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Radiation Dose in CT Scanning: A Team Approach John R. Mayo, MD Director of Advanced Cardiac Imaging Professor of Radiology and Cardiology University of.

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Presentation on theme: "Radiation Dose in CT Scanning: A Team Approach John R. Mayo, MD Director of Advanced Cardiac Imaging Professor of Radiology and Cardiology University of."— Presentation transcript:

1 Radiation Dose in CT Scanning: A Team Approach John R. Mayo, MD Director of Advanced Cardiac Imaging Professor of Radiology and Cardiology University of British Columbia

2 Overview Background Background Diagnostic utility Diagnostic utility Radiation exposure Radiation exposure Evidence for harm from CT radiation exposure Evidence for harm from CT radiation exposure Subject effect Subject effect In my practice: In my practice: Appropriate indications Appropriate indications Appropriate dose: Diagnostic reference values Appropriate dose: Diagnostic reference values Scanner dose modulation Scanner dose modulation Relationship between image quality and dose Relationship between image quality and dose

3 CT Diagnostic Utility Provides anatomic information equivalent to gross pathology, diagnostic if pathology causes anatomic changes (e.g. lung cancer) Provides anatomic information equivalent to gross pathology, diagnostic if pathology causes anatomic changes (e.g. lung cancer) Contrast media, physiologic maneuvers add information (e.g. PE, airways disease) Contrast media, physiologic maneuvers add information (e.g. PE, airways disease) Fast, available, relatively cheap Fast, available, relatively cheap Compatible with devices and sensors Compatible with devices and sensors Summary: superb imaging modality Summary: superb imaging modality

4 Limitation: Radiation Exposure Relative to plain radiography, CT is a high radiation exposure examination Relative to plain radiography, CT is a high radiation exposure examination Low scatter fraction, therefore noise visible Low scatter fraction, therefore noise visible Combined with current high utilization, CT accounts for >60% of population medical radiation exposure Combined with current high utilization, CT accounts for >60% of population medical radiation exposure Radiation surveys* show wide variation in radiation exposure for identical exams Radiation surveys* show wide variation in radiation exposure for identical exams *Aldrich J, Bilawich A, Mayo J. CARJ 2006;57:79-85

5 Increasing CT Dose at VGH CT Exams 4% CT Exams 26% CT Dose 20% CT Dose 60% CT Dose from all other exams All other exams CT

6 Dose Variation in BC: Chest CT

7 Is CT Radiation Exposure Harmful? Debate about harm from exposures <20 mSv Debate about harm from exposures <20 mSv Limitations in Atomic Bomb data: Limitations in Atomic Bomb data: Limited dosimetry Limited dosimetry Particulate as well as x-ray, gamma exposure Particulate as well as x-ray, gamma exposure Environmental toxins Environmental toxins Mono-ethnic exposure (Japanese) Mono-ethnic exposure (Japanese) War time stressed population War time stressed population Advantages of Atomic Bomb data Advantages of Atomic Bomb data Population cross section with point exposure Population cross section with point exposure

8 New Low Level Radiation Study 15 country study* of low level radiation exposure 15 country study* of low level radiation exposure Outcome: cancer incidence, fatal cancer rate Outcome: cancer incidence, fatal cancer rate Cohort: 407,000 atomic industry workers, >5 million person years follow-up, 90% males, average exposure 19 mSv, excellent dosimetry Cohort: 407,000 atomic industry workers, >5 million person years follow-up, 90% males, average exposure 19 mSv, excellent dosimetry Results: Increased risk of cancer, dose response effect, risk not dominated by high level exposure Results: Increased risk of cancer, dose response effect, risk not dominated by high level exposure Conclusion: supports concept of small but measurable cancer risk at low exposure (<20 mSv) Conclusion: supports concept of small but measurable cancer risk at low exposure (<20 mSv) *Cardis E et al. Radiation Research 2007;167:

9 New Low Level Radiation Study Limitation: Limitation: No data on children No data on children Limited data on females, 98% of the dose was received by males Limited data on females, 98% of the dose was received by males The study loses significance if lung cancer in Canadian workers is excluded The study loses significance if lung cancer in Canadian workers is excluded This may indicate inadequate control for smoking in Canadian cohort This may indicate inadequate control for smoking in Canadian cohort

10 CT scanner dose modifiers The cancer inducing effect of low dose radiation varies according to: The cancer inducing effect of low dose radiation varies according to: The subject (age, sex) The subject (age, sex) The exposed region’s radiation sensitivity The exposed region’s radiation sensitivity The CT scanner radiation distribution: The CT scanner radiation distribution: Position in scanner Position in scanner Bow tie filtration Bow tie filtration Dose modulation Dose modulation Position of arms, subcutaneous fat, radio-opaque objects Position of arms, subcutaneous fat, radio-opaque objects CT has highly asymmetric dose, (high surface, low central) which causes problems in dosimetry CT has highly asymmetric dose, (high surface, low central) which causes problems in dosimetry

11 Age versus Cancer Mortality Risk Lifetime mortality risk (%/Sv) Age at time of exposure female male ICRP 60 average 1996 Re-analysis Hiroshima data Higher risk conversion factor Lower risk conversion factor

12 Estimation of risk: Equivalent Dose For the reference subject, a 30 year old hermaphrodite, the risk is 50 excess fatal cancers per million exposed to 1 mSv For the reference subject, a 30 year old hermaphrodite, the risk is 50 excess fatal cancers per million exposed to 1 mSv This compares to the natural cancer risk of 250,000 cancer deaths per million This compares to the natural cancer risk of 250,000 cancer deaths per million Risk is strongly influenced by age (lower in older patients (mobile fossils)), and gender (higher in females) Risk is strongly influenced by age (lower in older patients (mobile fossils)), and gender (higher in females)

13 Summary Since there appears to be a risk, we should only perform “indicated” exams Since there appears to be a risk, we should only perform “indicated” exams Unfortunately, the evidence base for “indicated” imaging investigations is minimal Unfortunately, the evidence base for “indicated” imaging investigations is minimal Radiologists should minimize CT radiation exposure without compromising diagnostic accuracy Radiologists should minimize CT radiation exposure without compromising diagnostic accuracy Special consideration: children, young adults Special consideration: children, young adults

14 Appropriate Use All CT examinations must have appropriate indications with supportive: All CT examinations must have appropriate indications with supportive: History History Clinical findings Clinical findings Laboratory findings Laboratory findings When evidence based, appropriate clinical decision making support (e.g. Well’s criteria for PE) When evidence based, appropriate clinical decision making support (e.g. Well’s criteria for PE) Screening exams (e.g. lung cancer screening) should be evidence based Screening exams (e.g. lung cancer screening) should be evidence based Follow up exams should affect management Follow up exams should affect management

15 Appropriate dose Diagnostic reference levels have been developed using the Dose Length Product (DLP), the CTDIw times the scan length Diagnostic reference levels have been developed using the Dose Length Product (DLP), the CTDIw times the scan length DLP is a measure of CT radiation exposure DLP is a measure of CT radiation exposure Radiologists should be familiar with DLP values for clinical scans in their institution Radiologists should be familiar with DLP values for clinical scans in their institution Average DLP values should be at or below the reference level, indicating good practice Average DLP values should be at or below the reference level, indicating good practice

16 EC Diagnostic Reference Levels for CT

17 Monitoring Appropriate dose

18 Convert DLP to Effective Dose Region of Body E/DLP Conversion Factor mSv.mGy -1. cm -1 Head Neck Chest0.017 Abdomen0.015 Pelvis0.019

19 Example: Cardiac CT dose 743 times equals 12.6 mSv 743 times equals 12.6 mSv Above the EC reference value for chest CT Above the EC reference value for chest CT Reason for the high dose is the helical retrospective acquisition protocol of cardiac CT Reason for the high dose is the helical retrospective acquisition protocol of cardiac CT Chest CT dose in our hospital Chest CT dose in our hospital Standard dose, DLP 200 to 400, mSv Standard dose, DLP 200 to 400, mSv Low dose, DLP 100, 1.7 mSv (follow up, screening studies, young patients) Low dose, DLP 100, 1.7 mSv (follow up, screening studies, young patients)

20 CT Scanner Dose Modulation Manufacturers have devised systems to adjust radiation dose based on: Manufacturers have devised systems to adjust radiation dose based on: Body part size Body part size ECG tube current modulation (Cardiac) ECG tube current modulation (Cardiac) Z axis overscan** (Collimator shutter action) Z axis overscan** (Collimator shutter action) * Tzedakis A, Damilakis J et al. The effect of z overscanning on patient effective dose from multidetector helical computed tomography examinations. Medical Physics 2005; 32:

21 Tube Current Modulation – x,y 40 cm 20 cm 0 cm 100% mAs 50% mAs 0% mAs mA is constantly changed as the tube rotates depending on patient thickness lat AP

22 Tube Current Modulation – z neck mA lung shoulders hip liver legs Attenuation is measured every 180 o rotation and corrected the following rotation. This type of adaptive modulation can reduce dose by %. Z axis

23 Combined tube current modulation (x,y,z) Provides acceptable noise and diagnostic information Provides acceptable noise and diagnostic information Substantial reduction in radiation dose, up to 42%* Substantial reduction in radiation dose, up to 42%* Should be used in most patients Should be used in most patients * Rizzo S et al, AJR 2006; 186:

24 Technologist training Radiologists must ensure that technologists are minimizing exposure by: Radiologists must ensure that technologists are minimizing exposure by: Ensuring the minimum patient volume is scanned Ensuring the minimum patient volume is scanned Ensuring all dose modulation techniques are consistently used Ensuring all dose modulation techniques are consistently used Ensuring patients are centered in the gantry Ensuring patients are centered in the gantry

25 Image quality and dose Radiologists consistently correlate increased image quality with increased dose Radiologists consistently correlate increased image quality with increased dose However, little research into the impact of radiation dose on diagnostic accuracy However, little research into the impact of radiation dose on diagnostic accuracy Computer simulated dose reduction is a useful experimental technique for this research* Computer simulated dose reduction is a useful experimental technique for this research* *Mayo JR et al. Radiology 1997;202:

26 Real 100 mA scan

27 Simulated 100 mA scan

28 Computer simulated reduced dose scans In a side by side trial of real versus simulated reduced dose scans the real scan was correctly identified 50.1% of the time In a side by side trial of real versus simulated reduced dose scans the real scan was correctly identified 50.1% of the time Advantages Advantages No additional radiation dose No additional radiation dose Reduced dose scans have identical location, level of inspiration and artifact Reduced dose scans have identical location, level of inspiration and artifact

29 Investigated simulated dose reduction on chest CT findings Repeated measures experimental design Repeated measures experimental design 150 clinical chest CT scans (200 – 350 mA) 150 clinical chest CT scans (200 – 350 mA) Computer simulated 100 and 40 mA scans Computer simulated 100 and 40 mA scans 4 chest radiologists interpreted the complete chest CT scans in random order assessing 14 mediastinal structures and lung findings 4 chest radiologists interpreted the complete chest CT scans in random order assessing 14 mediastinal structures and lung findings Mayo, J. R. et al. Radiology 2004;232:

30 Copyright ©Radiological Society of North America, 2004 Mayo, J. R. et al. Radiology 2004;232: mAs

31 Copyright ©Radiological Society of North America, 2004 Mayo, J. R. et al. Radiology 2004;232: mAs

32 Copyright ©Radiological Society of North America, 2004 Mayo, J. R. et al. Radiology 2004;232: mAs

33 Copyright ©Radiological Society of North America, 2004 Mayo, J. R. et al. Radiology 2004;232: mAs

34 Copyright ©Radiological Society of North America, 2004 Mayo, J. R. et al. Radiology 2004;232: mAs

35 Results Significant (p<0.05) decrease in subjective image quality Significant (p<0.05) decrease in subjective image quality Significantly more disagreements on image findings at reduced dose Significantly more disagreements on image findings at reduced dose Concluded that reduced dose affects reader evaluation of CT findings Concluded that reduced dose affects reader evaluation of CT findings But, no evaluation of diagnostic accuracy But, no evaluation of diagnostic accuracy

36 Summary Do the obvious first: Do the obvious first: Create a team approach to radiation dose minimization and quality optimization between radiologists, technologists, technical support and medical physicists Create a team approach to radiation dose minimization and quality optimization between radiologists, technologists, technical support and medical physicists Eliminate unnecessary examinations Eliminate unnecessary examinations Monitor the actual dose delivered in practice and compare to reference dose levels Monitor the actual dose delivered in practice and compare to reference dose levels Utilize all available dose reduction tools Utilize all available dose reduction tools Encourage further research into the relationship between CT dose, image quality and diagnostic accuracy Encourage further research into the relationship between CT dose, image quality and diagnostic accuracy

37 Thank you


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