Quantifying Image Quality

LinkpingUniversityMedicalDissertationsNo.
1050
Quantifyingimagequalityin
diagnosticradiologyusing
simulationoftheimaging
systemandmodelobservers
GustafUllman
RadiationPhysics,DepartmentofMedicineandHealth
FacultyofHealthSciences
LinkpingUniversity,Sweden
Linkping2008
ii
GustafUllman,2008
Cover picture/illustration: An oil painting by Gustaf Ullman representing a

chestradiograph
Publishedarticlesandfigureshavebeenreprintedwiththepermissionofthe
copyrightholder.
PrintedinSwedenbyLiUTryck,Linkping,Sweden,2008
ISBN9789173939522
ISSN03450082
Dontworryaboutsavingthesesongs!
Andifoneofourinstrumentsbreaks,
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Thestrummingandtheflutenotes
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Stopthewordsnow.
Openthewindowinthecenterofyourchest,
andletthespiritsflyinandout.

JalalalDinRumi
iii

iv
v
CONTENTS
1. INTRODUCTION................................................................................................ 1
1.1. Radiationprotectionindiagnosticradiology..................................... 1
1.2. Optimisationofdiagnosticradiology .................................................. 2
1.3. OptimisationusingaMonteCarlobasedcomputationalmodel ... 2
2. OBJECTIVE ........................................................................................................... 5
3. MONTECARLOBASEDCOMPUTATIONALMODELOFTHE
IMAGINGSYSTEM................................................................................................... 7
3.1. Introduction............................................................................................... 7
3.2. Computationalmodelofthexrayimagingsystems ........................ 9
3.2.1. Modeloftheimagingsystem........................................................... 9
3.2.2. MonteCarlosimulationofphotontransport............................... 14
3.2.3. Scoringquantities............................................................................. 18
3.2.4. Calculatedquantities ....................................................................... 19
3.3. Calculationofimagesfromthehighresolutionphantom ............ 20
3.4. Uncertainties............................................................................................ 22
3.4.1. Stochasticuncertainties ................................................................... 22
3.4.2. Systematicuncertainties.................................................................. 22
4. ASSESSMENTOFIMAGEQUALITY.......................................................... 25
4.1. Introduction............................................................................................. 25
4.2. Imagequalityassessmentasdevelopedinthiswork..................... 26
4.2.1. Thetask.............................................................................................. 26
4.2.2. Modeloftheimagingsystemandpatient.................................... 27
4.2.3. Observers........................................................................................... 29
4.2.4. Figuresofmerit ................................................................................ 30
5. RESULTSANDDISCUSSION....................................................................... 41
5.1. Idealobserverwithasimplifiedpatientmodel .............................. 41
Contents
5.2. Lowresolutionvoxelphantom............................................................ 43
5.3. Highresolutionvoxelphantom........................................................... 44
5.4. Idealobserverwithsimpleanatomicalbackground....................... 46
5.5. Correlationtohumanobservers.......................................................... 49
5.6. Modelobserverswithcomplexanatomicalbackground ............... 52
6. SUMMARYANDCONCLUSIONS............................................................... 59
7. FUTUREWORK................................................................................................. 61
8. ACKNOWLEDGEMENTS ............................................................................... 63
9. REFERENCES...................................................................................................... 65
vi
Abstract
vii
ABSTRACT
Accuratemeasuresofbothclinicalimagequalityandpatientradiationriskare
neededforsuccessfuloptimisationofmedicalimagingwithionisingradiation.
Optimisation in diagnostic radiology means finding the image acquisition
technique that maximises the perceived information content and minimises
the radiation risk or keeps it at a reasonably low level. The assessment of
image quality depends on the diagnostic task and may in addition to system
andquantumnoisealsobehamperedbyoverlyingprojectedanatomy.
The main objective of this thesis is to develop methods for assessment of

image quality in simulations of projection radiography. In this thesis, image
quality is quantified by modelling the whole xray imaging system including
the xray tube, patient, antiscatter device, image detector and the observer.
This is accomplished by using Monte Carlo (MC) simulation methods that
allow simultaneous estimates of measures of image quality and patient dose.
Measuresofimagequalityincludethesignaltonoiseratio,SNR,ofpathologic
lesions and radiation risk is estimated by using organ doses to calculate the
effective dose. Based on highresolution anthropomorphic phantoms,
synthetic radiographs were calculated and used for assessing image quality
with modelobservers (LaguerreGauss (LG) Hotelling observer) that mimic
real,humanobservers.Breastandparticularlychestimagingwereselectedas
studycasesastheseareparticularlychallengingfortheradiologists.
In chest imaging the optimal tube voltage in detecting lung lesions was
investigatedintermsoftheirSNRandthecontrastofthelesionsrelativetothe
ribs.ItwasfoundthatthechoiceoftubevoltagedependsonwhetherSNRof
thelesionortheinterferingprojectedanatomy(i.e.theribs)ismostimportant
fordetection.TheLaguerreGauss(LG)Hotellingobserverisinfluencedbythe
projected anatomical background and includes this into its figureofmerit,
SNR
hot,LG
. The LGobserver was found to be a better model of the radiologist
than the ideal observer that only includes the quantum noise in its analysis.
Themeasuresofimagequalityderivedfromourmodelarefoundtocorrelate
relatively well with the radiologists assessment of image quality. Therefore
MCsimulationscanbeavaluableandanefficienttoolinthesearchfordose
efficientimagingsystemsandimageacquisitionschemes.
Listofpapers
ix
LISTOFPAPERS
Thisthesisisbasedonthefollowingpapers
I. Gustaf Ullman, Michael Sandborg, David R Dance, Martin Yaffe,

Gudrun Alm Carlsson. A search for optimal xray spectra in iodine
contrastmediamammography.Phys.Med.Biol.50,31433152(2005)*
II. Gustaf Ullman, Michael Sandborg, David R Dance, Roger Hunt, and
Gudrun Alm Carlsson. Distributions of scatter to primary ratios and
signal to noise ratios per pixel in digital chest imaging. Radiat Prot
Dosim,114,no13,355358(2005)*
III. GustafUllman,MichaelSandborg,DavidRDance,RogerAHuntand
Gudrun Alm Carlsson. Towards optimization in digital chest
radiography using Monte Carlo modelling. Phys Med Biol 51, 2729
2743(2006)*
IV. Michael Sandborg, Anders Tingberg, Gustaf Ullman, David R Dance
and Gudrun Alm Carlsson. Comparison of clinical and physical
measuresofimagequalityinchestandpelviscomputedradiographyat
differenttubevoltages.Med.Phys.33(11)41694175(2006)*
V. GustafUllman,AlexandrMalusek,MichaelSandborg,DavidR.Dance
and Gudrun Alm Carlsson. Calculation of images from an
anthropomorphic chest phantom using Monte Carlo methods. Proc of
SPIE6142,(2006)*
VI. Gustaf Ullman, Magnus Bth, Gudrun Alm Carlsson, David R Dance,
Markku Tapiovaara, and Michael Sandborg. Development of a Monte
Carlo based model for optimization using the LaguerreGauss
Hotellingobserver.(TobesubmittedtoMedPhys)
*Reprintshavebeenincludedwiththepermissionfromthepublisher
Listofpapers
Otherpeerreviewedpapersbytheauthornotincludedinthethesis
1. Gustaf Ullman, Michael Sandborg, David R Dance, Roger Hunt, and

Gudrun Alm Carlsson. The influence of patient thickness, tube voltage
and image detector on patient dose and detail signal to noise ratio in
digitalchestimaging.RadiatProtDosim,114,no13,294297,2005
2. MarkusHkansson,MagnusBth,SaraBrjesson,SusanneKheddache,
GustafUllman,LarsGunnarMnsson.Noduledetectionindigitalchest
radiography: effect of nodule location. Radiat Prot Dosim 114, no 13,
9296,2005
3. R A Hunt, D R Dance, P R Bakic, A D A Maidment, M Sandborg, G
Ullman and G Alm Carlsson. Calculation of the properties of digital
mammogramsusingacomputersimulation.RadiatProtDosim114,no
13,395398,2005
4. D R Dance, R A Hunt, P R Bakic, A D A Maidment, M Sandborg, G
Ullman and G Alm Carlsson. Breast dosimetry using a highresolution
voxelphantom.RadiatProtDosim114,no13,359363,2005
5. Roger A Hunt, David R Dance, Marc Pachoud, Gudrun Alm Carlsson,
Michael Sandborg, Gustaf Ullman and Francis R Verdun. Monte Carlo
simulation of a mammographic test phantom. Radiat Prot Dosim, 114,
no13,432435,2005.
Conferencepresentations
1. Ullman G, Sandborg M, Dance D R, Skarpathiotakis M, Yaffe MJ, Alm

Carlsson G. (2002) A search for optimal xray energy spectra in digital
iodine subtraction mammography using Monte Carlo simulation ofthe
imaging chain. Digital Mammography IWDM 2002: Proceedings of the
Workshop, Bremen, Germany, June 2002. Ed. Peitgen HO (Springer
Verlag,Berlin)pp152154,2002
2. M. Bth, M. Hkansson, S. Brjesson, S. Kheddache, C. Hoeschen, O.
Tischenko, F. O. Bochud, F. R. Verdun, G. Ullman, L. G. Mnsson.
Investigation of components affecting the detection of lung nodules in
digital chest radiography. Accepted for presentation at Medical
Imaging,1217February2005,SanDiego,USA.Proc.SPIE5749,231242,
2005.
x
Listofpapers
Internalreports(notreviewed)
1. GustafUllman,MichaelSandborg,RogerHuntandDavidRDance.
Implementationofsimulationofpathologiesinchestandbreast
imagingReportno94,ISRNULIRADR94SE,2003
2. Gustaf Ullman, Michael Sandborg and Gudrun Alm Carlsson.
Validation of a voxelphantom based Monte Carlo model and
calibration of digital systems. Report no 95, ISRN ULIRADR95SE,
2003
3. Gustaf Ullman, M Sandborg, D R Dance, R Hunt and G Alm Carlsson
Optimisation of chest radiology by computer modelling of image
quality measures and patient effective dose Report no 97, ISRN ULI
RADR97SE,2004
4. GustafUllman,MSandborg,AndersTingberg,DRDance,RogerHunt
and G Alm Carlsson Comparison of clinical and physical measures of
imagequalityinchestPAandpelvisAPviewsatvaryingtubevoltages
Reportno98,ISRNULIRADR98SE,2004
5. Gustaf Ullman, M Sandborg, D R Dance, M Bth, M Hkansson, S
Brjesson,RHuntandGAlmCarlssonOntheextentofquantumnoise
limitationindigitalchestradiographyReportno99,ISRNULIRADR
99SE,2004
6. Gustaf Ullman, Michael Sandborg, David R Dance, Roger Hunt and
GudrunAlmCarlssonDistributionsofscattertoprimaryandsignalto
noiseratiosperpixelindigitalchestimagingReportno100,ISRNULI
RADR100SE,2004
xi
Abbreviations
xiii
ABBREVIATIONS
AGD Averageglandulardose
ALARA Aslowasreasonableachievable
APR Apicalpulmonaryregion
AUC AreaundertheROCcurve
BKE Backgroundknownexactly
BV Backgroundvarying
C Contrast
CC Craniocaudal
C/CB Noduletobonecontrast
Crel Relativecontrast
DQE Detectivequantumefficiency
E Effectivedose
FN Falsenegative
FOM Figureofmerit
FP Falsepositive
Ht Equivalentdose
HIL Hilarregion
Kc,air Collisionairkerma
LG LaguerreGauss
LAT Lateralpulmonaryregion
LME Lowermediastinalregion
LNT Linearnonthresholdhypothesis
MC MonteCarlo
MTF Modulationtransferfunction
NPS Noisepowerspectrum
PA PosteriorAnterior
RET Retrocardialregion
ROC Receiveroperatingcharacteristics
SKE Signalknownexactly
SNR Signaltonoiseratio
SNRhot,LG LaguerreGaussHotellingobserversignaltonoiseratio
SNRI Idealobserversignaltonoiseratio
SNRp Signaltonoiseratioperpixel
TN Truenegative
Listofpapers
TP Truepositive
UME Uppermediastinalregion
VGA Visualgradinganalysis
VGAS VGAscore
Energyimpartedperunitareafromprimaryphotons
p
A
c
s
A
c
p
Energyimpartedperunitareafromscatteredphotons
Meanenergyimpartedperprimaryphoton
Meansquaredenergyimpartedperprimaryphoton
2
p
s
Meanenergyimpartedperscatteredphoton
Meansquaredenergyimpartedperscatteredphoton
2
s
xiv
Introduction
1
1. INTRODUCTION
1.1. Radiationprotectionindiagnosticradiology
Diagnostic xray examinations can support the radiologist with valuable
information that can be utilised to give a patient an accurate diagnosis, and
subsequently a successful treatment. However, imaging with ionising
radiation is also associated with a small risk for cancer induction or genetic
detriment.Whenxrayphotonsarescatteredorabsorbedinsidethecellsofthe
human body, ionisations occur that can alter molecular structures and thus
makeharmtothecell.Themostimportantdamagetothecellisdamageinthe
DNA since this may induce mutations. Ultimately, the damage may lead to
thatthecelliskilled,andifenoughcellsarekilled,thefunctionofthetissueor
organ will be deteriorated. This type of acute harm due to large radiation
exposuresisreferredtoasadeterministiceffect.However,attherelativelylow
radiation exposures in diagnostic radiology, the damages caused by ionising
radiation are often rather easily repaired. Yet, sometimes the damage on the
DNAismorecomplex.Thiscancausemutationsorchromosomeaberrations,
which in turn may lead to a modified cell but with retained reproduction
capacity.Insomecases,suchmodifiedcellscanresultinacancer.Inthecase
wheretheharmfuleffectsofionisingradiationareonlyknownstatistically,it
is referred to as a stochastic effect. The risk related to stochastic effects to a
human from exposure from ionising radiation is often quantified with the
effectivedose,E(ICRP1991,ICRP2007).
According to the linear nonthreshold (LNT) hypothesis, there is a linear

relation between the effective dose and risk for cancer induction (ICRP 2005)
andmeansthatthecollectivedosecanbeusedasameasureoftheharmtothe
population. The collective dose from medical radiography is according to the
Swedishradiationprotectionauthority(Anderssonetal2007)8000manSvper
year or 0.9 mSv on average per capita, and contributes the largest fraction of
thetotaldosetothepopulationfrommanmadesources.
Diagnosticradiologyisinvaluableforthehealthcarebutduetotheradiation
risks, radiation protection of the patient becomes an important issue. Three
different principles are used for radiation protection (ICRP 2007). The first
principle is justification. Ionising radiation should only be used in those
situations where it brings more good than harm. The second principle is
Introduction
optimisation.Itmeansthat,inthosecaseswheretheuseofionisingradiationis
justified, doses should be kept as low as reasonable achievable. This is often
referredtoastheALARA(AsLowAsReasonablyAchievable)principle.The
thirdprincipleisdoselimitstotheindividual.However,thisprincipleismore
applicableforpersonnelratherthanforpatientsindiagnosticradiology.
1.2. Optimisationofdiagnosticradiology
Optimisationmeanstobalancethediagnosticinformation(imagequality)and
patient dose so as to maximize the ratio between the two; either to keep the
information constant and minimize the dose or to increase information at
constantdose.Thedosetothepatientundergoinganxrayexaminationhas,in
digital systems, a close relation to the quantum noise in the image. The
quantum noise depends on the number of photons incident on the image
detector and is approximately described with a compound poisson
distribution,whichtakestheenergyabsorptionpropertiesofthedetectorinto
account.Ifweusetoofewphotons,theimagewillbenoisyanditwillmakeit
difficult or even impossible for the radiologist to give a correct diagnosis. It
mayalsotakelongertimefortheradiologisttogiveadiagnosisusinganoisy
image. Yet, above a certain dose level, the quantum noise may become
negligible in comparison to the noise naturally present in the projected
anatomy (Hoeschen et al 2005). There will therefore be limited benefit to
increasethedoseabovethislevel.
How to make the trade off between the dose to the patient and the image
quality is a complex subject. A key aspect for the optimisation of diagnostic
radiologyistounderstandtherelativeimportanceofthequantumnoiseinthe
image and the structures in the projected anatomy that act as noise. Several
authors including Kundel et al (1985), Samei et al (1999), Burgess et al (2001)
and Hkansson et al (2005b) have acknowledged the importance of projected
anatomy in relation to quantum noise. The consensus from these studies is
that at normal exposures, the projected anatomy is the most important factor
in hampering the detection of subtle nodules in chest radiographs and
mammograms.
1.3. OptimisationusingaMonteCarlobasedcomputationalmodel
One method that has been utilised to search in a systematic way for the
optimal imaging parameters in diagnostic radiology is to use a model of the
imaging system, including the patient and observer, and to simulate the
photontransportthroughtheimagingsystemusingtheMonteCarlomethod.
2
Introduction
With this method it is possible to simultaneously calculate the dose to the
patientandmeasuresofimagequality.
However, the physical measures of image quality derived from simulations

must in some sense give us information on the usefulness of the image for a
radiologist to solve a specific clinical task. Our physical measures of image
quality must therefore correlate to clinical measures of image quality. Two
methods for assessment of clinical image quality are given attention in this
work,receiveroperatingcharacteristics(ROC)(Metz1986)andvisualgrading
analysis(VGA)(Tingberg2000).Achallengeinthisworkhasbeentodevelop
a model, which includes realistic measures of image quality that takes the
projectedanatomyintoaccount.
3
Objective
5
2. OBJECTIVE
While patient doses are relatively straightforward to calculate, image quality
assessment is a more complex task and crucial for the optimisation process.
The main objective of this thesis is therefore to further develop methods for
assessment of image quality in xray projection radiography. The main
method is Monte Carlo photon transport simulation (Monte Carlo model)
through the whole xray imaging system including a model of the image
observer. As study cases, chest posterioranterior (PA) and mammography
craniocaudal (CC) projections are used as these are particularly challenging
fortheradiologist.
Thespecificobjectivesare:
- Tostudyhowphysicalmeasuresinfluencingimagequalityare
distributedovertheimageplane(paperII)
- Todevelopmethodsforcalculatingphysicalimagequalitymeasures
fromsimulatedradiographsandsearchforcorrelationsbetweenthese
measuresandmeasuresofclinicalimagequality(papersIIIandIV)
- Todeveloppatientmodelsofhigherrealismandfineranatomical
structuresforcalculationofsyntheticxrayimagestobeusedforimage
qualityanalysis(papersVandVI)
- To complete our model of the imaging system by including a more

realistic model observer that can be used to directly make any task
related clinical image quality assessment from synthetic images
calculatedbythemodel(papersVandVI)
- Touseourmodeloftheimagingsystemtowardsoptimisationofimage
qualityandpatientdose(paperIandIII)
MonteCarlomodel
7
3. MONTE CARLO BASED
COMPUTATIONAL MODEL OF THE
IMAGING SYSTEM
3.1. Introduction
The Monte Carlo method relies on taking random samples from known
distributions and is particularly useful for studying complex problems with
many degrees of freedom. One of the first applications of the method was in
Los Alamos, USA, during the Second World War where it was used to
simulate neutron diffusion. Today, Monte Carlo methods are employed in
widely diverse fields, from the evaluation of shares on the stock market
(Glasserman 2003) to the calculation of energy levels of molecules with
quantumMonteCarlo(CeperleyandAlder1986).
In radiation physics, the Monte Carlo method is employed for simulating

radiation transport, mathematically described by the Bolzmann equation.
There are several generalpurpose computer codes available for the study of
radiation transport, for example, MCNP (Monte Carlo NParticle transport)
(Briesmeister 2000) developed in Los Alamos and designed to transport
neutrons, electrons and photons; EGSnrc (Electron Gamma Shower)
(Kawrakow and Rogers 2003, Nelson et al 1985), initially developed in
Stanford, which transports photons and electrons; PENELOPE (PENetration
and Energy Loss Of Positrons and Electrons) (Baro et al 1995) developed at
University of Barcelona, and used to transports electrons, positrons and
photons.
In diagnostic radiology, one of the most common applications of the Monte

Carlomethodisinpatientdosimetry.ThereareseveralMonteCarlocomputer
codesthatareusedtoestimatetheeffectivedose.JonesandWall(1985)used
the Monte Carlo method to compute organ doses using a mathematical
representation (Cristy 1980) of a human anatomy. Zankl and Wittman (2001)
havedevelopedafamilyofmorerealistic,segmentedanthropomorphicvoxel
phantomsfororgandosimetryforexternalphotonbeams.ZanklandPetoussi
Henss(2002)calculatedconversionfactorsbasedontheVIPman(Spitzerand
Whitlock 1998) anthropomorphic model. The userfriendly Monte Carlo
computer program PCXMC by Servomaa and Tapiovaara (1998) calculates
MonteCarlomodel
organandeffectivedosesbasedoneithermeasuredairkermaareaproductor
entranceairkermavalues.
There are also Monte Carlo codes developed for optimisation in diagnostic
radiology.Suchcodesrelyonthefactthattheyareabletoestimatebothorgan
oreffectivedosesandmeasuresofimagequality.Themainapplicationofthe
MonteCarlomethodisforestimatingthenegativeeffectofscatteredphotons
reaching the image detector. Chan and Doi (1985) used the Monte Carlo
method to characterise scattered radiation in xray imaging. Chan et al (1985)
also investigated the performance of antiscatter grids in screenfilm imaging
whereas Sandborg et al (1994a) did taskdependent, antiscatter grid
optimisation for digital imaging. More recently McVey et al (2003) did an
optimisation study of lumbar spine radiography and Lazos et al (2003) have
developed a software package for mammography. The Lazos model also
includesarealisticmodelofthebreast(Bliznakovaetal2003).Sonetal(2006)
have developed software that calculates images from the visual human (VIP
man)(Xuetal2000).TheyhaveusedtheEGSnrccodeasabasisofthemodel,
usedmodelobserversandcalculatedeffectivedose.
InthisworkwehaveusedaninhouseMonteCarlocodeVOXMANadapted
for conditions usually encountered in diagnostic radiology.Itoriginatesfrom
Dance and Day (1984) and Persliden (1986) who independently developed
computer programs to estimate scattered radiation in the image plane in
mammographyandconventionalradiography,respectively.Afewyearslater,
Danceetal(1992)andSandborgetal(1994b)mergedthecodesanddidfurther
validation of the computer programs. McVey et al (2003) replaced the simple
homogeneous water or tissue phantoms, used in the earlier versions of the
code,byavoxelisedanthropomorphicmalephantomdevelopedbyZubaletal
(1994).Thisstepenabledmorerealisticorgandosimetryandmadeitpossible
to describe how measures of physical image quality vary in the image plane
behindthepatient.
The main focus of this thesis is on chest imaging. Therefore we have mainly
usedtheVOXMANmodel,adaptedtosimulatechestradiography.InpaperI
we used the version of the computer program dedicated for mammography.
This computer program was further developed by Hunt et al (2005) to
incorporateananthropomorphicmodelofthebreastdevelopedbyBakicetal
(2002).AbriefdescriptionoftheVOXMANmodelispresentedbelow.
8
MonteCarlomodel
3.2. Computationalmodelofthexrayimagingsystems
The Monte Carlo based computational method used in this thesis models the
xrayimagingsystemandsimulatesphotontransportfromthesourcethrough
patient, antiscatter grid and into the image detector. The computational
methodconsistsofthefollowingcomponents:
A model of the imaging system. This comprises different sources of

input data and the imaging geometry. Input data includes xray
spectrum, patientbased voxel phantom, antiscatter grid, tableorchest
supportcouchandimagedetector.
Monte Carlo simulation of photon transport through the imaging

system.Themodelusesdifferentvariancereductiontechniques,briefly
describedbelow,toincreasetheefficiencyofthemodel.
Scoring variables such as organ and effective doses and calculation of

differentmeasuresofimagequalitysuchascontrastandsignaltonoise
ratio of nodule lesions or anatomical structures within the patient
model.
3.2.1. Modeloftheimagingsystem
The input data files are described below including geometry, xray spectra,
voxelphantom,antiscattergridandimagedetector.
3.2.1.1 Imaginggeometry
Theimaginggeometriesforthechestandmammographymodelsareshownin
figures 3.1 and 3.2, respectively. Examples of specific imaging configurations
are listed in table 3.1. Substantial variations of the imaging system
configuration were employed particularly inpapersI,IIIandIVandtosome
extentalsoinpapersII,VandVI.
9
MonteCarlomodel
Figure 3.1. The simulated imaging geometry used in chest PA radiography

including an xray source, voxel phantom, antiscatter grid and image
detector.
Figure 3.2. The simulated imaging geometry used in Craniocaudal (CC)

mammography. Notations are a) focusdetector distance; thickness of b)
breast, c) compression plate, d) adipose layer, e) contrasting detail, f) breast
support,g)antiscattergridandh)imagedetector.
10
MonteCarlomodel
Table3.1.Examplesofimagingsystemconfigurationsforchestandbreast
imagingsystemcomponent ChestPA BreastCC
imagingusedinthiswork.
Typical
values
Focusdetectordistance(cm) 180 65
Tubevoltage(kV) 90150
) Cu Cu
PatientPAorbreastthickness(cm) 028
es1025 ocalcifications
Compressionplate exiglas
erial arbonfibre/Al
/gridratio
(mg/cm
2
)
2055
Totalfiltration(mm 0.10.5mm
0.3mm
25mRh
2 28
Typicaldiagnostictasksandsizeof
details
Nodul
mm
Micr
andsofttissue
masses
3mmpl
Gridinterspacemat C Carbonfibre
Lamellafrequency(cm
1
) 40/12 60/5
Imagedetectormaterial BaFCl,CsI CsI
Imagedetectorthickness 100 100
.2.1.2 Xrayspectra
was calculated with a computer program based on a
t
the VOXMAN model, the relative fractions of Bremsstrahlung and
3
The xray spectrum
spectral model by Birch and Marshall (1979). The program calculates
Bremsstrahlung and characteristic xrays from a tungs en or molybdenum
anode target and allows the user to select appropriate thicknesses of added
filtration of aluminum, copper or molybdenum. In paper I, tungsten,
molybdenum andrhodiumanodetargetspectrawereinsteadcalculatedwith
MCNP4C Monte Carlo code since the Birch and Marshall program did not
includearhodiumtargetorarhodiumfilter.
In
characteristic xrays were computed and a random number selected from
which of the distributions the photon emerged. If a Bremsstrahlung photon
was selected, the photon energy was chosen using rejection sampling
(Sandborgetal1994b).
11
MonteCarlomodel
3.2.1.3
was
Lowresolutionchestphantom
anthropomorphic voxel phantoms were
Voxelphantoms
tom
a
A Mammographyphan
Inthemammographymodel, simplerepresentationofthefemalebreast
used (Ullman et al 2005). The breast was assumed to be a cylinder with
semicircular crosssection and made of a homogeneous mixture of glandular
and adipose tissue in the central region surrounded by an adipose layer. The
tissuecompositionsweretakenfromHammersteinetal(1979).Thedensityof
glandular tissue was 1.04 g cm
3
and for adipose tissue 0.93 g cm
3
. The
glandularityofthecentralpartofthebreastmodelwasforthemainpartsetto
50%, but was allowed to vary between 1090% to represent both dense and
fattybreasts.

B
In the chest model, three different
usedasamodelofthepatient.Themainphantomwastheonedevelopedby
Zubal et al (1994) and used in papers II, III and IV. The Zubal phantom
(displayed in figure 3.3) was segmented into organs such as lungs, heart and
bone marrow. It therefore allows for calculation of organ and effective doses.
Thefemalespecificorgans:breast,ovariesanduteruswereaddedmanuallyto
the male body to enable effective dose to be calculated (McVey et al 2003).
However, the phantom has relatively large voxels (3x3x4 mm
3
) and is
thereforenotsuitableforcalculatingrealisticimages(seefigure3.4below).In
addition, the lungs are comparably small since the phantom was based on a
CTscanwherethemalepatientwasimagedwithnoninflatedlungsandina
nonuprightposition,contrarytothetypicalchestPAimagingsituation.
igure3.3.VolumerenderedrepresentationoftheZubalphantom(left)and F
theKyotoKaguku(PBUX21)phantom(right).Anoutlineofthelungs,
trachea,heartandbreastareshownintheleftimage.
12
MonteCarlomodel
C Highresolutionchestphantoms
s (voxel size Two highresolution voxel phantom 0.97x0.97x0.6 mm) were
hemanufactureroftheKyotoKagakuphantomclaimsthatitiscomposedof
createdfromCTscansoftwodifferentanthropomorphicthoraxphantoms:the
Alderson phantom and the Kyoto Kagaku PBUX21 phantom. The Alderson
phantom was used in paper V anddidnotincludesmallervessels.Themore
recent Kyoto Kagaku phantom was more realistic since it contained a more
humanlike distribution of small and mediumsized vessels. Simulated xray
images of the Zubal, Alderson and Kyoto Kagaku phantoms are shown in
figure3.4demonstratinganincreasingrealismfromlefttoright.
T
materials with linear attenuation coefficients ( values) resembling those of
human tissues. However, they failed to provide us with details of the atomic
compositions of the tissue substitute materials, which complicate a more
rigorouscomparisonwithrealxrayimagesoftheirchestphantom(seepaper
VI). A more detailed description of the segmentation of the Kyoto Kagaku
phantom is given in Malusek (2008). The Alderson and Kyoto Kagaku
phantoms are used mainly for simulation of synthetic images with high
resolution but are not yet segmented into organs and tissue types and can
thereforenotbeusedfordirectcalculationofeffectivedose.
Figure3.4.Projectionimagesofthethreechestvoxelphantomsusedinthis
.2.1.4 Antiscattergrid
as simulated by specifying the lamella thickness,
thesis.TotheleftthelowresolutionZubalphantom,centraltheAlderson
phantomandtotherighttheKyotoKagakuphantom.
3
The antiscatter grid w
interspace material and thickness as well as cover thickness and grid ratio.
Typical grids are listed in table 3.1. In the Monte Carlo program the focused
grid was simulated by an analytical transmission formula developed by Day
13
MonteCarlomodel
andDance(1983).Scatteredphotonsgeneratedinthegriditselfwassimulated
byaseparateMonteCarlosimulationinaparallelgrid(Sandborgetal1994b).
3.2.1.5 Imagedetector
ge detector was simulated in a separate Monte Carlo
heimagedetectorthicknesswasspecifiedintermsofasurfacedensityinmg
.2.2. MonteCarlosimulationofphotontransport
tionisdescribedby
( )
n n n n n
w E , , , r =
The response of the ima
model of a semiinfinite layer of the image detector material. This model is
included as a subroutine to the main VOXMAN program. Energy imparted
per unit area was assumed proportional to the image detector signal. The
imagedetectormodeldoesnotincludethetransportofsecondaryelectronsas
the kerma approximation was assumed. The transport of light photons was
also neglected. In papers V and VI, the detector response was calculated
separately with MCNP4C and was used for the calculation of primary
projections(Malusek2008).
T
cm
-2
(seetable3.1).InpaperI,thedetectormaterialwasneedlecrystalsofCsI;
in paper II, III and IV an unstructured mixture of BaFCl grains simulating a
computed radiography (CR) fluorescent screen and finally in paper VI, a
Gd2O2Sindirectflatpanel(DR)fluorescentscreenwasemployed.
3
Thephysicalstateofthephotonafterthen:thinterac
o (3.1)
here r
n
is the position, E
n
is the energy, O
n
is the solid angle and w
n
is the
.2.2.1 Photoninteraction,crosssectionsandmaterialcompositions
w
statistical weight of the photon. Photon interaction types in the energy range
of diagnostic radiology (10150 keV) are: coherent scattering, incoherent
scattering and photoelectric effect. The photon interactions are described by
thedifferentialcrosssectionsfortheseeventsbasedontheatomiccomposition
of the materials and tissue types in the geometry. A flow chart of the main
steps in the Monte Carlo program is given in figure 3.6. A central part of the
Monte Carlo method is the utilisation of a random number generator. In this
work we have used the random number generators embedded in UNIX or
LINUXoperatingsystems.
3
Thedifferentialcrosssectionforcoherentscatteringisgivenby
14
MonteCarlomodel
) , ( ) cos 1 (
2
2 2
2
Z x F
r
d
d
e coh
u
o
+ =
O
(3.2)
wherer
e
istheclassicalelectronradius,xisdefinedby ) 2 / sin(u
hc
E
x = whereh
isPlancksconstantandcthespeedoflight.Fistheatomicformfactor,u the
scatteringangleandZtheatomicnumber.
For incoherent scattering the differential crosssection is given by the Klein

NishinarelationtimestheincoherentscatteringfunctionS(x,Z):
) , ( sin
2
2
2
2
Z x S
E
E
E
E
E
E
r
d
d
e incoh
|
.
|
\
|
'
+
'
|
.
|
\
|
'
=
O
u
o
(3.3)
Here, E is the incident photon energy and E is the scattered photon energy
givenbytheComptonrelation
) cos 1 ( 1 u k +
= '
E
E
2
/ c m E
e
= k
(3.4)
where ,m
e
istheelectronrestmass.
Forthephotoelectriceffect,itisassumedthatthephotonislocallyabsorbedin
interactions with atoms of low atomic number (such as carbon and oxygen).
Elements with high atomic numbers such as those in the grid (lead) and
detector materials (e.g. barium, gadolinium, cesium, iodine) may emit (high
energy)characteristicxraysifvacanciesarecreatedintheKorLshells.
To describe these photon interactions we have used tabulated crosssections

from the XCOM library by Berger and Hubbell (1987). Crosssections for
compounds were computed based on the relative weight of individual
elements.Theatomicformfactors,F(x,Z),weregivenbyHubbellandverb
(1979)andtheincoherentscatteringfunctions,S(x,Z),weregivenbyHubbellet
al(1975).
Inthevoxelphantommodelofthepatient,eachorganisidentifiedwithoneof
four tissue types, with different densities: average soft tissue (1.03 g cm
3
),
healthylung(0.26gcm
3
),corticalbone(1.49gcm
3
)andbonespongiosa(1.18
gcm
3
).ThetissuedensitiesandcompositionsweretakenfromICRU46(1992)
exceptforcorticalbone,whichwasobtainedfromKramer(1979).
15
MonteCarlomodel
3.2.2.2 Primaryphotons
Primarytransmissionwascalculatedbyfirstsamplingtheinitialenergyfrom
theprecalculatedenergyspectrum,anduseSiddonsalgorithm(Siddon1985)
tocalculatetheradiologicalpathlengthfromthefocustothedetector
n
N
n
n
d L
=
=
1
(3.5)
The radiological pathlength can be used to calculate the contribution to the

energyimpartedperunitareafromprimaryphotonsas
dE E f e E
r
E s
L
E
p
A
) , (
) (
2
,
c
O
}
=
E
s
, O
) , (
(3.6)
where isthesourceintensity, E f isthedetectorabsorptionefficiency

function depending on the photon energy E and cosine of incidence angle,
u cos =
) , (
,atthedetectorsurface;risthefocusdetectordistance.
Equation3.6iscalculatedbytwoseparatemethods.Intheoriginalversionof
the VOXMAN program, this calculation was embedded inside the Monte
Carlo code. It is then calculated by first sampling the photon energy E, from
thexrayspectrum,subsequentlytheopticalpathLfromthesourcetoapoint
inthedetectoriscalculated.Finallythephotonistransportedinasemiinfinite
layer corresponding to the detector thickness in order to calculate E f
) , (
.
However, this did not allow for the calculation of highresolution images,
sincewewereforcedtoruntheMonteCarlosimulationforallthesepoints.In
papers I, III and IV, the energy imparted to the image detector per unit area
from primary photons was therefore calculated to a very limited number of
points (115) in the detector plane corresponding to those points where the
projectionofthecontrastingdetailorlesionwaslocated.InpaperII,VandVI
the Monte Carlo simulations where performed for 40 x 40 points in the
detector. This is rather timeconsuming and is only feasible to perform with
highprecisionwithafast,moderncomputer.
InpapersVandVI,adifferentmethodwasimplementedforthecalculationof
primary projections. The detector absorption efficiency function E f was
calculatedseparatelywithMCNP4C(Malusek2008)andtheprojectionswere
calculatedanalyticallyaveragedovertheenergyspectrum.Thisallowedfora
separatecalculationofprimaryprojectionswithhighresolution.
16
MonteCarlomodel
3.2.2.3 Scatteredphotonsandvariancereductiontechniques
The simulation of scattered photons is time consuming. Therefore, different
variancereductiontechniques,describedbrieflybelow,wereusedtoincrease
theefficiency.MonteCarlomethodsthatdonotemployanyvariancereducing
techniques are often referred to as analogue Monte Carlo methods. An
algorithmforsamplingthefreepathofthescatteredphoton,referredtoasthe
Colemansalgorithmisalsobrieflydescribedbelow.
A Colemansalgorithm
Thefreepathofthescatteredphotonissampledusinganalgorithmdescribed
by Coleman (1968). The sampling of the free path consists of several steps.
First, the distance to the first interaction point is sampledforahomogeneous
medium with the linear attenuation coefficient,
max
, corresponding to the
material with highest attenuation (e.g. bone). The sampling is performed by
testingwhetherasampledrandomnumberfromauniformdistributioninthe
interval [0,1] is less than the quotient /
max
, where is the attenuation
coefficientofthematerialattheinteractionpoint.Ifyesthenthenewpointis
acceptedandthealgorithmends.Ifnothenthesamplingofthedistancetothe
first interaction in the homogenous medium is repeated until the sampled
randomnumberislessthan/max.
B Collisiondensityestimator
AnalogueMonteCarlomethodsareinefficientinestimatingscatteredphotons
intheimageplaneduetothelowprobabilitythatascatteredphotonwillpass
a given small target area in the image detector. Therefore in the VOXMAN
code, the collision density estimator (Persliden and Alm Carlsson 1986) is
used.Thecontributiontotheenergyimpartedperunitareaatagivenpointof
interest in the image detector is obtained from each interaction point in the
phantom.Thecontribution isderivedthrough
-
s
c
s n
N
n
n n s
T w
,
1
) ( o c
=
-
= (3.7)
where
n,s
is the contribution from the n:th interaction and T(o) is the
probabilityforthephotonofstateo
n
tobescatteredtothepointofinterest;w
n
is the photon weight. In the collision density estimator, incoherent and

coherent scattering are treated separately. The radiological pathlength from
the interaction point to the point of interest in the detector is calculated with
Siddonsalgorithmasinthecaseofprimaryphotons.
17
MonteCarlomodel
C AnalyticalaveragingofsurvivalandRussianroulette
ThemainpurposeoftheMonteCarlomodelistoachieveanaccurateestimate
ofscatteredphotonsgeneratedinthepatientandemergingtowardstheimage
detector.Ifphotonsareabsorbedinthepatienttheywillnotcontributetothis
estimate. Therefore, a technique known as analytical averaging of survival is
used which does not allow photons to interact by the photoelectric effect. All
interactions in the phantom are therefore constrainedtobeeithercoherentor
incoherentscatterings.Thenewstatisticalweight,w
n+1
,forthephotonafterthe
n:thinteractioniscalculatedfromthecrosssectionsforphotoelectric, t(E)and
scattering processes, o(E) to correct for the bias which this method would
otherwiseintroduce.
( )
( ) ( ) E E
E
w w
n n
t o
o
(3.8)
+
=
+1
Forhighphotonenergies,E,theratiow
n+1
/w
n
islessthan,butcloseto1andthe
statisticalweightisonlyslightlyreducedateachinteraction.However,asthe
photon energy is reduced the relative importance of photoelectric cross
sections increases, and the number of interactions before a scattered photon
escapes from the phantom geometry may be large. Hence, the statistical
weight of the photon may eventually be low and so its contribution to the
estimated image detector signal. Therefore, an unbiased procedure called
Russianroulette(Salvatetal2003)isused.Oncetheweightislessthan0.05a
random number is selected and in 95% of the cases the photon history is
terminated; in the other 5% of the cases the photon history continues with a
twentytimeshigher(100%/5%)statisticalweightw
n+1
comparedtotheoriginal
weight. Photon histories are also terminated once the photon is scattered out
oftheboundariesofthephantom.
3.2.3. Scoringquantities
3.2.3.1 Energyimpartedtotheimagedetector
Estimates of the mean energy imparted per unit surface area of the image
detector from scattered photons,
s
A
c and primary photons
p
A
c are computed.
The total energy imparted is calculated as the sum of primary and scatter
contributions
s p
A A
t
A
c c c + =
p
. In order to estimate the signaltonoise ratio and
varianceintheimagedetectorsignal,thefirstandsecondmomentsofenergy
imparted per incident primary (
and ) and scattered (

2
p
s
and )
photon at the image detector was calculated (Dick and Motz 1981, Sandborg
andAlmCarlsson1992).
2
s
18
MonteCarlomodel
3.2.4. Calculatedquantities
3.2.4.1.Contrast
Acontrastingdetail(e.g.correspondingtoalesion)isaddedtothemodelwith
a thickness and location specified by the user. The contrasting detail is not
addeddirectlyintothevoxelphantombutinanartificialwayinasubroutine
insidetheVOXMANmodel.Thecontrastofthisdetailiscalculatedas

1 1
2 1
1
1
p s p
p p
C
c c c
c c
+
= (3.9)
where c
p1
is the mean energy imparted to the detector per unit area from
primary photons with the nodule present, c
p2
the mean energy imparted per
unit area from primary photons with the nodule absent and c
s
is the mean
energyimpartedperunitareafromscatteredphotons.
3.2.4.2.Signaltonoiseratios
Theprogramcalculatestwotypesofsignaltonoiseratios.Thesignaltonoise
ratioperpixel,SNR
p
iscalculatedas

2 2
s s p p
p
A
p
N N
SNR

c
+
= (3.10)
where N is the number of photons incident on a pixel. The indices p and s

standsforcontributionsfromprimaryandscatteredphotons,respectively.The
quantitiesand
2
aremeanandmeansquaredvaluesoftheenergyimparted
toaspecifiedpixelperincidentphoton.
Given the location and thickness of a specified lesion (detail), the computer
program calculates the signaltonoise ratio for this detail with a projection
areacorrespondingtoonepixel.ItisherecalledtheSNR
MC
andisgivenby

2 2
1 1
2 2 1 1
s s p p
p p p p
MC
N N
N N
SNR

+

= (3.11)
wheretheindexn=1referstoapixelintheimagebehindthenodule,andn=2
referstothesamepixelwiththenoduleabsent.
19
MonteCarlomodel
3.2.4.1 Aircollisionkerma
Theaircollisionkerma,K
c,air
isgivenby
( ) ( ) ( )
}
= dE / E E E K
air en E c,air
air en
) / (
, (3.12)

where isthemassenergyabsorptioncoefficientforairand is
thedifferentialphotonfluencewithrespecttoenergy.
) ( E
E
u
t t
H w E
3.2.4.2 Effectivedose
The effective dose is the tissueweighted sum of the equivalent doses in all
specifiedtissuesororgansofthebodycalculatedaccordingtoICRP60(ICRP
1991).
(3.13)
wherew
t
isthetissueororganweightingfactorandH
t
theequivalentdosefor
that tissue or organ. It is recognized that a new ICRP publication 103 (ICRP
2007)hasrecentlybeenadoptedandusesslightlydifferentvaluesofthetissue
weightingfactorsinthecalculationofeffectivedose.Adetailedanalysisofthe
effect on the figures of merit due to this change, for example signaltonoise
ratio per effective dose, SNR
2
/E, has not been performed here. The absolute
values of SNR
2
/E may change, but the main conclusions on for example the
appropriatetubevoltageforchestPAradiographyisunlikelytobeaffectedby
thechangeofweightingfactors,particularlysincetheweightingfactorsforthe
lungsarethesameinICRP60asinICRP103.
3.3. Calculationofimagesfromthehighresolutionphantom
The scatter projection, SNR
p
and other quantities calculated with the MC
methodarerescaled(i.e.from40x40points)tofitthenumberofpixelsinthe
primary image. In paper V this number is 1760 x 1760, and in paper VI the
number of pixels is 2688 x 2688. The rescaling is performed using a bilinear
interpolation function in MATLAB. The interpolated scatter projections are
addedtotheprimaryimagetogivetheestimateofthemeanenergyimparted
per unit area of the detector for the i:th pixel,
s
,
p
,
t
, i A i A i A
c c c + = . Noise is
subsequently added to the image. In paper V, white gaussian noise is added
withthestandarddeviation

20
MonteCarlomodel
i p,
p
,
SNR
i A
i
c
o = .

The white noise is generated by adding sampled random numbers for each
pixelifromtheappropriatedistributiontothecalculatedimage.InpaperVI,
correlated noise is added with a method similar to the one used in Bth et al
(2005c). In order to add correlated noise, knowledge of the noise power
spectrum(NPS)fortheclinicalsystemisneeded.TheNPSisthennormalized
tocorrespondtounitvariance.Arandomphaseisaddedtothesquarerootof
the normalized NPS with the constraint that the random phase image ) , ( v u |
should have the symmetry ) , ( ) , ( v u v u = | | . By taking an inverse Fourier
transformofthisspectrumarealandcorrelatednoiseimage iscreated.The
vector isamultivariaterandomvariablewithmeancorrespondingtoanull
vector and covariance matrix corresponding to the measured NPS. The noise
fluctuation for each pixel is rescaled with the relation

i A i i A

, ,
oc c o = . It is
assumedthattheNPSwasinvariantunderalogarithmictransformation.The
totalenergyimpartedtothedetectorperunitareaincludingnoisefluctuations
becomes
i A
t
i A i A , ,
t
,
oc c c + =
t
,i A
c
c b a g
i A i
+ = ) ln(
t
,
c
.Thepixelvalueinthei:thpixeliscalculatedbytaking
alogarithmictransformationof usingtherelation
(3.14)
where the parameters a, b and c are calculated with nonlinear regression to

make the best fit to the real phantom images. The method to add primary,
scatteredandnoiseimagesisillustratedinfigure3.5.
+ =
+
Figure 3.5. The method for calculating images illustrated in a cutout in the
retrocardial region (see further figure 4.1.). From the left: primary projection,
scatterprojection,noiseimageandtotalimage(totheright).
21
MonteCarlomodel
3.4. Uncertainties
3.4.1. Stochasticuncertainties
Thechoiceofthenumberofphotonhistoriesusedinthesimulationisatrade
off between computer time and statisticalprecision.Ifthestatisticalprecision
of the simulation is doubled, the computer time is increased by a factor of 4.
For instance, the computer time for a typical simulation (for calculating the
scatter contribution to a synthetic image) on the computer Alpha (AMD
Opteronprocessor250,2.4GHz;6.26GBRAM)in40x40pointsofinterest,at
thetubevoltage141kV,withaprecisionof1%(onestandarddeviation)takes
approximately 17 hours. The statistical uncertainty has to be kept low when
we are calculating images, since if the statistical uncertainty is too high, the
scatter projection often contains artifacts when it is interpolated to a higher
resolution.
3.4.2. Systematicuncertainties
There are several sources of uncertainty that affect the results. These include
uncertainties in the cross sections, but also uncertainties in estimation of the
differentparametersintheinputfiles.Inaninternalreport,Ullmanetal(2003)
studied the effects of uncertainties in xray spectrum half value layer (HVL),
field size, grid lamella thickness and detector thickness. The conclusion from
this study is that the systematic uncertainty due to these factors in the
estimated c
s
/c
p
behind the grid is approximately 11%. Later, analysis of
variance (ANOVA) and regression analysis was used to analyse similar
uncertainties and the systematic uncertainty in c
s
/c
p
behind the grid was
estimated to be approximately 9%. However, these relatively large
uncertaintiesonlyapplyinthosecaseswhereweattempttomimicarealxray
imagingsystemandcomparemeasuredquantitiesfromthatsystemwithour
calculated quantities. In the cases where we only use simulations to study
relative differences between alternative acquisition schemes for an imaging
system,thestochasticuncertaintyismorerelevant.
22
MonteCarlomodel
23

Figure3.6.FlowchartdescribingthemostimportantstepsintheMonteCarlo
program
Yes
Set-up geometry, voxel phantom, cross-
sections, image detector and grid
Select photon energy
Calculate contributions from primary
photons analytically to point of interest
(Siddons algorithm)
Start calculating contributions
from scattered photons
Select direction of motion
of incident photon
Calculate free path with Colemans
algorithm.
Calculate the contribution to collision density
estimator from scattered photons.
Select type of interaction
and assign weight
Store energy imparted to the
phantom
Sample new direction of motion and
continue photon history
Terminate
by Russian
roulette?
Select new path length
(Colemans algorithm)
Yes Is the next
interaction within
the phantom?
No
Was this the
last history?
Calculate scoring
quantities
MonteCarlomodel
24
Assessmentofimagequality
25
4. ASSESSMENT OF IMAGE QUALITY
4.1. Introduction
Image quality assessment means quantifying the usefulness of an image to
solveaspecificdiagnostictask.Itispreferredifthisimagequalityassessment
is objective. There are, according to Barrett (1990), four criteria that are
essentialforobjectiveassessmentofimagequality.
A.Thetask
Image quality can only be described in relation to a welldefined task. This
often means detection of an object in a structured or homogeneous
background.Asummaryofdifferenttaskstobesolvedinchestradiographyis
giveninICRU70(ICRU2003).Amongthose,thesearchformalignantnodules
at different positions in the lung is a common case treated in the literature
(Samei et al 1999). In mammography it is common to search for calcifications
ormasses(Burgessetal2001).Severaldifferenttypesoftasksarediscussedin
theliterature(BarrettandMyers2004).
B.Imageandobjectproperties
We need to understand the physical and statistical properties of the imaging
systemaswellastheobjectbeingimaged.Forexample,theradiologisthasan
internal model of both the human anatomy as well as a large data bank of
commonpathologiesinorderbeabletodistinguishamalignantnodulefrom
normalanatomy.Theradiologistalsoneedstounderstandsomeofthephysics
behindtheimagingtechnologyinordertorecognizesomeoftheartefactsthat
maybepresentintheimage.
C.Observer
An observer that can perform the task is needed. This can be a human or a
modelobserver.Itisthehumanobserver(radiologist)thatisthefinaldecision
maker. Therefore, measures of image quality should always take the human
observerintoaccount.Yet,clinicaltrialsinvolvinghumanobserversarecostly
andtimedemanding.Modelobserversmaythenbeusedtogiveinsightsinto
how image quality depends on the physical and technical image acquisition
parameters.
D.Figureofmerit
The figure of merit (FOM) is a number that tells us how well the observer
performsthetask.TheFOMdependsonthedetectiontask;acommonlyused
FOM is the signal to noise ratio (SNR) or AUC, the area under the receiver
operatingcharacteristiccurve(ROC).Insomecases,imagequalityisdescribed
byphysicalpropertiesderivedfromtheimageratherthanbytheperformance
ofanobserveronaspecifictask,forexample,themodulationtransferfunction
(MTF) or the noise power spectrum (NPS). We will refer to this as physical
imagequality.
4.2. Imagequalityassessmentasdevelopedinthiswork
In this work, different tasks and figures of merit have been used, changing
alongwithanimprovedmodelingoftheimagingsystemincludingthepatient
andimprovedmodelobservers.Insomecases,figuresofmeritbasedonpure
physical measures of image quality were used and correlated to measures of
the performance of human observers in clinical trials. A summary of the
developmentisgivenbelow.
4.2.1. Thetask
Twomaintypesoftasksareusedinthiswork.Thefirsttaskistosearchfora
known signal (e.g. a nodule) in a known background, referred to as the
SKE/BKE(signalknownexactly/backgroundknownexactly)task.Thesecond
task is to search for a known signal (e.g. a nodule) in a varying background,
referredtoastheSKE/BV(signalknownexactly/backgroundvarying)task.
The SKE/BKE task was addressed in paper I, which was devoted to the
optimization of tube voltage and filtration in iodine subtraction
mammography. The task was to detect a blood vessel filled with iodine
contrastofthickness6mgcm
2
againstahomogeneousbackground.
InpaperIVthetaskwastocomparetwoimagesfromanxraychestphantom
and see in which image the structures corresponding to the image criteria
weremostclearlyvisible(theVGAstudy).Insomesense,thebackgroundcan
be considered as known in this study since the same anthropomorphic
phantom(theAldersonchestphantom)isusedforallcomparisons.Thus,the
observermaybeabletorememberthebackground.Inaddition,thephantom
used in this study does not contain as fine and complex structural details as
arepresentinrealphantoms(seefurtherfigure5.4).
26
The SKE/BV task was addressed in papers III and VI were the task was
detectionofnodulesatvariouspositionsinthelungs.InpaperIII,thesizeand
shapeofthenodulescorrespondedtothoseusedinthetrialbyHkanssonet
al (2005b). The anatomical structures vary at different positions in a chest
image and differ from patient to patient. When the background is unknown
fortheobserverithampersthedetectionofsubtledetails(Sameietal2000).
The two papers II and V were dedicated to describe the physical

characteristicsofthesimulatedimageratherthantosolveaspecificdetection
task.PaperIIwasdedicatedtocalculatethevariationofthescattertoprimary
ratiocs/cpintheimageplaneinachestexaminationaswellthevariationinthe
signaltonoise ratio per pixel (SNRp). These quantities influence contrast and
noise and thus detectability of lesions varies with position in the imaged
anatomy.
4.2.2. Modeloftheimagingsystemandpatient
Knowledge of the imaging system is in this work translated into a model of
the system including the patient. This model is used together with Monte
Carlo techniques to calculate dosimetric and image quality parameters,
needed for optimising the imaging system. The realism of the system, in
particular the model of the patient, has been increased during the work.
DetailsofthemodelandMonteCarlocalculationsaregiveninChapter3.The
developmentofthemodelofthepatientcanbesummarisedasfollows.
In paper I the breast was modeled using a slab phantom with homogeneous
materials and the detail (blood vessel) was modeled as a layer of iodine, see
Figure3.2.
To allow for more realistic calculations of how the scattertoprimary ratios

variesatvariouspositionsintheanatomybehindlargeanatomicalstructures
like the spine, heart and lungs, a lowresolution anthropomorphic phantom,
the Zubal phantom, was used in papers IIIV. In paper III the anatomy was
dividedintoseveralregionscorrespondingtodifferentanatomicalproperties,
seefigure4.1.ThisapproachwasalsousedinpaperVI.
In order to simulate images with realistic anatomical background variations,

(see section 3.3) a highresolution anthropomorphic phantom was created
fromCTimagesofananthropomorphic(Alderson)phantominpaperV.This
is an important step in the model development, since it has been shown in
27
clinicaltrialsthatthefinedetails(suchassmallandmediumsizedvessels)of
theprojectedanatomicalbackgroundstronglyinfluencedetectability(Kundel
etal1985,Sameietal1999,Hkanssonetal2005b)andthusactasnoisebesides
system (quantum) noise. In Paper VI a new and still more realistic high
resolution anthropomorphic phantom (Kyoto Kagaku) was implemented in
the model. A mathematical model of a lesion, referred to as a designer nodule
(Burgess et al 1997) was inserted in the projection radiographs for studies of
detectabilityusingmodelobservers.Figure4.2showscutoutsofachestimage
fromthehilarregionwithoutlesion(4.2a)andwithanaddeddesignernodule
(4.2b).Figures4.2cand4.2dshowcorrespondingimagesagainstabackground
of quantum/system noise only. The figures clearly demonstrate the large
difference in difficulty between detecting a nodule in an image containing
anatomicalstructuresandinapurequantumnoiseimage,respectively.

Figure4.1.ThesixanatomicalregionsofthechestPAimageusedinpapersIII
andVI:APR:Apicalpulmonaryregion,LAT:Lateralpulmonaryregion,RET:
Retrocardial region, LME: Lower mediastinal region, HIL: Hilar region and
UME:Uppermediastinalregion.
28
ab

cd

Figure4.2.Cutoutsofasimulatedchestimagefromthehilarregionwithout
lesion (4.2a) and with an added designer nodule (4.2b). Figures 4.2c and 4.2d
showcorrespondingimagesagainstabackgroundofquantumnoiseonly.The
contrast (C=0.10) and size (D=10 mm) of the nodule are the same in images
4.2band4.2d.Theamountofquantumnoise(correspondingtoacollisionair
kerma K
c,air
=0.3 Gy central in the image) is the same in all four images. The
doseleveliskeptunrealisticallylowforillustrationpurposes.
4.2.3. Observers
Two model observers have been used, the ideal observer and the Laguerre
GaussHotellingobserver.ThemethodforcalculatingtheidealobserverSNR
I
was developed in the previous work by Sandborg et al (1994b) using an

expressionfromICRU1996.Thisobserverisonewhocanmakeuseofallthe
information in the image and is often used to describe the ultimate
29
performanceofanimagingsystem.Also,thisobserverisabletoperformnon
linear operations on the data. It works most easily under the condition of
SKE/BKEwhenthedetectiononlyisdisturbedbysystemnoise.TheLaguerre
Gauss Hotelling observer was applied in Paper VI utilizing the method to
simulatehighresolutionimagesdevelopedinpaperV.Thisobservercanalso
be used for the SKE/BV task. The Hotelling observer is limited to perform
linear operations and is likely to more faithfully reflect the capabilities of
humanobservers(ICRU1996).Ithasbeendescribedindetailfortheproblem
ofimageassessmentinmedicalimagingby,e.g.,inBarrettandMyers(2004).
Results of human observers were used in paper IV. To design and perform
human observer studies is time consuming and requires close collaboration
with radiologists. The main objective of this work was to create a complete
model of the imaging system including automatic performance evaluation,
whichallowsforrapidevaluationofimagequality,sothatalargenumberof
acquisitionparameterscanbetested.Thisisanimportantsteptowardstheuse
of our model for system optimisation. An inspiration was a recent study by
Son et al (2006), where they used simulated images and a model observer for
image quality assessment. The results of our model have repeatedly been
testedagainstresultsofhumanobserverstudiesperformedbyourpartnersin
our network collaboration (Sweden Associated Imaging Laboratories, SAIL;
Gteborg, Linkping and Malm). Through this collaboration, we have had
access to detailed information about the imaging systems used in their
experiments. Our efforts have been concentrated to finding model observers
thatarecapableofsimulatingtheperformanceofhumanobservers.
4.2.4. Figuresofmerit
4.2.4.1 Humanobservers
Clinical trials with human observers are essential in the assessment of image
quality.Itisthereforeofgreatimportancetocomparetheresultsofourmodel
towhatisrelevantfromtheclinicalpointofview.Aswaspointedoutabove,
such comparisons have been performed in close collaboration with our
partners from Malm and Gteborg. Two main types of human observer
studieswereusedintheirclinicaltrials.Thetwotypesare:receiveroperating
characteristic(ROC)andvisualgradinganalysis(VGA)studies.
30
A ROCstudies
Receiver operating characteristics (ROC) (Metz 1986, Metz 2000, ICRU 1996)
studieswithhumanobserversformthegoldstandardforassessmentofimage
quality.
When a human observer performs a specific task, for instance, decides

whetherasignalispresentornotpresent,therearefourpossibleoutcomes:

(1) FalsePositive(FP):signalisabsentobserverdecidessignalpresent
(2) TruePositive(TP):signalispresentobserverdecidessignalpresent
(3) FalseNegative(FN):signalispresentobserverdecidessignalabsent
(4) TrueNegative(TN):signalisabsentobserverdecidessignalabsent
Thedecisionmakeralsostrivestominimizethecost.Afalsepositivedecision
maymeanthatthepatienthastoundergoextraexaminations.Afalsenegative
decision may mean that, for instance, a tumour is missed and the patient has
less probability for recovery if the tumour is discovered later. The strategy
usedbytheobserverthereforedependsonwhichkindoferror(FPofFN)that
is most costly. The relation between the false positive fraction and the true
positive fraction is illustrated in the receiver operating characteristic (ROC)
curve,seefigure4.3.Eachpointonthiscurvecorrespondstoathresholdlevel
(observer strategy). The area under the ROC curve, AUC (also commonly
denoted Az in the literature), is a common figure of merit used in
discrimination tasks and can be translated to a value for the signaltonoise
ratioSNR(BarrettandMyers2004)using
(4.1) ) 1 2 ( 2 ) (
1
=
AUC erf AUC SNR
where erf
1
is the inverse error function. The quantity SNR(AUC) is often
referred to as the detectability index d
A
. A short description of the
methodologyisgivenbelow.
ArecentreviewofROCandrelatedmethodsisgivenbyKrupinskyandJiang
(2008).Toreachsufficientstatisticalpowermanyimagesandseveralobservers
areneeded.AnotherprobleminROCstudiesisthatthetrueanswerhastobe
known. This can be accomplished by using so called hybrid images where
lesionsaresimulatedandpasteintorealimages(Metz2000).
31
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
False positive fraction
T
r
u
e

p
o
s
i
t
i
v
e

f
r
a
c
t
i
o
n
Figure4.3.IllustrationofanROCcurve.Theareaunderthecurve(AUC)is
usedasafigureofmeritandcanberelatedtotheSNR.Inthisfigure:AUC=0.8
(SNR=1.19).ThedottedlinecorrespondstoAUC=0.5(SNR=0),whichmeans
thattheobserverisguessing.
B VGAstudies
In a visual grading analysis (VGA) study, the observer is presented to two
images. One image is a reference image and used in every comparison. The
observer has to decide if the quality of the image compared to the reference
imageissimilar,betterorworse.
InpaperIV,resultsfromaVGAstudybyTingbergandSjstrm(2005)were
usedtosearchforcorrelationsbetweenphysicalimagequalityparametersand
clinicalimagequality.IntheVGAstudy,slightlymodifiedCEC(Carmichaelet
al1996)imagecriteriawereused.Thecriteriawerebasedonstructuresinthe
normal anatomy that are described in table 4.1 for chest PA and Pelvis AP
examinations. The radiologists were asked to give a graded response of the
fulfilment (=visibility of the structures) of the criteria compared to the
fulfilment of the criteria in the reference image. The grading was given in
quantitative terms as: clearly inferior (VGA=2), inferior (1), equal to (0),
superior (+1)orclearlysuperior(+2).Thescorewasaveragedoverallcriteria
andallradiologiststoformanaveragescore,VGAS.
32

Table4.1.StructuresusedintheVGAevaluation
(TingbergandSjstrm2005)

ChestPA PelvisAP
1 Vesselsseen3cmfromthepleuralmargin Sacrum(spongiosa)
2 Thoraticvertebrabehindtheheart Sacralforamina
3 Retrocardiacvessels Pubicandishialrami
4 Pleuralmargin Sacroiliacjoints
5 Vesselsseenanfaceinthecentralarea Femoralbilateral
6 Hilarregion
4.2.4.2 Theidealobserver
For the Ideal observer used in this work, the background and the signal are
assumed to be known exactly, corresponding to a SKE/BKE task. From the
SNR
MC
(see section 3.2.4.2), the ideal observer signaltonoise ratio, SNR
I
for a
givennoduleiscalculatedfromequation4.2as

2 2 2
DF
p
M I
r
a
A
SNR SNR = (4.2)
where A is the projected area of the nodule in the image plane, ap is the pixel
area and r
2
DF
is the signal to noise ratio degradation factor caused by the
systemunsharpness.Thequantityr
2
DF
includeseffectsonSNRoftheimaging
systemunsharpness(modulationtransferfunction,MTF)andcorrelatednoise
(noisepowerspectrum(NPS))asdeterminedfromexperimentswiththeactual
detector type and additional detector noise. It is derived separately for each
nodule at its actual position in the anatomy, and depends on the nodule
projected area and the air kerma at the image detector. Geometrical (focal
spotandmagnification)unsharpnessandmotionunsharpnessaretakeninto
accountinadditiontodetectorunsharpness.Thelatterisexpressedintermsof
thepresampledMTF(Sandborgetal2003).
A FigureofmeritcorrespondingtotheVGASinaVGAstudy
In paper IV we calculated a figure of merit that is intended to correspond to
theVGASobtainedintheVGAstudy(TingbergandSjstrm2005).Foreach
contrastingdetail,denotedwithindexq,theSNRI,qrelativetoitsvalueatthe
reference tube voltage, SNRI,q(Uref), was computed (SNRI,q(U)/ SNRI,q(Uref)).
These ratios were then averaged for all the structures and a figure of merit
(FOM) was computed as given in equation 4.3. Here, unity was subtracted
fromtheaveragevalueinordertoobtainthevaluezeroforthereferencetube
33
voltageandallownegativevalueswhentheimagequalityisinferiortothatof
thereferencesystem(correspondingtotheordinatescaleoftheVGAS)
( )
1
) (
1
) (
,
,
=
q ref q I
q I
U SNR
U SNR
N
U FOM , (4.3)
whereNisthenumberofdetails.
4.2.4.3 Figuresofmeritusingphysicalimagequalitymeasures
A Noduletobonecontrast
In Paper III weattemptedtoperformoptimizationusingtheZubalphantom.
SincetheSNR
I
ascalculatedinthisworkdoesnottakeintoaccountanatomical
details and these are known to influence detectability, alternative figures of
merit were also used. The ribs obscure large parts of the lungs but are also
needed for the radiologist to orient himself in the image (SvenGran
Fransson,personalcommunication).Thecontrastofthenodulerelativetothe
contrastoftheribsmayindicatethedisturbinginfluenceoftheribs.Wehave
therefore defined a noduletobone contrastratiobycomputingthequotient
C/C
B
.TheC/C
B
isthenodulescontrastdividedbythecontrastofabonedetail
of a thickness corresponding to a rib or transverse processes at the same
position in the image. The use of the noduletobone contrast as a
complementary figure of merit was inspired from the work by Dobbins et al
(2003)andSameietal(2005).
B Relativecontrast
The radiologist often wants to adjust the contrast window. This choice of
contrast window affects the contrast of other objects in the image. We have
defined a relative contrast, Crel, as the signal difference in the image detector
dividedbythedynamicrangeofthewholeimageofthechest

% 5 % 95
2 1
c c
c c
=
p p
rel
C , (4.4)
wherec
p1
istheenergyimpartedtothedetectorperunitareainthepresenceof
the nodule, c
p2
is the energy imparted in the absence of the nodule, and
c
95
c5% is the dynamic range in the chest image, here defined by the 95
th
percentile minus the 5

th
percentile of the energies imparted to the image
detector in the whole chest image. The relative contrast is thus a measure of
the nodules contrast as a percentage of the dynamic range in the image. It
34
corresponds to the radiologist first impression of the image before adjusting
thecontrastwindow.
4.2.4.4 TheHotellingobserver
Ultimately, the measures of image quality should correspond to how an
observer (radiologist) performs a specific task with the aid of the image. In
ordertocompleteourmodel,weneedanobserverthatcanreplacethehuman
observer and perform image quality assessment automatically using our
synthetic images. We therefore exploited (in paper VI), a model observer,
which is known to mimic human observers more closely than the ideal
observer.Suchmodelobserversarebasedonstatisticaldecisiontheory.Oneof
the pioneers in using statistical decision theory for diagnostic radiology was
Wagner (Wagner et al 1979). A good thorough introduction to statistical
decisiontheoryandmodelobserversisgivenbyBarrettandMyers(2004).
Todescribetheimage,itisusefultorepresenttheimageasavector
(4.5) n Hf g + =
whereHisanoperatorrepresentingtheimagingsystem,farepresentationof
theobjectandnrepresentsthenoise.
If H
1
denotes the hypothesis that the signal is present and H
0
denotes the
hypothesisthatthesignalisabsent,theHotellingobserverusesateststatistic
basedonthelikelihoodratio
) | (
) | (
) (
0
1
H p
H p
g
g
g = A
c
A
) | ( b a p
(4.6)
to compare to a threshold in order to decide between H

1
and H
0
. The
notation meanstheconditionalprobabilityofagivenb(Jaynes2003).
Under the assumption that g is described by a multivariate Gaussian
distribution, the performance of the Hotelling observer is given by (Barrett
andMyers2004)
(4.7) g K g
g
A A =
1 2 t
Hot
SNR
where g A is the mean difference of the image vector with signal absent and
signal present and K
g
is the covariance matrix, which can take into account
35
both quantum noise and variations in anatomy. The superscript t means the
transposeofthevector.Inthecasewherethesignalsisknownexactly(SKE)
thissimplifiesto
(4.8) s K s
g
1 2
=
t
Hot
SNR
The covariance matrix can be estimated from a set of images g. In the case
wheregisreal,thecovariancematrixisdefinedby
(4.9)
t
) )( ( g g g g K =
where g is the mean image vector. If g is M dimensional, the resulting

covariancematrixwillbeMxMdimensional.Thenumberofimagesgusedto
estimate the covariance matrix must be larger than the number of pixels;
otherwise the covariance matrix is singular and noninvertible. Even for a
relatively small region of interest of 100 x 100 pixels this would make the
covariance matrix virtually impossible to calculate since we would need at
least 10
4
images to perform the estimation. For a more accurate estimation of
the covariance matrix it would require an even larger set of images. Also, a
matrixofthesize10
4
x10
4
isdifficulttomanageinthecomputermemory.
A ChannelizedLaguerreGaussHotellingobserver
Onesolutiontotheproblemmentionedaboveistousechannelstoreducethe
sizeofthematrix(MyersandBarrett1987).
g U
T
=
K
ch
A A =
1 2
,
t
ch Hot
SNR
(4.10)
whereUisaMxNmatrixcontainingNchannelprofilesu
p
ascolumnvectors.
The vector v can be interpreted as the image seen through the channels. A
diagramofthechannelizedobserverisshowninfigure4.4.Thesignaltonoise
ratioforthechannelizedHotellingobserveris
(4.11)
where K
ch
is the N x N covariance matrix of the channelized images. In this
case the size of the covariance reduces significantly since often only 650
channelsareneeded,dependingonthetypeoftask.Becauseofthisdimension
reduction, the channelized covariance matrix can be estimated from a
relatively small number of images. Another advantage of the channelized
36
approach is that the channelized observer better models human performance
(Myers and Barrett 1987). To further increase the realism in simulating the
humanobserver,internalnoisecorrespondingtoneuralnoiseandfluctuations
in observer decision criterion can be added (Burgess et al 1981, Zhang et al
2007).
u
v1
1
u2
u3
un
Image
vector
g
v2
v3
vn
Observer
Test statistic
(v)
Figure 4.4. Diagram illustrating the channelized observer. The channelized

observerdoesnotinterprettheimagevectorgdirectly,butthoughaseries(u
1
,
u
2
, , u
n
)ofchannels.
In paper VI we used LaguerreGauss channels. LaguerreGauss function is a

productbetweenaLaguerrepolynomialandaGaussfunction.TheLaguerre
Gausschannelsaregivenby
)
2
( ) exp(
2
) , (
2
2
2
2
a
r
L
a
r
a
a r U
n n
t t
= (4.12)
whereaisascalingfactorthatcanbechoseniterativelytomaximisetheSNR,r
is the radial distance and L
n
is the n:th Laguerre polynomial. The Laguerre
Gauss model assumes rotational symmetry. The LG channels of order 0, 3, 6
and 9 are shown in figure 4.5. Other authors have used the LG observer in
diagnostic radiography. Chawla et al (2007) studied observer performance in
mammography for normal and reduced doses. Pineda et al (2006) studied
tomosynthesis and compared with planar radiography. Son et al used the
Hotelling and LG Hotelling observer to search for calcifications in Monte
Carlo simulated images. Gabor channels (Chawla et al 2007) are sometimes
used.TheGaborchannelsaremoreaccurateinmodellingthehumanobserver
sincetheydonotassumerotationalsymmetry.
37
abcd

Figure4.5.LaguerreGausschannelsindifferentorders:a)0:th,b)3:rd,c)6:th
andd)9:thorderLGchannel.
B LaguerreGaussHotellingobserverusingatemplate
InsteadofcalculatingSNRdirectly,itisalsopossibletosimulatetheobserver
byusingatemplate.InearlierversionsofpaperVIthismethodwasusedasa
compliment to the direct calculation. The direct calculation is used for the
reasonthatitisfaster.ThechannelizedHotellingobserverusesthetemplate
s K w
g
1
=
Hot
w
t
Hot
=
t
(4.13)
andcomparesistothe(channelized)imagevectorwiththescalarproduct
(4.14)
inordertocalculatethedecisionvariable.Themodelobservercomparesthe
decision variable to a threshold
t
in order to choose between the hypothesis
H
1
(lesion absent) or H
2
(lesion present). For instance, if > the model
observermaychoosethatthelesionispresent.Inthisway,themodelobserver
canbeusedforROCstudiessimilartothoseperformedbyhumanobservers.
Two ROC curves for the channelized LG Hotelling observer are shown in
figure4.6.
38
a
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
1
T
r
u
e

p
o
s
i
t
i
v
e

f
r
a
c
t
i
o
n
b
1
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
T
r
u
e

p
o
s
i
t
i
v
e

f
r
a
c
t
i
o
n
Figure4.6.ROCcurvescalculatedfortheLaguerreGaussHotellingobserver.
Figure 4.6a corresponds to figure 4.2b in the Hilar region with a lesion of the
same contrast (C=0.10) and diameter (D=10 mm). The AUC is approximately
0.99(SNR=3.2).Infigure4.6bthesituationissimilarbutwithreducedcontrast
(C=0.05). The AUC is approximately 0.87 (SNR=1.6). The dotted line
correspondstothecasewhenthereisnosignal.
39
40
Resultsanddiscussion
41
5. RESULTS AND DISCUSSION
5.1. Idealobserverwithasimplifiedpatientmodel
In paper I we used a simple model of the breast for optimisation of iodine
subtractionmammography.Insubtractionimaging,theoverlayinganatomical
structures are suppressed. The ideal observer signaltonoise ratio, SNR
I
, is
here used in a situation where the detection or visibility of a lesion is only
limitedbythequantumnoiseintheimage.Thisinturnisdeterminedbythe
air kerma at the image detector and efficiency by which the image detector
absorbedthexrayquantaandconvertsittoanimagesignal.
The SNR
I
was calculated for a special case when iodine contrast media were
injected in the patients arm and images were acquired at set intervals before
and after injection in order to follow the leakage of contrast medium in the
vicinity of the breast tumor. During the whole image acquisition, the breast
remains compressed and images after injection of the contrast medium are
subtracted from the image prior to injection. In mammography such contrast
media may be valuable to distinguish between benign and malignant tumors
andfordemonstratingtumorsthatmightnototherwisebeseenindensetissue
andhenceinprovidingaclearerpictureoftheextentofdisease.

Figure 5.1 shows the SNR
I
2
/AGD as a function of tube voltage for three
different anodefilter combinations. The AGD is the average glandular dose
typically used as the radiation risk measure in mammography (Zoetelief et al
1996). For both the W/Cu and Rh/Cu spectra and at all breast thicknesses, a
maximum of the SNR
2
/AGD was found at approximately 45 kV and a
minimum at 33 kV. The dominating Kedge of iodine is at 33.17 keV (see
figure 5.2) and hence photons with energies just above this energy are
absorbed to a high degree and therefore provide a higher object contrast
comparedtothebackgroundinthevicinityofthecontrastfilledvessel.At45
kVandusingcopperfiltration,asignificantportionofthexrayspectrumhas
energiesintheoptimalrangejustabovetheiodineKedge.Using45kVforthe
Rh/Cu spectrum yields three to four times lower dose for 4 cm thick breasts
compared to using the Rh/Rh combination for producing images with equal
SNR for the iodine contrast medium. The SNR
2
/AGD is approximately 1.8
timeshigherwith33.2keVphotonscomparedtoitsmaximumvalueusingthe
polyenergeticspectrafromtheW/0.3mmCucombinationat45kV.Theresults
agreewithSkarpathiotakisetal(2002).
20 25 30 35 40 45 50
50
0
100
150
200
250
300
350
55
Tube voltage (kV)
S
N
R
2
/
A
G
D

(
m
G
y
1
)
Figure5.1.SNR
I
2
/AGDasafunctionoftubevoltagefora4cmthickbreastand
50%glandularity.A=Rh/25mRh,O=Rh/0.3mmCu, =W/0.3mmCu.
10
5
20 25 30 35 40 45 50 55
10
2
10
3
10
4
Photon energy (keV)
C
r
o
s
s
-
s
e
c
t
i
o
n

(
b
a
r
n
s
/
a
t
o
m
)
Figure5.2.Atomiccrosssectionofiodineasafunctionofphotonenergy.
42
5.2. Lowresolutionvoxelphantom
Inordertocomparetheresultofthemodelwithclinicalimagequality,itmay
beusefultocalculatedistributionsofphysicalimagequalityrelatedquantities
overthewholeimageandtostudyhowthesevarywithposition,patientsize
and imaging system configuration. The aim of paper II was to calculate
distributionsofSNRperpixel(SNRp)andthescattertoprimaryratio,cs/cpin
termsofenergyimpartedperunitareatotheimagedetector(seechapter3for
details). Figure 5.3 shows scattertoprimary ratios (cp/cs) and signal to noise
ratios per pixel (SNRp) using the lowresolution anthropomorphic chest
phantom. The figures show that the cp/cs varies significantly in the chest PA
imageplaneandistypicallyabove2inthemediastinumandabout0.5inthe
lungs. A comparison to measured cs/cp in patient images (Jordan et al 1993)
with calculated values in different regions shows that the mean values from
the calculations agree reasonably well in the heart region (behind the whole
heart including the part covered by the spine), with average cs/cp=2.0 (our
work) vs. 1.9 (Jordan); in the lung region (entire lung) with average cs/cp=0.6
(ourwork)vs.0.4(Jordan).
AsscatteredphotonsaddtothenoisetermintheSNRpexpression(seechapter
3), the SNRp is significantly reduced in the mediastinum compared to in the
lungs. Therefore, if nodule detection were limited by quantum noise, the
visibility of such nodules would be higher in the lungs where the scatter to
primaryratioislowerthaninthemediastinum.
43
Figure5.3.Distributionsofc
p
/c
s
(a)andSNR
p
(b) for a 24 cm thick patient. Figures
(c) and (d) show values of c
p
/c
s
and the SNR
p
along the vertical lines in the upper
figures.
5.3. Highresolutionvoxelphantom
The images produced based on the lowresolution voxelphantom VOXMAN
areusefulfordeterminingmapsofphysicalmeasuresofimagequalitysuchas
SNRp. Yet, they are of limited use for clinical image quality evaluation by
human or model observers due to its relatively coarse spatial resolution.
AnthropomorphicchestphantomswerethereforeimagedinaCTscannerand
thereconstructedvolumeofCTnumbersusedtocreatehighresolutionvoxel
phantoms (Malusek 2008). In paper V, the older Alderson phantom was
modelled and in paper VI, a more recently developed and more clinically
realistic(KyotoKagaku)phantom,wasutilised.
Real phantom xray images of those two phantoms are shown to the left in
figures 5.4 and 5.5 and simulated images calculated with the Monte Carlo
44
modelareshowntotheright.TheparametersintheMonteCarlosimulations
wereadjustedtofittheimagingconditionsusedintherealacquisition.

Figure 5.4. A real phantom image of the Alderson chest phantom (a) and a
calculatedimageincludingscatterandstatisticalnoise(b).Anantiscattergrid
wasusedatthetubevoltage141kV.

Figure5.5.ArealphantomimageoftheKyotoKagakuchestphantom(a)and
a calculated image including scatter and statistical noise (b). An antiscatter
gridand141kVwereused.

45
Figure 5.6. Calculated primary projection (a) and scatter projection (b) of the
Alderson phantom. The intensity values are given in logarithmic scale in
J/m
2
.Theaverageairkermaattheimagedetectorwas5Gycorresponding
toasensitivityclassofapproximately200.
Theimagesofthescatteredphotonswerecomputedinacoarsegridofpoints
40x40whereastheimageoftheprimaryphotonswascomputedinthesame
number of pixels as the original real image (Alderson: 1760 x 1760 Kyoto
Kagaku 2688 x 2688). The primary projection and the scatter projection were
combinedtocreateatotalimage.Noisewasaddedtotheimages.InpaperV
gaussiannoisewasaddedwiththeaidofthecalculatedSNRpvalues.Inpaper
VIweaddedcorrelatednoise.However,atthepointofwritingthisthesis,the
correctnoisepowerspectrum(NPS)forthesystemusedintheclinicalsystem
used for acquiring the real phantom images was not available. Instead, a
provisoryNPSmeasuredfromaFujiFCR9501CRThoraxsysteminGteborg
wasused.ThesimulatedimageswereusedinpaperVItoassessimagequality
using the LaguerreGauss Hotelling observer SNR
hot,LG
(see section 5.6). We
argue that the increased realism provided by the Kyoto Kagaku phantom is
usefulforamoreclinicallyrealisticassessmentofimagequality.
5.4. Idealobserverwithsimpleanatomicalbackground
InpaperIIItheoptimaltubevoltageindetectinglunglesionswithdiameter10
mm but of varying thickness according to Hkansson et al (2005a) was
investigated in terms of the ideal observer SNR
I
in six anatomical regions of
the chest PA image. In addition to this figureofmerit, the contrast of the
46
lesion in relation to structures in the normal anatomy such as ribs and
transverse processes, C/C
B
was derived, since these structures may interfere
with the radiologists detection of the lesion. The optimal tube voltage and
scatterrejectiontechniqueweresought.
Figure 5.7 shows the figureofmerit SNR

I
2
/E, or the dosetoinformation
conversion efficiency (Tapiovaara 1993) for a 25 mm thick lesion in the hilar
regionanda15mmthicklesioninthelowermediastinalregion.Inboththese
regions a low tube voltage results in a higher SNR
I
2
/E indicating superior
performance.Inthelowermediastinalregion,ahigherSNR
I
2
/Eisfoundwhen
larger grid ratios or longer air gaps are used. In the hilar region, with
significantlylowerscattertoprimaryratiocomparedtothelowermediastinal
region(seepaperII),theSNR
I
2
/Eisindependentofgridratioorairgaplength.
The air gap results in significantly higher SNR
I
2
/E than with the grid,
suggestingthattheairgapisthesuperiorscatterrejectiontechniquefordigital
chestPAradiography.Theabsorptionofprimaryradiationinthegridreduces
theimagequalityandincreasesthebuckyfactor;thisisavoidedusingtheair
gaptechnique.
Figure 5.7. SNR

I
2
/E as a function of tube voltage and scatter rejection
technique; grid ratio in (a) and (c) and air gap length (b) and (d), for a 20 cm
thick patient. Two anatomical regions were considered: the hilar region(a,b)
andthelowermediastinalregion(c,d).
47
Figure 5.8 shows the ratio between the contrast of the lesion divided by the
contrastofabonestructure,C/C
B
inthesameregion.ContrarytotheSNR
I
2
/E,
the C/C
B
increases with increasing tube voltage, indicatingrelativelysuperior
contrast of the lesion in comparison to the projected anatomical background
structure such as rib or transverse process, at high tube voltages. Hence we
havetwoconflictingargumentsforselectingtheappropriatetubevoltage.
Inasimilarstudy,Dobbinsetal(2003)madebothexperimentsandcomputer
spectrum modelling to search for the optimum xray spectrum for chest
radiography for a CsIaSi flat panel image detector. They studied the SNR
squared per exposure, SNR
2
/X, and a contrast ratio similar to our, C/C
B
, as a
function of tube voltage and added filtration. The experimental results from
their study are essentially in agreement with our results. SNR
2
/X decreases
and C/C
B
increases with increasing tube voltage, and the tubevoltage120kV
was considered to be optimal. We use SNR
2
/E instead of SNR
2
/X since the
effective dose is a better measure of radiation risk than exposure or incident
aircollisionkerma.However,conversionfactorspublishedbyHartetal(1994)
can be used to convert SNR
2
/X to SNR
2
/E. Such data shows that the optimal
tube voltage is reduced when the effective dose is used as a measure of
radiationriskinsteadofincidentaircollisionkerma.

We conclude that the choice of tube voltage depends on whether SNRI of the
lesion or the interfering projected anatomy (i.e. ribs) is more important for
lesion detection. The simple model of the patient used here is incapable of
making this selection and therefore alternative model observers and more
complex anatomical background are needed for a proper treatment of this
task.
48
Figure 5.8. C/C

B
as a function of tube voltage and scatter rejection technique;
gridratioin(a)and(c)andairgaplength(b)and(d),fora20cmthickpatient.
Twoanatomicalregionswereconsidered:thehilarregion(a,b)andthelower
mediastinalregion(c,d).
5.5. Correlationtohumanobservers
The aim of paper IV was to study the dependence of image quality in digital
chest and pelvis radiography on tube voltage, and to explore correlations
betweenclinicalandphysicalmeasuresofimagequality.Theeffectonimage
quality of tube voltage was assessed using two methods. The first method
relies on radiologists observations of specified image criteria of images of
anthropomorphic phantoms (Visual grading analysis, VGA), and the second
method was based on computer modelling of the imaging system using an
anthropomorphicvoxelphantom.
Thetubevoltageisoneoftheindependentvariablesthatcanbealteredprior
to exposure of each patient and view. In the study, the effective dose to the
patient phantom was kept constant independent of tube voltage. The visual
gradingstudywasperformedbyTingbergandSjstrm(2005)butourgroup
performedtheMonteCarlosimulation(seechapter4).
49
Figure 5.9 and 5.10 show the clinical and physical image quality measures as
functionoftubevoltageforthesameeffectivedosetothechestphantom.Both
measuresindicatethatsuperiorimagequalityisachievedatlowtubevoltages
compared to the reference system tube voltage 125 kV. Similar results were
obtainedforthepelvisexamination.
Chest PA
-0.5
0
0.5
1
1.5
2
V
G
A
S
-2
-1.5
-1
60 70 80 90 100 110 120 130 140 150
Tube voltage (kV)
Figure 5.9. The visual grading analysis score (VGAS) for the chest images as
function of the tube voltage. The VGAS values represent averages over all
imaged structures and radiologists. The uncertainty bars show the reader
variability(onestandarderror).Thesolidline(r
2
=0.90)indicatesthatthereisa
linear relationship between VGAS and tube voltage (data redrawn from
TingbergandSjstrm(2005)).
Chest PA
-0.5
-0.4
-0.3
-0.2
-0.1
0
0.1
0.2
0.3
0.4
0.5
60 70 80 90 100 110 120 130 140 150
Tube Voltage (kV)
F
O
M
Figure 5.10. The average relative change in SNR (FOM) in chest PA

examinationasafunctionoftubevoltage.
50
Chest PA
-2
-1
0
1
2
-0.5 -0.3 -0.1 0.1 0.3 0.5
FOM
V
G
A
S
Figure 5.11. The correlation between VGAS and SNR (FOM) for a simulated
chestPAexamination.Theerrorbarscorrespondtoonestandarderrorandare
duetoreadervariabilityintheresultsoftheobserverstudies(seeFig.5.9).The
r
2
of the fitted line (r
2
=0.91) indicates that the VGAS and FOM are linearly
correlated.LowertubevoltageshavepositiveVGASandFOMandhightube
voltagesnegativevalues.
Figure5.11showstherelationbetweenclinicalimagequalitymeasuredusing
visual grading analysis score (VGAS) and the physical measure of image
quality,quantifiedbytherelativechangeinSNRandFOM.Thereisapositive
linearrelationshipbetweenthetwomeasuresofimagequality,indicatingthat
the SNR is related to the radiologists grading of the image criteria. Hence,
results by Tingberg and Sjstrm (2005) and results from this study indicate
that,withmoderndigitalimagingsystem,itwouldbefavourabletouselower
tubevoltagesthantraditionallyusedwithscreenfilmradiography.
ArgumentsforandagainstthisproposalarelistedinpaperIVandinTingberg
and Sjstrm (2005). At low photon energies, the image detectors DQE
(detectivequantumefficiency)ishigherandthecontributiontoeffectivedose
per incident air collision kerma is lower. However, at low tube voltages, the
tube charges typically increase compared to at higher voltages to maintain a
constant effective dose. Hence the risk for increased motion and focal spot
unsharpness increases due to prolonged exposure time and focus size
blooming, respectively. In examinations where iodine contrast media are
employed, the use of lower tube voltages than used today (approximately 70
kV)seemstobeanadvantage(Tapiovaaraetal1999,Wiltzetal2005).
51
The statistical analysis of a relative VGA study, such as in Tingberg and

Sjstrm(2005)andinpaperIVisquestionablesincethescalestepsused(e.g.
2 to +2) are an ordinal scale and the numerical representations do not
represent numbers on an interval scale and one cannot assume equal steps
betweenthescalesteps.Thisproblemissolvedwithacloselyrelatedmethod,
visualgradingcharacteristics(VGC)(BthandMnsson2007).Inthistypeof
study, the observer is asked to rate his/her confidence about the fulfilment of
imagequalitycriteria.Thedataisthenanalysedinamannerthatissimilarto
ROC studies, where the resulting figure of merit is the area under the VGC
curve. However, we have not been able to translate our results to a VGC
study, since the question asked to the observer slightly differs between those
twotypesofstudies.
Also,theimportanceofaclinicalimagequalitymeasuresuchasVGAanalysis
that relies on evaluation of structures in the normal anatomy may be
questioned. This is since the detection of pathological lesions may to a large
degreealsodependonotherobjectsintheimagesuchasobscuringanatomical
backgroundstructures(Tingbergetal2005).
5.6. Modelobserverswithcomplexanatomicalbackground
In paper VI, The LaguerreGauss Hotelling observer was implemented. This
observerisinfluencedbytheanatomicalbackgroundandincludesthisintoits
figureofmerit,SNR
hot,LG
.Sonetal(2006)andChawlaetal(2007)implemented
similar observers. In the work by Son et al (2006), being an extension of the
workbyWinslowetal(2005),validationoftheirmodelisnotconsidereddue
to the use of a virtual phantom. We believe that it is important to verify that
the computational model can faithfully reproduce variations in, e.g., tube
voltage since this is an important parameter influencing image quality and
patient dose. The implementation of the LaguerreGauss Hotelling model
observer,SNR
hot,LG
,isdescribedinpaperVIandchapter4.
Figure 5.12 and 5.13 show SNR

hot,LG
for the SKE/BV and SKE/BKE tasks as
functionsoftubevoltage.TheSKE/BVandSKE/BKEcasesrepresentsituations
wherethepatientprojectedanatomyisassumedtoactasnoise(SKE/BV)orto
beknownexactly(SKE/BKE).ThefiguresshowthatfortheSKE/BVtaskthere
isasmallincreaseinSNR
hot,LG
withincreasingtubevoltageintheregionsLAT,
RETandHIL.InthebonyregionsLMEandUMEtheincreaseofSNR
hot,LG
with
increasing tube voltage is larger. For the SKE/BKE task, the SNR
hot,LG
steadily
52
decreases with increasing tube voltage as SNR
I
in paper III. Hansson et al
(2005)investigatedtheoptimaltubevoltageinneonatalchestradiography.In
their phantom study (a rabbit lung) they found a positive trend when
increasingthetubevoltageinthevisibilityofthecarinaandmainbronchi,but
no trend for the reproduction of central and peripheral vessels. Thoracic
vertebrae were better visualized at low tube voltages. Their validation study
(neonatal patients) showed no significant preference for any tube voltage in
the4090kVrangewithregardtocentralandperipheralvesselsbutthecarina
wasbetterreproducedatthehighesttubevoltageintheirstudy;90kV.These
results are in qualitative agreement with our work, although there are
significant differences in the material as adult patients were studied in our
work.
60 70 80 90 100 110 120 130 140 150

0
1
2
3
4
5
6
7
8
Tube voltage (kV)
S
N
R
h
o
t
,
L
G

(
S
K
E
/
B
V
)
Figure 5.12. SNR

hot,LG
(SKE/BV) as function of tube voltage at the air kerma 5
Gy in the center of the image detector. The markers symbolize different
regionsintheimage:*lateralpulmonaryregion(LAT),oretrocardialregion
(RET), V lower mediastinum (LME), hilar region (HIL), + upper
mediastinum(UME).
53
60 70 80 90 100 110 120 130 140 150
0
200
400
600
800
1000
Tube voltage (kV)
S
N
R
h
o
t
,
L
G
(
S
K
E
/
B
K
E
)
Figure5.13.SNR
hot,LG
(SKE/BKE)asafunctionoftubevoltageattheairkerma
5 Gy in the center of the image detector. The markers symbolize different
regionsintheimage:*lateralpulmonaryregion(LAT),oretrocardialregion
(RET), V lower mediastinum (LAT), hilar region (HIL), + upper
mediastinum(UME).
Figure 5.14 and 5.15 show SNR

hot,LG
for the SKE/BV and SKE/BKE tasks as
functions of air kerma at the image detector in the center of the image plane.
Figure 5.14 shows that in the regions located in the lung (LAT and HIL),
increasingthedoselevelhasanegligibleinfluenceontheSNR
hot,LG
.However,
in the regions containing more bony structures (LME and UME) there is a
larger increase in the SNR
hot,LG
with increasing dose level. For values of air
kermaabove0.51Gy,thevaluesofSNR
hot,LG
arehighestinthebonyregions
LME and UME. In 5.15 for the SKE/BKE task, the SNR
hot,LG
increases in
accordancewiththeRosemodel(Rose1948).
54
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
1
2
3
4
5
6
7
8
Air kerma central in detector (Gy)
S
N
R
h
o
t
,
L
G
(
S
K
E
/
B
V
)
Figure5.14.SNR
hot,LG
(SKE/BV)asafunctionofincidentairkermaattheimage
detector in the center of the image plane at 141 kV. The markers symbolize
different regions in the image: * lateral pulmonary region (LAT), o
retrocardialregion(RET),Vlowermediastinum(LME), hilarregion(HIL),
+uppermediastinum(UME).
700
600
500
400
300
200
100
0
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
Air kerma central in detector ( Gy)
S
N
R
h
o
t
,
L
G
(
S
K
E
/
B
K
E
)
Figure 5.15. SNR

hot,LG
(SKE/BKE) as a function of incident air kerma at the
image detector in the center of the image plane at 141 kV. The markers
symbolize different regions in the image: * lateral pulmonary region (LAT),
o retrocardial region (RET), V lower mediastinum (LME), hilar region
(HIL),+uppermediastinum(UME).
55
Bth et al (2005b) evaluated human detection of 10 mm lung nodules in the

presenceofnormalpatientprojectedanatomyincludingquantumnoiseandin
imageswithquantumnoiseonly.Theyconcludedthatforthedetectionofthe
lungnodules,thequantumnoiseisofalmostnoimportanceatclinicallyused
doselevelsinchestradiography.Theregionswherelesiondetectionwasleast
influenced by quantum noise were the hilar and lateral pulmonary regions.
TheresultsfortheSKE/BKEcaseinourworkagreewiththeresultsinBthet
al. for images containing quantum noise only concerning the ranking of the
regions with respect to the ease of detecting the lesions or SNRhot,LG. In the
quantum noise images, the lower and upper mediastinum were by these
authors ranked as the most difficult regions (most quantum noise) for lesion
detection and the hilar and lateral pulmonary regions as the least difficult
(least quantum noise) ones in agreement with the results in figures 5.13 and
5.14.
TheresultsfortheSKE/BVcaseagreerelativelywellwiththeresultsbyBthet
al(2005a)forimageswherestationarynoise(correspondingtostructuralnoise
indifferentregions)wasused.Inbothcases,thehilarregionisrankedasthe
mostdifficultregionforlesiondetectionandthelowermediastinumrankedas
the least difficult one, in opposite order to the case with images containing
quantum noise only. The results concerning ranking order also agree
reasonably well for the retrocardial and lateral pulmonary regions. For the
uppermediastinalregion,however,theresultsdisagree.Thisisprobablydue
to a less rich structural background in the anthropomorphic phantom in the
uppermediastinumcomparedtoinpatientimages.Althoughourmodeldoes
not produce results that fully agree with nodule detection in a structured
anatomicalbackground,ourstudyshowsthattherearereasonstobelievethat
the SKE/BV model is more realistic than the SKE/BKE model. The SKE/BV
model also predicts that higher tube voltages result in a higher SNR in
compliance with the tradition in Sweden of using high tube voltages in chest
radiography.WeconcludethattheSNRhot,LGobserverisabettermodelofthe
radiologist than model observers that only includes the quantum noise (i.e.
idealobserver)initsanalysisandsuggestthatsuchmodelshavelittlevalidity.
Figure 5.15 shows that the SNRhot,LG(SKE/BKE)observer increases its score

withthesquarerootoftheairkermaattheimagedetectorinaccordancewith
the Rosemodel whereas the SNRhot,LG(SKE/BV)observer (fig. 5.14) shows a
56
score,thatinthehilarandlateralpulmonaryregions,isindependentoftheair
kermaattheimagedetector.
57
Summaryandconclusions
59
6. SUMMARY AND CONCLUSIONS
We have developed patient models of high realism and fine anatomical
structuresforcalculationofsyntheticxrayimagesthatcanbeusedforimage
quality analysis. The projection images from these images contain fine
structuredetailssuchassmallandmediumsizedvessels.Thishasallowedfor
imagequalityassessmentwithincreasedrealism.
Astudywasalsoperformedtoinvestigatehowphysicalmeasuresinfluencing
image quality are distributed over the radiographic image. These physical
measures of image quality show a large variation in the chest PA image. The
scattertoprimaryratiobetweenspineandinthelungdifferswithafactorof4.
Correlations between clinical and physical image quality measures were

sought. In Paper IV we found a correlation between the VGA score and a
figure of merit based on the quantum noise (ideal observer) signal to noise
ratio, SNR
I
. In paper VI we implemented the LaguerreGauss Hotelling
observer for the assessment of image quality in simulated highresolution
images.ArelativelygoodcorrelationwasfoundbetweentheLaguerreGauss
Hotelling observer figure of merit, SNR
hot,LG
for the SKE/BV task, and the
clinical study by Bth et al (2005a) for images where stationary noise
corresponding to the structural noise in different regions was used. The
conclusion is therefore that the LG Hotelling observer mimics human
detection performance better than the ideal observer for tasks were the
anatomicalbackgroundvaries.
In the special case of iodine subtraction mammography (Paper I) the optimal

tubevoltagewasfoundtobesignificantlyhigher(45kV)comparedtowhatis
standard in conventional mammography. The optimisation of chest
radiographywithregardtotubevoltageismorecomplexanddependsonthe
task. For tasks limited by quantum noise, or in those cases where the clear
visualisation of bone structures are essential, then low tube voltages (90120)
shouldbepreferred.Ifwebelievethatthedetectionofsofttissuedetails(such
asnodules)ishamperedbybonedetailssuchasribs,thenhightubevoltages
(120150)shouldbepreferred.
Futurework
61
7. FUTURE WORK
The ultimate purpose for the model presented here is to serve as a tool to
perform optimisation of diagnostic radiology given a specific task. As
mentioned, a reliable and objective method for image quality assessment is
needed for this purpose. Our method using the LaguerreGauss Hotelling
observerisinaratherearlystageofdevelopment.Animportantfutureproject
is therefore to further develop and validate this method against human
observers. For instance, the LaguerreGauss method assumes rotational
symmetry,yettheanatomyisnotrotationallysymmetric.TheGaborHotelling
observerdoesnotassumerotationalsymmetryandwouldtherefore,ifitwere
implemented, provide a more accurate model of the human observer. In
addition,anotherimprovementistoaddinternalnoisetothemodelobserver
to give a better agreement with human observers. One possible way to
validate the model is to perform an ROC study where human observers and
model observers are evaluating the same images, searching for the same
pathologies. The methods for objective image quality assessment based on
statisticaldecisiontheoryarealsoapplicableinmanyotherfieldsofradiation
physics,suchasnuclearmedicineandMR.Therefore;theworkpresentedhere
couldserveasinspirationforfutureworkforresearchersinthosefields.
Another possible future prospect is to develop a model for optimisation of

chestandbreasttomosynthesis.Itthatcase,theVOXMANmodelneedstobe
improved to calculate several projections for different angles. In the case of
breasttomosynthesis,arealisticanthropomorphicbreastmodelisalsoneeded.
Another improvement of the model is to segment the highresolution
anthropomorphic phantoms so that organ and effective doses can be
calculated.
If a userfriendly version of the Monte Carlo model together with model

observers is created, it could be distributed to medical physicists who could
useitforstudyandoptimisationpurposes.
Acknowledgements
63
8. ACKNOWLEDGEMENTS
Acommonquestionfromtheopponentatthedissertationis,whydidyouchooseto
makeresearchinthisspecificfield?MyanswertothatquestionisthatIwouldhave
studied every field of Science simultaneously if that had been possible.
Unfortunately,itisnotpossible.IwouldliketouseapoembytheEnglishpoetand
artistWilliamBlakeasanillustration
ToseeaWorldinagrainofsand,
andaHeaveninawildflower.
HoldInfinityinthepalmofyourhand,
andEternityinanhour.
My belief is that any grain of sand, when studied in the depth, always contains
something interesting. I stood at the seashore and picked up one grain of sand. I
studiedthisgrainofsandineverydetailandeveryaspect,andactually,itgavemea
deeper understanding of the World. And even if I sometimes doubted, I found that
somethingsinsidewerereallyinteresting.SoIthankthisgrainofsand,andreturnit
totheseashore.
Iwanttoexpressmygratitudeto
MysupervisorsMichaelSandborgandGudrunAlmCarlssonforintroducingmeto
this field and for all the support during these years I have been working on this
thesis.ThetimeasaPhDstudenthasbeenaprocess,fromwhichIhavelearnedalot,
andithasmademedevelopasaperson.IespeciallywanttothankMickeforhelping
me to attain a rather large production as a PhD student, and Gudrun for her
enthusiasm.Sheobviouslylovesherresearch,andthatinspiresothers.
David Dance. As a coauthor of all my papers he has helped me greatly in my

research. Especially during my visits in London where he taught me about the
VOXMAN program. I also want to thank David for his hospitality during these
visits.
MagnusBth.Magnuspartinthisthesisshouldnotbeunderestimated.Intheinitial
stage of my PhD studies, being a Monte Carlo theorist, I was rather ignorant about
the clinical aspects of image quality. Largely due to Magnus, I was put out of this
ignorance.Nowadayswealmostspeakthesamelanguageandgetsimilarresults.
Acknowledgements
Alexandr Malusek. For all your support with LINUX and UNIX. You have shown
much patience with the LINUXlamer next door, who has asked many trivial
questions about even more trivial LINUXcommands. Also for all interesting
discussions during lunch about everything from TV programs on the discovery
channeltoworldpolitics.
Other coauthors: Martin Yaffe, Anders Tingberg, Markus Hkansson, Roger Hunt
and Markku Tapiovaara for theirvaluablecontributionstothepaperstheyhaveco
authored.
MycolleaguesattheRadiationPhysicsDepartment
JalilBahar.Forbeingatruefriend,andforourdiscussionsaboutRumi(seethepoem
atthefirstpageofthisthesis)andourtalksaboutbeautyofdifferentkinds.
EvaLund.Ithinkthatyoudeeplyunderstoodmyfeelingsduringthefinalstagesof
preparingthisthesis.OurtalkswhenIwasfeelingstressedreallyhelpedme.
HkanGustafsson,foroursquashgames.Theyhelpedmenottogettoounfitduring
my PhD studies. Hkan Pettersson, for our common interest in music and for your
goodsenseofhumourthatenrichedmytimeasaPhDstudent.AnnaOlssonforthe
timesyoumademelaugh.PernillaNorbergforyourkindness.
MagnusGrdestig,PeterLarsson,AxelIsraelsson,SaraOlsson,AgnethaGustafsson,
Eilert Viking, Dan Olsson, Ebba Helmrot, Henrik Karlsson, Marie Karlsson, Jonas
NilssonAlthn,PeterLundberg,DanJosefsson,MuhammedSultan,HkanHedtjrn,
LottaJonsson,LauraAntonovic,KristianSeiron.Etc.
Myfriends
GunnarCedersundforallourdiscussionsaboutreligionandscience,andforreading
and responding to the loads of emails about my successes and adversities as a PhD
student. Lena Malmberg for your inspiration. Evelina Jansson, you have also
inspired me, especially about art. All other friends, no one mentioned, no one
forgotten.
Myfamily
Everyone in my family, my parents, siblings, uncles, cousins and (deceased)

grandparents.MygrandmotherEbbaUllmanwhorecentlydeparted.
Finally,myprecious,belovedKarinWermelin.
64
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Quantifying Image Quality

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LinkpingUniversityMedicalDissertationsNo.

Cover picture/illustration: An oil painting by Gustaf Ullman representing a

The main objective of this thesis is to develop methods for assessment of

I. Gustaf Ullman, Michael Sandborg, David R Dance, Martin Yaffe,

1. Gustaf Ullman, Michael Sandborg, David R Dance, Roger Hunt, and

1. Ullman G, Sandborg M, Dance D R, Skarpathiotakis M, Yaffe MJ, Alm

According to the linear nonthreshold (LNT) hypothesis, there is a linear

However, the physical measures of image quality derived from simulations

- To complete our model of the imaging system by including a more

In radiation physics, the Monte Carlo method is employed for simulating

In diagnostic radiology, one of the most common applications of the Monte

A model of the imaging system. This comprises different sources of

Monte Carlo simulation of photon transport through the imaging

Scoring variables such as organ and effective doses and calculation of

Figure 3.1. The simulated imaging geometry used in chest PA radiography

Figure 3.2. The simulated imaging geometry used in Craniocaudal (CC)

the VOXMAN model, the relative fractions of Bremsstrahlung and

For incoherent scattering the differential crosssection is given by the Klein

To describe these photon interactions we have used tabulated crosssections

The radiological pathlength can be used to calculate the contribution to the

where isthesourceintensity, E f isthedetectorabsorptionefficiency

is the photon weight. In the collision density estimator, incoherent and

and ) and scattered (

where N is the number of photons incident on a pixel. The indices p and s

where the parameters a, b and c are calculated with nonlinear regression to

The two papers II and V were dedicated to describe the physical

To allow for more realistic calculations of how the scattertoprimary ratios

In order to simulate images with realistic anatomical background variations,

was developed in the previous work by Sandborg et al (1994b) using an

When a human observer performs a specific task, for instance, decides

AUC erf AUC SNR

percentile minus the 5

to compare to a threshold in order to decide between H

where g is the mean image vector. If g is M dimensional, the resulting

Figure 4.4. Diagram illustrating the channelized observer. The channelized

In paper VI we used LaguerreGauss channels. LaguerreGauss function is a

Figure 5.7 shows the figureofmerit SNR

Figure 5.7. SNR

Figure 5.8. C/C

Figure 5.10. The average relative change in SNR (FOM) in chest PA

The statistical analysis of a relative VGA study, such as in Tingberg and

Figure 5.12 and 5.13 show SNR

60 70 80 90 100 110 120 130 140 150

Figure 5.12. SNR

Figure 5.14 and 5.15 show SNR

Figure 5.15. SNR

Bth et al (2005b) evaluated human detection of 10 mm lung nodules in the

Figure 5.15 shows that the SNRhot,LG(SKE/BKE)observer increases its score

Correlations between clinical and physical image quality measures were

In the special case of iodine subtraction mammography (Paper I) the optimal

Another possible future prospect is to develop a model for optimisation of

If a userfriendly version of the Monte Carlo model together with model

David Dance. As a coauthor of all my papers he has helped me greatly in my

Everyone in my family, my parents, siblings, uncles, cousins and (deceased)

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