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Day 1 - Thursday - 1330 PM - Larry Rot Hen Berg
Day 1 - Thursday - 1330 PM - Larry Rot Hen Berg
Day 1 - Thursday - 1330 PM - Larry Rot Hen Berg
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CT Radiation Exposure/Dose/Risk:
Why the concern?
Brenner/Hall NEJM 2007
NCRP Report No. 160 and recent UNSCEAR Data
CT the major source of medical radiation exposure to the public
Man-made radiation (mostly medical) exposure in the US now
equal to natural background
Image Gently Campaign
Major overdosing of pediatric and small adult patients
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IMAGE WISELY CAMPAIGN IS NOW UNDER WAY FOR ADULT IMAGING
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Arch of Internal Med Dec 2009
Dr. R. Redberg, Ed.
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NCRP
Report
No. 160
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NCRP Report No. 160
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CT Dose Parameters
CTDI100 (mGy)
CTDIw (mGy) (2/3 peripheral, 1/3 central CTDI100)
CTDIvol (mGy)* (divide CTDIw by pitch)
DLP (mGy-cm)*
*Presented on control console for most new CT scanners
E C
A
PMM-Acrylic Cylinder
32 cm diam, 15-20 cm length
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Effective Dose, E, for Chest CT
Multiply DLP (mGy-cm) by 0.014 mSv/mGy-cm
(Recently revised from 0.017, a reduction of 18%)
Conversion factor from EU Committee,
& AAPM Task Group Report No. 96
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Shrimpton PC, Hillier MC, Lewis MA. BJR 2006; 79:968-980
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Effective Dose (E) Factors
E for adults can be calculated from product of DLP
and “normalized effective dose factors”
from (AAPM Report No. 96, 2008)
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UK 2003 Lung CT Doses
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Notes for Effective Dose Calculations
To get Effective Dose in mSv, multiply DLP in mGy-cm
by 0.014 mSv/mGy-cm.
CTDIvol and DLP calculated from ImpactScan Tables.
ImpactScan Phantom Scan from 39 cm to 72 cm. A
longer Z-axis scan will increase the DLP and Effective
Dose proportionately.
All pitches were chosen to be 1.0. Effective dose and
CTDIvol are inversely related to pitch.
Calculations for GE VCT
Effective Dose vs kVp/mAS
kVp mAs Beam Width CTDIvol DLP Eff Dose
mm mGy mGy-cm mSv
120 200 20 20.5 675 9.45
120 40 20 4.1 135 1.89
120 20 20 2.0 68 0.95
100 200 20 13.5 440 6.16
100 40 20 2.7 88 1.23
100 20 20 1.3 44 0.62
80 200 20 7.5 240 3.36
80 40 20 1.5 48 0.67
80 20 20 0.7 24 0.34
What is low dose chest CT?
Used for screening
Usually 100 mAs down to 30 mAs or less.
Also, lower kVp for CT scans is being used
Instead of 120-140 kVp, chest CT scans are being
performed at 100 kVp or even 80 kVp, leading to dose
reductions of 30% - 60%
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Low Dose Chest CT Values from NLST
F. Larke et al at RSNA 2008 (SSG18-09)
Data from 96 CT scanners at NLST sites, 2003-2007
Mean CTDIvol: 3.4 mGy, S.D.: 1.7 mGy
Assumed typical scan length of 35 cm
Mean Effective Dose: 2.0 mSv, S.D.: 1.0 mSv
Min/Max: 0.5 – 7.0 mSv
For comparison:
Standard chest CT: 8 - 9 mSv
Screening chest radiograph: 0.08 – 0.12 mSv
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Review Article
T. Kubo et al. Radiation Dose Reduction in Chest CT:
A Review. AJR 2008; 190: 335-343.
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CT Radiation Risks
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Of course, radiation dose and risk
are also reduced to zero if CT scans
are not performed! But:
What are the risks of not performing the scans?
Essential information lost
Patient not managed most effectively
What are the benefits of performing the scans?
Patient managed more effectively
Invasive procedures more accurately performed
Some invasive procedures and associated risks avoided
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What are some recommended Low
Dose Chest CT parameters?
From NLST
120 - 140 kVp
40 - 80 mAs (20 – 60 effective mAs)
Pitch 1.0 – 2.0
1.0 – 2.5 mm, effective < 3.2 mm section thickness
FOV: < 3 cm beyond outer rib margins
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Key Questions for Screening
How much below 40 mAs can you go and still
maintain adequate image quality?
30 mAs? 20 mAs?
How much below 120 kVp can you go and still
maintain adequate image quality?
100 kVp? 80 kVp?
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Some comparison doses
Annual Natural Background in US:
Effective Dose estimate: 3.0
mSv
Two-View Screening Mammography:
(both breasts of an average patient: 4.5 cm thick
compressed breast of 50% adipose/50% glandular
composition) will produce a mean glandular dose of
about 3.0 – 6.0 mGy
Effective Dose estimate: 0.4 - 1.0 mSv
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Radiology Info.org (ACR RSNA)
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Radiology Info.org - Chest
Notes:
Low Dose CT Scans for Lung Screening are being reduced to < 0.5 mSv (< 2 months)
Dr. Yankelevitz is evaluating scans at 0.2 mSv
The dose from a diagnostic CT Exam of the Chest is equal to that from many, many
chest radiographs
From Redberg Editorial
but not often stressed:
There is a Latent Period and Incidence >> Mortality
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From ACR Response to Arch Int Med articles:
Also, the articles ─ after excluding patients with
cancer or within five years of the end of life ─
assumed that those undergoing CT scanning have
the same life expectancy as the general population.
This is not accurate, so the estimates are
undoubtedly high. Moreover, 25 percent of people in
the United States die of cancer with a life time
incidence of 40 percent, about 1.5 million new
cancers per year. The 29,000 figure, if even close to
accurate, is overall a very small risk versus the
immediate, proven life saving benefits of CT.
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From Dr. E. Stephen Amis, ACR commenting
on projected deaths from CT radiation:
“The problem with that,” he notes, “is there’s
absolutely no way to prove, for any given
cancer, whether it is radiation induced or it
just arose by itself. If you look under the
microscope, there are no markers that say
one way or the other, so the whole thing is
based on projections, on models, and on
guesses based on data from the atomic
bombings back in 1945.”
imagingBiz interview Jan 18, 2010
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From the FDA Notices on CT Perfusion
Overdoses:
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Things to keep in mind
Effective Dose in mSv is a very different concept than
absorbed dose (CTDIvol) in mGy
Almost all knowledge of radiation risk is from
Japanese A-bomb survivors who got a total body dose
from higher energy radiation with some neutron
component
Benefit-Risk is a very different calculation for
screening than for diagnostic patient management
Radiation Risks for older adults are much lower than
for children or young adults
Benefit is usually immediate , while cancer induction
has a latent period of 10 years, or more
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Things to keep in mind
Multiple low doses likely do not have the same effect
as one large dose
LNT Hypothesis may not apply to diagnostic radiation
Lung cancer risk from CT depends on many factors:
age, sex, smoking history, occupation
CT Doses should be kept as low as reasonably
achievable (ALARA)
Automatic dose reduction technology for CT should
be used when available
Physicians, technologists, and medical physicists
should meet periodically to review CT techniques
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Thank You! Comments?
For further information contact:
rothenbl@mskcc.org
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