750

CHEST Special Features

CHEST IMAGING
Special Features
H
ealth risks of medical imaging, particularly CT scan,
have captured the attention of the medical com-
munity and the public. Medical providers and patients
often are underinformed about the potential adverse
health effects of radiation exposure from medical imag-
ing.
1-6
Estimates suggest that 6,800 future cancers
may be attributable to chest CT scan examinations
performed in 2007 alone
7
and that 0.7% to 2% of all
future cancers in the United States may be caused by
radiation from CT scan.
8,9
As society begins to recog-
nize the potential public health impact of imaging-
associated radiation,
10-12
it is important for medical
providers to become familiar with radiation dose
In the past 3 decades, the total number of CT scans performed has grown exponentially. In
2007, . 70 million CT scans were performed in the United States. CT scan studies of the chest
comprise a large portion of the CT scans performed today because the technology has trans-
formed the management of common chest diseases, including pulmonary embolism and coronary
artery disease. As the number of studies performed yearly increases, a growing fraction of the popu-
lation is exposed to low-dose ionizing radiation from CT scan. Data extrapolated from atomic
bomb survivors and other populations exposed to low-dose ionizing radiation suggest that CT scan-
associated radiation may increase an individuals lifetime risk of developing cancer. This nding,
however, is not incontrovertible. Because this topic has recently attracted the attention of both
the scientic community and the general public, it has become increasingly important for physi-
cians to understand the cancer risk associated with CT scan and be capable of engaging in pro-
ductive dialogue with patients. This article reviews the current literature on the public health
debate surrounding CT scan and cancer risk, quanties radiation doses associated with specic
studies, and describes efforts to reduce population-wide CT scan-associated radiation exposure.
CT scan examinations of the chest, including CT scan pulmonary and coronary angiography,
high-resolution CT scan, low-dose lung cancer screening, and triple rule-out CT scan, are specif-
ically considered. CHEST 2012; 142(3):750760
Abbreviations: CTCA 5 CT scan coronary angiography; CTPA 5 CT scan pulmonary angiography; HRCT 5 high-resolution
CT; LET 5 linear energy transfer ; TROCT 5 triple rule-out CT
Radiation and Chest CT Scan Examinations
What Do We Know?
Asha Sarma , MD ; Marta E. Heilbrun , MD ; Karen E. Conner , MD ; Scott M. Stevens , MD ;
Scott C. Woller , MD ; and C. Gregory Elliott , MD , FCCP
Manuscript received November 9, 2011; revision accepted
February 13, 2012.
Afliations: From the Department of Medicine (Dr Sarma);
Department of Radiology (Dr Conner); and Division of Pulmo-
nary and Critical Care Medicine (Dr Elliott) and Division of Gen-
eral Internal Medicine (Drs Stevens and Woller), Department
of Medicine, Intermountain Medical Center, Murray, UT; and
Department of Radiology (Dr Heilbrun) and Department of
Internal Medicine (Drs Stevens, Woller, and Elliott), University
of Utah School of Medicine, Salt Lake City, UT.
Correspondence to: Asha Sarma, MD, c/o Cami Bills, Transi-
tional Year Residency Program, 5121 S Cottonwood St, Ste 303,
Murray, UT 84107; e-mail: asha.sarma@imail.org
2012 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.11-2863
For editorial comment see page 549
reduction strategies and gain comfort in discussing
risks with patients.
This review focuses on chest CT scan, including
CT scan pulmonary angiography (CTPA); CT scan
coronary angiography (CTCA); high-resolution CT
(HRCT) scan; low-dose screening for lung cancer;
and triple rule-out CT (TROCT) scan, a modality that
simultaneously assesses the aorta and the pulmonary
and coronary vascular beds in patients with nonspe-
cic acute chest pain. We provide relevant denitions
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journal.publications.chestnet.org CHEST / 142 / 3 / SEPTEMBER 2012 751
( Table 1 ) and review evidence for the association
between medical radiation and cancer. In addition,
we review published radiation dose estimates asso-
ciated with specic study types and discuss method-
ologies for estimating and reducing radiation dose.
Radiation Effects of Chest
CT Scans on the Individual Patient
Pioneers of radiation science discovered that ion-
izing radiation from x-rays causes damaging physical
effects.
13
Electrons are liberated when x-rays traverse
living cells. Free electrons may mutate DNA directly
or ionize water molecules to form harmful reactive
oxygen species. Most damage is readily repaired,
though persistent DNA damage may lead to cellular
loss of function, necrosis, or malignancy.
8,12,14

The term stochastic effect refers to tissue damage
from low doses of radiation that is unpredictable and
random in nature. This occurs after long latency
periods, 5 to 20 years after exposure.
12
Doses used
for medical imaging, referred to as low linear energy
transfer (LET) radiation, generally are , 100 mSv
and result in stochastic effects, the most signicant of
which is the development of cancer.
8,15
The risk of
Table 1 Denitions of Relevant Terms
Term Denition Unit
Absorbed dose Amount of energy deposited in tissue (J/kg); does not account for variable
radiosensitivity of tissues.
Gy, mGy
Effective dose Estimate of the amount of whole-body radiation equivalent to a partial-body
exposure, such as a CT scan; accounts for tissue-specic weighting factors.
Not useful for assessing individual risk but for comparing studies and
exposure types.
Sv, mSv
a

Organ dose Estimate of the amount of radiation deposited in a specic organ by a
radiologic procedure; accounts for tissue-specic weighting, patient,
and technical factors based on direct measurements of radiation absorbed by
anthropomorphic phantoms with components representing human organs.
Better metric for individual risk than effective dose.
Gy, mGy or Sv, mSv
Excess relative risk The risk added to population baseline cancer risk from an exposure such as
ionizing radiation. For example, if baseline risk is 42% and excess relative
risk of radiation-induced cancer from a particular study is 1%, then an
individual undergoing that study carries a total lifetime cancer risk of 43%.

Low-linear energy transfer radiation Radiation doses under about 100 mSv, such as those associated with medical
imaging studies, that are believed to result in stochastic effects on human
tissues, most signicantly, malignancy.

Stochastic effects Effects of radiation on tissues that are random and unpredictable. Believed
to result from low linear-energy transfer radiation, stochastic effects
manifest after long lag periods. The linear-no-threshold model describes
these effects, which are seen even at minimal doses. The probability, though
not the severity, of stochastic effects is believed to correlate with individual
cumulative radiation dose. The most medically signicant stochastic effect
is malignancy.

Deterministic effects Effects of radiation on tissues that are predictable and occur within hours
to days after acute exposure to large doses of radiation ( . 100 mSv). These
doses may be incurred from radiotherapy and nuclear accidents. Severity
of resultant widespread cell death correlates with dose, and there is a
minimum threshold dose required to observe these effects. Examples
include pulmonary brosis and GI necrosis.

a
In the context of whole-body, uniform exposures to x-radiation, the gray and the sievert are equivalent.
heritable defects from damage to germ cells is negligi-
ble.
16
Generally, younger female patients are at higher
risk for developing cancers from low-LET radiation
exposure because they possess a greater proportion
of actively dividing cells than older male patients and
have longer remaining life spans in which malignant
transformation could occur.
15

Acute exposure to high doses ( . 100 mSv) of radi-
ation, such as those used for radiotherapy, results in
what is termed deterministic effect. This is dened
as widespread cell death in affected tissues, generally
within days or weeks of exposure, that results in clinical
manifestations such as burn-like dermatitis, radiation
pneumonitis, pulmonary brosis,
17
and GI illness.
12,16,18

Such nonneoplastic tissue damage does not result
from low doses associated with medical imaging.
National and international bodies have concluded
from current evidence that for low-LET radiation,
the relationship between dose and cancer risk is lin-
ear, with some risk even at minimal doses (the linear,
no-threshold model).
5,11,12,15,18-20
Study of atomic bomb
survivors, nuclear plant workers, and other groups
exposed to low-LET radiation yields sufcient data to
conclude that organ doses between 5 and 125 mSv
cause a small, but statistically signicant increase in
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752 Special Features
CT scanning with patients. It may be important to
avoid citing numeric values for which patients have
no frame of reference. A comparison with natural
background radiation exposure may be better under-
stood. In 1 year, individuals receive slightly less than
one-half the dose associated with a routine chest
CT scan from background sources, including cosmic
radiation and radon gas (3 mSv).
19
Another compar-
ator is risk from exposure to normal activities. For
example, driving 2,000 miles carries a risk of death
of one in 10,000 (from a motor vehicle accident), which
is comparable to the added risk of cancer fatality
associated with an exposure of 1 to 10 mSv of ioniz-
ing radiation. As another alternative, one may express
CT scan-radiation dose in relation to the dose from
a chest radiograph, where radiation from a chest
CT scan is 100 to 400 times higher than from a two-
view chest radiograph.
5,35
In discussions with patients,
it is worth emphasizing the compounded risk of
repeated CT scans and encouraging personal dose
recording and reporting to all providing clinicians.
9,20

Public Health Effects of Chest CT Scans
CT scanning has revolutionized the management
of many diseases.
5,11
Its cost, availability, convenience,
and versatility have made it one of the most used and
fastest growing imaging technologies.
11,15
In 1993,
about 18 million CT scans were performed in the
United States, and in 2007, this number had increased
to . 70 million.
5,7
During this period, CT scan utili-
zation grew at 10 times the rate of US population
growth.
14

Diseases of the chest are major public health con-
cerns, and advances in CT scan technology have rev-
olutionized the management of many pulmonary and
cardiac conditions. Of the 67 million CT scans per-
formed in the United States in 2006, 11.6 million
(17.4%) included the chest. Because the thyroid, breast,
and lungs are among the most cancer-susceptible organs
in the body and are included in chest CT scan, the large
scale of use may have epidemiologic signicance.
14,36

Efforts to Reduce Radiation Dose
Efforts have been made to decrease CT scan-
related radiation dose on the population and individual
levels.
9,11,28
Dose reduction strategies are summarized
in Table 2 .
Population-Wide Dose Reduction Initiatives
In the United States, medical radiation has
replaced background radiation as the primary source
of population-wide exposure.
18,29
The threshold for
cancer risk.
8,15,20
The mean effective dose in atomic
bomb survivors was 40 mSv,
8
a dose similar to that
incurred from ve to six routine chest CT scans.
21

Although there is active discourse on whether the ran-
dom risks associated with stochastic effects on tissues
are strictly additive probabilities (a core assumption
of the linear, no-threshold model), experts agree that
each exposure carries incremental risk, increasing the
cumulative probability of developing a malignancy
with repeated exposures.
5,19,22
The effect of interval
length between low-dose imaging studies on cancer
risk is unresolved partly because of the undened
inuence of cell repair mechanisms.
23-25
Overall, how-
ever, the radiation risk from two CT scans is believed
to be roughly twice the risk of a single scan, irrespec-
tive of the time interval between the two.
26

There may be logical error in extrapolating risks
of medical radiation from epidemiologic studies of
Japanese atomic bomb survivors and other cohorts
exposed to low-LET radiation that is dissimilar from
the acute, partial-body exposure of a CT scan.
27
Esti-
mating the risk of cancer from a given effective dose
is associated with statistical limitations inherent in
assumptions for the calculation of risk.
28,29
Further-
more, existing data may not denitively establish that
the cancer risk associated with exposure to small doses
of ionizing radiation adds signicantly to human high
baseline lifetime risk (25%-42%).
9,12,27-30
Large stud-
ies designed to conclusively dene the relationship
between imaging-associated radiation and cancer are
underway, including a UK-based longitudinal study
of about 250,000 patients.
11

A clinician may appropriately become more liberal
in ordering CT scans of most body regions as his or
her patients age because of declining risk of carcino-
genesis; however, this may not be a prudent strategy
for chest CT scan. Perhaps counterintuitively, an older
age (50-60 years) at the time of exposure correlates
with increased respiratory tract cancer risk in atomic
bomb survivors.
15,31-33
Therefore, lung cancer risk is
likely higher when radiation exposure occurs at an
older age. This is in contrast to other forms of cancer,
such as lymphoma and breast cancer, where the risk
of developing cancer is higher with exposure at a
younger age. Patients with lung cancer often are
especially vulnerable to radiation-induced carcino-
genesis because of both advanced age and an estab-
lished synergistic carcinogenic effect of radiation and
tobacco smoke.
34
The benets of imaging surveillance
studies in patients with lung cancer should be weighed
carefully against the risks.
Discussing Risks With Patients
Given the complex nature of the subject, it can
be challenging to discuss the radiation risks of
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where motivated and informed patients can enter
their own data.
5,9,20
Recently, there has been a move-
ment toward institutionalized dose recording and
reporting of unintended exposures. California recently
adopted Senate Bill 1237, requiring facility accred-
itation, recording of individual cumulative radiation
doses, and reporting of accidents to a state agency.
35

It is likely that other institutional bodies will adopt
similar measures. The US Food and Drug Adminis-
tration recently recommended that CT scanners be
manufactured with the capability of alerting techni-
cians if safe doses are exceeded. Additional authori-
zation would then be required to proceed with the
study, and nally, data would be transmitted to auto-
matically initiate an audit.
45

Tracking an individual patients cumulative radia-
tion dose remains difcult, particularly because patients
commonly receive care from unafliated providers.
Ideally, after protocols are standardized, consensus
is reached on how to accurately measure adminis-
tered doses, and the majority of institutions gain
technical dose recording ability, reporting to central-
ized registries will be implemented. Although such
a registry for radiation dose does not currently exist,
registries founded on similar principles for public
health measures, such as childhood vaccination, have
been instituted.
46

Reducing Radiation Dose
From Individual Studies
Reducing the dose administered during each study
decreases individual radiation burden from CT scan.
Evidence-based decision-making identies patients
for whom a CT scan study would provide clear net
benet and situations in which imaging tools that do
not deliver radiation (eg, MRI, ultrasonography) are
appropriate.
5,15
Once the decision for a CT scan has
been made, it is important to optimize technical
parameters to minimize risk and maximize diagnostic
utility. Dose reduction strategies have been variably
incorporated into CT scanning protocols. In under-
standing these technologies, it is important to consider
a fundamental concept: Higher doses of radiation
yield clearer CT images. Therefore, with all dose
reduction measures, dose and image clarity must be
balanced.
15

Several factors determine the amount of radiation
delivered during CT scan, including patient size, body
habitus, and anatomic area of interest. User-set param-
eters are important determinants of radiation dose.
8

The relationship of various factors with delivered
dose is presented in Table 3 . Image quality for a given
dose depends on the volume and density of a given
slice of tissue. Smaller, less-dense slices require less
radiation to generate images of sufcient clarity. Small
ordering CT scan has lowered even in younger,
healthier patients for whom risks may outweigh
benets.
5,15,30
Risk-benet analyses are difcult to per-
form, and available decision aids often are underused
in practice.
11

It has been estimated that 26% to 44% of CT scans
are ordered inappropriately.
5,11,15,37
To counter this,
appropriateness criteria and decision support soft-
ware are increasingly being incorporated into com-
puterized physician order entry systems.
38
In addition,
focused educational programs have been shown to
increase appropriate use.
39,40
Professional organizations
have initiated national campaigns (Image Gently,
41,42

Step Lightly,
41,42
and Image Wisely
43
) to educate the
general public and professionals about dose reduc-
tion measures.
Technical shortfalls represent another source of
excessive exposure. Wide dose variation exists within
and across institutions; therefore, it has been proposed
that CT scan protocols be optimized and standard-
ized across sites.
5
Quality control recommendations,
such as facility accreditation offered by the American
College of Radiology,
11
have been put forth to ensure
that patients are exposed to doses that are as low as
reasonably achievable.
Some patient populations, including those with
chronic conditions such as cystic brosis and screening-
eligible patients at risk for various diseases, are often
exposed to high cumulative radiation doses from
repeated CT scans.
9,34,44
To date, recording of indi-
viduals cumulative CT scan radiation doses has been
limited to mobile device applications and websites
Table 2 Dose Reduction Strategies
Dose Reduction Strategy Available Tools
Determine whether
imaging is indicated
Guidelines
Appropriateness criteria
Decision support
Radiology consultation
Appropriate study selection Guidelines
Patients past imaging
record/exposure
Appropriateness criteria
Decision support
Radiology consultation
Alternative modalities (eg,
ultrasound, MRI)
Dose reduction during study Refer to accredited imaging facilities
Optimized user-set parameters
(see Table 3 )
Bismuth shielding
Automated exposure control
ECG gating, iterative reconstruction
Reporting and recording Patient medical record
Dose calculating/recording software
or websites
Reporting to appropriate agencies as
necessary
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754 Special Features
the breast, rather than just at the shielded surface,
without increasing image noise or producing the arti-
facts associated with bismuth shielding.
53

ECG gating in cardiac CT scan eliminates the
artifact produced by movement of the heart. Syn-
chronizing CT scan data with simultaneous ECG
recordings allows image reconstruction from scan data
obtained from the portion of the cardiac cycle where
the heart is most still (diastole).
11,14,48,54
In typical (ret-
rospective) ECG gating, the heart is imaged through-
out its cycle, and systolic data are subtracted afterward.
Prospective ECG gating activates the x-ray beam only
during diastole and may allow radiation dose reduc-
tions of . 90%.
55

Radiation, Cancer Risk, and Specific
Chest CT Scan Modalities
Dose estimates from various chest CT scan studies
are summarized in Table 4 .
CT Scan Coronary Angiography
CTCA has emerged as a noninvasive alternative to
traditional coronary angiography. An additional appli-
cation of CTCA is coronary artery calcium screen-
ing.
14
Although CTCA once required high doses of
radiation, developments such as prospective ECG
gating and reconstruction techniques have led to
signicant dose reductions.
14,48,50,54
Concern over radia-
tion risk from CTCA arises from lack of standardiza-
tion of protocols and increasingly widespread use for
screening.
14

As in other CT scan examinations of the chest,
the lungs and breasts absorb the highest radiation
doses and are at greatest risk for developing cancers.
Einstein et al
75
estimated lifetime attributable risk of
cancer in a 20-year-old woman from a single, standard
CTCA without dose reduction measures at 0.70%.
Using different methods, Hurwitz et al
56
determined
that, for a 25-year-old woman undergoing CTCA,
excess relative risk for breast cancer was 1.4% to 2.6%
and for lung cancer, 2.4% to 3.8%.
It is important to note that older individuals at high
risk for coronary artery disease but at lower risk for
most radiation-induced cancers (except respiratory
tract cancers) are much more likely to undergo car-
diac CT scan in clinical practice. Reecting this, in a
cohort referred for CTCA by clinicians, an estimate
of the average lifetime radiation-induced cancer risk
was only 0.13%.
26
Another study estimated that 21 to
23 individuals per 100,000 62-year-old individuals
undergoing one low-dose CTCA study would develop a
radiation-induced cancer; nonetheless, the lower-risk
characteristics of actual screening populations do not
adult patients and children, therefore, require smaller
doses than larger adults. Automated exposure control
(automatic tube current modulation), which has been
shown to reduce dose by 40% to 70%, is a feature
based on this principle.
11,47
Because different parts
of the body have different size and density character-
istics, data from a CT scan scout image may be used
to determine how much radiation must be delivered
to each region. The well-aerated chest requires less
radiation for a clear image than the denser, larger
abdomen. During a study that evaluates both the
chest and the abdomen, automated exposure control
allows a smaller x-ray tube current to be used on the
chest, protecting sensitive chest structures from the
larger current required for abdominal imaging.
Another software-based approach applies mathe-
matical models called noise reconstruction algorithms,
enhancing the performance characteristics of lower-
dose scans by retrospectively subtracting artifact from
CT images.
48
A newer processing innovation known
as model-based iterative reconstruction may provide
chest CT images of similar quality to those obtained
with traditional methods using doses similar to a chest
radiograph.
49

The protection of radiosensitive tissues, such as the
breast and thyroid, with bismuth shields is another
method being used for dose reduction.
48,50
Although
traditional shielding (eg, of the gonads during pelvic
radiography) is meant to block virtually the entire
x-ray beam, bismuth shielding allows partial penetra-
tion.
48
Bismuth breast shields have been associated
with dose reductions of 29% to 57% and have poten-
tial to become ubiquitous public health tools.
8,48,51

Experts disagree about the importance of image
artifacts produced by bismuth breast shields. Although
the practice does affect image quality, it does not
seem to impair diagnostic discrimination, especially
when shields are spaced 1 to 2 cm from the body.
52

Technical strategies such as organ-based angular tube
current modulation (not currently commercially avail-
able), which decreases tube current as the tube passes
closest to specic organs, decrease dose throughout
Table 3 Relationships Between Test and Patient
Properties and Radiation Dose From CT Scan
Examinations
Test and Patient Property Proportionality to Dose
Patient body habitus Direct
a

Maximum tube potential Exponential
Tube current Direct
a

Table speed Inverse
Gantry rotation time Direct
a

Scan length Direct

a
Increased doses necessary for acceptable image quality with increas-
ing BMI.
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756 Special Features
68% greater risk for breast cancer by age 35 years
than a 20-year-old woman without such exposure.
79

Low-Dose CT Scan Screening for Lung Cancer
The landmark National Lung Screening Trial
80

showed that annual screening with low-dose CT scan-
ning for 3 years reduced all-cause mortality by 6.7%
and death from lung cancer by 20.0% compared with
screening by conventional radiography. Similarly, the
Italung-CT trial
32
showed a 10% to 30% reduction in
mortality risk from low-dose CT screening. The risk of
radiation-induced cancer was not assessed by these
studies because of insufcient length of follow-up.
80

Estimates of average effective dose from screening
chest CT scans range from 0.6 to 1.1 mSv per study.
14

The large population eligible for lung cancer screen-
ing is vulnerable to radiation-induced lung cancer
because of advanced age and smoking status (in con-
trast to other types of cancer, as discussed previously).
Brenner
34
estimated that if 50% of current and for-
mer smokers in the United States underwent annual
CT scan screening from age 50 to 75 years, associated
radiation-induced lung cancer would increase the
total lung cancer burden by 1.8%. Without account-
ing for annual repeat or follow-up examinations, the
International Commission on Radiologic Protection
60

determined that per 100,000 screened, three to
six cases of radiation-induced cancer would occur
over a 15- to 20-year period. From Italung-CT trial
data, it is estimated that 4-year effective doses of
3.3 to 5.8 mSv would be incurred, accounting for
additional follow-up and interventional CT scans for
indeterminate, suspicious nodules.
32
This exposure is
predicted to result in 11.7 to 20.5 radiation-induced
fatal cancers per 100,000 50- to 70-year-old subjects
screened. Despite this, the measured benets of a
4-year screening program outweigh the risks for both
female and male smokers. Similarly, Brenner
34
sug-
gested that a 5% reduction in overall mortality from
CT scan screening would outweigh radiation risks.
The results of both Italung-CT trial and National
Lung Screening Trial far exceed this threshold.
HRCT Scan of the Lung
HRCT scan, a technique used to obtain detailed
images of the lung parenchyma and interstitium, is
useful in evaluating diseases that affect the lung dif-
fusely, such as bronchiectasis and interstitial lung
disease. One-millimeter slices, spaced 1 to 2 cm apart,
are imaged. Technical hallmarks of this technique
include thin collimation, in which the peripheral,
nonuseful portion of the x-ray beam is eliminated
for improved resolution, and a specialized high-
frequency spatial mathematical algorithm for image
reconstruction.
61-63

completely negate the potential public health impact
of CTCA because of the scale on which screening
studies may be performed. Hall and Brenner
15
esti-
mated that about 7,000 deaths would result from
radiation-induced lung cancer if all 61 million eligible
Americans were screened for coronary artery calcium.
CT Scan Pulmonary Angiography
CTPA has replaced ventilation-perfusion scintig-
raphy and conventional pulmonary angiography as
the imaging study of choice for suspected pulmo-
nary embolism.
14,76
CTPA is widely available, relatively
noninvasive, and has higher rates of diagnostic reso-
lution and interobserver agreement than ventilation-
perfusion scintigraphy.
14,76

Because of the epidemiologic characteristics of pul-
monary embolism, CTPA is used to evaluate patients
of all ages.
14
Over a 2-year period at one institution,
60% of CTPA studies were performed in women.
Nearly 30% of those women were aged , 40 years.
57

Because CTPA use is common, and because radiation-
associated risks to younger patients and women are
higher, increasing use may elevate the population-
wide risk for breast and other cancers.
76
Use of CTPA
and the resultant cancer risk could be reduced by
closer adherence to emerging appropriate-use criteria.
Use of radiation-sparing modalities, such as ventilation-
perfusion scintigraphy and ultrasound of the lower
extremities, remains the approach of choice in certain
situations.
77
For example, lower-extremity venous ultra-
sonography has been put forth as the rst-line study
for a stable, female patient of reproductive age with a
high clinical probability of pulmonary embo lism and
an elevated D-dimer. In addition, nearly one-third of
PIOPED II (Prospective Investigation of Pulmonary
Embolism Diagnosis) investigators favor ventilation-
perfusion scanning over multidetector CTPA in eval-
uating for pulmonary embolism.
78

As with other CT scan examinations of the chest,
strategies such as automated exposure control, decreased
tube voltage, and limited-range scanning that excludes
nonessential anatomic structures have resulted in
decreased doses without detriment to diagnostic per-
formance.
14
The average effective dose range for
CTPA has been estimated to be 1.4 to 15 mSv.
21,58,59

For comparison, the average dose incurred from con-
ventional pulmonary angiography is about 7.1 mSv
(range, 3.3-17.3 mSv) and from ventilation-perfusion
scintigraphy, 1.2 mSv.
58,59
The average organ-absorbed
dose delivered per breast to an average 60-kg woman
undergoing CTPA is 20 mGy (by contrast, the average
organ dose per breast from ventilation-perfusion
scintigraphy is 0.28 mGy).
57
A 20-year-old woman
receiving a breast-absorbed dose of 40 mGy from
a single CTPA study has been estimated to be at
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journal.publications.chestnet.org CHEST / 142 / 3 / SEPTEMBER 2012 757
ECG-gated cardiac CT scan) to 1% (20-year-old woman,
nongated TROCT scan).
75
Even with dose reduc-
tion, the lifetime cancer risk from one study could be
30 times greater for a young woman than for an
elderly man, highlighting the importance of careful
risk stratication.
75

Conclusions
Even if single CT scans increase the individual risk
of malignancy minutely, expanding use amplifies
population-wide risk.
5,8,14,15
There is still scientic uncer-
tainty surrounding the risk and likelihood of devel-
oping a radiation-induced malignancy from CT scan.
However, at our current level of understanding, it
appears unwise to assume that there is no increased risk
and, thereby, to expose patients to doses that future
study may reveal to be critical.
26
Chest physicians can
minimize patient exposure to imaging-associated radia-
tion through (1) self and patient education; (2) use of
evidence-based guidelines, appropriateness criteria,
and decision support to eliminate unnecessary studies;
(3) mindfulness of the number and type of CT scans
each patient has received; (4) referral of patients to
accredited imag ing facilities that use current dose
reduction strategies; and (5) recording and reporting
of radiation doses.
Acknowledgments
Financial/nonnancial disclosures: The authors have reported
to CHEST that no potential conicts of interest exist with any
companies/organizations whose products or services may be dis-
cussed in this article .
Other contributions: Jana Johnson provided additional edi-
torial and formatting assistance. We thank Julie Felice, CPM,
and Ulrich Rassner, MD, for their advice on the topic of medical
physics.
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