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 This lecture deals with the important subject of patient dose from CT exams.

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

CT Diagnostic Utility 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) Fast, available, relatively cheap Compatible with devices and sensors Summary: superb imaging modality

Limitation: Radiation Exposure Relative to plain radiography, CT is a high radiation exposure examination Low scatter fraction, therefore noise visible 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 *Aldrich J, Bilawich A, Mayo J. CARJ 2006;57:79-85

Increasing CT Dose at VGH CT Exams 4% CT Dose 20% CT 1991 Dose from all other exams All other exams CT Exams 26% CT Dose 60% In the early 1990s I carried out a study of the patient dose from all radiological procedures for the whole of Canada. For BC CT studies accounted for 4% of all x-ray exams but accounted for 20% of the patient dose. I do not have the same figures for the whole of BC, but at VGH in 2002 CT studies accounted for 26% of the studies and for 74% of the patient dose. CT 2002 CT

Dose Variation in BC: Chest CT

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

New Low Level Radiation Study 15 country study* of low level radiation exposure 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 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) *Cardis E et al. Radiation Research 2007;167:396-416.

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

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

Age versus Cancer Mortality Risk Lifetime mortality risk (%/Sv) 10 70 60 40 50 30 20 15 5 25 Age at time of exposure female male ICRP 60 average 1996 Re-analysis Hiroshima data Higher risk conversion factor Lower risk conversion factor Young persons, especially females, are much more radiosensitive than the 30 yo male for which the standard risk is taken. Conversely all persons over 50 are less radiosensitive.

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 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)

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

Appropriate Use All CT examinations must have appropriate indications with supportive: History Clinical findings Laboratory findings 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 Follow up exams should affect management

Appropriate dose 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 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

EC Diagnostic Reference Levels for CT

Monitoring Appropriate dose

Convert DLP to Effective Dose Region of Body E/DLP Conversion Factor mSv.mGy-1.cm-1 Head 0.0023 Neck 0.0054 Chest 0.017 Abdomen 0.015 Pelvis 0.019 Using the DLP value it is possible to estimate patient dose.

Example: Cardiac CT dose 743 times 0.017 equals 12.6 mSv Above the EC reference value for chest CT Reason for the high dose is the helical retrospective acquisition protocol of cardiac CT Chest CT dose in our hospital Standard dose, DLP 200 to 400, 3.4 - 7 mSv Low dose, DLP 100, 1.7 mSv (follow up, screening studies, young patients)

CT Scanner Dose Modulation Manufacturers have devised systems to adjust radiation dose based on: Body part size ECG tube current modulation (Cardiac) 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; 32:1621-1629.

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

Tube Current Modulation – z Attenuation is measured every 180o rotation and corrected the following rotation. This type of adaptive modulation can reduce dose by 10 -30%. shoulders hip liver mA lung legs neck Z axis

Combined tube current modulation (x,y,z) Provides acceptable noise and diagnostic information Substantial reduction in radiation dose, up to 42%* Should be used in most patients * Rizzo S et al, AJR 2006; 186:673-679

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

*Mayo JR et al. Radiology 1997;202:453-457 Image quality and dose Radiologists consistently correlate increased image quality with increased dose However, little research into the impact of radiation dose on diagnostic accuracy Computer simulated dose reduction is a useful experimental technique for this research* *Mayo JR et al. Radiology 1997;202:453-457

Real 100 mA scan

Simulated 100 mA scan

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 Advantages No additional radiation dose Reduced dose scans have identical location, level of inspiration and artifact

Investigated simulated dose reduction on chest CT findings Repeated measures experimental design 150 clinical chest CT scans (200 – 350 mA) 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 Mayo, J. R. et al. Radiology 2004;232:749-756

200 mAs Mayo, J. R. et al. Radiology 2004;232:749-756 Copyright ©Radiological Society of North America, 2004

100 mAs Mayo, J. R. et al. Radiology 2004;232:749-756 Copyright ©Radiological Society of North America, 2004

40 mAs Mayo, J. R. et al. Radiology 2004;232:749-756 Copyright ©Radiological Society of North America, 2004

200 mAs Mayo, J. R. et al. Radiology 2004;232:749-756 Copyright ©Radiological Society of North America, 2004

100 mAs Mayo, J. R. et al. Radiology 2004;232:749-756 Copyright ©Radiological Society of North America, 2004

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

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

Thank you