SCIENTIFIC ANNALS OF ALEXANDRU IOAN CUZA DIN IAI UNIVERSITY Tomul II, s.

Biomaterials in Biophysics, Medical Physics and Ecology 2009

PACIENT DOSE REDUCTION IN COMPUTED TOMOGRAPHY

Alina-Mihaela Cojocariu 1 , Anamaria Doag1, S.T. Makkai-Popa1, P.C. Constantin1,2 , G. P. Panayiotakis 3 , Danisia Haba2,4 , C. Borcia1 KEYWORDS: dose reduction, computed tomography, CTDI
One of the basic principles of radiological practice is to minimize the dose to the patient but also to the staff working on the radiology department. In order to achieve such a goal, an open communication should always exist between the medical physicist, the radiological technician and the radiologist who interprets the image. Moreover, the radiologist should also be able to guide the rest of the staff to achieve a minimum patient-dose with an adequate quality of the image. We firstly review the major factors that influence the dose in conventional radiology and discuss them taking into account the way in which they affect the quality of the image. Secondly we present an experimental study on the protocols used in the neuro-radiology department of Prof. dr. Nicolae Oblu Emergency Hospital Iasi and on the way they meet the Romanian regulation. We took into account the slice thickness and the table index which are the most widely modified parameters in CT protocols.

1.

INTRODUCTION

Reducing the doses that a patient is exposed to during a medical imaging procedure that involves the use of X-rays is one of the basic principles of the optimization of practice in regard to radiation protection [1-5]. In order to realize the goal of reducing patient doses, the medical physicist has to take into account all the basic principles of radiological imaging [6, 7]. The interaction of radiation with living tissues implies some alteration and consequently some element of damage to the tissue [2, 8]. This damage may act by destroying healthy, but also unhealthy cells in the body. The first case is a concern for the use of ionizing radiations in practice and is the object of study for radiological protection. In the second case the radiation has a beneficial effect and is used for radiation therapy.

1 2

Faculty of Physics, Al.I. Cuza University, Blvd. Carol I, No.11, 700506, Iasi, Romania Department of Radiology and Medical Imaging, Emergency Hospital "Prof.Dr. N.Oblu", Str. Ateneului, No. 2, 700309 , Iasi, Romania 3 Department of Medical Physics, School of Medicine, University of Patras, 265 00 Patras, Greece 4 Faculty of Dental Medicine, Gr.T.Popa University of Medicine and Pharmacy, Str. Universitatii, No. 16, 700115, Iasi, Romania

42

Alina-Mihaela Cojocariu et. al.

Ionizing radiation is introduced into the body as quanta of energy. As such, it has effects at the level of individual cells in the body. The DNA of the cell nucleus is the only component which is of importance if changed or damaged by the radiation [14]. If the damage takes place in a germ cell the change in function may be passed to a descendant this is the genetic effect of radiation. If the damage is done to other cells, the damage is passed on to a population of cells in the body of the person that is irradiated this constitutes a somatic effect [2, 3]. On the other hand radiation is a fundamentally random process and it can never be predicted which cells in the body will be affected. However it is natural to expect that a high number of quanta will affect a high number of cells, the severity of the damage and/or the frequency of the damaging events depending on the intensity of the radiation. It is also conceivable that organs are affected when a certain amount of cells are damaged. It means that changes might not occur until a threshold of absorbed radiation is reached. Those effects are called deterministic and they result in increasing severity of damage and increasing number of transformed cells. In contrast, a single affected cell, whose DNA is modified by radiation, can induce the development of a cancer. In this case, small amount of radiation may generate biological effects, called stochastic effects. The probability of their occurrence depends on the exposure parameters [2,3]. It is important to quantify the exposure level in order to establish the threshold for deterministic effects or the probability that a stochastic effect occurs. In this respect one uses the absorbed dose, which is defined as the energy absorbed by the mass unit of tissue from the radiation to which it is exposed. The effective dose is used in order to express the risk of occurrence of stochastic effects after radiation exposure. While the absorbed dose can be measured, the effective dose is calculated by weighting the absorbed dose with factors depending on the nature of the radiation and of the exposed organ. 2. THEORETICAL CONSIDERATIONS

In examining the effects of radiation, three populations are of interest because of the different ways they are exposed: patients, professional workers and the public. Three risks from the low level radiation used in diagnosis are of concern: (1) the risk of genetic damage passed on as inherited disease, (2) the risk of malformation or cancer to the foetus of an irradiated pregnant woman and (3) the risk of development of cancer, or death from cancer, induced by radiation [1-4]. The reason why doses are measured is to estimate the radiation risk and the reason for dose reduction is to minimize the risk for all of the categories named above. The acceptability of the risks above has been studied and acceptable dose limits have been established. For workers, the limits are set at 20 mSv per year averaged over five years (and not exceeding 50 mSv in any one year) and 500 mSv per year to the skin or the hands and feet. For public, the values are lower: 1 mSv per year averaged over five years and 50 mSv per year equivalent dose to the skin. Risks from exposure to low levels of radiation are still difficult to estimate accurately [2.3].

PATIENT DOSE REDUCTION IN COMPUTED TOMOGRAPHY

43

Reducing the dose of radiation can have an adverse effect on image quality. Therefore in the absence of risk to the patient much higher doses would frequently be used in order to obtain a higher quality image. There is a very high attenuation as a diagnostic X-ray beam passes through the body. Thus the exit dose will be typically between 0.1% and 1% of the entrance dose [6]. The entrance surface dose is defined as the absorbed dose in air at the point of intersection of the X-ray beam axis with the entrance surface of the patient, including back-scattered radiation, and a well defined protocol must be followed if results from different hospitals and different countries are to be compared. If TLD devices (thermoluminescent dosimeters) are not available, the dose estimate using indirect methods of dose measurement, may be required. In this respect, the X-ray tube output is measured under specified conditions using an ionization chamber in air, generally as part of routine quality assurance checks. The entrance surface dose can then be calculated from knowledge of the exposure factors, applying any necessary correction for a source-skin distance and a factor to allow for back-scatter from the patient. Indirect methods also allow a large number of dose estimates to be made from a small number of measurements and may be useful at very low doses close to the detection limit of the TLDs [7]. There are four main categories of factors that could influence the patient dose. The first ones are technical factors, which characterize the X-ray device and the parameters used for the exposure [6-7, 9-10]. One of them is the anode material, which should be chosen in order to match the beam energy required. For example in mammography molybdenum is used because of its characteristic radiation that falls between 17,9 (17.9) and 19,5 (19.5) keV. A second factor is the applied voltage on the X-ray tube. For relative high voltage level, the voltage increase leads to a patient skin dose decrease but also to a decrease in contrast. The current on the X-ray tube is another important parameter. High values of the current means a large number of electrons which interact with the anode leading to a high number of X-ray generated photons and subsequently to an increase in patient dose. The exposure time can also play a key role in reducing the dose to the patient. An increase in exposure time means an increase in the dose to the patient, but this leads to a severe reduction in the optical density of the image. The filtration of the emitted X-rays eliminates low energy photons from the beam. Those photons are responsible for an increased dose to the patient, while they are entirely absorbed by this one and do not lead to any benefit on the image quality. The sensitivity of screen-film combinations is also influencing the dose to the patient. Intensifying screens reduce the X-ray dose, while less photons are needed to obtain the image. A film of higher speed can also determine a reduction in dose, while the exposure time needed for the image formation is shorter. Higher speeds can be achieved using films with greater silver chloride grains, but this entrains a loss in the image resolution. The exposure time is often controlled by an automatic exposure device. This one should be checked regularly for reliability, in order to ensure proper exposure for the film. The film processing is a key process for the image quality. Improper film processing leads to an increase in the number of retakes which leads to an increase in the dose delivered to the patient.

44

Alina-Mihaela Cojocariu et. al.

Grids are used in order to reduce the amount of scattered radiation which could affect the image quality. The use of grids leads also to a reduction in the amount of primary radiation that reaches the film; therefore, higher doses must be used. Linear anti-scatter grids lead to cut-off phenomena, whereas focused ones show no signs of cut-off. Another group of factors which can contribute to a reduction of the dose to the patient are the so-called geometrical factors. The magnification, being achieved by a reduction in focus-patient distance, leads to a dose increase. Reducing the penumbra implies the increase of the focus-patient distance, resulting in a reduction of the dose. Patient-film distance should also be minimized to reduce the dose. Low focus-patient distance determines an increase in dose. Finally, the field size should fit the size of the cassettes, in order to deliver a low dose to the patient. A third group of factors which influence the dose to the patient are the patient factors. The area to be imaged should be, as practicable, consistent with the area being investigated. A large area could lead to an increase of the dose. The patient thickness is influencing the dose and scatter radiation, which increase with patient thickness. The tissue content varies with the age of the patient, determining variation in the delivered dose There are also some other factors that are influencing the dose to the patient. Inappropriate radiological examinations could lead to repeated exposures and to a dose increase. In this respect it is important to ensure a proper personnel training because the staff should know exactly which are the procedures that involves the smallest dose to the patient with no affect for the image quality. 3. EXPERIMETAL

In the following we will discuss some methods to achieve dose reduction for neuro-radiology CT (computer tomography) protocols while preserving the diagnostic quality of imaging studies. These methods are available at the Emergency Hospital "Prof. Dr. N. Oblu", which is equipped with a CT type mono-slice Aura, produced by Philips. Some technical data of this device are presented in Table1. The guidelines presented in [9] give recommendations on how to optimize CT protocols and encourage the elimination of inappropriate referrals for CT as well as the reduction of the number of unnecessary repeat examinations. To understand the radiation dose a patient receives for a particular scan, one must have knowledge of the methods of dose measurement. Currently, the Computed Tomography Dose Index (CTDI), along with its variants, and the Dose Length Product (DLP) are the standard parameters used to describe CT-associated radiation dose. The CTDI was initially defined as the radiation dose measured from 14 contiguous sections and normalized to beam width taking into account the radiation dose delivered both within and beyond the scanning volume. Indeed, scattered radiation, divergence of radiation beam, and limits in efficiency of beam collimation result in the radiation delivered during a CT scan not fully contained within the scanning volume. The setting of CT acquisition parameters, such as tube current, tube rotation time, peak voltage, pitch, table index and slice thickness is a major contributor of the

PATIENT DOSE REDUCTION IN COMPUTED TOMOGRAPHY

45

radiation dose received during a CT study [9, 10]. Typically, if one of these parameters is decreased, another needs to be increased to maintain image quality. The most often changed parameters in the CT protocol are the slice thickness and the table index. The slice thickness represents the width of the projection which is reconstructed by the scanner and forms the image.

Table 1. Gantry's technical specifications: the generator, X-ray tube and detector which are used in computer tomography CT Aura.
Patient aperture Gantry Fan angle Maximum scan field of view Focus-detector distance Focus-isocenter distance Generator Peak power Type X-ray tube Anode diameter Target angle Focal spot size (1EC 336) Detector Type Elements 67 cm effective aperture at -280/+300 48cm 55 0 484 mm 950 mm 515 mm 30 kW MRC 160 mm 100 1.0 x 0.6 ClearView solid state 696

Table 2. CTDI values (expressed as mGy/100mAs) versus slice thickness and table index. The values written in italic indicate the doses that are still in excess of the permissible dose of legislation; the bold values are most commonly used doses in neuro-radiological CT protocols. The rest of the values come under the limit laws for exploring CT.
T

SLICE THICKNESS 1 mm 75.10 37.50 25.03 18.77 15.02 12.52 10.73 9.39 8.34 7.51 6.83 43.30 2 mm 75 37.50 25 18.75 15 12.50 10.71 9.38 8.33 7.50 6.82 86.60 3 Mm 112.80 56.40 37.60 28.20 22.56 18.80 16.11 14.10 12.53 11.28 10.25 88.20 5 mm 181 90.50 60.33 45.25 36.20 30.17 25.86 22.62 20.11 18.10 16.45 97.70 7 mm 255,50 127,75 85.17 63.88 51.10 42.58 36.50 31.94 28.39 25.55 23.23 99.20 10 mm 338 95.10 112.67 84.50 67.60 56.33 48.29 42.25 37.56 33.80 30.73 95.10

T A B L E I N D E X

1 mm 2 mm 3 mm 4 mm 5 mm 6 mm 7 mm 8 mm 9 mm 10 mm 11 mm Efficacy (%)

46

Alina-Mihaela Cojocariu et. al.

We should stress that the slice thickness is smaller than the width of the irradiated region of the patient body. The table index represents the movement of the patient table between two sequential scans. Depending on the chosen values for these parameters, the patient receives different levels of the dose. For the slice thickness values one can choose between 1mm, 2mm, 3mm, 5mm, 7mm and 10mm. Table indexes go from 1mm to 11mm. The values of the dose for different slice thickness and table indexes are shown in Table 2. The last line shows the efficacy dose values, e.g. the percentage which contribute to the imaging process. One can see that the values for which the dose is best used for imaging purposes corresponds to values for the slice thickness of 5mm and 7mm. The most frequently values used in the Department of Radiology and Medical Imaging are written with bold in Table 2. Results of a study including the total number of patients being imaged at the Department of Radiodiagnostic and Medical Imaging is presented in Table 3. The last but one column contains the averaged values of the effective dose per patient exposure for three main types of examinations: head, cervical column and spine. These values are analyzed by comparing with the reference levels provided by Romanian legislation. Table 3. The total number of patients who were explored during 2009 in the Department of Radiodiagnostic and Medical Imaging of the Emergency Hospital "Prof. Dr. N. Oblu " Iasi. Patients are ordered according to the procedure performed, total number of examinations, by age, sex and groups of average effective dose/procedure.
Organ subject to examination No. Tota l exa ms 9,414 85 87 No. examinations by age No. sex exams Average effective dose / exposure (mGy) 19.819 19.58 23.87 Referen ce levels (mGy)

< 15 years 657 2 1

Head Cervical column Lumbar spine

16 40 years 2,119 32 39

> 40 years 6,638 51 47

5,618 53 49

3,796 32 38

50 35 25

(a)

(b)

(c)

Fig. 1 CT slices obtained after reconstruction of data acquired with the following parameters: slice thickness 3mm, table index 3mm (a), 7mm (b) and 10mm (c).

PATIENT DOSE REDUCTION IN COMPUTED TOMOGRAPHY

47

Article 174 of the Rules on radiation protection of persons in medical exposures to radiation (issued by Romanian Nuclear authority - CNCAN), provides the reference levels for exploration by computed tomography for a standard adult patient (body weight 70kg). The results show that the investigations performed in our department fulfill the regulations. However, our goal is to enhance the acquisition parameters in order to achieve the minimum effective dose to the patient, keeping a high level of imaging quality. In this respect, we have performed some investigations of the influence of the table index and slice thickness on the contrast and noise level of the reconstructed image. It is important that the dose reduction process does not affect the quality of the diagnostic. In this respect, the image should show a small amount of noise, in order to preserve a good level of the contrast. In Fig. 1 three reconstructed slices are presented using as scanning parameters a constant slice thickness (3mm) and variable table indexes: 3, 7, and 10mm. One can see that the level of noise is increasing with the table index. The first two images have a fair level of noise, which is not influencing the quality of the diagnostic process. However, the third image has a larger amount of noise, showing poor level of contrast which could make it unusable for diagnosis. Taken into account the delivered dose to the patient, derived from the values of CTDI (see Table 2), one can observe that the table index of 7mm is preferred, which ensures a minimum amount of the dose. For example, a head CT protocol with sections of 3/7 mm has a dose value of 16.11mGy, which means that we fit in the amount required by law (50mGy). After a closer comparison of these doses we can conclude that using these sections values allows us to make 3 computer tomography explorations of a patient: an exploration for diagnosis and two explorations for postoperative monitoring. 4. CONCLUSIONS

CT scanners represent a major contribution to the radiation dose received in radiology department. There are many methods of reducing doses, such as reducing the X-ray tube voltage and current, the gantry rotation time, the pitch, the slice thickness or the table index. Reducing these parameters leads to the reduction of image quality, so the result would be a wrong diagnosis or images that cant be interpreted by the radiologist. The achievement of an optimized dose is a highly desired goal and as such most of the efforts of the medical physicist should be involved in trying to achieve it. As discussed above, a very low dose can only be achieved by sacrificing some of the quality of the image e.g. the decrease in the optical density of the film that is due to the decrease of the exposure time can lead to a poor quality radiological image and is desired only within the limits of an acceptable decrease in the image quality. What is an acceptable decrease in the image quality can only be established by the physician depending on the objective of the investigation, but all of the decisions regarding those should be taken by the entire team in the department and they should follow the guidelines of the ALARA principle and those of the principle of the acceptability of practice

48

Alina-Mihaela Cojocariu et. al. REFERENCES R. Wootton, Radiation protection of patient, Published in association with the Royal Postgraduate Medical School, Cambridge University Press, 1993. 2. ICRP Publication 60: Recommendation of the International Commission on Radiological Protection By the International Commission on Radiological Protection, Annals of the ICRP vol 21(1-3), Elsevier Science Publishing Company, 1991. 3. ICRP Publication 73: Radiological Protection and Safety in Medicine, Annals of the ICRP vol 26(2), Elsevier Science Publishing Company, 1996. 4. S.B. Dowd, .R. Tilson, Practical Radiation Protection and Applied Radiobiology, W.B. Saunders Company; 2nd edition, 1999. 5. J. Shapiro, Radiation protection a guide for scientists, regulators and physicians, Harvard University Press, 2002 6. P.P. Dendy, B. Heaton, Physics for diagnostic radiology, Ed. Taylor & Francis Group, New York 1999. 7. Physics of diagnostic radiology An European course on biomedical engineering and medical physics, University of Patras, 2007. 8. J. E. Martin, Physics for Radiation Protection, WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim, 2006. 9. A. B. Smith, W. P. Dillon, R. Gould, M. Wintermark, Radiation dose-reduction strategies for neuroradiology CT protocols, American Journal of Neuroradiology, Vol. 28, p. 1628-1632, 2007 10. M.K. Kalra, M.M. Maher, T.L. Toth, L.M. Hamberg, M.A. Blake, J.A. Shepard, S. Saini, Strategies for CT radiation dose optimization, Radiology., Vol. 230(3). p. 619-28, 2004. 1.