ACRIN-NLST CT SCANNER CERTIFICATION & ANNUAL TESTING

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1 ACRIN-NLST CT SCANNER CERTIFICATION & ANNUAL TESTING Please complete one copy of this form for each multi-detector helical CT Scanner when introduced into the ACRIN-NLST and annually thereafter. Detailed instructions for phantom tests are included in the ACRIN-NLST Manual of Operations. All information for CTDI should be completed electronically on the Excel Spreadsheet embedded in this document; as an alternative, standalone Excel spreadsheets can be provided to the Site Study Coordinator or available at the web site: Completed forms may be sent to ACRIN by to Erin Cunningham at: or by fax at Transmit all relevant phantom image data (CTDI and Water Phantom) to the ACRIN Headquarters QC Image Archive. Follow the Image Naming conventions in the ACRIN-NLST QA IMAGE IDENTIFICATION & SUBMISSION instructions document. 1. ACRIN Site: 2. Site PI: 3. Date of Testing: 4. Site Physicist: 5. CT Manufacturer: check one GEMS General Electric PHMS Philips SIEC Siemens SHIM Shimadzu TOSE Toshiba OTHER Other 6. Model Name: 7. Site s Scanner ID Code: (Whatever scanner name/id you use to distinguish your scanner.) 8. Multi-Slice Capability: 1 Yes 2 No 9. Maximum number of axial images able to be acquired simultaneously in one rotation (Nmax) 1: 10. Minimum Time for one Tube Rotation: sec / rotation 11. Slice Thicknesses (in mm): choose all that are available Other: Type of Detectors: choose one 1 Solid state 2 Xenon gas 13. Types of Dose Reduction Options Available: 14. Ionization chamber 14a. Model Name: 14b. Serial Number: 14c. Calibration Date*: 15. Electrometer 15a. Model Name: 15b. Serial Number: 15c. Calibration Date*: *Bi annual OK 1 Definitions for Completion of Form: T = Z axis collimation, or the width of one data channel. In multi-detector CT scanners, several detector elements may be combined to form one data channel. N = # data channels, or the actual number of data channels used during an acquisition. Nmax = Maximum # of data channels (the maximum number of data channels along the z-axis). I = Increment, the table increment per rotation of the x-ray tube in a helical scan. Pitch = I / N T ACRIN-NLST CT Scanner Certification Form Page 1 of 5

2 Section 1.1 Radiation Dosimetry (Adult Body Phantom)- Exposure Low dose helical CT technique Please complete this section if your dose measurements are made with a meter that records EXPOSURE ACRIN-NLST dosimetry can be performed as part of a site s routine scanner testing provided date indicated above reflects annual dosimetry measurements. Please refer to the corresponding section in the Manual of Operations to complete the tables below. Use the Low Dose Helical CT parameters used for NLST on this scanner, BUT in a single axial (non-spiral) scan. Record the technical parameters. Enter data directly on the Excel Dose spreadsheet below to electronically compute all calculations. If this Excel calculator is not accessible, standalone Excel spreadsheets are available at the web site: "Screen Save" the CTDI phantom images from which measures were obtained. Transmit the screen save image to the ACRIN QC archive for review and permanent archive. Use the naming conventions in the NLST QA IMAGE IDENTIFICATION & SUBMISSION instructions. *** CTDI data must be acquired using a single axial (non-spiral) scan *** ACRIN SITE NUMBER Section 1.1- Radiation Dosimetry ( Low Dose Chest CT) Dose Calculator (Exposure) CTDI Body Phantom (32-cm diameter PMMA Phantom) Measured Calculated kvp ma Exposure time per rotation (s) Z axis collimation T (mm) 1 # data channels used (N) 1 Table Incrementation - as per ACRIN NLST technique chart (mm/rot) = (I) 1 Active Chamber length (mm) Chamber correction factor Isocenter Measurement 1 (mr) Measurement 2 (mr) Measurement 3 (mr) Average of above 3 measurements (mr) Body CTDI at isocenter in phantom (mgy) 12 o'clock position Measurement 1 (mr) Measurement 2 (mr) Measurement 3 (mr) Average of above 3 measurements (mr) Body CTDI at12 o'clock position in phantom (mgy) CTDIw (mgy) Clinical Exam Dose Estimates (using measured CTDIw and site's Low Dose Chest CT Protocol) CTDIvol (mgy) DLP (mgy-cm) Eff Dose (msv) 1 See definitions on page 3 of the Phantom Testing Instructions. =CTDIw*N*T/I =CTDIvol*40 =DLP*0.017 ACRIN-NLST CT Scanner Certification Form Page 2 of 5

3 Section 1.2 Radiation Dosimetry (Adult Body Phantom)- Air Kerma Low dose helical CT technique Please complete this section if your dose measurements are made with a meter that records Air Kerma Please refer to the corresponding section in the Manual of Operations to complete the tables below. Use the Low Dose Helical CT parameters used for NLST on this scanner, BUT in a single axial (non-spiral) scan. Record the technical parameters. Enter data directly on the Excel Dose spreadsheet below to electronically compute all calculations. If this Excel calculator is not accessible, standalone Excel spreadsheets are available at the web site: "Screen Save" the CTDI phantom images from which measures were obtained. Transmit the screen save image to the ACRIN QC archive for review and permanent archive. Use the naming conventions in the NLST QA IMAGE IDENTIFICATION instructions. *** CTDI data must be acquired using a single axial (non-spiral) scan *** ACRIN SITE Number Section Radiation Dosimetry ( Low Dose Chest CT) Dose Calculator (Air Kerma) CTDI Body Phantom (32-cm diameter PMMA Phantom) Measured Calculated kvp ma Exposure time per rotation (s) Z axis collimation T (mm) 1 # data channels used (N) 1 Table Incrementation - as per ACRIN NLST technique chart (mm/rot) = (I)1 Active Chamber length (mm) Chamber correction factor Isocenter Measurement 1 (mgy) Measurement 2 (mgy) Measurement 3 (mgy) Average of above 3 measurements (mgy) Body CTDI at isocenter in phantom (mgy) 12 o'clock position Measurement 1 (mgy) Measurement 2 (mgy) Measurement 3 (mgy) Average of above 3 measurements (mgy) Body CTDI at12 o'clock position in phantom (mgy) CTDIw (mgy) Clinical Exam Dose Estimates (using measured CTDIw and site's Low Dose Chest CT Protocol) CTDIvol (mgy) DLP (mgy-cm) Eff Dose (msv) 1 See definitions on page 3 of the Phantom Testing Instructions. =CTDIw*N*T/I =CTDIvol*40 =DLP*0.017 ACRIN-NLST CT Scanner Certification Form Page 3 of 5

4 Section 2 Water Phantom Testing Low dose helical CT technique Refer to the corresponding section in the ACRIN-NLST Manual of Operations to complete the table. Use the Low Dose Helical CT parameters used on this scanner for NLST. Record the technical parameters below. "Screen Save" the water phantom tests with ROI's recorded on the image. Transmit the phantom image and Screen Save image to the ACRIN QC archive for review and permanent archive. Use the naming conventions in the NLST QA IMAGE IDENTIFICATION instructions. Table 1: Record the scanning parameters used to acquire the water phantom measurements 1 Note: Vendors may use different terminology. Please indicate which parameter is shown on your scanner console and the value for that parameter. {* For Siemens and Philips scanners, users input mas or mas/slice at the scanner console; which is really an effective mas = (ma* time/pitch. ) Scanning Parameters Date of Phantom Test ( mm / dd / yyyy ) Scanning Technologist ID kv Gantry Rotation Time (sec) ma, mas, or Effective mas 1 (check one) T = Detector collimation (one channel) N = Number detectors actually used to scan I = Increment of Table per Tube rotation (mm/rot) Pitch = I / N T Nominal slice width (mm) Reconstruction interval (mm) Reconstruction Algorithm (Filter) Water Phantom Test ACRIN-NLST CT Scanner Certification Form Page 4 of 5

5 TABLE 2- MEASURED AND CALCULATED VALUES NOTE: Use a Region of Interest (ROI) ~ 400 mm 2 size. ACRIN-NLST Use Only Parameter Measured Calculated Acceptable Limits Review Low Dose Chest CT Technique Test date: Center Std. Deviation Standard deviation = HU for example (15 to 40 HU) OK Action Req d Center Mean Mean CT # = HU (0 ± 4) OK Action Req d 12 o clock Mean Mean CT # = HU Center 12:00 = HU ( 7) OK Action Req d 3 o clock Mean Mean CT # = HU Center 3:00 = HU ( 7) OK Action Req d Artifacts Ring Y/ N Streak Y/ N Other Ring=N, Streak=N OK Action Req d FOR ACRIN-NLST USE ONLY Initial Review Date: 1. Scanner Description: OK Action Required 2. CTDI Measurements: OK Action Required Primary Reviewer : Reviewer ID: Secondary Reviewer (if necessary) : Reviewer ID: Action(s) Required or Notes : Data re-submission (If required) Follow-up review Date: 1. Scanner Description: OK Action Required 2. CTDI Measurements: OK Action Required Primary Reviewer : Reviewer ID: Secondary Reviewer (if necessary) : Reviewer ID: Action(s) Required or Notes : ACRIN-NLST CT Scanner Certification Form Page 5 of 5

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