Analysis of effective and organ dose estimation in CT when using mA modulation : a single scanner pilot study

Effective dose (ED) estimation in CT examinations can be obtained by combining dose length product (DLP) with published ED per DLP coefficients or performed using software. These methods do not account for tube current (mA) modulation which is influenced by patient size. Aim To compare different methods of organ and ED estimation to measured values when using mA modulation in CT chest, abdomen and pelvis examinations. Method Organ doses from CT of the chest, abdomen and pelvis were measured using digital dosimeters and a dosimetry phantom. ED was calculated. Six methods of estimating ED accounting for mA modulation were performed using ImPACT CTDosimetry and Dose Length Product to ED coefficients. Corrections for the phantom mass were applied resulting in 12 estimation methods. Estimated organ doses from ImPACT CTDosimtery were compared to measured values. Results Calculated EDs were; chest 12.35 mSv (±1.48 mSv); abdomen 8.74 mSv (±1.36 mSv) and pelvis 4.68 mSv (±0.75 mSv). There was over estimation in all three anatomical regions. Correcting for phantom mass improved agreement between measured and estimated ED. Organ doses showed overestimation of dose inside the scan range and underestimation outside the scan range. Conclusion Reasonable estimation of effective dose for CT of the chest and abdomen can be obtained using ImPACT CTDosimetry software or k-coefficients. Further work is required to improve the accuracy of ED estimation from CT of the pelvis. Accuracy of organ dose estimation has been shown to depend on the inclusion or exclusion of the organ from the scan range

Radiation dose assessment : measurement, estimation and interpretation

New technologies or methods of image acquisition are driven by the need for increased anatomical information to improve diagnostic accuracy or surgical planning. These new technologies are often accompanied with additional radiation dose yet this can be justified through the consideration of the benefit it brings. Examples include the use of CT colonography instead of double contrast barium enemas, CT urography replacing intravenous urography and, in nuclear medicine imaging the increased use of CT imaging as part of single photon emission tomography and positron emission tomography to correct emission data or localise or characterise identified lesions. Manufacturers are quick to promote their systems as “low-dose” but little independent evaluation of this claim existed. In the context of nuclear medicine, the additional imaging raised questions as to the use of the attenuation correction data specifically. The question of should the cross sectional images be reviewed for pathology was has been the focus of debate. It was recognised that the quality of these images is poor due to the “low-dose” acquisition. The research presented in this thesis and portfolio of published work aimed to establish an accurate method of assessing the radiation dose, initially from the CT attenuation correction acquisition, but later in other imaging modalities. In this thesis eight papers are used to illustrate the methods developed in this work, and how they were applied to other fields of medical imaging. Six of these papers were completed as the first author and the remainder as co-author. Initially, the concepts of radiation dose were critically evaluated. Following identification of sub-optimal techniques, steps were taken to improve the accuracy of dose measurement using thermoluminescent dosimeters, digital dosimeters and simulation through software. These techniques have been analysed critically and where appropriate improvements are recommended. Radiation dose, in particular the associated risk, is a challenging concept to convey to patients and care givers and simply providing a figure of dose does not convey the required information needed to allow consent to be given. Methods by which radiation dose and risk can be interpreted is critiqued with reference to published literature. The thesis concludes with a description of the intellectual contribution illustrating the role played as first author and as a co-author in the works included in the portfolio and a review of impact considering citation metrics and downloads. It was also decided to include citations from within the Diagnostic Imaging Research Programme and PhD theses from The University of Salford to demonstrate how research activities within the portfolio of published works have influenced other methodologies and outputs

Does collimation affect patient dose in antero-posterior thoraco-lumbar spine?

BACKGROUND: The purpose of this study is to determine the effect of collimation on the lifetime attributable risk (LAR) of cancer incidence in all body organs (effective risk) in patients undergoing antero-posterior (AP) examinations of the spine. This is of particular importance for patients suffering from scoliosis as in their case regular repeat examinations are required and also because such patients are usually young and more susceptible to the effects of ionising radiation than are older patients. METHOD: High sensitivity thermo-luminescent dosimeters (TLDs) were used to measure radiation dose to all organs of an adult male dosimetry phantom, positioned for an AP projection of the thoraco-lumbar spine. Exposures were made, first applying tight collimation and then subsequently with loose collimation, using the same acquisition factors. In each case, the individual TLDs were measured to determine the local absorbed dose and those representing each organ averaged to calculate organ dose. This information was then used to calculate the effective risk of cancer incidence for each decade of life from 20 to 80, and to compare the likelihood of cancer incidence when using tight and loose collimation. RESULTS: The calculated figures for effective risk of cancer incidence suggest that the risk when using loose collimation compared to the use of tight collimation is over three times as high and this is the case across all age decades from 20 to 80. CONCLUSION: Tight collimation can greatly reduce radiation dose and risk of cancer incidence. However collimation in scoliotic patients can be necessarily limited

Scoliosis imaging : an analysis of radiation risk in the CT scan projection radiograph and a comparison with projection radiography and EOS

Introduction: Scoliosis is defined as a deformity of the spine with lateral curvature in the coronal plane. It requires regular X-ray imaging to monitor the progress of the disorder, therefore scoliotic patients are frequently exposed to radiation. It is important to lower the risk from these exposures for young patients. The aim of this work is to compare organ dose (OD) values resulting from Scan Projection Radiograph (SPR) mode in CT against projection radiography and EOS® imaging system when assessing scoliosis. Methods: A dosimetry phantom was used to represent a 10-year old child. Thermoluminescent dosimetry detectors were used for measuring OD. The phantom was imaged with CT in SPR mode using 27 imaging parameters; projection radiography and EOS machines using local scoliosis imaging procedures. Imaging was performed in anteroposterior, posteroanterior and lateral projections. Results: 17 protocols delivered significantly lower radiation dose than projection radiography (p <0.05). OD values from the CT SPR imaging protocols and projection radiography were statistically significant higher than the results from EOS. No statistically significant differences in OD were observed between 10 imaging protocols and those from projection radiography and EOS imaging protocols (p >0.05). Conclusion: EOS has the lowest dose. Where this technology is not available we suggest there is a potential for OD reduction in scoliosis imaging using CT SPR compared to projection radiography. Further work is required to investigate image quality in relation to the measurement of Cobb angle with CT SPR

An overview of measuring and modelling dose and risk from ionising radiation for medical exposures

PURPOSE: This paper gives an overview of the methods that are used to calculate dose and risk from exposure to ionizing radiation as a support to other papers in this special issue. BACKGROUND: The optimization of radiation dose is a legal requirement in medical exposures. This review paper aims to provide the reader with knowledge of dose by providing definitions and concepts of absorbed, effective and equivalent dose. Criticisms of the use of effective dose to infer the risk of an exposure to an individual will be discussed and an alternative approach considering the lifetime risks of cancer incidence will be considered. Prior to any dose or risk calculation, data concerning the dose absorbed by the patient needs to be collected. This paper will describe and discuss the main concepts and methods that can be utilised by a researcher in dose assessments. Concepts behind figures generated by imaging equipment such as dose-area-product, computed tomography dose index, dose length product and their use in effective dose calculations will be discussed. Processes, advantages and disadvantages in the simulation of exposures using the Monte Carlo method and direct measurement using digital dosimeters or thermoluminescent dosimeters will be considered. Beyond this special issue it is proposed that this paper could serve as a teaching or CPD tool for personnel working or studying medical imaging

Effective lifetime radiation risk for a number of national mammography screening programmes

Background and purpose: The performance of mammography screening programmes is focussed mainly on breast cancer detection rates. However, when the benefits and risks of mammography are considered, the risk of radiation-induced cancer is calculated for only the examined breast using Mean Glandular Dose (MGD). The risk from radiation during mammography is often described as low or minimal. This study aims to evaluate the effective lifetime risk from full field digital mammography (FFDM) for a number of national screening programmes. Material and Methods: Using an ATOM phantom, radiation doses to multiple organs were measured during standard screening mammography. Sixteen FFDM machines were used and the effective lifetime risk was calculated across the female lifespan for each machine. Once the risks were calculated using the phantom, the total effective lifetime risk across 48 national screening programmes was then calculated; this assumed that all these programmes use FFDM for screening. Results: Large differences exist in effective lifetime risk, varying from 42.21 [39.12 - 45.30] cases/106 (mean [95% CI]) in the Maltese screening programme to 1099.67 [1019.25 - 1180.09] cases/106 for high breast cancer risk women in the United States of America. These differences are mainly attributed to the commencement age of screening mammography and the time interval between successive screens. Conclusions: Effective risk should be considered as an additional parameter for the assessment of screening mammography programme performance, especially for those programmes which recommend an early onset and more frequent screening mammography

Mathematical modelling of radiation-induced cancer risk from breast screening by mammography

Objectives: Establish a method to determine and convey lifetime radiation risk from FFDM screening. Methods: Radiation risk from screening mammography was quantified using effective risk (number of radiation-induced cancer cases/million). For effective risk calculations, organ doses and examined breast MGD were used. Screening mammography was simulated by exposing a breast phantom for cranio-caudal and medio-lateral oblique for each breast using 16 FFDM machines. An ATOM phantom loaded with TLD dosimeters was positioned in contact with the breast phantom to simulate the client’s body. Effective risk data were analysed using SPSS software to establish a regression model to predict the effective risk of any screening programme. Graphs were generated to extrapolate the effective risk of all screening programmes for a range of commencement ages and time intervals between screens. Results: The most important parameters controlling clients’ total effective risk within breast screening are the screening commencement age and number of screens (correlation coefficients were -0.865 and 0.714, respectively). Since the tissue radio-sensitivity reduces with age, the end age of screening does not result in noteworthy effect on total effective risk. Conclusions: The regression model can be used to predict the total effective risk for clients within breast screening but it cannot be used for exact assessment of total effective risk. Graphical representation of risk could be an easy way to represent risk in a fashion which might be helpful to clients and clinicians

Effect of reconstruction methods and x-ray tube current-time product on nodule detection in an anthropomorphic thorax phantom : a crossed-modality JAFROC observer study

Purpose: To evaluate nodule detection in an anthropomorphic chest phantom in computed tomography (CT) images reconstructed with adaptive iterative dose reduction 3D (AIDR3D) and filtered back projection (FBP) over a range of tube current-time product (mAs). Methods: Two phantoms were used in this study: (i) an anthropomorphic chest phantom was loaded with spherical simulated nodules of 5, 8, 10 and 12mm in diameter and +100, -630 and -800 Hounsfied Units electron density; this would generate CT images for the observer study; (ii) a whole-body dosimetry verification phantom was used to ultimately estimate effective dose and risk according to the model of the BEIR VII committee. Both phantoms were scanned over a mAs range (10, 20, 30, and 40) while all other acquisition parameters remained constant. Images were reconstructed with both AIDR3D and FBP. 34 normal cases (no nodules) and 34 abnormal cases (containing 1-3 nodules, mean 1.35±0.54) cases were chosen for the observer study. Eleven observers evaluated images from all tube current-time product and reconstruction methods under the free-response paradigm. A crossed-modality jackknife alternative free-response operating characteristic (JAFROC) analysis method was developed for data analysis, averaging data over the two factors influencing nodule detection in this study: mAs and image reconstruction (AIDR3D or FBP). A Bonferroni correction was applied and the threshold for declaring significance was set at 0.025 to maintain the overall probability of Type I error at α = 0.05. Contrast-to-noise (CNR) was also measured for all nodules and evaluated by a linear least squares analysis. Results: For random-reader fixed-case crossed-modality JAFROC analysis there was no significant difference in nodule detection between AIDR3D and FBP when data was averaged over mAs (F(1,10) = 0.08, p = 0.789). However, when data was averaged over reconstruction methods, a significant difference was seen between multiple pairs of mAs settings (F(3,30) = 15.96, p<0.001). Measurements of effective dose and effective risk showed the expected linear dependence on mAs. Nodule CNR was statistically higher for simulated nodules on images reconstructed with AIDR3D (p<0.001). Conclusion: No significant difference in nodule detection performance was demonstrated between images reconstructed with FBP and AIDR3D. Tube current-time product was found to influence nodule detection, though further work is required for dose optimisation

Effective dose and effective risk from post-SPECT imaging of the lumbar spine

Purpose Planar bone scans play an important role in the staging and monitoring of malignancy and metastases. Metastases in the lumbar spine are associated with significant morbidity, therefore accurate diagnosis is essential. Supplementary imaging after planar bone scans is often, required to characterise lesions, however, this is associated with additional radiation dose. This paper provides information on the comparative effective dose and effective risk from supplementary lumbar spine radiographs, low-dose CT (LDCT) and diagnostic CT (DCT). Method Organ dose was measured in a phantom using thermo-luminescent dosimeters. Effective dose and effective risk were calculated for radiographs, LDCT, and DCT imaging of the lumbar spine. Results Radiation dose was 0.56mSv for the antero-posterior and lateral lumbar spine radiographs, 0.80mSv for LDCT, and 3.78mSv for DCT. Additional imaging resulted in an increase in effective dose of 12.28%, 17.54% and 82.89%for radiographs, LDCT and DCT respectively. Risk of cancer induction decreased as age increased. The difference in risk between the modalities also decreased. Males had a statistically significant higher risk than female patients (p=0.023) attributed to the sensitive organs being closer to the exposed area. Conclusion Effective Dose for LDCT is comparable to radiographs of the lumbar spine. Due to the known benefits image fusion brings it is recommended that LDCT replace radiographs imaging for characterisation of lumbar spine lesions identified on planar bone scan. DCT is associated with significantly higher effective dose than LDCT. Effective risk is also higher and the difference is more marked in younger female patients