Professional Documents
Culture Documents
Phantom and Abdominal Circumference
Phantom and Abdominal Circumference
Phantom and Abdominal Circumference
T
i
m
e
P
r
o
d
u
c
t
,
K
i
l
o
v
o
l
t
a
g
e
,
a
n
d
A
b
d
o
m
i
n
a
l
C
i
r
c
u
m
f
e
r
e
n
c
e
(
A
C
)
S
e
t
t
i
n
g
s
A
C
,
T
u
b
e
C
u
r
r
e
n
t
T
i
m
e
P
r
o
d
u
c
t
8
0
k
V
p
1
0
0
k
V
p
1
2
0
k
V
p
1
4
0
k
V
p
C
T
D
I
(
c
G
y
)
O
v
e
r
a
l
l
N
o
i
s
e
(
H
U
)
L
i
v
e
r
N
o
i
s
e
(
H
U
)
C
T
D
I
(
c
G
y
)
O
v
e
r
a
l
l
N
o
i
s
e
(
H
U
)
L
i
v
e
r
N
o
i
s
e
(
H
U
)
C
T
D
I
(
c
G
y
)
O
v
e
r
a
l
l
N
o
i
s
e
(
H
U
)
L
i
v
e
r
N
o
i
s
e
(
H
U
)
C
T
D
I
(
c
G
y
)
O
v
e
r
a
l
l
N
o
i
s
e
(
H
U
)
L
i
v
e
r
N
o
i
s
e
(
H
U
)
1
0
0
c
m
5
0
m
A
s
0
.
4
3
1
4
.
0
3
9
.
3
1
.
0
1
6
6
.
3
2
0
.
8
1
.
4
9
9
.
9
1
2
.
5
2
.
1
7
4
.
7
9
.
3
1
0
0
m
A
s
0
.
8
1
8
1
.
6
2
2
.
7
1
.
8
1
1
1
.
0
1
3
.
9
2
.
6
6
1
.
3
7
.
7
3
.
7
4
5
.
3
5
.
7
2
0
0
m
A
s
1
.
7
1
4
1
.
2
1
7
.
7
3
.
6
6
1
.
0
7
.
6
5
.
1
3
8
.
0
4
.
8
7
.
6
3
1
.
8
4
.
0
3
0
0
m
A
s
2
.
5
1
2
0
.
2
1
5
.
0
5
.
2
4
6
.
5
5
.
8
7
.
7
3
1
.
4
3
.
9
1
1
.
7
2
3
.
7
3
.
0
4
0
0
m
A
s
3
.
6
9
8
.
1
1
2
.
3
7
.
6
3
5
.
9
4
.
5
1
1
.
3
2
7
.
0
3
.
4
1
5
.
5
2
0
.
2
2
.
5
5
0
c
m
5
0
m
A
s
1
.
0
2
9
.
7
3
.
7
2
.
1
1
8
.
4
2
.
3
3
.
0
1
3
.
8
1
.
7
4
.
6
1
2
.
0
1
.
5
1
0
0
m
A
s
2
.
1
1
8
.
7
2
.
3
4
.
2
1
3
.
3
1
.
7
5
.
7
1
0
.
4
1
.
3
8
.
3
8
.
7
1
.
1
2
0
0
m
A
s
3
.
7
1
4
.
4
1
.
8
7
.
7
8
.
8
1
.
1
1
1
.
5
7
.
9
1
.
0
1
6
.
0
6
.
1
0
.
8
3
0
0
m
A
s
5
.
7
1
2
.
1
1
.
5
1
2
.
3
7
.
3
0
.
9
1
8
.
4
6
.
1
0
.
8
2
5
.
4
5
.
3
0
.
7
4
0
0
m
A
s
8
.
0
9
.
0
1
.
1
1
6
.
4
6
.
9
0
.
9
2
4
.
4
6
.
0
0
.
8
3
5
.
5
4
.
7
0
.
6
3
0
c
m
5
0
m
A
s
1
.
1
1
6
.
3
2
.
0
2
.
3
1
0
.
3
1
.
3
3
.
5
8
.
9
1
.
1
4
.
8
8
.
3
1
.
0
1
0
0
m
A
s
2
.
2
1
0
.
8
1
.
4
4
.
4
8
.
3
1
.
0
6
.
5
7
.
0
0
.
9
8
.
9
7
.
0
0
.
9
2
0
0
m
A
s
4
.
3
8
.
4
1
.
1
8
.
9
6
.
8
0
.
9
1
2
.
4
6
.
9
0
.
9
1
7
.
5
5
.
7
0
.
7
3
0
0
m
A
s
6
.
5
8
.
1
1
.
0
1
3
.
2
6
.
1
0
.
8
1
8
.
8
5
.
3
0
.
7
2
8
.
3
4
.
4
0
.
6
4
0
0
m
A
s
8
.
8
8
.
1
1
.
0
1
7
.
1
5
.
4
0
.
7
2
6
.
5
5
.
2
0
.
7
3
9
.
1
4
.
4
0
.
6
N
o
t
e
O
p
t
i
m
a
l
v
a
l
u
e
s
w
e
r
e
c
h
o
s
e
n
o
n
t
h
e
b
a
s
i
s
o
f
o
p
t
i
m
a
l
n
o
i
s
e
(
2
0
H
U
)
a
n
d
d
o
s
e
(
2
c
G
y
)
,
s
h
o
w
n
i
n
b
o
l
d
t
y
p
e
.
B
o
r
d
e
r
l
i
n
e
n
o
i
s
e
a
n
d
d
o
s
e
l
e
v
e
l
s
(
2
2
.
5
c
G
y
)
a
r
e
s
h
o
w
n
i
n
i
t
a
l
i
c
t
y
p
e
.
C
T
D
I
=
C
T
d
o
s
e
i
n
d
e
x
.
AJR:199, September 2012 675
Use of Abdominal Phantom to Determine Pediatric CT Parameters
from 140 kVp (used in the largest patients) to
80 kVp (used in infants and small children)
resulted in a 40% increase in CNR. On the
other hand, a dose reduction of 70% can be
achieved from 140 to 80 kVp while still main-
taining a desired CNR. The technique optimi-
zation tables include tube currenttime prod-
uct and kilovoltage recommendations based
on AC for all children.
Efforts to decrease kilovoltage have im-
portant implications in pediatric abdominal
CT in that intrinsic tissue contrast rises with
a decrease in kilovoltage, leading to superi-
or ability to distinguish between two tissues
with similar attenuation properties. In addi-
tion, because the K-edge of iodine is 33 keV,
lower-kilovoltage imaging lies closer to the
iodine K-edge, prompting discussion of po-
tentially lowering the volume of iodinated
contrast agent needed for an individual pe-
diatric CT scan [15]. In a study of 40 adult
patients randomized to one of two low-kilo-
voltage abdominal CT protocols, Nakayama
et al. [27] showed that one could reduce the
iodinated IV contrast bolus by at least 20%
at 90 kVp and achieve solid organ and vas-
cular enhancement that was superior to that
achieved at 120 kVp. In a similar study de-
sign, Marin et al. [28] showed improved sol-
id organ and vascular enhancement in CT for
pancreatic carcinoma using a low kilovoltage
and higher tube currenttime product tech-
nique, while lowering the radiation dose by
71% and improving the CNR by 37%. The
double dose reduction achieved in reducing
kilovoltage and IV contrast agent is an ap-
pealing concept for pediatric CT.
Improvements in CNR are related to both
increases in contrast and decreases in noise.
Improved contrast provides the greatest ben-
et in detecting small low-contrast structures,
such as liver lesions in fungal septicemia. One
must bear in mind that, by lowering the ki-
lovoltage, improved lesion detection through
improved contrast might be outweighed by
the negative effects of decreased dose (and
increased noise) such that kilovoltage reduc-
tion would have to be paired with a modest
increase in tube currenttime product. In the
case of small-vessel detection with CT angi-
ography, a reduction in kilovoltage provides
its greatest benet in dose reduction, not low-
contrast lesion detection, because contrast is
already maximized through IV iodinated con-
trast agent administration. In these cases, tube
currenttime product may be further reduced
without signicant effect on image quality.
A limitation of the current work was the
inability to adequately address how body
shape changes with age and how this change
can affect girth and, therefore, CT techniques
based on girth. We recognize that, as chil-
dren grow in height and weight from infancy
to adulthood, the patterns of growth can be
nonuniform [17]. Some children will add sig-
nicantly to their weight while increasing in
height marginally for a time. This pattern of
growth will likely add to girth. Other children
may grow rapidly in height and marginally in
weight for periods in their growththis pat-
tern, while not affecting girth much, may af-
fect the oval ratio of the childs cross-section.
In each case, girth and cross-sectional shape
can change dramatically as age increases. In
the tall lean child, signicant oval shape may
be present, greater than that studied in this ar-
ticle. In the child who adds weight without a
signicant increase in height, a more circu-
lar cross-section may be present; this was ad-
dressed in our rst article [14]. More work is
needed concerning how different oval ratios
at xed girth and also xed oval ratio at vari-
ous girths affect CT techniques to maintain
adequate noise at reasonable radiation doses.
Another limitation was that one vendors CT
platform was used to collect data. A more com-
plete sampling of various manufacturers and
detector geometries with a vendor product list
0
0.0
0.5
1.0
1.5
2.0
3.0
3.5
5.0
4.5
4.0
2.5
60 50 40 30 20 10 80 70 90 100 110 120
AC (cm)
D
o
s
e
(
c
G
y
)
80 kVp (120 mAs)
100 kVp (65 mAs)
120 kVp (65 mAs)
140 kVp (50 mAs)
Tube Voltage (kVp)
80
10
20
30
40
50
100 120 140
C
N
R
Tube Voltage (kVp)
80
0.0
0.4
0.8
1.2
1.6
2.0
100 120 140
D
o
s
e
(
c
G
y
)
Fig. 5Technique optimization curve shows optimal kilovoltage and tube
currenttime product dose pairs (shaded area) for absorbed dose and abdominal
circumference (AC).
Fig. 6Contrast-to-noise ratio (CNR) was reduced with higher kilovoltage while
keeping dose at 0.65 cGy (measured with 16-cm-diameter CT dose index phantom).
Fig. 7Radiation dose
was measured at different
kilovoltage to maintain
contrast-to-noise ratio at
40 (dose measured with
16-cm-diameter CT dose
index phantom).
676 AJR:199, September 2012
Dong et al.
is warranted. This is especially true regarding
row number; as detector array width increases,
the effects of scattered radiation into adjacent
rows may have an effect on signal-to-noise ra-
tio, thereby changing our results. No attempt
was made in this article to maximize or even
characterize CNR. In large measure, this was
the result of limitations in our phantom and lack
of funding for this work. Future CNR work in
conjunction with other limitations, as already
discussed, is planned. We did not explore in
this work how our technique recommendations
would affect spatial resolution. The phantom
we used did not contain tools adequate to in-
vestigate this question. The issue of selecting
an upper level of tolerable noise in a clinical
setting is not so much a limitation as it is an
unavoidable reality; it is, however, somewhat
subjective. In a more exhaustive setting, other
radiologists would be queried as to what upper
level of noise they would accept. The question
of what upper level of noise is acceptable in CT
images where noise is a limiting factor is under
way and will be reported separately. Finally, a
limitation of this work was to use the liver as
a proxy for all soft abdominal or retroperitone-
al organs. We chose the liver for the following
reasons: it is host to many diseases; it is large
enough (even in small patients) to get an ade-
quate ROI circle from which noise can be as-
certained; and it is reasonably homogeneous. It
is planned that in clinical studies more organs
of interest will be included.
Regarding automated dose reduction tech-
niques available on commercial CT scanners,
we acknowledge their presence, use, and po-
tential for dose reduction in certain situations.
The goal of our work was to study the basic
effect that kilovoltage has on dose in the con-
text of adequate image quality, as determined
by a maximum permissible noise value. Our
intent was to use kilovoltage as the primary
driver for dose reduction and to use tube cur-
renttime product as the ne-tuning mecha-
nism within a kilovoltage selection (and girth
range). In later work, we plan to look at in-
plane and z-axis modulation once a kilovolt-
age stop has been selected according to girth.
Many centers performing pediatric CT are
now using safe practices for radiation dose re-
duction using technique charts for tube cur-
renttime product reduction based on patient
weight or age. We have shown that, because
pediatric patients of the same age and weight
come in all shapes and sizes, AC is a useful
clinical parameter on which to base CT scan
techniques controlling radiation output, name-
ly kilovoltage and tube currenttime product.
References
1. Amis ES, Butler PF, Applegate KE, et al. American
College of Radiology white paper on radiation dose
in medicine. J Am Coll Radiol 2007; 4:272284
2. [No authors listed]. Looking back on the millen-
nium in medicine. N Engl J Med 2000; 342:4249
3. Brenner DJ. Should we be concerned about the
rapid increase in CT usage? Rev Environ Health
2010; 25:6368
4. Fayngersh V, Passero M. Estimating radiation risk
from computed tomography. Lung 2009; 187:143148
5. Schauer DA, Linton OW. National Council on Ra-
diation Protection and Measurements report
shows substantial medical exposure increase. Ra-
diology 2009; 253:293296
6. Rabin RC. With rise in radiation exposure, ex-
perts urge caution on tests. The New York Times,
June 19, 2007
7. Mozes A. Certain tests in ERs raise cancer risk for
some. The Washington Post, May 29, 2008
8. Brenner DJ, Elliston C, Hall E, Berdon W. Esti-
mated risks of radiation-induced fetal cancer from
pediatric CT. AJR 2001; 176:289296
9. National Research Council, Committee on the Bio-
logical Effects of Ionizing Radiations. Health effects
of exposure to low levels of ionizing radiation: BEIR
V. Washington, DC; National Academy Press, 1990
10. National Research Council, Committee on the
Biological Effects of Ionizing Radiations. Health
effects of exposure to low levels of ionizing radia-
tion: BEIR VII. Washington, DC; National Acad-
emy Press, 2007
11. Goske MJ, Applegate KE, Boylan J, et al. The Im-
age Gently campaign: increasing CT radiation dose
awareness through a national education and aware-
ness program. Pediatr Radiol 2008; 38:265269
12. Strauss KJ, Goske MJ, Frush DP, Butler PF, Mor-
rison G. Image Gently Vendor Summit: working
together for better estimates of pediatric radiation
dose from CT. AJR 2009; 192:11691175
13. Strauss KJ, Goske MJ, Kaste SC, et al. Image
Gently: ten steps you can take to optimize image
quality and lower CT dose for pediatric patients.
AJR 2010; 194:868873
14. Reid J, Gamberoni J, Dong F, Davros W. Optimi-
zation of kVp and mAs for pediatric low-dose
simulated abdominal CT: is it best to base param-
eter selection on object circumference? AJR 2010;
195:10151020
15. Kalva SP, Sahani DV, Hahn PF, Saini S. Using the
K-edge to improve contrast conspicuity and to
lower radiation dose with a 16-MDCT: a phantom
and human study. J Comput Assist Tomogr 2006;
30:391397
16. Boone JM, Geraghty EM, Seibert JA, Wootton-
Gorges SL. Dose reduction in pediatric CT: a ra-
tional approach. Radiology 2003; 228:352360
17. Fernndez JR, Redden DT, Pietrobelli A, Allison
DB. Waist circumference percentiles in nationally
representative samples of African-American, Eu-
ropean-American and Mexican-American children
and adolescents. J Pediatr 2004; 145:439444
18. Frush DP, Soden B, Frush KS, Lowry C. Improved
pediatric multidetector body CT using a size-based
color-coded format. AJR 2002; 178:721726
19. Thomas KE, Wang B. Age-specic effective dos-
es for pediatric MSCT examinations at a large
childrens hospital using DLP conversion coef-
cients: a simple estimation method. Pediatr Ra-
diol 2008; 38:645656
20. Kleinman PL, Strauss KJ, Zurakowski D, et al.
Patient size measured on CT images as a function
of age at a tertiary care childrens hospital. AJR
2010; 194:16111619
21. Arch ME, Frush DP. Pediatric body MDCT: a 5-year
follow-up survey of scanning parameters used by
pediatric radiologists. AJR 2008; 191:611617
22. Kim J-E, Newman B. Evaluation of a radiation
dose reduction strategy for pediatric chest CT.
AJR 2010; 194:11881193
23. Huda W, Scalzetti EM, Levin G. Technique factors
and image quality as functions of patient weight at
abdominal CT. Radiology 2000; 217:430435
24. Szucs-Farkas Z, Kurmann L, Strautz T, et al. Pa-
tient exposure and image quality of low-dose pul-
monary computed tomography angiography:
comparison of 100- and 80-kVp protocols. Invest
Radiol 2008; 43:871876
25. Wintersperger B, Jakobs T, Herzog P, et al. Aorto-
iliac multidetector-row CT angiography with low
kV settings: improved vessel enhancement and
simultaneous reduction of radiation dose. Eur Ra-
diol 2005; 15:334341
26. Nakayama Y, Awai K, Funama Y, et al. Abdominal
CT with low tube voltage: preliminary observations
about radiation dose, contrast enhancement, image
quality, and noise. Radiology 2005; 237:945951
27. Nakayama Y, Awai K, Funama Y, et al. Lower
tube voltage reduces contrast material and radia-
tion doses on 16-MDCT aortography. AJR 2006;
187:1266 [web];W490W497
28. Marin D, Nelson RC, Barnhart H, et al. Detection of
pancreatic tumors, image quality, and radiation dose
during the pancreatic parenchymal phase: effect of a
low-tube-voltage, high-tube-current CT technique
preliminary results. Radiology 2010; 256:450459