Low Dose CT Lung Screening: What is Technically Required?

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1 Low Dose CT Lung Screening: What is Technically Required? COMP/CCPM Annual Scientific Meeting Ottawa, Ontario July 15 th, 2017 Yogesh Thakur, PhD, MCCPM Medical Physicist Lead and Regional RSO (X-Ray) Vancouver Coastal Health Authority Clinical Assistant Professor The University of British Columbia 1

2 Disclosure Statement 1. Paid speaker: GE sponsored scientific symposium, 2. Paid speaker: Siemens sponsored scientific symposium, 3. No direct or indirect financial stake in any company mentioned. 2

3 Talk Overview 1. Why Low Dose CT (LDCT) for Lung Screening 2. CT Technical Requirements for LDCT 3. QC in CT: Do we need an accreditation program? 4. Comparison of current standards with Mammography Accreditation Program 3

4 Audience Poll Audience composition: Do you have Clinical Certification (CCPM/ABR)? If yes, what sub-speciality? 1. Oncology (CCPM) 2. Radiological Physics (CCPM) 3. Nuclear Medicine (CCPM) 4. MRI (CCPM) 5. Other (ABR, other) 6. No 4

5 Audience Poll Is Imaging Medical Physics a Certified Profession within your Provincial Jurisdiction (either direct or indirect)? 1. Yes 2. No 3. No, but in process of College formation 4. Not Sure 5

6 Talk Overview 1. Why Low Dose CT (LDCT) for Lung Screening 2. CT Technical Requirements for LDCT 3. QC in CT: Do we need an accreditation program? 4. Comparison of current standards with Mammography Accreditation Program 6

7 Why CT Lung Screening? Mortality: 436 deaths per day in the US Survival Rate (current state): When diagnosed, disease is typically in an advanced state Result: 5 year survival rate estimated at 17.4% One of top 4 deadliest cancers, but potentially curable at early stage of diagnosis (thus screening clinically indicated to improve survival rate) National Lung Cancer Screening Trial (NLST) First randomized trial (53,454 participants, aged 55-74) LDCT (Helical) or CXR First trial to find significant reduction of relative mortality (20%) 320 patients need to be screened to reduce 1 mortality Fintelmann,, et al

8 Why CT Lung Screening? Thoracic LDCT: only imaging test that has been demonstrated to reduce mortality from lung cancer in high risk and former cigarette smoking populations Additional benefits: Potential to combine with a smoking cessation program, thus improve long-term outcome Optimal performance (for radiologists): Knowledge of normal anatomy, anatomic variations, pathophysiology, and risk associated with a screening program. Kazerooni, et al

9 Why CT Lung Screening? (cont..) Radiation Dose: Low Dose CT (LDCT), required (exam risk/population benefit ratio) Positive findings may lead to multiple imaging exams Maybe repeated annually for decades Potential for large lifetime radiation dose, if marginal findings occur Imaging technique & reconstruction: Related to exam dose Ability for clinicians to visualize lesions (i.e. ground glass) or other pathology of interest, In screening, longitudinal evaluation allows for review of pathology changes of history of screening (similar to Mammography) Primary goal: detect abnormalities that may represent lung cancer and may require further diagnostic evaluation or clinical intervention Kazerooni, et al

10 Talk Overview 1. Why Low Dose CT (LDCT) for Lung Screening 2. CT Technical Requirements for LDCT 3. QC in CT: Do we need an accreditation program? 4. Comparison of current standards with Mammography Accreditation Program 10

11 Diagnostic Task: Technical Requirements The primary goal of lung cancer screening CT is to detect abnormalities that may represent lung cancer and may require further diagnostic evaluation. Therefore, the primary task is to detect nodules or masses, and characterize their size, shape and relationship to organs. Contrast, Breath Hold & Key Elements, Parameter Contrast Breath hold Recon Dose Description Studies are non-contrast, inherent tissue/pathology contrast Image during 1 breath hold (full inspiration), requires fast imaging to complete - minimizing motion artifact Thickness: 2.5 mm, prefer 1.0 mm, coronal & sagittal reformats and MIPS recommended CTDI vol 3.0 mgy, adjusted for patient size AAPM: Lung Cancer Screening CT, CT Protocols v4.0,

12 Technical Requirements Other Key Parameters: Parameter Patient Positioning Range Description Supine scanner isocentre to ensure proper AEC function, arms above head (dose reduction) Lung apex to past diaphragm Radiation Dose Management: Parameter Description Average Patient Approximately 170 cm ( 5 7 ), 70 kg (155 lbs), BMI 24 Technique Adjustment CTDI vol DLP Automatic: Use AEC or kv selection based on localizer Manual: Setup protocols based on fixed ma based on body habitus 3.0 mgy, for average patient 75 mgy cm AAPM: Lung Cancer Screening CT, CT Protocols v4.0,

13 Technical Requirements Approximate Volume CTDI based on Patient Size: Patient Size Weight (kg) Weight (lbs) CTDT vol (mgy) Small Average Large Patient Classification using BMI: Weight BMI (kg/m 2 ) Underweight <18.5 Average Overweight Obese > 30 AAPM: Lung Cancer Screening CT, CT Protocols v4.0,

14 Talk Overview 1. Why Low Dose CT (LDCT) for Lung Screening 2. CT Technical Requirements for LDCT 3. QC in CT: Do we need an accreditation program? 4. Comparison of current standards with Mammography Accreditation Program 14

15 CT QC For Lung Screening Key Questions? What Nodule does Classification: this mean for a Clinical Medical Physicist? In Lung Cancer Screening, Radiologist may implement the Lungs-RADs classification system, depending on jurisdiction. Classification is based on the ACR Lung Cancer Screening Committee Classification is for radiologist interpretation. Nodule size is a key component of clinical management Medical Physicist objective for patient care: pathway What is the size of the nodule? Consistent, repeatable measures, dose, nodule sizes, manage population risk etc Was this nodule present in a prior scan? Has the size changed significantly? 7 categories (0, 1, 2, 3, 4a, 4b, and 4x) with 2 category modifiers (S and C) Should it similar to MAP (CAR Screening Mammo)? Similar to mammography, 7 categories (0-6). AAPM: Lung Cancer Screening CT, CT Protocols v4.0,

16 Does Nodule Size Matter? Nodule Size & composition matter Directly related to clinical management (size and composition) Changes in size, new nodules will influence LUNG-RADS classification and subsequent clinical management. Fintelmann et al

17 Clinical Example (a) Axial LCS chest CT image (lung window) in a 77-year-old man shows a solid nodule in the right lower lobe. The average of the longest and shortest axial diameters (A and B, respectively) is 20 mm. (b) Axial CT image (mediastinal window) shows fat ( 77.5 HU) in the nodule, compatible with a hamartoma. Despite the large size of the nodule, its benign characteristics make this a Lung-RADS category 1 lesion. Appropriate management is to resume annual screening with low-dose CT in 12 months. Dev = deviation. Fintelmann et al

18 Clinical Example Axial LCS chest CT image (lung window) in a 59-year-old man shows a solid nodule in the left lower lobe. The average of the longest and shortest axial diameters (A and B) rounded to the nearest whole number is 5 mm. This is a Lung-RADS category 2 lesion. Appropriate management is to continue annual screening with low-dose CT in 12 months. Fintelmann et al

19 Clinical Example Axial LCS chest CT image (lung window) in a 61-year-old man shows a lingular nonsolid (ground-glass) nodule. The average of the longest and shortest axial diameters (A and B) rounded to the nearest whole number is 14 mm. This is a Lung-RADS category 2 lesion. Appropriate management is to continue annual screening with low-dose CT in 12 months. Fintelmann et al

20 Clinical Example Axial LCS chest CT images in a 66-year-old man. (a) Lung window image shows a solid nodule in the right upper lobe. The average of the longest and shortest axial diameters (A and B) rounded to the nearest whole number is 4 mm. This is a Lung-RADS category 2 lesion. Appropriate management is to follow-up in 12 months with low-dose CT. (b) At 12-month follow-up low-dose CT, the nodule had grown to 9 mm. Because of the interval growth, this lesion was reclassified as a Lung-RADS category 4B lesion. Resection revealed adenocarcinoma. 20 Fintelmann et al. 2015

21 Review of QC Requirements Current Diagnostic CT have QC programs based jurisdiction (ACR, Health Canada Safety Code 35, BC: DAP Standards). Does Lung Cancer CT Screening require separate/additional or QC/Accreditation Program? We will review each programs QC requirements. 21

22 ACR-AAPM vs. HC SC35 Task ACR-AAPM CT Tech Standard Health Canada Safety Code 35 Laser Alignment Annually Semi-Annually Image Localization from scanned projection localization Annually Semi-Annually Table movement (patient load) Annually Semi-Annually Phantom Position (HU Value) NA Annually Radiation Beam Width Annually Annually Scout Dose NA Annually Reconstructed image thickness Annually Monthly Image Quality Annually spatial, low contrast, uniformity, noise, artifacts Weekly CT Noise, uniformity Quarterly spatial res/lcd CT Number Accuracy Annually Weekly/Monthly clinical kvp Dosimetry Annually Semi-Annually (CTDI 100 ) Protocol Review Annually NA BC Annually Safety (including scatter surveys) Annually State Local Recommendations Annual Safety systems Scatter - Acceptance, in BC every 4 years 22

23 Audience Poll For Diagnostic Imaging, has your Jurisdiction implemented Health Canada Safety Codes (i.e. HCSC35)? 1. Yes 2. No 3. Not Sure 23

24 Review of QC Requirements HC SC 35 vs ACR-AAPM HC SC35 QC is more rigorous than the ACR-AAPM (in my opinion) too rigorous for some parameters (i.e. noise, table position HU value dependency). Missing: lesion measurement In Mammo, accuracy of measurement at workstation is conducted. In CT, no requirement. What about different reconstructions? Important for nodule classification, especially if recon is FBP vs. IR In general, if we follow HC SC35 is it enough for QC of a lung screening CT? 24

25 What about AEC? Automatic Exposure Control (AEC, tube current modulation- TBM) tests are not mandated HC SC 35 AAPM/RSNA Medical Physics 3.0 is recommending using the Mercury Phantom for this test As the technical requirements for LDCT use helical exams with AEC, then AEC evaluation is a must (and similar to Mammo). Should this be part of the next safety code, or a lung screening program? Dr. Samie s Lab - Duke 25

26 Audience Poll Is the QC program stipulated by Health Canada Safety Code 35 sufficient for LDCT? 1. Yes, it is the perfect Health Code! 2. Yes, but with AEC & Lesion Measurement 3. No, it is inadequate for screening 4. Possibly, but with some modification (other than AEC/measurement) 26

27 Talk Overview 1. Why Low Dose CT (LDCT) for Lung Screening 2. CT Technical Requirements for LDCT 3. QC in CT: Do we need an accreditation program? 4. Comparison of current standards with Mammography Accreditation Program 27

28 MAP compared with HC SC35 (BC) Task MAP Health Canada Safety Code 35 Laser Alignment NA Semi-Annually Image Localization from scanned projection localization NA Semi-Annually Gantry/Table movement Annually (Gantry) Semi-Annually (Table/Gantry Tilt) Phantom Position (HU Value) NA Annually Radiation Beam Width/ Collimation Annually Annually Tube output (kvp/mas) Annually At acceptance (BC) AGD/Dosimetry Annually Semi-Annually (CTDI 100 ) Image Quality Monthly/ Annually ACR Phantom (fibrils, specs, masses) Weekly/Annually CT Noise, uniformity Quarterly spatial res/lcd HVL Annually (for common thickness) NA too complex - clinically Protocol Review Annually NA BC Annually Safety (including scatter surveys) Every 4 years (BC) Annual Safety systems Scatter - Acceptance, in BC every 4 years 28

29 Is a CAR Mandated Program Required? MAP Accreditation goes beyond Quality Control (Competence + QC) Staff competence is a key component: # of exams conducted by technologists # of cases interpreted by radiologists # of equipment survey by physicists (+ CCPM + Mammo) Data sent to MAP for evaluation and accreditation If we follow HC SC35, is that sufficient? RSO such as CCPM (no sub-speciality stated) 28 CCPM Diagnostic Physicists in Canada (Nov. 2016) If provinces already follow HCSC35, is this sufficient? 29

30 Is a CAR Mandated Program Required? Only BC/Alberta require a CCPM physicist in imaging (by law or regulation, to my knowledge) In BC: WorkSafeBC, BC College of Physicians and Surgeons Should a National LDCT Program stipulate CCPM Certification? If CCPM Certification is required, should it stipulate a specific sub specialty? 30

31 Audience Poll Should the CCPM/COMP Support CAR in the development of a National Lung Screening Program? 1. Yes 2. No 31

32 Audience Poll If a National LDCT Program is implemented, what speciality/subspecialty certification must be required for physics support (CCPM based)? 1. All CCPM Certifications are acceptable 2. All CCPM Certifications concerned with ionizing radiation 3. Radiological Physics Only this is a diagnostic system 4. Oncology Physics Only this is part of cancer care 5. A new specialization, similar to mammography 6. No clinical certification necessary 7. NA to my practice 32

33 CCPM Subspecialty The ACR-AAPM has jointly published multiple technical specification documents Each document highlights a different ACR Physics subspecialty required to perform physics related tasks (including continuing education) In BC (via The BC College of Physicians and Surgeons) most imaging modalities require physics support from a specific CCPM certification Radiological Physics (CT), Nuclear Medicine, MRI and Mammography Clinical contribution is beyond QC Protocol Optimization (Dose/IQ), scatter assessment (site specific use), DRL s, tech specific QC (i.e. children s 80/100 kvp, DE-CT protocols, etc ) Based on ACR criteria 33

34 Considerations: Continuing Education Patient safety/outcome, and public safety is our key concern. Understanding the technology and optimizing imaging is part of the Medical Physics Profession (My Bias) Diagnostic Radiological Physicists: Improved recognition as a clinical sub speciality Dual certification possibility (similar to mammo)? Continuing Education (MPCEC): Focus on technological and scientific advancement Technology is changing rapidly (i.e. detectors, reconstruction, etc..) Usage is also changing (i.e. DE-CT, treatment planning, intervention, fluoroscopy) Service maybe beyond QC and radiation safety Is the 5 year recertification sufficient (CAR/CCPM MAMMO: 3 years)? 34

35 References 1. Cancer facts and figures American Cancer Society. documents/webcontent/acspc pdf. Accessed June 29, SEER stat fact sheets: lung and bronchus cancer. Surveillance, Epidemiology, and End Results program. Accessed June 29, Fintelmann et al. The 10 Pillars of Lung Cancer Screening: Rationale and Logistics of a Lung Cancer Screening Program, Radiographics, ACR STR Practice Parameter for the Performance and Reporting of Lung Cancer Screening Thoracic Computed Tomography (CT), ACR Resolution 4, Lung Cancer Screening CT Protocols Version 4.0, AAPM CT Protocols, February, 23 rd, Fujii et al. Patient Size Specific Analysis of Dose Indexes From CT Lung Cancer Screening, AJR:208, January Winslow et al. AAPM 2014, Austin, TX. 8. ACR-AAPM Technical Specifications (various) 35

36 Thank You! Yogesh Thakur, PhD, MCCPM 36

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