, instead of or in combination
with conventional kVCT imaging offers a potential solution, which becomes more efficient
when an adequate MAR algorithm can be applied in the images resulting in good dose agree-
ment of the analytical calculation and measurements in phantoms.
Metal artifacts from dental fillings or implants present another important challenge in
radiation therapy treatment planning and dose calculation, in the treatment of head-and-neck
tumors, especially when extended clusters of dental implants of high-Z materials (gold) are
close to the target volume. Phantom-based measurements reveal target dose discrepancies
between the delivered and calculated dose distribution on the artifact-affected CT image in
the order of 11–13% on average. Simple correction methods, such as manual assignment of
appropriate HU in the soft tissue volumes affected by the artifact within or surrounding the
target volume, seem to improve the dosimetric agreement. However, these solutions greatly
depend on the planner’s ability and experience, are subject to inconsistencies and should be
verified by dose measurements to guarantee the necessary patient treatment plan quality. The
use of VMAT delivery method was shown advantageous for head-and-neck or brain tumor
treatments where significant CT artifacts due to dental implants are present. Since VMAT is
delivered continuously during wide-angle rotations of the treatment head, it has a potential
averaging effect to the dose inhomogeneity caused by the artifacts. CT artifacts within the oral
cavity, due to dental implants, significantly increase the HU number, making the cavities to
appear filled with high density material. This can result in significant dosimetric errors, espe-
cially if the target volume is adjacent to the oral cavity. To reduce the dosimetric error in these
cases proper immobilization device for the head-and-neck, including a bite-block maintaining
the mouth’s closed position, is important.
The majority of spinal implants in patients treated with radiation therapy are located within
or close to the desired treatment volume, as they are related to the surgical removal of spinal
tumors prior to radiation therapy. Although the delineation of the treatment volume becomes
very challenging due to the metal artifacts in these cases, their effect to the dosimetric acc
uracy of external photon beam radiation therapy has been reported as small compared to
higher-Z metal implants such as gold dental fillings. MVCT imaging-based treatment plan-
ning, when possible, may facilitate organ delineation and improve the dosimetric accuracy,
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even though the artifacts are not completely eliminated and soft tissue resolution suffers sig-
nificantly. MC dose calculations in phantom geometries revealed the potential of increasing
dosimetric errors of the analytical calculation algorithm with decreasing distance to titanium
rods used as spinal implants. Assigning the appropriate electron density to the titanium rods
in the CT images decreases significantly the dosimetric error while inaccuracies in the density
assignment of the titanium rods cause only a small error when multi-beam IMRT treatment
planning is employed.
Concerning CT artifacts caused by Onyx implants during stereotactic radiosurgery treat-
ment of arteriovenus malformations, due to the originally homogeneous tissue density of the
normal brain, manual assignment of individual electron densities to the normal brain, bone
and Onyx volumes can be a sufficient solution improving dose calculation accuracy. However,
again, this method is subject to planner’s level of experience and expertise, requiring signifi-
cant effort and subject to the risk of inconsistency errors.
6.2. Brachytherapy treatment
In high dose rate (HDR) brachytherapy artifacts caused by the brachytherapy applicators pose
the most significant challenge in CT-based dose calculation accuracy and treatment planning.
Due to the metal artifacts and the assumption that homogeneous tissue is surrounding the
brachytherapy sources, the use of CT image based 3D dose calculation in brachytherapy treat-
ment was introduced much later compared to external beam radiation therapy. Application of
MAR methods to reduce metal artifacts mainly from brachytherapy applicators has allowed
for CT-based treatment planning and 3D dose calculation, greatly facilitating organ delinea-
tion and significantly improving the dose calculation accuracy. MVCT imaging for clinical
GYN brachytherapy has also shown the potential to improve the dosimetric accuracy of treat-
ment planning, despite the decreased soft tissue image resolution of the MVCT image. A com-
bination of both kV- and MVCT imaging could provide an improved solution for these cases.
In LDR brachytherapy, apart from the applicators, the metal encapsulation of the implanted
seed imposes an additional source of artifacts. Due to the low energy spectrum emitted by the
permanent implanted LDR seeds, the photoelectric effect becomes a significant energy trans-
fer mechanism, increasing the dependence of the dose calculation accuracy to the accuracy
of the electronic density of the material as estimated from the HU value and corresponding
conversion curves. Application of MAR methods allows for much more accurate CT-based
MC dose calculation in permanent seed implant brachytherapy and greatly facilitates the post-
implant radiation seed position and dose verification in LDR brachytherapy.
6.3. Proton and heavy ion therapy
The effect of metal artifacts in particle therapy can be more significant compared to con-
ventional therapies due to the stronger dependence of the dose calculation method on the
material stopping power determined from CT numbers via appropriate calibration curves.
Furthermore, particle therapy plans generally consist of fewer beams compared to photon
treatments, increasing the potential contribution of dosimetric errors introduced to the dose
calculation in a single beam due to the CT artifacts.
In patients treated for chordoma tumors with proton radiation therapy the presense of
titanium-based surgical stabilization was associated with worse outcome in terms of tumor
control. Contrary to the photon radiation therapy, if no MAR method is applied, the potential
errors in dose distributions calculated for proton beams are substantial. Reported dosimetric
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errors of more than 10% in the target volume (Dietlicher et al 2014) and range calculation
errors of up to 10 mm or higher (Verburg and Seco 2013) can become clinically significant due
to compromised dose coverage of the target volume. Selecting appropriate beam directions,
perpendicular to the metal artifact when possible, may lead to increased dosimetric accuracy,
however this approach is dependent on each planner’s experience and expertise and subject
to inconsistencies.
In proton therapy of prostate patients with bilateral hip replacement, the dark band between
the two high-density implants caused by photon starvation, results in significant underestima-
tion of the CT value and the corresponding proton stopping power. If no correction is applied
to the CT image, the dose distribution from an anterior–posterior proton beam can be greatly
overestimated leading to a range calculation error of more than 10 mm and significantly com-
promised target coverage. For lateral proton beams, parallel to the artifact, the range calcul
ation error can be even more significant, in the order of 20 mm (Andersson et al 2014). The
application of MVCT-assisted treatment planning has the potential to improve the dosimetric
accuracy for these cases as well, provided that appropriate calibration of the TPS is performed
to simultaneously accommodate kV- and MC-CT image sets for proton dose calculation.
6.4. Need for a global MAR method
Although numerous attempts have been made to address the issue of CT metal artifacts in
radiation therapy, their efficiency in terms of improvement of radiation dose calculation acc
uracy greatly depends on the type of metal implant, the treatment site, and the radiation treat-
ment technique. So far no solution has been proven to provide complete elimination of metal
artifacts for a variety of metal implants and treatment sites, since most methods target specific
characteristics of metal artifacts. Moreover, common MAR methods on clinical scans have
shown mixed results because new artifacts have been introduced in some cases. Sinogram
completion methods can lead to a loss of spatial resolution due to the removal of projections,
while beam hardening correction methods can be effective only when sufficient photons pass
through the implant and model-based iterative approaches require prior knowledge of the
implant material which may not be always available in clinical practice.
The physics behind CT metal artifacts is very different depending on the implant mat
erial, so the ideal MAR algorithm would need to account for these differences and incorpo-
rate appropriate models depending on the physical principles causing each artifact. Mixed
approaches combining physics correction algorithm, designed to reduce beam hardening
effects, with projection interpolation and iterative projection replacement methods can result
in significant improvement of the image quality compared to standard projection interpolation
methods for all types of metal implants, without introducing new artifacts (Verburg and Seco
2012). This demonstrates the significance of the a priori knowledge of the implant material in
the MAR process. Combining an iterative MAR with frequency-split metal artifact reduction
(FSMAR) can also provide improved dosimetric agreement between calculation and measur-
ments in phantoms (Axente et al 2015). However, although this improvement can be sufficient
for photon beam plans, in the case of proton beam treatment further improvements are neces-
sary to achieve necessary dosimetric accuracy.
Since no universal solution with the above characteristics currently exists, treatment plan-
ners in radiation treatment centers select case-specific solutions based on their experience and
expertise. Manual delineation of artifact-affected areas and electron density assignment is a
common practice. The accuracy, reproducibility and consistency of such methods however
are highly dependent on the planner’s level of experience. Furthermore the level of distortion
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of the artifact contaminated image may not allow for accurate delineation of these areas and
organs of interest.
In order for standard treatment planning techniques to be used based on CT images from
patients with metal implants, correction of the metal artifacts accurately predicting the HU
number is necessary. A universal solution would be desirable with the possibility to distin-
guish and appropriately treat the variety of physics properties and interactions resulting in
metal artifacts in a CT image used in radiation therapy treatment planning. A priori knowledge
of the composition and geometry of the metal implant has been shown significantly advanta-
geous and all studies point to the fact that a sophisticated segmentation method in the projec-
tion space and a combination rather than a single MAR technique will provide such potential.
An ideal MAR solution should correct artifact-affected CT images for any geometrical prop-
erties of implants causing the artifacts, providing correction steps depending on the size of the
affected regions and number of affected projections, distinguishing between the different size
and material composition of the implants. Advanced physics correction algorithms c orrecting
for beam hardening should be applied at the presence of low-Z metal or small size seeds or
screws of a few millimeters diameter while projection completion methods are more efficient
in cases of large diameter or high-Z materials causing significant photon starvation presented
with extreme white streaking artifacts. Improved scanning techniques allowing for selective
increased photon fluence through areas of interest including metal implants could also be
applied as a solution against photon starvation. Also significant specifically to proton therapy
is the ability to correctly depict and estimate the dimensions of the metal implant in order
to achieve accurate range calculation based on the corrected image when the metal is in the
path of the beam. When CT image acquisition is intended for radiation treatment planning,
potential increased dose from CT scanning can be considered of secondary priority, given the
radiation treatment dose to be received by the patient, since the potential dosimetric accuracy
and dose sparing of the OARs based on improved image quality and organ delineation can be
orders of magnitude higher.
7. Conclusions
The level of dosimetric effect of CT metal artifacts in radiation therapy varies greatly depend-
ing on the implant site, its relative position to the treatment, the level of tissue inhomogeneity
and treatment modality. In the presence of high density or large size metal implants, such as
hip replacement in the treatment of prostate cancer, dosimetric errors of up to 25% have been
reported for 6 MV photon beams. The effect however is reduced for increasing number of
beams and higher photon energies. When dental implants exist in the treatment of brain or
head-and-neck tumors, the reported effect is lower, in the order of 11–13%. The effect can be
more significant in particle therapy, since there is a stronger dependence of the dose calcul
ation method on the material stopping power determined from the CT number. In patients
treated for chordoma tumors with proton radiation therapy, dosimetric errors of more than
10% in the high-dose area were reported, leading to range calculation errors of up to 10 mm,
due to the presence of CT metal artifacts.
Current MAR algorithms can lead to reduction of the dosimetric error, however further
improvement is desirable. Developing a universal MAR solution, with a combination of
improved acquisition protocols, physics correction and reconstruction algorithms, requires
a collaboration between multiple groups from different disciplines. An additional existing
challenge when attempting to evaluate the efficiency of a MAR method is the absence of
a standardized approach and tools to be used as benchmark. Phantom geometries utilized
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in most studies cannot provide the appropriate level of detail and differ significantly from
actual clinical patient cases. When patient cases are used, the lack of a reference ground-truth
image-set quality and dose calculation metric only allows for relative studies. Developing a
MAR evaluation protocol based on standardized patient-like phantom geometries and actual
patient cases with available reference images would be a significantly effective step towards
improvement in image quality and dose calculation in CT images affected by the presence of
metal implants.
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impact of metal artifact reduction

2017 Phys. Med. Biol. 62 R49

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Nuclear physics in particle therapy: a review

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Phys. Med. Biol. 62 (2017) R49–R80 https://doi.org/10.1088/1361-6560/aa5293

Metal artifacts in computed tomography

Received 3 August 2016, revised 20 October 2016

artifacts in treatment planning, as reported in the literature, and the potential

Keywords: computed tomography, metal artifacts, dose effect, radiation

(Some figures may appear in colour only in the online journal)

2. CT MAR algorithms in radiation therapy treatment planning

Figure 1. Scheme of NMAR (Reproduced with permission from Meyer et al 2010).

interpolation in the normalized sinogram. Finally, the normalized sinogram is multiplied by

Figure 2. General iterative reconstruction scheme. Starting from the current

Figure 3. Schematic diagram of iterative algorithm.

3. External photon beam treatment

3.1. Pelvic implants (hip prostheses)

The dosimetric effect of artifacts in conventional kilovoltage CT (kVCT) imaging caused

Figure 5. Schematic diagram of the methodology by Keall et al (2003, Reproduced

Figure 7. Comparisons of dose distributions for 6 MV 5 × 10 cm2 parallel-opposed

3.2. CT artifacts from dental implants

3.3. Spinal implants

3.4. AVM following embolization with Onyx

Figure 10. Isodose comparisons among 3 dose calculation methods in a patient

In intracavitary brachytherapy (ICB) treatment, most commonly for GYN malignancies,

4.1. Intracavitary applicator treatment for GYN

2009, Dimopoulos et al 2012, Viswanathan et al 2015). Appropriate, MRI-compatible brachy-

4.2. Lung brachytherapy

4.3. Prostate LDR brachytherapy

Figure 11. Scheme of MAR method suggested by Takahashi et al (2006, © Japan

5. Proton and heavy ion therapy

Figure 12. Dose calculations of a posterior–anterior proton beam passing through

5.1. Titanium rod implants in the treatment of spinal bone tumors

Figure 13. Comparison between the dose calculations based on artifact-contaminated

5.2. Hip prostheses in the treatment of prostate cancer

differed by 13 mm and 9 mm respectively from those generated based on the artifact-contam-

5.3. Artifacts present in head-and-neck treatments

6.1. External beam radiation therapy

6.2. Brachytherapy treatment

6.3. Proton and heavy ion therapy

6.4. Need for a global MAR method

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