Metal artifact reduction in cervix brachytherapy with titanium applicators using dual‐energy CT through virtual monoenergetic images and an iterative algorithm: A phantom study

To evaluate an iterative metal-artifact reduction (iMAR) algorithm, dual-energy CT (DECT) through virtual monoenergetic images (VMI), and a combination of iMAR and DECT for reducing metal artifact severity (AS) induced by Fletcher titanium applicators used in cervix brachytherapy, the efficacy of which are hitherto unreported.120 kVp single-energy CT (SECT) (Siemens) of BEBIG tandem applicators, varying in shape (straight or curved) and diameter (3.5 mm or 5 mm) in a custom-made water-filled phantom, and their DECT images obtained from extrapolation of 80 kVp and 140 kVp, were reconstructed using four methods: DECT through VMI±iMAR, and SECT±iMAR. The DECT images were reconstructed monoenergetically at 70, 150, and 190 keV. AS was evaluated using measured values and statistical analysis.iMAR, DECT, and combined DECT and iMAR reduced AS (p < 0.05). DECT had a lower AS than SECT, even without iMAR (p < 0.025). SECT+iMAR was more effective than DECT-iMAR with VMI at 70 and 190 keV (p < 0.05), whereas showing no statistically significant difference at 150 keV. With DECT and iMAR combined, AS was reduced more effectively compared to the SECT+iMAR or DECT alone. It also reduced the mean interobserver uncertainty by 0.2 mm.These findings indicate that iMAR reduces the AS caused by Fletcher titanium applicators for both SECT and DECT, a combination of iMAR and DECT is superior to either strategy alone, and at low energies, DECT+iMAR also produces similar artifact reduction. These practical strategies promise more accurate source-position and structure definitions in CT-based gynecological brachytherapy treatment planning.