IDENTIFICATION OF CT NUMBER (NCT) AT THE PRIMER AREA (GTV) OF

ASTROCYTOMA AND CERVICAL CANCER

Lovina Wijayanti1, Unggul P. Juswono1, Sri Martono2, Ubaidillah1
1

Department of Physics, Faculty of Matemathics and Natural Sciences,

University of Brawijaya Malang, East Java, Indonesia
2
Department of Radiology, Saiful Anwar General Hospital Malang, East Java, Indonesia
Email: lovinaliu@gmail.com
Abstract-Treatment planning system (TPS) is a fundamental procedure in external radiotherapy. One of TPS
procedure is cancer segmentation using the results of a CT-Scan image. Cancer area is segmented in each slice
of CT -scan image by an expert radiation oncologist. This procedure is very dependent on the experience,
expertise of the doctor and requires a high level of accuracy. Therefore, this study aimed to identify and define
CT Numbers (NCT) that can explain quantitatively about how radiation oncologist perform cancer segmentation
based on qualitative observation on CT-Scan result. Determination of CT Numbers (NCT) was done by using
descriptive statistical analysis on the CT Numbers (NCT) that was obtained from the CT scan DICOM file
(Digital Imaging and Communications in Medicine) of a patient with astrocytomas and two patients with stage
III cervical cancer. The results showed that NCT = +31 HU to +38 HU indicates the presence of a tumor on the
left side of the astrocytomas patient (PX-1) head. NCT = +7 HU to +45 HU in the case of cervical cancer patient
(PY-1) shows the hypodense area that indicates the cancer area. Whereas in patient PY-2 was obtained NCT = +6
HU to +49 HU that indicates the homogeneous density in the area of cervical cancer spreading.
Key Words : CT Number, DICOM, CT-Scan, Astrocytoma, cervical cancer, Bilangan CT, DICOM, CT-Scan,
astrositoma, cervical cancer, external radiotherapy

until the tumor has a large size and cause

symptoms that can be felt clearly, for
example, epileptic seizures and headache [3].
One of effective technique for cancer
treatment is external radiotherapy [7]. The
success of external radiotherapy procedure is
influenced by the accuracy of defining the
location and area of cancer spread. The results
of volume and location determination of the
cancer is useful to determine the magnitude
and direction of the radiation dose to be
administered to the patient [8]. Cancer
volume definition is done carefully by a
radiation oncologist based on qualitative
observations on the results of a CT-scan
patients [9].
The process of defining the primary
cancer area (Gross Tumor Volume, GTV) and
the area of spread of cancer, namely CTV
(Clinical Target Volume) and PTV (Planning
Target Volume) performed by a specialist in
each slice axial CT scan of the patient.
Defining the cancer area is very dependent on
the experience and expertise of the doctor. In
addition, the process of defining the area of
cancer performed by expert doctors also
require quite a lot of time because it had to be
done in each axial slice of the patient's body
into the location where the cancer was

1.

INTRODUCTION
Cancer is one of the leading causes of
morbidity and mortality in Indonesia,
amounting to 111 people per 100.000
population (WHO, 2014). In November 2014,
there were 8,990 cancer patients in Saiful
Anwar General Hospital consisting of 5,058
breast cancer cases, 2,316 cases of cervical
cancer and 1,616 cases of nasopharyngeal
cancer [2]. In addition, cases of brain tumors
is also a quite dangerous because it can affect
people at any age and is generally difficult to
diagnose at an early stage [3].
Cervical cancer is the second type of
cancer that is a most deadly disease for
women worldwide after breast cancer cases
[4]. The absence of specific symptoms or
signs of early stage cervical cancer causes it is
often detected only upon entering an
advanced [3].
Astrocytoma is one type of glioma
brain tumor that is most common in adults at
the middle ages, 30-40 years [5].
Astrocytomas have a tendency to become
glioblastoma (stage IV astrocytoma) when it
was not given by an effective treatment [6].
Characteristics of early stage (I and II)
astrocytoma is slowly grow that will cause the
patient did not experience specific symptoms
1

diagnosed. Therefore, we need a method to

help semiautomatic segmentation cancer area
[10].
This study aims to identify the range of
CT Number (NCT) which may represent the
area of primary cancer and its spread. It also
can explain the results of cancer diagnosis by
a radiation oncologist through a quantitative
approach. CT Number (NCT) is a value which
represents the attenuation of material. NCT has
a value that varies depending on the type of
material and the quality of X-ray beam used
in the procedure of CT-Scan [11]. The results
of CT Number identification in the area of
cancer can be used to determine the
differences between the constituent cells of
cancerous tissue and the normal tissue located
around the cancer.

The defining of cancer area is done through

CT-Scan image overlapping technique of the
patient who had been given cancer contour
(GTV, CTV and PTV) by radiation oncologist
using HU Inspector application.

2.

METHODS
This research was conducted in
Department of Radiology, Saiful Anwar
General
Hospital
and
Computation
Laboratory Department of Physics, University
of Brawijaya, Malang.
The equipment used in this study
include a computer with an Intel Core i3 1.7
GHz, 4GB RAM, 500GB hard drivers that are
equipped with Windows 8 operating system,
compiler NetBeans IDE 8.0.1, the application
HU Inspector, SPSS v20, and Agnosco
DICOM viewer.
The data used to identifying the value
of NCT in the case of astrocytoma is DICOM
CT-Scan of 5 patients comprising a control
patients (PX-1) who suffered from
astrocytoma tumor and 4 reference patients
(PX-2, PX 3, PX -4, and PX-5) which is not
an astrocytoma patients. Patients selected by
criteria of age (46.2 6.3) years old, female,
and underwent head CT scan procedure on the
part of the brain without contrast medium
injection. While in the case of cervical cancer,
used two DICOM data of patients with stage
III cervical cancer by contrast medium
injection, the PY-1 patients (36 years) and
patients PY-2 (56 years).
Procedures for the identification and
evaluation of the distribution of CT Number
(NCT) conducted by HU Inspector application
that was created by author using Java
language and NetBeans IDE 8.0.1 compiler.
Identification of CT Number was done in the
area of cancer in accordance with the
radiation
oncologist's
diagnosis.

Figure 1 An Example of defining procedures to

make contours of cancerous area based on the CTScan image that had been diagnosed by a radiation
oncologist. (A) The CT-Scan image of PX-1
(patients with astrocytoma) patients head (looks
inferior) were reconstructed using HU Inspector
application. (B) Overlapping contour area of
cancer on CT-scan image (Figure 1A). (C)
Defining the tumor area with HU Inspector
application in accordance with the contour cancer
that had been made by a radiation oncologist.

NCT value of each pixel from the CT-

Scan image in the area of cancer that has been

defined in accordance with procedures shown
in Figure 1 will be displayed by HU Inspector
in the form of numerical data. NCT values
obtained are then analyzed using descriptive
statistical techniques (mean, median, mode,
standard deviation) with SPSS v20 to
determine the frequency distribution and the
range of CT Number (NCT) that dominate the
cancer area of patients PX-1, PY-1 and PY-2,
While the evaluation of the CT Number
distribution conducted qualitatively in each
slice of CT scan result using certain colors
represent a certain range of NCT value. NCT
value was classified into color classes by
using a formulation derived from Sturges
interval rule.
2

is displayed as an area with a dark (black)

color, while the area with NCT = (+ 31 NCT
<+39) HU appear grayish color according to
the magnitude value of NCT in each pixel of
CT-Scan image. While the area with NCT
values> +38 HU displayed as white areas.

42.00
40.00

CT Number (HU)

38.00
36.00
34.00
32.00
30.00
28.00
26.00
24.00
22.00
20.00

9 10

Number of slice location on the PX-1 patients' head

GTV

CTV

PTV

Figure 2 NCT range value of astrocytoma

patients (PX-1)
3.

RESULTS
The results of this research will discuss
the value of CT numbers (NCT) which
dominates the primary astrocytoma tumor
area (GTV area) of patients PX-1, a primary
cervical cancer area (GTV area) of patients
PY-1, and the cervical cancer area (CTV area)
of patients PY -2.
3.1

Astrocytoma Case
NCT range value in the area of GTV,
CTV, and PTV of astrocytoma patients (PX1) in Figure 2 is the result of NCT value
identification contained in eight sequential
axial slices (1st up to 8th) of PX-1 patient's
head that is being the location of
astrocytomas. The slices of 9th is the result of
NCT identification in the area of GTV, CTV,
and PTV as a whole from the 1st up to 8th
axial slices.
Figure 2 shows that the value of NCT on
GTV area of astrocytoma patients (PX-1) has
a mean value greater than the CTV and PTV
area. Thus, GTV area of astrocytoma patients
is dominated by the range values of NCT = (35
4) HU tend to have a greater density than
the surrounding tissue which can be proved
by the results of windowing result (Figure 3).
Figure 3 is a CT-Scan image display of PX-1
head which has been given gradation settings
(windowing) with a minimum value NCT =
+31 HU and maximum value NCT = +38 HU
in accordance with the format Monochrome 2.
Brain area that have a value of NCT < +31 HU

More hypodense area that GTV area

Cranial bone

Figure 4 The windowing result on four

sequential slices of PX-1 CT-Scan image

The windowing results on PX-1 CTScan image (Figure 3) shows that the range of
values NCT = +31 HU up to +38 HU can be a
marker for the location of the primary area
(GTV) of astrocytomas that are seen as an
area with relatively greater density (lighter
color) compared to the surrounding area.

Color
HU 8
HU 7
HU 6
HU 5

NCT (HU)
+37 s.d +38
+35 s.d +36
+33 s.d +34
+31 s.d +32

Figure 3 Comparison of color distribution

3 between normal and astrocytoma patients.

NCT value evaluation on the results of a

CT scan result of patients PX-1 (Astrocytoma)
and PX-2 who is a normal patients (without
brain tumors) conducted qualitatively by
comparing the distribution pattern of color
that represent the NCT value of each pixel in a
slice of CT-Scan image (Figure 4). Figure 4
shows that a normal brain tissue (without
astrocytoma) near the cranial bone (orange
circle) is also has a value of NCT = +31 HU up
to +38 HU (Class of HU5 to HU8) same as
with NCT value in the GTV of astrocytoma in
PX-1 patients.
Figure 4.a indicates appearance of a
relatively symmetrical distribution of color in
both parts of the right brain and the left brain
areas of PX-2 patients compared with the PX1 patients. Symmetry properties of the brain
in patients PX-2 is a characteristic of the
normal anatomical structure of the human
brain [12].

with the brain tissue near the cranial bone

(NCT = +31 HU up to +38 HU). Identical value
of NCT in the area of GTV and brain tissue
near to PX-1 patients cranial bone can be
explained by a histological approaches about
the constituent cell of astrocytoma tumor.
Astrocytoma tumor cells was derived
from astrocytes, which are glial cells exist

in the brain. Glial cells are as numerous as

neurons that is 50% of brain volume and it
has function to protect and give the
nutrients for nerve cells [13].
CT Number values are specific to a
particular tissue depends on the capabilities of
the X-ray attenuation by cell components
making up a tissue [14]. Therefore, the
similarity of the color distribution of the
identification results NCT = +31 HU up to +38
HU in the area of the astrocytoma tumor
(GTV) and surrounding areas of the brain
near with cranial bone in PX-1 patients, which
represents the structure of the gray substance
(Figure 5) shows that the astrocytoma tumor
cells in patients PX-1 is derived from
astrocytes cells which are in substance grisea.
3.2

1. Cranial bones
2. Dura mater
3. Subarachnoid space
4. Gray matter
5. White matter

Color
HU 11
HU 10
HU 9
HU 8
HU 7
HU 6
HU 5

Cervical Cancer Case

The results of NCT identification in the
case of cervical cancer indicate a difference in
the homogeneity of the X-ray attenuation,
although it was found that PY-1 and PY-2
have the similiar NCT range value, that are
NCT = +7 HU up to +45 HU in patients PY-1
and NCT = +6 HU up to +49 HU in patients
PY-2.

NCT (HU)
+43 up to +44
+41 up to +42
+39 up to +40
+37 up to +38
+35 up to +36
+33 up to +34
+31 up to +32

Figure 5 Brain structure comparison of PX-1

patients with the structure of the normal human
brain without astrocytoma. (a) The inset picture
is a normal brain area (without tumor) of PX-1,
(b) normal brain structure [1], (c) color
identification results for a range of values NCT =
+31 HU up to +44 HU in brain of PX-1 (axial
slices no.3, looked inferior).

Kelas HU 5 to HU 7
Color
HU 10
HU 9
HU 8
HU 7
HU 6
HU 5

The asymmetry of brain tissue that was

found on the left side of PX-1 brain is
characterized by the presence of GTV area
(Figure 4.b) which has the same NCT value

Figure

Kelas HU 8 to HU 10

NCT (HU)
+72 up to +84
+59 up to +71
+46 up to +58
+33 up to +45
+20 up to +32
+7 up to +19

6 Qualitative observations which

represent the NCT value distribution in the cervical
area of PY-1 patients
4

NCT value that dominates the center of

the GTV area in cervical cancer patients (PY1) is NCT = +7 HU up to HU +45 (Class of
HU5 to HU 7). While the color grade HU 8
until HU 10 (NCT = +46 HU up to +84 HU)
dominates the edge of the GTV area of PY-1
as shown in Figure 6.
NCT range value differences in cervical
patients PY-1 indicate the presence of
heterogeneity attenuation (attenuation) X-ray
between the center of the cervix and cervical
edge. The edge of the cervix tends to absorb
more X-rays than the center of the cervix
which is characterized by the value of NCT on
the edge of the cervix area which is relatively
large compared with the central part of the
cervix. Whereas qualitative observations on
the color distribution in cervical area of PY-2
patients were more likely to indicate the
presence of X-ray attenuation homogeneity
which is marked by the distribution of color
on the class of HU 9 until HU 12 (NCT = +17
HU up to +49 HU) that is homogeneous
throughout the area surrounding the cervix
(Figure 7).
Color
HU 12
HU 11
HU 10
HU 9
HU 8
HU 7
HU 6

The lower NCT value is a consequence

of cell damage due to cancer. Normal blood
vessels are strong and not easily fragile, while
the blood vessels that grow in the cancer cells
are fragile and easily broken [3]. Rupture of
blood vessels in cancer cells are characterized
by bleeding out through the patient's vagina
will cause a shortage of cancer cells
vascularization. Lack of vascularization in
cancer cells resulting in cancer cells undergo
necrosis and become less active in absorbing
material contrast compared with normal cells
[15].
4.

CONCLUSION
Results
of
NCT
range
value
identification in astrocytoma tumor area and
cervical cancer that were obtained in this
study has been able to provide quantitative
explanations on the results of cancer diagnosis
that has made by radiation oncologist. In the
case of astrocytoma patients (PX-1), NCT =
+31 HU up to +38 HU is an indication that
the astrocytma tumor in PX-1 has a radiation
absorption characteristics similar to cells of
astrocytes in the gray substance. NCT = +7 HU
up to +45 HU in PY-1 patients showed the
hypodensity area that indicate the presence of
cervical cancer. Whereas in PY-2 patients was
obtained a NCT = +6 HU up to +49 HU
showing the homogeneity of cervical cancer
that become a indication that the cervical
cancer potentially to spread toward the pelvic
wall.

NCT (HU)
+39 up to +49
+28 up to +38
+17 up to +27
+6 up to +16
-5 up to +5
-16 up to -6
-27 up to -17

Figure 7 Qualitative observations which represent

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PY-2 patients

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NCT range value identification results in

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