[Intl_DxMedPhys] ACR CT test question

Wed Sep 16 08:27:51 EDT 2026

I should also say, I tested one of those scanners with an AI recon and a normal recon using the same acquisition setup. The recon type isn’t a problem.  Both would fail the CNR with the acquisition parameters it has been selecting. The CNR was higher with the AI recon and the images also qualitatively looked better.

[cid:image001.png at 01DD45AC.E063A0E0]<https://urldefense.com/v3/__https://wearememorial.com/__;!!KGKeukY!2C1_WNovzDvi-J4k_lZoDvwCn9aeduU-BMLqVDiTew1osgst5POCBlwkz3x0H5p9fPrCvlADCNgi5zqWEnxKxhhNMIyefKAfdHAa$ >
D. SCOTT WINTER

CHIEF DIAGNOSTIC MEDICAL PHYSICIST
O:
228-865-3475<tel:228-865-3475>

From: David S. Winter
Sent: Wednesday, September 16, 2026 7:25 AM
To: 'Tyler Fisher' <sdtyler at gmail.com>; Matt Wait <Matt.Wait at kp.org>
Cc: DxMedPhys List <intl_dxmedphys_wd_osu_list at lists.osu.edu>
Subject: RE: [Intl_DxMedPhys] ACR CT test question

ALCON,

Thanks for all the input.

Tyler, I actually formally submitted the “part 1” of my original query to the ACR the other day (before I saw your reply.) I will make sure I forward the results of that response to this group (particularly if different from what you previously said.)

Apart from this being generally a good thing to discuss, it is largely being sparked by my attempts to navigate some brand new scanners I am dealing with. They are Canon system that have some AI powered reconstructions and, more saliently, AEC acquisition protocols that drive imaging parameters on the assumption that the recons will be AI. The patient doses are very low…. (CTDIvols close to 3 for patients that would be around “70 kg average’). The limited feedback on image quality from radiologist has allegedly been positive. But if scanned at the techniques the Apps people advocated (the AI ones) for around a 70 kg patient they will simply fail the CNR test criteria. I could always “conveniently reinterpret” the definition of patient average… but those who know me know that’s not how I roll. That said, 70 kg is not indicative of the average the patients the scanners are scanning. So selecting a higher mA may be legitimate.

As a side note… I have a tangential conversation with some others about “stand-ins” for “average” patients that could be used to sanity check actual patient data and facilitate protocol experimentation and/or brand new system testing. It obviously is dependent on what we define as “average”. I also have some empirical data to backup theoretical calculations. There are a few options…. But I will say that the three tier CTDI phantom (e.g 32 cm, 16cm, and 10cm) was a very similar water equivalent diameter to where I think the “average 70kg mid liver” would be, if you image the 32 cm with the 16 cm removed but the 10 cm placed back in (probe holes filled). That combination has a phantom Dw = 31.2 cm versus a low statistic patient average of Dw = 31.5cm. When scanned on a scanner the mA it selected was almost identical (phantom mA = 90 cm, low statistic patient average of mA = 92.8, other acquisition protocol setting identical).  There are a few thoughts on other combinations that might be good for other patient categories (e.g. adult head)

Sincerely,
Scott

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D. SCOTT WINTER

CHIEF DIAGNOSTIC MEDICAL PHYSICIST
O:
228-865-3475<tel:228-865-3475>

From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces+dwinter=mhg.com at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list-bounces+dwinter=mhg.com at lists.osu.edu>> On Behalf Of Tyler Fisher via Intl_dxmedphys_wd_osu_list
Sent: Tuesday, September 15, 2026 12:36 PM
To: Matt Wait <Matt.Wait at kp.org<mailto:Matt.Wait at kp.org>>
Cc: DxMedPhys List <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>>
Subject: Re: [Intl_DxMedPhys] ACR CT test question

Hi Everyone, This has been a very good discussion. I'll add my two cents but also state up-front that I am the current chair of the ACR CT Physics Accreditation Sub-Committee, so there may be a pro-ACR bias coming through. In general, the
Hi Everyone,
This has been a very good discussion.  I'll add my two cents but also state up-front that I am the current chair of the ACR CT Physics Accreditation Sub-Committee, so there may be a pro-ACR bias coming through.

In general, the ACR technical standards, QC Manuals, and Accreditation program requirements are overlapping but independent.  The QC manuals are assembled and maintained by ACR staff and committees of volunteer members who represent the accreditation programs and other stakeholders.  Slight variations in language or specifics like this are to be expected.

The intent of the "average-sized" language in the accreditation program, as I interpret it, is site and scanner specific.  When I test a CT system, I will look through the patients scanned recently for what I think is their standard adult abdomen protocol.  I check the scout first to make sure they're not tiny or bariatric, then I'll scroll through the primary axial images until I get to mid-liver and record the mA.  I'll take an average of 6 or 8 patients.  I don't look at patient sex or age.  If a site has additional data (ACR DIR or dose-tracking software) that will give me techniques for an average-sized patient, I'll use that, but more often than not, the sites that I visit do not.  This method would be more accurate than my average of 6 or 8 scans, but I think we have to remember that the majority of scanners in the country aren't being monitored like this.  The ACR would love for everyone to participate in the ACR DIR, but this is not a requirement for accreditation.  Also, we're measuring and reporting a single CTDI value for a protocol whose standard deviation of CTDI values is huge.

For new scanners, Scott's suggested methods all seem reasonable.  I tend to take my knowledge of similar (or exactly the same make/model) scanners, the site's standard protocols for other scanners if available, default protocols, and my own personal expertise to come up with an average technique.  I will note in my report that the protocols tested may not match the clinical protocols established during applications training and the next time I lay hands on that scanner, I'm going to closely review what they're actually doing.  Also, I'll make sure at acceptance testing that the reported CTDI values match what I measure, so that if the protocols are different than what I tested, at least they'll know that the doses are accurate.

The discussion about finding a "21 or 23 cm effective diameter patient" to set as the "average-patient" is wrong.  The "DFOV close to 21 cm" is strictly based on the size of the image quality phantom - it has nothing to do with an average patient.  If the image quality phantom was 30 cm diameter, we'd tell you to scan with a DFOV close to 31 cm.

Last thing I'll say is this:  The ACR believes that qualified diagnostic medical physicists have the expertise and integrity to perform quality medical physics testing on scanners.  Can someone iteratively increase dose to get CNR to pass?  Of course.  Can we cheat the average technique down to make sure that we're within the dose thresholds?  Sure.  The accreditation programs work on the assumption that we're all doing our best.  The programs try to balance being overly prescriptive on how to do every single test vs. allowing physicists free-reign to do whatever we want.  Over 25 years of the CT accreditation program, I think we've gotten pretty close to the right balance, but as the chair, I'm open to suggestions of how we can improve.

Thanks.
Tyler Fisher
Therapy Physics, Inc.

On Mon, Sep 14, 2026 at 1:53 PM Matt Wait via Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>> wrote:
To clarify: I had been going on the assumption that 70 kg correlated with a patient with an abdomen of about 21 cm in diameter. Maybe I had gotten it mixed up with the phantom diameter somewhere down the line. The point is, I don't really have
To clarify: I had been going on the assumption that 70 kg correlated with a patient with an abdomen of about 21 cm in diameter. Maybe I had gotten it mixed up with the phantom diameter somewhere down the line.

The point is, I don't really have any idea what the abdomen of a 70 kg patient "looks like". It would be much easier to have a rough estimate of an abdomen diameter range to use.

Matt Wait, MS, DABR, DABSNM, MRSE
Senior Diagnostic Physicist

Associate Radiation Safety Officer

Assistant Residency Director

Kaiser Permanente

Southern Permanente Medical Group

Medical Imaging Technology and Informatics
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(818) 232-2427<tel:(818)%20232-2427> (mobile phone)

________________________________
From: Douglas Pfeiffer <xraydoug at me.com<mailto:xraydoug at me.com>>
Sent: Monday, September 14, 2026 1:47 PM
To: Matt Wait <Matt.Wait at kp.org<mailto:Matt.Wait at kp.org>>
Cc: DxMedPhys List <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>>; Bob Kobistek <bob at rjkmedphys.com<mailto:bob at rjkmedphys.com>>
Subject: Re: [Intl_DxMedPhys] ACR CT test question

The 21 cm DFOV is to make it easier to analyze - nothing to do with patient size. It doesn’t impact dose in any way. Using a small Scan FOV is to reduce non-uniformities due to the bowtie not being matched to the object size on some scanners.

Best regards,
Doug

Douglas Pfeiffer, MS, DABR FACR, FAAPM (he/him)
Medical Physicist, Radiation Safety Officer
Boulder Community Health
xraydoug at me.com<mailto:xraydoug at me.com>
303.415.7515<tel:(303)%20415-7515>

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The opinions expressed in this message are the product of the gray and white matter loitering in my cranium. I speak for myself and no one else, unless I say otherwise.

On Sep 14, 2026, at 2:42 PM, Matt Wait <Matt.Wait at kp.org<mailto:Matt.Wait at kp.org>> wrote:

That's good to hear, that's the practice I've been using. But I have never found a good reference for correlating the abdomen diameter (21 cm?) with 70 kg.

Matt Wait, MS, DABR, DABSNM, MRSE
Senior Diagnostic Physicist
Associate Radiation Safety Officer
Assistant Residency Director
Kaiser Permanente
Southern Permanente Medical Group
Medical Imaging Technology and Informatics
4867 Sunset Blvd<https://urldefense.com/v3/__https://www.google.com/maps/search/4867*Sunset*Blvd**A0D*0A**A0D*0A*Los*Angeles,*CA*90027**A0D*0A**A0D*0A*x5347*(office?entry=gmail&source=g__;KysrJSUrJSUrKysrKyUlKyUlKys!!KGKeukY!x0papCM_iTVWnSTQkMc_SHwci_FgU-ejRnjPVU_cgUbJqe-P2hx_f5xsdNZb_QTzWtxmZZ6JO-vfe_fkP6jHa56k6UJ_NeNp2uhMtA$>
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________________________________
From: Douglas Pfeiffer <xraydoug at me.com<mailto:xraydoug at me.com>>
Sent: Monday, September 14, 2026 1:35 PM
To: Matt Wait <Matt.Wait at kp.org<mailto:Matt.Wait at kp.org>>
Cc: DxMedPhys List <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>>; Bob Kobistek <bob at rjkmedphys.com<mailto:bob at rjkmedphys.com>>
Subject: Re: [Intl_DxMedPhys] ACR CT test question

Going through the list of scanned patients on the scanner and looking for abdomens that look about the right size, and looking at the mA at mid-liver (belly button-ish).

Best regards,
Doug

Douglas Pfeiffer, MS, DABR FACR, FAAPM (he/him)
Medical Physicist, Radiation Safety Officer
Boulder Community Health
xraydoug at me.com<mailto:xraydoug at me.com>
303.415.7515<tel:(303)%20415-7515>

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The opinions expressed in this message are the product of the gray and white matter loitering in my cranium. I speak for myself and no one else, unless I say otherwise.

On Sep 14, 2026, at 2:16 PM, Matt Wait <Matt.Wait at kp.org<mailto:Matt.Wait at kp.org>> wrote:

Doug, how did you envision determining the automatic tube current selection for Standard Man?

Matt Wait, MS, DABR, DABSNM, MRSE
Senior Diagnostic Physicist
Associate Radiation Safety Officer
Assistant Residency Director
Kaiser Permanente
Southern Permanente Medical Group
Medical Imaging Technology and Informatics
4867 Sunset Blvd<https://urldefense.com/v3/__https://www.google.com/maps/search/4867*Sunset*Blvd**A0D*0A**A0D*0A*Los*Angeles,*CA*90027**A0D*0A**A0D*0A*x5347*(office?entry=gmail&source=g__;KysrJSUrJSUrKysrKyUlKyUlKys!!KGKeukY!x0papCM_iTVWnSTQkMc_SHwci_FgU-ejRnjPVU_cgUbJqe-P2hx_f5xsdNZb_QTzWtxmZZ6JO-vfe_fkP6jHa56k6UJ_NeNp2uhMtA$>
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________________________________

From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces+matt.wait=kp.org at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list-bounces+matt.wait=kp.org at lists.osu.edu>> on behalf of Douglas Pfeiffer via Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>>
Sent: Monday, September 14, 2026 1:12 PM
To: Bob Kobistek <bob at rjkmedphys.com<mailto:bob at rjkmedphys.com>>
Cc: DxMedPhys List <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>>
Subject: Re: [Intl_DxMedPhys] ACR CT test question

Caution: This email came from outside Kaiser Permanente. Do not open attachments or click on links if you do not recognize the sender.
________________________________
For what it’s worth now, the intent when I was working on the manual was Standard Man (i.e., 70 kg). It was an unfortunate oversight on my part that I did not catch that and state it explicitly way back when. I’m not sure what is assumed now by the ACR, but that was the original thinking.

Best regards,
Doug

Douglas Pfeiffer, MS, DABR FACR, FAAPM (he/him)
Medical Physicist, Radiation Safety Officer
Boulder Community Health
xraydoug at me.com<mailto:xraydoug at me.com>
303.415.7515<tel:(303)%20415-7515>

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The opinions expressed in this message are the product of the gray and white matter loitering in my cranium. I speak for myself and no one else, unless I say otherwise.

On Sep 9, 2026, at 1:45 PM, Bob Kobistek via Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>> wrote:

Hi.

I also beat my head against a wall searching for answers to these questions when the ACR CT accreditation program was started. I stopped overthinking it, and now I pretty much wing it.

For average size patient, I look through patient scans to find one with an A-P dimension through the abdomen of around 23 cm. If I can find more than one (hard to find nowadays), I’ll toss out the outliers and take an average of the mAs values.

For new scanners I use nearly all the options you presented. If it’s a scanner with a similar model in use at the facility, I refer to patients scanned on the existing scanners. If it’s a scanner that I see at other facilities, I’ll make adjustments for differences in protocols and use that. If it’s a scanner I’ve never seen before, I’ll pull up the manufacturer’s suggested protocols and take a guess at the mAs when TCM is used. If I use the second or third option, I’ll take a look at patient scans once the scanner has been operating for a few weeks. If I can make adjustments to my measurements based on the clinical data, I will. If I have to, I’ll repeat the measurements using the clinical protocols. If the site is going to be ACR accredited I will always make a second trip so I can use the actual protocols and clinical mAs values for accreditation, not matter which of the three options above that I use.

There is very little guidance on how to chose mAs (and kVp when applicable) for automated technique selection. So we use out best judgment.

Robert J. Kobistek, MS, FACR, DABR, MRSE(MRSC™)
Medical Physicist
RJK Medical Physics, Inc.
440-463-7879<tel:(440)%20463-7879>

From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list-bounces at lists.osu.edu>> On Behalf Of David S. Winter via Intl_dxmedphys_wd_osu_list
Sent: Monday, September 7, 2026 4:02 PM
To: DxMedPhys List <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>>
Subject: [Intl_DxMedPhys] ACR CT test question

All, I apologize as this has no doubt been discussed in the past, but I have a two part inquiry related to ACR CT testing. I am happy to clarify directly with the ACR, but I figured I would touch base with this forum first. (Especially since
All,

I apologize as this has no doubt been discussed in the past, but I have a two part inquiry related to ACR CT testing. I am happy to clarify directly with the ACR, but I figured I would touch base with this forum first. (Especially since only part 1 would be good to ask the ACR directly.)

Part 1:  The ACR’s scanning instructions webpage and the CT QC manual both give a weight range for the pediatric abdominal exam of 40-50lbs, but only the QC manual has a weight for the adult abdomen (i.e. 70 kg, ~154 lbs). The webpage merely says “average sized patient”. The exclusion of the 70 kg reference could be an accidental omission, but that requires the same omission to have been repeated in multiple different locations on their webpage.

“Average sized” could be interpreted to mean average across the entire US population, the region a CT scanner is in, or the specific patient population a specific CT scanner sees (which could be massively different if the scanner is the go-to scanner for bariatric patients.) The CDC says the current adult average weights are 199 lbs for men and 171.8 lbs for women. (Both significantly more than 154). In addition, the ACR’s mandatory dose calculation sheet calculates the adult abdomen SSDE for a 35 cm water equivalent diameter. While you can’t exactly convert abdominal water equivalent diameter to a patient weight, that value would likely correspond to a patient significantly heavier than 154 lbs.

Has anyone specifically seen anything that dictates which is definitively correct for determining what techniques to set, and by extension, determine whether or not the scanner is really passing the CNR test?

Part 2: In practice, I am curious how people are determining the mA that CT scanners are selecting for the “average”, particularly for brand new scanners without much/any historic patient data. I can imagine four different general approaches. 1) Analysis of historical data aggregated by a dose metric monitoring system like Radimetrics. 2) Manually looking for a few historical patients that look to be roughly “average size” and then averaging the mA from a representative slice from a few of those studies. 3) For new systems, using values from a similar system with similar settings. 4) Conducting scans of a standard (e.g. their CTDI phantom), seeing what the CT scanner picks for mA, and then applying a scaling factor to that mA to adjust for the size difference.

Sincerely,
Scott

D. SCOTT WINTER

CHIEF DIAGNOSTIC MEDICAL PHYSICIST
O:
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4500<https://urldefense.com/v3/__https://www.google.com/maps/search/4500*13th*St**A0D*0A**A0D*0A**A0D*0A*,**A0D*0A**A0D*0A**A0D*0A*Gulfport**A0D*0A**A0D*0A**A0D*0A*,**A0D*0A**A0D*0A**A0D*0A*MS**A0D*0A**A0D*0A**A0D*0A*,**A0D*0A**A0D*0A**A0D*0A*39501?entry=gmail&source=g__;KysrJSUrJSUrJSUrKyUlKyUlKyUlKyslJSslJSslJSsrJSUrJSUrJSUrKyUlKyUlKyUlKyslJSslJSslJSs!!KGKeukY!x0papCM_iTVWnSTQkMc_SHwci_FgU-ejRnjPVU_cgUbJqe-P2hx_f5xsdNZb_QTzWtxmZZ6JO-vfe_fkP6jHa56k6UJ_NeNUWk_9Hg$> 13th<https://urldefense.com/v3/__https://www.google.com/maps/search/4500*13th*St**A0D*0A**A0D*0A**A0D*0A*,**A0D*0A**A0D*0A**A0D*0A*Gulfport**A0D*0A**A0D*0A**A0D*0A*,**A0D*0A**A0D*0A**A0D*0A*MS**A0D*0A**A0D*0A**A0D*0A*,**A0D*0A**A0D*0A**A0D*0A*39501?entry=gmail&source=g__;KysrJSUrJSUrJSUrKyUlKyUlKyUlKyslJSslJSslJSsrJSUrJSUrJSUrKyUlKyUlKyUlKyslJSslJSslJSs!!KGKeukY!x0papCM_iTVWnSTQkMc_SHwci_FgU-ejRnjPVU_cgUbJqe-P2hx_f5xsdNZb_QTzWtxmZZ6JO-vfe_fkP6jHa56k6UJ_NeNUWk_9Hg$> St<https://urldefense.com/v3/__https://www.google.com/maps/search/4500*13th*St**A0D*0A**A0D*0A**A0D*0A*,**A0D*0A**A0D*0A**A0D*0A*Gulfport**A0D*0A**A0D*0A**A0D*0A*,**A0D*0A**A0D*0A**A0D*0A*MS**A0D*0A**A0D*0A**A0D*0A*,**A0D*0A**A0D*0A**A0D*0A*39501?entry=gmail&source=g__;KysrJSUrJSUrJSUrKyUlKyUlKyUlKyslJSslJSslJSsrJSUrJSUrJSUrKyUlKyUlKyUlKyslJSslJSslJSs!!KGKeukY!x0papCM_iTVWnSTQkMc_SHwci_FgU-ejRnjPVU_cgUbJqe-P2hx_f5xsdNZb_QTzWtxmZZ6JO-vfe_fkP6jHa56k6UJ_NeNUWk_9Hg$>
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