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Multisection CT Protocols:
Sex- and Age-specific Conversion
Factors Used to Determine Effective
ORIGINAL RESEARCH

Dose from Dose-Length Product1

Paul D. Deak, PhD
Purpose: To determine conversion factors for the new International
Yulia Smal, MSc
Commission on Radiological Protection (ICRP) publica-
Willi A. Kalender, PhD
tion 103 recommendations for adult and pediatric patients
and to compare the effective doses derived from Monte
Carlo calculations with those derived from dose-length
product (DLP) for different body regions and computed
tomographic (CT) scanning protocols.

Materials and Effective dose values for the Oak Ridge National Laboratory
Methods: phantom series, including phantoms for newborns; 1-, 5-,
and 10-year-old children; and adults were determined by
using Monte Carlo methods for a 64-section multidetec-
tor CT scanner. For each phantom, five anatomic regions
(head, neck, chest, abdomen, and pelvis) were considered.
Monte Carlo simulations were performed for spiral scan-
ning protocols with different voltages. Effective dose was
computed by using ICRP publication 60 and publication
103 recommendations. The calculated effective doses were
compared with those derived from the DLP by using pre-
viously published conversion factors.

Results: In general, conversion factors determined on the basis

of Monte Carlo calculations led to lower values for adults
with both ICRP publications. Values up to 33% and 32%
lower than previously published data were found for ICRP
publication 60 and ICRP publication 103, respectively. For
pediatric individuals, effective doses based on the Monte
Carlo calculations were higher than those obtained from
DLP and previously published conversion factors (eg, for
chest CT scanning in 5-year-old children, an increase of
about 76% would be expected). For children, a variation
in conversion factors of up to 15% was observed when the
tube voltage was varied. For adult individuals, no depen-
dence on voltage was observed.

Conclusion: Conversion factors from DLP to effective dose should be

specified separately for both sexes and should reflect the
new ICRP recommendations. For pediatric patients, new
conversion factors specific for the spectrum used should
1
From the Institute of Medical Physics, University Erlangen- be established.
Nürnberg, Henkestr. 91, 91052 Erlangen, Germany.
Received January 6, 2010; revision requested February 26; q
RSNA, 2010
revision received April 15; accepted April 29; final version
accepted May 27. W.A.K. is a consultant for Siemens
Supplemental material: http://radiology.rsna.org/lookup
Healthcare (Forchheim, Germany). Y.S. supported by the
Fundação para a Ciência e a Tecnologia (Portugal) for
/suppl/doi:10.1148/radiol.10100047/-/DC1
her PhD studies. Address correspondence to W.A.K.
(e-mail: willi.kalender@imp.uni-erlangen.de).

q
RSNA, 2010

158 radiology.rsna.org n Radiology: Volume 257: Number 1—October 2010

MEDICAL PHYSICS: Sex- and Age-Specific Conversion Factors for Effective Dose at CT
C
omputed tomography (CT) is the
most substantial contributor to
the collective effective dose for all
radiographic procedures. Surveys (1–5)
have shown that the contribution of CT
to the total collective dose can be as
high as 67% in the United States and
40% in Europe, although CT examina-
tions represent only about 11% and 4%,
respectively, of all radiologic examina-
tions. Therefore, the dose levels de-
livered in CT examinations should be
known and available to patients and
their physicians. The effective dose is
primarily used to compare the stochas-
tic risk associated with the exposure
to ionizing radiation. According to the
International Commission on Radiologi-
cal Protection (ICRP) ( 6,7 ), effective
dose represents a weighted sum of the
equivalent doses in all tissues and or-
gans of the body, where the equivalent
dose for an organ represents the sum of
the absorbed dose averaged over a tis-
sue or organ weighted by the radiation
Advances in Knowledge
n With use of the International
Commission on Radiological Pro-
tection publication 103 organ and
tissue weighting factors, conver-
sion factors for adults for the
head, chest, and pelvis were
found to be 18%, 14%, and 32%
lower than the European Com-
mission published values, respec-
tively, and were up to 6% higher
for the neck and abdomen.
n Conversion factors for the chest
region of adult women are up to
76% higher than those for the
chest region of adult men.
n Conversion factors for children
are severely underestimated by
the European Commission pub-
lished conversion factors (eg, for
chest scanning in 5-year-old chil-
dren, an increase by about 76%
would be expected).
n A dependence of conversion fac-
tors on tube voltage of less than
3% was found for adults, but this
dependence was up to 15% for
pediatric patients.
Radiology: Volume 257: Number 1—October 2010
weighting factor (ie, 1 in case of pho-
tons and electrons).
Generally, the effective dose is com-
puted by using Monte Carlo dose simula-
tion tools for reference human phantoms
(8). The practical method that is most
often used in clinical routine is to estimate
the effective dose from dose-length prod-
uct (DLP) measurements. In 1999, the
European Commission published a set of
conversion factors for different regions of
the body for adults (9). These conversion
factors are often cited in the literature
when the effective dose is computed from
the DLP. However, published conversion
factors do not consider differences in
scanning voltages, specific sex issues,
age, or variation in body size and shape.
Moreover, according to the ICRP publica-
tion 103 recommendations, new weight-
ing factors and organs at risk have been
defined (Table 1). It is worth mentioning
that the conversion factors used in
practice today were defined on the basis
of Monte Carlo simulations for single-
section CT scanners. Consequently, con-
version factors should be revisited and
possibly updated.
Currently, there is a lack of pub-
lished data on conversion factors con-
sidering the new generation of CT scan-
ners (eg, 64-section scanners) for adult
patients and even less data for pedi-
atric patients (10,11). Huda et al (10)
reported conversion factors from DLP
to effective dose for adult phantoms af-
ter the use of several dosimetry tools
and 16-section CT scanners from vari-
ous manufacturers. However, their pub-
lished data do not contain references for
pediatric patients, and the conversion
factors were computed on the basis of
ICRP publication 60 recommendations
with respect to effective dose. Shrimpton
Implications for Patient Care
n Conversion factors specific for
sex and age should be used for
the estimation of effective dose
from dose-length product (DLP).
n For pediatric patients, separate
conversion factors that take the
tube voltage into account should
be used to determine the effec-
tive dose from DLP.
n radiology.rsna.org
Deak et al
(11) extended the conversion factor
computation to pediatric patients by
using mathematical phantoms that rep-
resented newborns and children of 1,
5, 10, and 15 years. The Monte Carlo
computations were based on three mod-
els of scanners representing the first gen-
eration of CT scanners, and the conver-
sion factors were computed on the basis
of the old ICRP recommendations (6).
The aim of our study was to deter-
mine conversion factors for the new
ICRP publication 103 recommendations
for adult and pediatric patients and to
compare the effective doses derived
from Monte Carlo calculations with those
derived from DLP for different body re-
gions and scanning protocols.
Materials and Methods
No industry support was received for this
study. One author (W.A.K.) is a consul-
tant of Siemens Healthcare (Forchheim,
Germany). Authors P.D.D. and Y.S. had
control of inclusion of any data or infor-
mation that might present a conflict of
interest for the consultant author.
CT Scanner
All dose simulations were performed
for scanner geometry, spectra, and fil-
tration equivalent to those of a Soma-
tom Sensation 64 CT scanner (Siemens
Healthcare).
Published online
10.1148/radiol.10100047
Radiology 2010; 257:158–166
Abbreviations:
CTDI = CT dose index
CTDIvol = volumetric CTDI
CTDIw = weighted CTDI
DLP = dose-length product
ICRP = International Commission on Radiological Protection
ORNL = Oak Ridge National Laboratory
Author contributions:
Guarantors of integrity of entire study, P.D.D., W.A.K.; study
concepts/study design or data acquisition or data analysis/
interpretation, all authors; manuscript drafting or manuscript
revision for important intellectual content, all authors;
manuscript final version approval, all authors; literature
research, all authors; clinical studies, P.D.D., W.A.K.;
experimental studies, P.D.D., W.A.K.; statistical analysis, all
authors; and manuscript editing, all authors
See Materials and Methods for pertinent disclosures.
159
MEDICAL PHYSICS: Sex- and Age-Specific Conversion Factors for Effective Dose at CT Deak et al

Table 1 Dosimetry Tool and Simulation Setup

Tissue Weighting Factors in ICRP Publication 60 versus Those in ICRP Publication 103 The Monte Carlo calculations were per-
formed by using a validated dosimetry
Weighting Factor in Weighting Factor in
tool (ImpactMC; CT Imaging, Erlangen,
Tissue or Organ ICRP Publication 60 ICRP Publication 103
Germany) for clinical CT scanners. De-
Gonads 0.20 0.08 tails regarding implementation and
Red bone marrow 0.12 0.12 tool validation have been reported else-
Colon 0.12 0.12 where (17). The dose simulations were
Lung 0.12 0.12 performed according to the data in
Stomach 0.12 0.12 Tables 2 and 3 with respect to scan-
Bladder 0.05 0.04 ning protocol and scanning length, re-
Liver 0.05 0.04 spectively. Thus, for each phantom, five
Esophagus 0.05 0.04 scanned regions were defined according
Thyroid 0.05 0.04 to a head, neck, chest, abdomen, and
Breast 0.05 0.12 pelvis examination. Table 3 summa-
Bone surface 0.01 0.01 rizes the irradiated lengths as a function of
Skin 0.01 0.01
age, sex, and body region, whereas in
Brain Remainder organ 0.01
Figure 1b, the anatomic landmarks of
Salivary glands None 0.01
the regions are depicted by colors for
Remainder organs 0.05 0.12
the adult subjects. Thus, the regions
Adrenal glands 0.005 0.0086
Kidneys 0.005 0.0086
were defined as follows: (a) the head
Muscle 0.005 0.0086
(the rostral part, comprising the brain,
Pancreas 0.005 0.0086 eyes, ears, nose, and mouth), (b) the
Small intestine 0.005 0.0086 neck (from the end of the head region
Spleen 0.005 0.0086 to the beginning of the torso), (c) the
Thymus 0.005 0.0086 chest (from the thoracic inlet to the
Uterus and cervix 0.005 0.0086 thoracic diaphragm), (d) the abdo-
Brain 0.005 See above men (from the thoracic diaphragm to
Upper large intestine 0.005 None the pelvic inlet), and (e) the pelvis
Extrathoracic region None 0.0086 (from the pelvic inlet to the pelvic dia-
Gallbladder None 0.0086 phragm). The same landmarks were
Heart None 0.0086 also used for pediatric subjects. For
Lymphatic nodes None 0.0086 each region, four spiral scanning proto-
Oral mucosa None 0.0086 cols (pitch, 1.0; collimation, 19.2 mm)
Prostate None 0.0086 were simulated for voltages of 80, 100,
Total 1.00 1.00 120, and 140 kV. All other scanning
Note.—None = no weighting factor defined. parameters were kept constant during
simulations. A total of 200 simulations
were performed with a precision of 1%
Phantoms not previously considered (eg, the sali- or greater.
The phantoms used for our study were vary glands, extrathoracic tissue, lymph After the simulations, the three-
developed in our institution and were nodes, prostate, oral mucosa, and the dimensional dose distributions were
based on the Oak Ridge National Labo- nasal vestibule). Therefore, the original used together with organ index files to
ratory (ORNL) phantom series de- phantoms were modified to include the compute the organ doses as the average
scribed by Cristy and Eckerman (12) new organs and tissues. The organs were values over the voxels having the same
that used a format created previously modeled by using a set of surface equa- index. The organ dose values were tab-
by Snyder et al (13) and Cristy (14). tions, such as those for ellipsoids, cylin- ulated and used to calculate the effec-
The series consists of mathematically ders, and spheres, that were also used in tive doses and to estimate appropriate
defined phantoms that mimic newborns; the original ORNL phantoms (Fig 1a). conversion factors.
1-, 5-, and 10-year-old children; and The masses of the above-mentioned or-
adults. gans were determined by using ICRP Conversion Factor Estimation
For all phantoms, the organs that publication 89 (15) and International For the calculations of effective dose,
contribute to the effective dose as defined Commission on Radiation Units and Mea- the old (ICRP publication 60 [6]) and
in ICRP publication 60 (6) were mod- surements report 48 (16). Further details the new (ICRP publication 103 [7])
eled. However, ICRP publication 103 (7) regarding the description of the organs published organ and tissue weighting
introduced organs and tissues that were are presented in Appendix E1 (online). factors were used.

160 radiology.rsna.org n Radiology: Volume 257: Number 1—October 2010

MEDICAL PHYSICS: Sex- and Age-Specific Conversion Factors for Effective Dose at CT Deak et al

Figure 1

Figure 1: (a) The organs in the head and neck that were newly given weighting factors in ICRP publication 103. The organs were defined as ellipsoids, cylinders, or
spheres, as in the original description by Cristy and Eckerman (12). (b) The ORNL phantom series used for computation of conversion factors. Colors = scanned re-
gions in adult phantoms. (For simplicity, scanned regions are shown only for the adult phantoms. The same region landmarks were used for the pediatric phantoms.)
The original phantoms contain all the necessary organs used for computation of effective dose as defined in ICRP publication 60.

The conversion factors (CFs) were Table 2

determined according to the following
equation: Scanning Protocols Used for Monte Carlo Dose Simulations
Parameter Datum

E RG, A , Phantom Newborn; 1-, 5 -, and 10-year-old children; adult

CFRG, A Region Head, neck, chest, abdomen, and pelvis
DLPR
Protocol Spiral scanning, pitch = 1.0
Tube voltage (kV) 80, 100, 120, And 140
where E is the effective dose, R denotes Exposure (mAs) 100
the scanned region, and G and A stand for Collimation (mm) 19.2 (32 detector rows 3 0.6-mm-thick sections)
sex and age, respectively. The DLPs were
determined as the product of the volumet-
ric CT dose index (CTDIvol) and the irradi- CTDI w , body phantoms of 16- and 32-cm diam-
CTDI vol eters and p is pitch (9). For our study,
ated length of region R (LR), as follows: p
with spiral examinations with a pitch
where CTDIw is the weighted CTDI factor of 1.0, the CTDIvol was equal
DLPR CTDI vol <L R and measured in standard acrylic head and to CTDIw. Table 4 gives the values of

Radiology: Volume 257: Number 1—October 2010 n radiology.rsna.org 161

MEDICAL PHYSICS: Sex- and Age-Specific Conversion Factors for Effective Dose at CT Deak et al

Table 3 Figure 3 presents the mean conver-

Irradiated Length as a Function of Age and Body Region sion factors, averaged over sex and volt-
age, for pediatric subjects computed with
Newborn 1-Year-Old 5-Year-Old 10-Year-Old Adult Female Adult Male ICRP publication 60 (Fig 3a) and ICRP
Body Region Phantom Phantom Phantom Phantom Phantom Phantom
publication 103 (Fig 3b), together with the
Head 11.47 15.56 17.25 18.75 19.56 20.36 European Commission conversion factors.
Neck 1.36 2.17 3.17 4.36 7.56 8.17 Generally, higher conversion factors com-
Chest 7.56 10.75 14.17 17.75 20.75 24.36 pared with published values were found
Abdomen 6.56 9.25 12.36 15.36 19.17 21.17 for the chest, abdomen, and pelvis.
Pelvis 6.57 9.67 12.86 15.97 19.97 22.17 For the chest, abdomen, and pelvis,
the conversion factors were higher for
Note.—Data are irradiated lengths in centimeters. Irradiated length incorporates both overbeaming and overscanning.
the adult female phantom than for the
adult male phantom for both ICRP pub-
lications (Fig 4). The largest differences
Table 4 subjects, the conversion factors were were observed in the pelvis (approxi-
much larger than the European Com- mately 97%) for ICRP publication 60
Values of Normalized CTDIw Measured mission values for all scanned regions. and in the chest (approximately 76%)
in Standard Head and Body CT The relative difference increased with for ICRP publication 103.
Dosimetry Phantoms the decrease in age. Values up to 4.7 times
CTDIw in Head CTDIw in Body higher were computed for the abdominal
region in the newborn phantom when Discussion
Voltage (kV) (mGy/100 mAs) (mGy/100 mAs)
the scanning and exposure parameters Although the dose levels in CT examina-
80 4.6 2.0
were kept constant. The largest differ- tions are generally well below the thresh-
100 9.5 4.5
ences were observed in the abdominal old dose for inducing deterministic ef-
120 15.7 7.7
region for the newborn, 1-year-old, and fects, they may have an influence on the
140 23.8 11.9
5-year-old phantoms; an exception was stimulation of gene mutations and car-
Note.—Data were acquired by using a Somatom the value for a 5-year-old subject com- cinogenesis (6). Because of the cumulative
Sensation 64 CT scanner (Siemens Healthcare) and a puted by using ICRP publication 60 rec- effects of radiation dose, special attention
total collimation of 19.2 mm.
ommendations. For 10-year-old subjects, has to be given, especially when repeated
the largest difference was found when examinations are conducted (18,19). The
scanning the neck region. quantity that tries to relate dose to the
normalized measured CTDIw as a func- For adult subjects, for the head, risk associated with radiation exposure
tion of voltage in head and body phan- chest, and pelvis, respectively, the sim- and thus the correlation with stochas-
toms, whereas Table 3 summarizes the ulated conversion factors were 33%, tic effects is the effective dose (20,21).
irradiated lengths. For the head and neck 20%, and 12% lower than the Euro- The effective dose cannot be directly
regions, the DLP was computed from pean Commission conversion factors determined by measurements. It is gen-
the CTDIw measured in the 16-cm head for ICRP publication 60 and 18%, 14%, erally computed by applying Monte Carlo
phantom, whereas the DLPs for the chest, and 32% lower for ICRP publication 103. methods to data gathered in reference
abdominal, and pelvic regions were de- For the neck and abdomen, the conver- human phantoms and requires dedicated
termined from the CTDIw measured in sion factors were slightly higher (by up dosimetry tools and detailed knowledge
the 32-cm body phantom for both adult to 6%) than the European Commission of photon transport mechanisms. There-
and pediatric individuals. conversion factors, except for the neck fore, in practice, alternative approaches
The conversion factors for each phan- when ICRP publication 103 recommen- such as the correlation between the
tom and scanned region obtained from dations were used (Fig 2a). DLP and effective dose are used.
our Monte Carlo calculations were com- As expected, conversion factors de- We have studied the influence of
pared with the conversion factors pub- creased with increases in age and volt- sex, age, tube voltage, and ICRP rec-
lished by the European Commission (9). age (Fig 2b). For pediatric subjects, the ommended tissue weighting factors on
difference between conversion factors conversion factors used to determine
when the voltage was varied from 140 the effective dose from the DLP. The re-
Results to 80 kV decreased with an increase in sults were compared with the published
Conversion factors calculated by using age. For example, for newborns, the conversion factors that are commonly
ICRP publication 60 as a reference led conversion factor was approximately used in clinical practice (22,23). Although
to larger differences with respect to the 19% larger at 80 than at 140 kV. For the findings are interesting and, in some
European Commission factors than with adult subjects, no major difference was cases, reveal substantial differences from
respect to the ICRP publication 103 fac- observed between conversion factors the published conversion factors pres-
tors for all ages (Table 5). For pediatric when the tube voltage was varied. ently in use, our primary intention was

162 radiology.rsna.org n Radiology: Volume 257: Number 1—October 2010

MEDICAL PHYSICS: Sex- and Age-Specific Conversion Factors for Effective Dose at CT Deak et al

Table 5
Conversion Factors from DLP to Effective Dose as a Function of Voltage, Region, and Age for ICRP Publication 60 and ICRP Publication
103 Recommendations
ICRP Publication 60 ICRP Publication 103
Phantom and Parameter* Head Neck Chest Abdomen Pelvis Head Neck Chest Abdomen Pelvis

Adult
Tube voltage (kV)
80 0.0015 0.0058 0.0138 0.0153 0.0165 0.0018 0.0052 0.0147 0.0151 0.0128
100 0.0015 0.0057 0.0135 0.0153 0.0165 0.0019 0.0051 0.0144 0.0151 0.0127
120 0.0016 0.0057 0.0136 0.0155 0.0167 0.0019 0.0051 0.0145 0.0153 0.0129
140 0.0016 0.0058 0.0137 0.0157 0.0169 0.0019 0.0052 0.0147 0.0155 0.0131
Mean 0.0016 0.0058 0.0137 0.0155 0.0167 0.0019 0.0052 0.0146 0.0153 0.0129
Percentage change 233 6 220 3 212 218 25 214 2 232
10 Year old
Tube voltage (kV)
80 0.0023 0.0109 0.0231 0.0258 0.0295 0.0026 0.0095 0.0248 0.0256 0.0226
100 0.0023 0.0106 0.0219 0.025 0.0286 0.0027 0.0093 0.0235 0.0247 0.0218
120 0.0023 0.0107 0.0217 0.0249 0.0283 0.0027 0.0094 0.0234 0.0246 0.0216
140 0.0023 0.0106 0.0215 0.0249 0.0283 0.0027 0.0093 0.0232 0.0246 0.0216
Mean 0.0023 0.0107 0.0221 0.0252 0.0287 0.0027 0.0094 0.0237 0.0249 0.0219
Percentage change 0 98 30 68 51 16 74 40 66 15
5 Year old
Tube voltage (kV)
80 0.0031 0.0141 0.0319 0.0381 0.0406 0.0035 0.0123 0.0344 0.0376 0.0315
100 0.0031 0.0138 0.0298 0.036 0.0385 0.0035 0.0121 0.0322 0.0355 0.0298
120 0.0031 0.0137 0.0291 0.0354 0.038 0.0035 0.012 0.0314 0.0349 0.0294
140 0.003 0.0138 0.0288 0.0351 0.0377 0.0035 0.0121 0.0312 0.0349 0.0291
Mean 0.0031 0.0139 0.0299 0.0362 0.0387 0.0035 0.0121 0.0323 0.0357 0.03
Percentage change 34 156 76 141 104 52 125 90 138 58
1 Year old
Tube voltage (kV)
80 0.0051 0.0194 0.0483 0.0578 0.0629 0.0056 0.0171 0.0525 0.0571 0.0481
100 0.0049 0.019 0.0442 0.0537 0.0582 0.0054 0.0167 0.048 0.053 0.0445
120 0.0047 0.0189 0.0427 0.0522 0.0564 0.0053 0.0166 0.0467 0.0514 0.0431
140 0.0046 0.0189 0.0418 0.0513 0.0558 0.0052 0.0166 0.0456 0.0506 0.0425
Mean 0.0048 0.0191 0.0443 0.0538 0.0583 0.0054 0.0168 0.0482 0.053 0.0446
Percentage change 110 253 160 258 207 134 210 184 254 134
Newborn
Tube voltage (kV)
80 0.0086 0.0238 0.0766 0.0949 0.1007 0.0094 0.0216 0.0823 0.0935 0.0776
100 0.008 0.023 0.0684 0.085 0.0908 0.0088 0.0209 0.0739 0.0838 0.0699
120 0.0077 0.0228 0.0651 0.0817 0.0876 0.0085 0.0206 0.0706 0.0804 0.0672
140 0.0074 0.023 0.0634 0.0795 0.0854 0.0082 0.0207 0.0689 0.0786 0.0655
Mean 0.079 0.0232 0.0684 0.0853 0.0911 0.0087 0.021 0.0739 0.0841 0.0701
Percentage change 245 329 302 469 380 279 288 335 461 269

Note.—Data are in mSv · mGy–1 · cm–1. The European Commission conversion factors (namely, 0.023 for the head, 0.0054 for the neck, 0.017 for the chest, 0.015 for the abdomen, and 0.019 for the
pelvis [9]) were based on ICRP publication 60 tissue weighting factors.
* Percentage change = relative difference in percentage between average values over all voltages and European Commission conversion factors.

to give insights regarding the depen-
dence of conversion factors on voltage,
age, or sex rather than claiming the re-
placement of existing reference values.
Our computations indicate that, for
adult subjects, the conversion factors
published in 1999 (9) systematically
estimate higher effective doses for the
head, chest, and pelvis, independent of
the organ weighting factors used in the
calculation of the effective dose. For
example, differences of up to 33% and
32% were found for the head and pelvic
examinations, respectively. This may be
related to the fact that the published
conversion factors were based on cal-
culations performed for CT scanners
that were in use in the early 1990s.

Radiology: Volume 257: Number 1—October 2010 n radiology.rsna.org 163

MEDICAL PHYSICS: Sex- and Age-Specific Conversion Factors for Effective Dose at CT Deak et al

Figure 2

Figure 2: Bar graphs show (a) simulated conversion factors for adult subjects in different scanned regions obtained by using ICRP publications 60 and 103 com-
pared with the published European Commission conversion factors (EC CF) and (b) dependence on tube voltage of conversion factors in the abdominal region with
ICRP publication 103 recommendations. A similar trend was found for conversion factors derived from ICRP publication 60. With an increase in age, the difference in
conversion factor caused by increasing voltage decreases. For adult subjects, the conversion factors are independent of tube voltage.

Figure 3

Figure 3: Bar graphs show conversion factors with (a) ICRP publication 60 and (b) ICRP publication 103 for the head, neck, chest, abdomen, and pelvis in pediatric
patients. European Commission conversion factors (EC CF) for adults are shown for comparison purposes.

Our results are in good agreement
with those reported by Shrimpton (11)
for adult subjects for the neck, chest,
abdomen, and pelvis using ICRP pub-
lication 60 recommendations. For the
head, Shrimpton reported a value of
0.0021 mSv/mGy, compared with the
value of 0.0016 mSv/mGy found in our
study. Slight discrepancies can be ex-
plained by differences in the phantoms
and scanned regions used.
With respect to pediatric subjects,
the computed conversion factors are
much larger than those published by the
European Commission for all scanned
regions and voltages. Our expectations
were confirmed that the effective doses
for children and, consequently, the
conversion factors are higher than in
adults when the exposure is kept con-
stant. This is to be expected because
in children, the organs responsible for
the main contribution to the effective
dose (lungs, liver, and gonads) receive
higher doses at constant exposure fac-
tors than the organs of adults because
of their smaller cross sections. In the
case of ICRP publication 60, the highest
conversion factors were found for the
pelvic region, whereas for ICRP publi-
cation 103, the highest values were ob-
tained for the abdominal region. This
is related to the differences in organ
weighting factors and effective dose
calculation between ICRP publication
60 and ICRP publication 103. For ex-
ample, in ICRP publication 103, the
new weighting factor for the gonads is
0.08, whereas in ICRP publication 60,
the weighting factor was 0.20.
Higher conversion factors, of course,
do not necessarily mean higher effective

164 radiology.rsna.org n Radiology: Volume 257: Number 1—October 2010

MEDICAL PHYSICS: Sex- and Age-Specific Conversion Factors for Effective Dose at CT Deak et al

Figure 4 parameters and the scan length are

kept constant. For shorter scan lengths
and higher pitch values, the conver-
sion factors may vary slightly owing to
the position of the organs and tissues
with respect to the scanning path.
The findings of our study were based
on the use of only one multidetector CT
scanner because the primary aim was
to investigate the influence of scanned
region, voltage, and patient age and sex
on conversion factors. Because no ap-
preciable dependence on tube voltage
(ie, on energy) was found, it can be
expected that the results are valid for
other scanners. Differences in filtra-
Figure 4: Bar graph shows sex comparison of conversion factors based tion, for example, will shift the effective
on ICRP publication 60 and those based on ICRP publication 103 for adult energy less than the changes in voltage
subjects. For the chest, abdomen, and pelvis, the conversion factors for women investigated here and should therefore
are higher than those for men owing to the position of the organs and organ not cause noticeable differences.
weighting factors used to calculate the effective dose. For all four cases, the Variations in conversion factors also
DLP is constant within a scanned region. F = female, M = male. have to be expected when using other
types of phantoms—for example, those
doses, as the DLP has to be kept ap- distribution of the radiosensitive organs derived from segmented image sets in
propriately low in pediatric CT practice, and tissues. Differences of up to 76% patients (24,25). In this respect, ICRP
which reduces the effective dose and were observed in, for example, the publication 103 recommends the com-
offsets the effects of higher conversion chest region with ICRP publication 103 putation of organ and effective doses on
factors. Compared with the values of because of the increased weighting fac- the basis of acquired scans developed by
Shrimpton (11), our computed conver- tor for the breast, whereas for the pelvic Zankl et al (26) as reference models. To
sion factors for children were lower on region, differences of up to 97% were our knowledge, phantoms representing
average by approximately 30% for the observed when the conversion factors pediatric patients were not made gen-
head and higher by 40%, 70%, and 83% were computed on the basis of ICRP erally available. This is another reason
for the neck, chest, abdomen, and pel- publication 60. For the first case (ie, the why established mathematical models
vis, respectively. This can be explained chest region and ICRP publication 103), were used for our study. Although they
by differences in DLPs (ie, different the weighting factor for breast tissue are modeled with sets of surface equa-
scan lengths) and phantom models. For increased from 0.05 in ICRP publica- tions that approximate the form and
our study, the DLPs were computed on tion 60 to 0.12 in ICRP publication 103, volume of human organs, the advantage
the basis of CTDIvol values measured in yielding a larger conversion factor for of mathematical phantoms is that they
the 32-cm CTDI phantom for the chest, adult women. For the second case, (ie, are more easy to implement and more
abdomen, and pelvis for both pediatric the pelvic region and ICRP publication flexible in use (8). However, they should
and adult subjects, whereas Shrimpton 60), this can be explained by the scan be compared with new phantoms when
used the CTDIvol measured in a 16-cm range and the position of the male go- these are made available.
CTDI phantom for pediatric subjects. nads. The male gonads were partially Another aspect that was not consid-
Evaluation of the dependence of irradiated, while the female gonads were ered in our study is related to the angular
conversion factor on tube voltage fully irradiated. This raises the question and longitudinal tube current modulation
showed that for adult subjects, the vari- of whether conversion factors should be that is provided by all modern multide-
ation was within 2.6% for all scanned specified separately for each sex instead tector CT scanners (27). For all simula-
regions and therefore can be neglected. of using an averaged value that will result tions, the tube current was kept constant.
For pediatric subjects, the variations in an overestimation of effective dose for As was shown in a recent study (28), a
were larger; they may go up by 19% male patients and an underestimation reduction of up to 8% can be expected in
when lower voltages are applied. Re- of effective dose for female patients. adult conversion factors when tube cur-
sults of the sex comparison showed The conversion factors in our study rent modulation schemes are taken into
generally that higher conversion fac- were determined for spiral examina- account. For pediatric subjects, especially
tors were obtained for adult women, tions performed by using a pitch fac- for newborns, this reduction is smaller:
especially for the chest, abdomen, and tor of 1.0. They are valid for other One- and 5-year-old children present
pelvis. This was expected, owing to the pitch values as long as other scanning an approximately circular cross section

Radiology: Volume 257: Number 1—October 2010 n radiology.rsna.org 165

MEDICAL PHYSICS: Sex- and Age-Specific Conversion Factors for Effective Dose at CT
rather than an ellipse, resulting in less ef-
ficient modulation. Nevertheless, further
work that takes into account all aspects
aimed at reducing radiation dose, such
as tube current modulation and scanning
protocol optimizations (29,30), may have
to be performed. No noticeable effect is
expected with respect to total collimation,
z-overscanning, and adaptive z-collimation,
because these effects are taken into ac-
count by the DLP.
Last but not least, an important as-
pect that has to be considered when the
effective dose is determined on the ba-
sis of the DLP indicated on the scanner
console is represented by the limitations
of the CTDI as an indicator of dose. In
practice, the CTDI is measured by using
10-cm ionization chambers. As shown
by Boone (31), the CTDI is a good indi-
cator of dose for a total collimation of up
to 40 mm. However, wider collimations
lead to underestimations of the dose,
with consequences that are not covered
at present in the conversion factors.
In conclusion, the conversion factors
used to compute the effective dose from
the DLP may have to be updated with
respect to modern cone-beam CT scan-
ners. They have to reflect the new ICRP
recommendations and should be speci-
fied separately for both sexes. With re-
spect to pediatric CT, new conversion
factors should be established that also
may have to include the influence of
tube voltage.
References
1. Federal Office for Radiation Protection. An-
nual report 2005. Langenhagen, Germany:
Schlütersche Druck, 2005. http://www.bfs
.de/en/bfs/druck/jahresberichte/jb2005
.pdf. Accessed May 4, 2010.
2. Brix G, Nagel HD, Stamm G, et al. Radia-
tion exposure in multi-slice versus single-
slice spiral CT: results of a nationwide sur-
vey. Eur Radiol 2003;13(8):1979–1991.
3. Mettler FA Jr, Wiest PW, Locken JA, Kelsey
CA. CT scanning: patterns of use and dose.
J Radiol Prot 2000;20(4):353–359.
4. Shrimpton PC, Edyvean S. CT scanner do-
simetry. Br J Radiol 1998;71(841):1–3.
5. Brenner DJ, Hall EJ. Computed tomography:
an increasing source of radiation exposure.
N Engl J Med 2007;357(22):2277–2284.
166
6. 1990 Recommendations of the International
Commission on Radiological Protection. Ann
ICRP 1991;21(1-3):1–201.
7. The 2007 recommendations of the Interna-
tional Commission on Radiological Protection.
ICRP publication 103. Ann ICRP 2007;37(2-4):
1–332.
8. Zankl M, Panzer W, Drexler G. The calcula-
tion of dose from external photon exposures
using reference human phantoms and Monte
Carlo methods. VI. Organ doses from tomo-
graphic examinations. Neuherberg, Germany:
Publisher, 1991.
9. European Commission. European guidelines
on quality criteria for computed tomogra-
phy. Report EUR 16262. Brussels, Belgium:
European Commission, 1999.
10. Huda W, Ogden KM, Khorasani MR. Con-
verting dose-length product to effective dose
at CT. Radiology 2008;248(3):995–1003.
11. Shrimpton PC. Assessment of patient dose in
CT. NRPB-PE/1/2004. Chilton, England: Na-
tional Radiological Protection Board, 2004.
12. Cristy M, Eckerman KF. Specific absorbed
fractions of energy at various ages from in-
ternal photon sources. I. Methods. Report
no. ORNL/TM-8381/V1. Oak Ridge, Tenn:
Oak Ridge National Laboratory, 1987.
13. Snyder WS, Ford MR, Warner GG, Wat-
son SB. A tabulation of dose equivalent per
microcurie-day for source and target organs
of an adult for various radionuclides: part 1.
Report no. ORNL-5000. Oak Ridge, Tenn:
Oak Ridge National Laboratory, 1974.
14. Cristy M. Mathematical phantoms represent-
ing children of various ages for use in esti-
mates of internal dose. Report no. ORNL/
NUREG/TM-367. Oak Ridge, Tenn: Oak Ridge
National Laboratory, 1980.
15. Basic anatomical and physiological data for
use in radiological protection: reference
values—a report of age- and gender-related
differences in the anatomical and physiologi-
cal characteristics of reference individuals.
ICRP Publication 89. Ann ICRP 2002;32(3-4):
5–265.
16. International Commission on Radiation Units
and Measurements. Phantoms and compu-
tational models in therapy, diagnosis and
protection. Bethesda, Md: International Com-
mission on Radiation Units and Measure-
ments, 1992.
17. Deak P, van Straten M, Shrimpton PC,
Zankl M, Kalender WA. Validation of a
Monte Carlo tool for patient-specific dose
simulations in multi-slice computed tomog-
raphy. Eur Radiol 2008;18(4):759–772.
18. Wagner LK, Eifel PJ, Geise RA. Potential
biological effects following high X-ray dose
radiology.rsna.org
Deak et al
interventional procedures. J Vasc Interv
Radiol 1994;5(1):71–84.
19. Struelens L, Vanhavere F, Bosmans H, Van
Loon R, Mol H. Skin dose measurements on
patients for diagnostic and interventional
neuroradiology: a multicentre study. Radiat
Prot Dosimetry 2005;114(1-3):143–146.
20. Huda W. Radiation dosimetry in diagnostic
radiology. AJR Am J Roentgenol 1997;169(6):
1487–1488.
21. McCollough CH, Schueler BA. Calculation
of effective dose. Med Phys 2000 ;27( 5):
828–837.
22. Einstein AJ, Moser KW, Thompson RC, Cer-
queira MD, Henzlova MJ. Radiation dose to
patients from cardiac diagnostic imaging.
Circulation 2007;116(11):1290–1305.
23. Stolzmann P, Scheffel H, Schertler T, et al.
Radiation dose estimates in dual-source
computed tomography coronary angiogra-
phy. Eur Radiol 2008;18(3):592–599.
24. Petoussi-Henss N, Zankl M, Nosske D. Es-
timation of patient dose from radiopharma-
ceuticals using voxel models. Cancer Biother
Radiopharm 2005;20(1):103–109.
25. Zankl M, Eckerman KF, Bolch WE. Voxel-
based models representing the male and female
ICRP reference adult: the skeleton. Radiat
Prot Dosimetry 2007;127(1-4):174–186.
26. Zankl M, Becker J, Fill U, Petoussi-Henss N,
Eckerman KF. GSF male and female adult
voxel models representing ICRP Reference
Man: the present status. In: Proceedings
of the Monte Carlo method: versatility un-
bounded in a dynamic computing world,
Chattanooga, Tenn. La Grange Park, Ill:
American Nuclear Society, 2005.
27. Kalender WA. Computed tomography: fun-
damentals, system technology, image qual-
ity, applications. Erlangen, Germany: Publicis
Corporate Publishing, 2005.
28. van Straten M, Deak P, Shrimpton PC, Kal-
ender WA. The effect of angular and lon-
gitudinal tube current modulations on the
estimation of organ and effective doses in
x-ray computed tomography. Med Phys 2009;
36(11):4881–4889.
29. Deak PD, Langner O, Lell M, Kalender WA.
Effects of adaptive section collimation on
patient radiation dose in multisection spiral
CT. Radiology 2009;252(1):140–147.
30. Kalender WA, Deak P, Kellermeier M, van
Straten M, Vollmar SV. Application- and pa-
tient size-dependent optimization of x-ray spec-
tra for CT. Med Phys 2009;36(3):993–1007.
31. Boone JM. The trouble with CTD100. Med
Phys 2007;34(4):1364–1371.
n Radiology: Volume 257: Number 1—October 2010