Investigating centering,scan length,and arm position impact on radiation dose across 4 countries from 4 continents during pandemic: Mitigating key radioprotection issues

PurposeOptimization of CT scan practices can help achieve and maintain optimal radiation protection. The aim was to assess centering, scan length, and positioning of patients undergoing chest CT for suspected or known COVID-19 pneumonia and to investigate their effect on associated radiation doses.MethodsWith respective approvals from institutional review boards, we compiled CT imaging and radiation dose data from four hospitals belonging to four countries (Brazil, Iran, Italy, and USA) on 400 adult patients who underwent chest CT for suspected or known COVID-19 pneumonia between April 2020 and August 2020. We recorded patient demographics and volume CT dose index (CTDI_vol) and dose length product (DLP). From thin-section CT images of each patient, we estimated the scan length and recorded the first and last vertebral bodies at the scan start and end locations. Patient mis-centering and arm position were recorded. Data were analyzed with analysis of variance (ANOVA).ResultsThe extent and frequency of patient mis-centering did not differ across the four CT facilities (>0.09). The frequency of patients scanned with arms by their side (11–40% relative to those with arms up) had greater mis-centering and higher CTDI_vol and DLP at 2/4 facilities (p = 0.027–0.05). Despite lack of variations in effective diameters (p = 0.14), there were significantly variations in scan lengths, CTDI_vol and DLP across the four facilities (p < 0.001).ConclusionsMis-centering, over-scanning, and arms by the side are frequent issues with use of chest CT in COVID-19 pneumonia and are associated with higher radiation doses.     

Establishment of national diagnostic reference levels (DRLs) for radiotherapy localisation computer tomography of the head and neck

Aim

The aim of this research is to establish if variation exists in the dose delivered for head and neck (HN) localisation computed tomography (CT) imaging in radiation therapy (RT); to propose a national diagnostic reference levels (DRLs) for this procedure and to make a comparison between the national DRL and a DRL of a European sample.

能谱CT优化胃肿瘤扫描辐射剂量对肾上腺嗜铬细胞瘤的诊断价值

目的:探讨能谱CT优化胃肿瘤扫描辐射剂量对肾上腺嗜铬细胞瘤的诊断价值。方法:采用回顾性、抽样、随机研究方法选择2012年9月到2017年2月在我院诊治的肾上腺嗜铬细胞瘤患者59例作为研究对象,所有患者都给予常规CT扫描与能谱CT优化胃肿瘤扫描,记录和比较辐射剂量与图像质量。结果:所有病例包膜均完整,边缘清楚,肿瘤内见单发或多发低密度区,肿瘤实质区呈不均匀显著强化。常规CT与能谱CT的图像质量主观评分分别为3.89±0.45分和4.54±0.34分;常规CT与能谱CT图像的胃肿瘤CT值分别为31.94±6.39HU和35.29±5.19HU,对比都有显著差异(P0.05)。能谱CT图像的膀胱和皮下脂肪图像噪声值都显著低于常规CT图像,对比差异都有统计学意义(P0.05);能谱CT扫描的CTDIvol和DLP分别为12.39±3.48mGy和624.10±39.19mGy.cm,都显著低于常规CT扫描的14.09±4.13mGy和653.92±56.29mGy.cm(P0.05)。结论:能谱CT优化胃肿瘤扫描在肾上腺嗜铬细胞瘤诊断中的应用能有效减少辐射剂量与图像噪声,提高图像CT值与主观质量,临床应用价值更高。     

Dose profiles for lung and breast regions at prospective and retrospective CT coronary angiography using optically stimulated luminescence dosimeters on a 64-detector CT scanner

PurposeThe purpose of our study was to acquire dose profiles at critical organs of lung and breast regions using optically stimulated luminescence (OSL) dosimeters; assess the actual radiation dose delivered at retrospective and prospective computed tomography coronary angiography (CTCA).Materials and methodsUsing a chest CT phantom we applied a prospectively-gated step-and-shoot- and a retrospectively-gated helical mode on a 64-detector row CT scanner. Retrospective scan mode was used with and without electrocardiogram (ECG) based tube current modulation. OSL dosimeters were used to measure dose profiles. In the both scan modes we acquired dose profiles and determined the mean and maximum dose in left lung and in left breast regions.ResultsIn prospective mode, the mean dose was 21.53 mGy in left lung- and 23.59 mGy in left breast region. With respect to the retrospective mode, the mean dose with tube current modulation was 38.63 mGy for left lung- and 46.02 mGy for left breast region, i.e. 0.56 and 0.55 times lower than the mean dose without modulation.ConclusionThe OSL dosimeter is useful for measurement of the actual radiation dose along z-axis at lung and breast regions in the prospective and the retrospective CTCA.     

Radiotherapy for non-malignant shoulder syndrome: Is there a risk for radiation-induced carcinogenesis?

PurposeTo estimate the organ-specific probability for carcinogenesis following radiotherapy for non-malignant shoulder syndrome.MethodsPhoton-beam radiation therapy to 6 Gy for shoulder syndrome was simulated with a Monte Carlo code. An androgynous computational phantom representing a typical adult was used to calculate the radiation dose to out-of-field organs having a predilection for carcinogenesis. The organ-specific lifetime attributable risk (LAR) for out-of-field cancer induction was estimated by the organ dose calculations and the proper risk factors introduced by the BEIR-VII report. The average dose (D_av) and organ equivalent dose (OED) of lung, which was partially included within the treatment volume, was found from 3d-conformal radiotherapy plans. The D_av and OED were used to estimate the lung cancer risk with a linear and mechanistic models, respectively. All risk assessments were made for 50- and 60-year-old male and female patients.ResultsMonte Carlo simulations resulted in an out-of-field organ dose range of 0.7–48.4 mGy. The LARs for out-of-field cancer induction were (1.4 × 10⁻⁴)% to (2.8 × 10⁻²)%. These probabilities were at least 403 times lower than the respective lifetime intrinsic risk (LIR) values. The D_av and OED of lung was up to 164.9 and 142.3 mGy, respectively. The LAR for developing lung malignancies varied from 0.11 to 0.18% by the model used and the patient’s age and gender. The lung cancer risks were 36–64 times smaller than the LIRs.ConclusionsThe estimated probabilities for developing malignancies due to radiotherapy for non-malignant shoulder syndrome are minor relative to the natural cancer occurrence rates.     

Impact of lung density on isolated lung tumor dose in VMAT using inline MR-Linac

PurposeThis study investigated the impact of lung density on the isolated lung tumor dose for volumetric modulated arc therapy (VMAT) in an inline magnetic resonance linear accelerator (MR-Linac) using the Monte Carlo (MC) simulation.MethodsCT images of the thorax phantoms with lung tumors of 1, 2, and 3 cm diameters were converted into voxel-base phantoms with lung densities of 0.1, 0.2, and 0.3 g/cm³, respectively. The dose distributions were calculated for partial-arc VMAT. The dose distributions were compared using dose differences, dose volume histograms, and dose volume indices.ResultsIn all cases, the inline magnetic field significantly enhanced the lung tumor dose compared to that at 0 T. For the 1 cm lung tumor, the inline magnetic field of 1 T increased the minimum dose of 95% of the Planning target volume (PTV D₉₅) by 14.0% in 0.1 g/cm³ lung density as compared to that in 0.3 g/cm³ at 0 T. In contrast, at 0 and 0.5 T, the PTV D₉₅ in 0.3 g/cm³ lung density was larger than that in lung density of 0.1 g/cm³. For the 2 cm lung tumor, a similar tendency to 1 cm was observed, whereas the dose impact of lung density was smaller than that for 1 cm. For the 3 cm lung tumor, the lung tumor dose was independent of lung density at 0.5 T and 1.0 T.ConclusionThe inline MR-Linac with the magnetic field over 1 T can enhance the PTV D₉₅ for VMAT regardless of the lung density.     

Establishing national diagnostic reference levels (DRLs) for computed tomography in Egypt

ObjectivesTo establish national diagnostic reference levels (DRLs) in Egypt for computed tomography (CT) examinations of adults and identify the potential for optimization.MethodsData from 3762 individual patient’s undergoing CT scans of head, chest (high resolution), abdomen, abdomen-pelvis, chest-abdomen-pelvis and CT angiography (aorta and both lower limbs) examinations in 50 CT facilities were collected. This represents 20% of facilities in the country and all of the 27 Governorates. Results were compared with DRLs of UK, USA, Canada, Japan, Australia and France.ResultsThe Egyptian DRLs for CTDI_vol in mGy are for head: 30, chest (high resolution): 22, abdomen (liver metastasis): 31, abdomen-pelvis: 31, chest-abdomen–pelvis: 33 and CT angiography (aorta and lower limbs): 37. The corresponding DRLs for DLP in mGy.cm are 1360, 420, 1425, 1325, 1320 and 1320. For head CT, the Egyptian DRL for CTDI_vol is 2–3 times lower than the DRLs from other countries. However, the DRL in terms of DLP is in the same range or higher as compared to others. The Egyptian DRL for chest CT (high resolution) is similar to others for DLP but higher for CTDI_vol. For abdomen and abdomen-pelvis DRLs for CTDI_vol are higher than others. For DLP, the DRLs for abdomen are higher than DRL in UK and lower than those in Japan, while for abdomen-pelvis they are higher than other countries.ConclusionDespite lower DRLs for CTDI_vol, an important consistent problem appears to be higher scan range as DRLs for DLP are higher.     

Fetal radiation dose in three common CT examinations during pregnancy – Monte Carlo study

PurposeTo determine fetal doses in different stages of pregnancy in three common computed tomography (CT) examinations: pulmonary CT angiography, abdomino-pelvic and trauma scan with Monte Carlo (MC) simulations.MethodsAn adult female anthropomorphic phantom was scanned with a 64-slice CT using pulmonary angiography, abdomino-pelvic and trauma CT scan protocols. Three different sized gelatin boluses placed on the phantom’s abdomen simulated different stages of pregnancy. Intrauterine dose was used as a surrogate to a dose absorbed to the fetus. MC simulations were performed to estimate uterine doses. The simulation dose levels were calibrated with volumetric CT dose index (CTDI_vol) measurements and MC simulations in a cylindrical CTDI body phantom and compared with ten point doses measured with metal-oxide-semiconductor field-effect-transistor dosimeters. Intrauterine volumes and uterine walls were segmented and the respective dose volume histograms were calculated.ResultsThe mean intrauterine doses in different stages of pregnancy varied from 0.04 to 1.04 mGy, from 4.8 to 5.8 mGy, and from 9.8 to 12.6 mGy in the CT scans for pulmonary angiography, abdomino-pelvic and trauma CT scans, respectively. MC simulations showed good correlation with the MOSFET measurement at the measured locations.ConclusionsThe three studied examinations provided highly varying fetal doses increasing from sub-mGy level in pulmonary CT angiography to notably higher levels in abdomino-pelvic and trauma scans where the fetus is in the primary exposure range. Volumetric dose distribution offered by MC simulations in an appropriate anthropomorphic phantom provides a comprehensive dose assessment when applied in adjunct to point-dose measurements.     

Ultra-low dose whole-body CT for attenuation correction in a dual tracer PET/CT protocol for multiple myeloma

PurposeTo investigate within phantoms the minimum CT dose allowed for accurate attenuation correction of PET data and to quantify the effective dose reduction when a CT for this purpose is incorporated in the clinical setting.MethodsThe NEMA image quality phantom was scanned within a large parallelepiped container. Twenty-one different CT images were acquired to correct attenuation of PET raw data. Radiation dose and image quality were evaluated.Thirty-one patients with proven multiple myeloma who underwent a dual tracer PET/CT scan were retrospectively reviewed. ¹⁸F-fluorodeoxyglucose PET/CT included a diagnostic whole-body low dose CT (WBLDCT: 120 kV-80mAs) and ¹¹C-Methionine PET/CT included a whole-body ultra-low dose CT (WBULDCT) for attenuation correction (100 kV-40mAs). Effective dose and image quality were analysed.ResultsOnly the two lowest radiation dose conditions (80 kV-20mAs and 80 kV-10mAs) produced artifacts in CT images that degraded corrected PET images. For all the other conditions (CTDI_vol ≥ 0.43 mGy), PET contrast recovery coefficients varied less than ± 1.2%.Patients received a median dose of 6.4 mSv from diagnostic CT and 2.1 mSv from the attenuation correction CT. Despite the worse image quality of this CT, 94.8% of bone lesions were identifiable.ConclusionPhantom experiments showed that an ultra-low dose CT can be implemented in PET/CT procedures without any noticeable degradation in the attenuation corrected PET scan. The replacement of the standard CT for this ultra-low dose CT in clinical PET/CT scans involves a significant radiation dose reduction.     

Preserving image texture while reducing radiation dose with a deep learning image reconstruction algorithm in chest CT: A phantom study

PurposeTo assess whether a deep learning image reconstruction algorithm (TrueFidelity) can preserve the image texture of conventional filtered back projection (FBP) at reduced dose levels attained by ASIR-V in chest CT.MethodsPhantom images were acquired using a clinical chest protocol (7.6 mGy) and two levels of dose reduction (60% and 80%). Images were reconstructed with FBP, ASIR-V (50% and 100% blending) and TrueFidelity (low (DL-L), medium (DL-M) and high (DL-H) strength). Noise (SD), noise power spectrum (NPS) and task-based transfer function (TTF) were calculated. Noise texture was quantitatively compared by computing root-mean-square deviations (RMSD) of NPS with respect to FBP. Four experienced readers performed a contrast-detail evaluation. The dose reducing potential of TrueFidelity compared to ASIR-V was assessed by fitting SD and contrast-detail as a function of dose.ResultsDL-M and DL-H reduced noise and NPS area compared to FBP and 50% ASIR-V, at all dose levels. At 7.6 mGy, NPS of ASIR-V 50/100% was shifted towards lower frequencies (f_peak = 0.22/0.13 mm⁻¹, RMSD = 0.14/0.38), with respect to FBP (f_peak = 0.30 mm⁻¹). Marginal difference was observed for TrueFidelity: f_peak = 0.33/0.30/0.30 mm⁻¹ and RMSD = 0.03/0.04/0.07 for L/M/H strength. Values of TTF_50% were independent of DL strength and higher compared to FBP and ASIR-V, at all dose and contrast levels. Contrast-detail was highest for DL-H at all doses. Compared to 50% ASIR-V, DL-H had an estimated dose reducing potential of 50% on average, without impairing noise, texture and detectability.ConclusionsTrueFidelity preserves the image texture of FBP, while outperforming ASIR-V in terms of noise, spatial resolution and detectability at lower doses.     

A “quality-control-based correction method” for displayed dose indices on CT scanner consoles in patient dose surveys

PurposeA new quality-control-based (QC-based) method is introduced to obtain correction factors to be applied to displayed patient dose indices (CTDI_Vol and DLP) on CT scanner consoles to verify improvement of dose surveys for diagnostic reference levels (DRLs) determination.MethodAn available data-base of QC documents and reports of 57 CT scanners in Tehran, Iran was used to estimate CTDI_Vol, DLP and relevant correction factors for three CT examination types including head, chest and abdomen/pelvis. The correction factor is the ratio of QC-based estimated dose to displayed dose. A dose survey was performed by applying on-site “data collection method” and correction factors obtained in order to select CT scanners in three modes for determination of CT DRLs by inclusion of: (a) all CT scanners before displayed dose indices were corrected (57), (b) only CT scanners calibrated by QC experts (41) and (c) all CT scanners after displayed dose indices were corrected (57).ResultsFor the 41 CT scanners, correction factors of three examination types obtained in this study are within the acceptance tolerance of IAEA HHS-19. The correction factors range from 0.45 to 1.7 (average of 3 examinations) which is due to the change in the calibrated value of CTDI_Vol over extended time. The DRL differences in three modes are within ±1.0% for CTDI_Vol and ±12.4% for DLP.ConclusionsThe “QC-based correction method” applied to mode (c) has improved the DRLs obtained by other two modes. This method is a strong alternative to “direct dose measurement” with simplicity and cost effectiveness.     

Technical Note: Quality assessment of virtual monochromatic spectral images on a dual energy CT scanner

PurposeTo assess the quality of images obtained on a dual energy computed tomography (CT) scanner.MethodsImage quality was assessed on a 64 detector-row fast kVp-switching dual energy CT scanner (Revolution GSI, GE Medical Systems). The Catphan phantom and a low contrast resolution phantom were employed. Acquisitions were performed at eight different radiation dose levels that ranged from 9 mGy to 32 mGy. Virtual monochromatic spectral images (VMI) were reconstructed in the 40–140 keV range using all available kernels and iterative reconstruction (IR) at four different blending levels. Modulation Transfer Function (MTF) curves, image noise, image contrast, noise power spectrum and contrast to noise ratio were assessed.ResultsIn-plane spatial resolution at the 10% of the MTF curve was 0.60 mm⁻¹. In-plane spatial resolution was not modified with VMI energy and IR blending level. Image noise was reduced from 16.6 at 9 mGy to 6.7 at 32 mGy, while peak frequency remained within 0.14 ± 0.01 mm⁻¹. Image noise was reduced from 14.3 at IR 10% to 11.5 at IR 50% at a constant peak frequency. The lowest image noise and maximum peak frequency were recorded at 70 keV.ConclusionsOur results have shown how objective image quality is varied when different levels of radiation dose and different settings in IR are applied. These results provide CT operators an in depth understanding of the imaging performance characteristics in dual energy CT.     

Radiation dose in repeated CT guided radiofrequency ablations

ObjectiveTo calculate the cumulative effective and skin doses in patients that underwent repeated CT guided radiofrequency ablations (RFA).Materials and methodsFrom all patients that had undergone RFA during a five years period those which had three or more RFAs were selected. Using the CT images DICOM data, the dose length product (DLP), effective dose (E), skin dose profiles as well as the peak skin dose (PSD) were calculated, using appropriate methods and software developed for this purpose. For each patient, cumulative DLP and E were also calculated from the sum of the respective figures of each individual procedure. To calculate PSD, the skin dose profiles of each procedure were overlaid on the same Z-axis scale using anatomical landmarks for reference and the skin doses to each point were summed up.ResultsFive patients were studied; four had undergone 3 RFAs and one 10 RFAs. Cumulative DLP, E and PSD ranges were 5.6–22.3 Gy cm, 0.08–0.36 Sv and 0.8–3.4 Gy, respectively. Median E and PSD values per RFA were 35 mSv and 0.4 Gy, respectively. For comparison purposes it must be noted that in this CT department a routine abdomen-pelvis scan results to an E of about 10 mSv.ConclusionsPatients that undergo repeated RFAs are exposed to considerably high radiation exposure levels. When these patients are in the final stage of malignant diseases, stochastic effects may not be of major concern. However, optimization of the exposure factors and monitoring of these patients to avoid skin injuries are required.     

A novel fast kilovoltage switching dual-energy CT with deep learning: Accuracy of CT number on virtual monochromatic imaging and iodine quantification

PurposeA novel fast kilovoltage switching dual-energy CT with deep learning [Deep learning based-spectral CT (DL-Spectral CT)], which generates a complete sinogram for each kilovolt using deep learning views that complement the measured views at each energy, was commercialized in 2020. The purpose of this study was to evaluate the accuracy of CT numbers in virtual monochromatic images (VMIs) and iodine quantifications at various radiation doses using DL-Spectral CT.Materials and methodsTwo multi-energy phantoms (large and small) using several rods representing different materials (iodine, calcium, blood, and adipose) were scanned by DL-Spectral CT at varying radiation doses. Images were reconstructed using three reconstruction parameters (body, lung, bone). The absolute percentage errors (APEs) for CT numbers on VMIs at 50, 70, and 100 keV and iodine quantification were compared among different radiation dose protocols.ResultsThe APEs of the CT numbers on VMIs were <15% in both the large and small phantoms, except at the minimum dose in the large phantom. There were no significant differences among radiation dose protocols in computed tomography dose index volumes of 12.3 mGy or larger. The accuracy of iodine quantification provided by the body parameter was significantly better than those obtained with the lung and bone parameters. Increasing the radiation dose did not always improve the accuracy of iodine quantification, regardless of the reconstruction parameter and phantom size.ConclusionThe accuracy of iodine quantification and CT numbers on VMIs in DL-Spectral CT was not affected by the radiation dose, except for an extremely low radiation dose for body size.     

Abdominal imaging dose in radiology and radiotherapy – Phantom point dose measurements,effective dose and secondary cancer risk

PurposeTo compare abdominal imaging dose from 3D imaging in radiology (standard/low-dose/dual-energy CT) and radiotherapy (planning CT, kV cone-beam CT (CBCT)).MethodsDose was measured by thermoluminescent dosimeters (TLD’s) placed at 86 positions in an anthropomorphic phantom. Point, organ and effective dose were assessed, and secondary cancer risk from imaging was estimated.ResultsOverall dose and mean organ dose comparisons yield significantly lower dose for the optimized radiology protocols (dual-source and care kV), with an average dose of 0.34±0.01 mGy and 0.54±0.01 mGy (average ± standard deviation), respectively. Standard abdominal CT and planning CT involve considerably higher dose (13.58 ± 0.18 mGy and 18.78±0.27 mGy, respectively). The CBCT dose show a dose fall-off near the field edges. On average, dose is reduced as compared with the planning or standard CT (3.79 ± 0.21 mGy for 220° rotation and 7.76 ± 0.37 mGy for 360°), unless the high-quality setting is chosen (20.30 ± 0.96 mGy). The mean organ doses show a similar behavior, which translates to the estimated secondary cancer risk. The modelled risk is in the range between 0.4 cases per million patient years (PY) for the radiological scans dual-energy and care kV, and 300 cases per million PY for the high-quality CBCT setting.ConclusionsModern radiotherapy imaging techniques (while much lower in dose than radiotherapy), involve considerably more dose to the patient than modern radiology techniques. Given the frequency of radiotherapy imaging, a further reduction in radiotherapy imaging dose appears to be both desirable and technically feasible.     

Effects of lung tissue characterization in radiotherapy of breast cancer under deep inspiration breath hold when using Monte Carlo dosimetry

PurposeTo investigate the sensitivity of Monte Carlo (MC) calculated lung dose distributions to lung tissue characterization in external beam radiotherapy of breast cancer under Deep Inspiration Breath Hold (DIBH).MethodsEGSnrc based MC software was employed. Mean lung densities for one hundred patients were analysed. CT number frequency and clinical dose distributions were calculated for 15 patients with mean lung density below 0.14 g/cm³. Lung volume with a pre-defined CT numbers was also considered. Lung tissue was characterized by applying different CT calibrations in the low-density region and air-lung tissue thresholds. Dose impact was estimated by Dose Volume Histogram (DVH) parameters.ResultsMean lung densities below 0.14 g/cm³ were found in 10% of the patients. CT numbers below −960 HU dominated the CT frequency distributions with a high rate of CT numbers at −990 HU. Mass density conversion approach influenced the DVH shape. V_4Gy and V_8Gy varied by 7% and 5% for the selected patients and by 9% and 3.5% for the pre-defined lung volume. V_16Gy and V_20Gy, were within 2.5%. Regions above 20 Gy were affected. Variations in air- lung tissue differentiation resulted in DVH parameters within 1%. Threshold at −990 HU was confirmed by the CT number frequency distributions.ConclusionsLung dose distributions were more sensitive to variations in the CT calibration curve below lung (inhale) density than to air-lung tissue differentiation. Low dose regions were mostly affected. The dosimetry effects were found to be potentially important to 10% of the patients treated under DIBH.