Dose Reduction of the Female Breast in Chest CT

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1 Cardiopulmonary Imaging Original Research Seidenfuss et al. Reduction of CT Radiation Dose to Female Breast Cardiopulmonary Imaging Original Research Downloaded from by on 1/12/18 from IP address Copyright ARRS. For personal use only; all rights reserved Anna Seidenfuss 1 Andreas Mayr 2 Matthias Schmid 2 Michael Uder 1 Michael M. Lell 1 Seidenfuss A, Mayr A, Schmid M, Uder M, Lell MM Keywords: chest CT, dose reduction, female breast, tube current modulation DOI:1.2214/AJR Received December 23, 12; accepted after revision August 24, Department of Radiology, University Erlangen-Nuremberg, Maximiliansplatz 1, Erlangen 9154, Germany. Address correspondence to A. Seidenfuss (Anna.seidenfuss@gmail.com). 2 Department of Medical Informatics, Biometry and Epidemiology, University Erlangen-Nuremberg, Erlangen, Germany. This article is available for credit. WEB This is a web exclusive article. AJR 14; 2:W447 W X/14/25 W447 American Roentgen Ray Society Dose Reduction of the Female Breast in Chest CT OBJECTIVE. Organ-based tube current modulation has been shown to significantly reduce the radiation dose to the female breast in phantom studies. We sought to assess the proportions of female breast and glandular tissues that are within the range of organ-based tube current modulation in different age groups and whether these proportions could be optimized by clothing. The secondary objective of our study was to determine whether metal parts of brassieres cause artifacts that impair the diagnostic value. SUBJECTS AND METHODS. Five hundred seventy-eight female patients undergoing chest CT were included in this study. Two hundred nine patients were prospectively examined wearing a brassiere (group A), and the control patients (group B; n = 369) were scanned according to our previous standard without wearing a brassiere during CT. The two groups were subdivided according to cup size (A E). For CT data acquisition, an angle-dependent tube current modulation, which reduces the tube current for anterior tube position to minimize direct exposure to anteriorly located organs, was used. The proportion of breast tissue and glandular tissue located within and outside the region of tube current reduction was assessed. RESULTS. The results showed that.4% of total breast tissue and 67.1% of glandular tissue was inside the region of tube current reduction in group B; the proportions were significantly improved, to an average of 91.3% and 96%, respectively, in group A. Diagnostically relevant artifacts were introduced in none of the patients. Patients age correlated with this effect, with higher rates of improvement in the older patient group. Angle-dependent tube current modulation was most effective in patients with cup size A while wearing a brassiere. In this group, 97.5% of breast tissue and 98.1% of glandular tissue was inside the region of tube current reduction. Women with a cup size of E had the largest effect of wearing a brassiere, increasing the rate of breast tissue that was affected by angle-dependent tube current modulation from 3.% to 83.3% and that of glandular tissue from 31.8% to 9.%. CONCLUSION. We show that wearing a brassiere increases the percentage of breast tissue within the region of reduced tube current and, therefore, improves the performance of angle-dependent tube current modulation technique. R adiation exposure caused by medical imaging is increasingly recognized as a potential source of cancer induction. It has been shown that the number of DNA double-stranded breaks is closely related to applied dose [1, 2]. The glandular tissue of the female breast is considered to be more susceptible to radiation exposure than other tissues, especially at a young age, resulting in a higher weighting factor, according to the International Commission on Radiological Protection [3]. Several different techniques have been introduced to reduce dose in CT recently, and many of them have made their way into clinical routine, including tube current modulation, automated exposure control, ECG pulsing, high-pitch scanning, and, increasingly, iterative reconstruction techniques and low-kilovoltage scanning. Breast shielding with lead or bismuth foils has also been proposed, but these shields are rather expensive because they are singleuse articles and are associated with artifacts in the frontal thoracic wall [4]. Vollmar and Kalender [4] found in a phantom study that radiation exposure to the fe- AJR:2, May 14 W447

2 Seidenfuss et al. Downloaded from by on 1/12/18 from IP address Copyright ARRS. For personal use only; all rights reserved male breast could be reduced up to 42% without decreasing the image quality with a partial scan (or organ-based tube current modulation) approach. This technique originally was developed to reduce dose to the hands of interventional radiologists using CT fluoroscopy; recently, it has become available for head and chest examinations on commercially available CT systems. Ketelsen et al. [5] tested a commercially available organ-based tube current modulation tool to measure its effect on radiosensitive organs in phantoms. It enables dose reduction to the female breast of 35.2% for the anterior 1 of projection. In many institutions, it is standard practice that female patients are instructed to take off their brassieres before chest CT and to only wear a T-shirt or hospital gown. The aim of our study was to assess the proportion of the female breast and glandular tissue that is within the range of angle-dependent tube current modulation and whether this proportion could be optimized by keeping the brassiere on. The secondary objective of our study was to determine whether metal parts of brassieres cause artifacts that impair the diagnostic value. Subjects and Methods Patients Five hundred seventy-eight female patients undergoing chest CT for various indications were included in this study. Written informed consent was obtained from each patient. The study was performed with institutional research board approval. Three age groups were analyzed: 16, 41 65, and years. Two hundred nine patients were prospectively examined wearing a brassiere (group A). The control group (group B) included 369 patients who were not wearing a brassiere during chest CT, whose examinations were retrieved from our PACS. Because body weight and size may not correlate well with breast size, we used cup size to characterize the habitus. Fortysix patients had cup size A, 184 patients had cup size B, 245 patients had cup size C, 89 patients had cup size D, and 14 patients had cup size E. Patients were not asked to wear a special type of brassiere for the CT examination or to avoid ones with metallic clips or appliances, so a large variety of different types was used. second, and mm slice acquisition), using an angle-dependent tube current modulation (X-CARE, Siemens Healthcare) scan protocol, which reduces the tube current to % within a range of 1 to direct irradiation of the breast tissue and automatically adjusts the tube current for the remaining projections to prevent a decrease in image quality. Images were reconstructed with 5-mm slice thickness with a soft-tissue (B31) and high-resolution (B7) kernel in a patient-specific FOV. Additional thin-slice reconstructions (slice thickness,.7 mm; reconstruction increment,.5 mm) were performed for multiplanar imaging. For image evaluation, window and level settings of and 5 HU, respectively, were used. The proportion of volume of breast tissue located within and outside the area of tube output reduction was assessed and differentiated in breast tissue and glandular tissue. All breast tissue except fat, muscle, and skin was considered glandular tissue for the purpose of this study and was used for volumetry. On each image containing breast tissue, this area was plotted, and the percentage of breast tissue and glandular tissue inside and outside this area was calculated. All measurements were performed on a dedicated 3D workstation (Syngo Via, Siemens Healthcare) connected to our PACS. Two independent reviewers rated artifacts related to the brassiere on a 3-point Likert scale, where indicates no relevant artifacts, 1 indicates artifacts impairing evaluation of breast tissue, and 2 indicates artifacts impairing evaluation of breast tissue or chest organs. Statistical Methods To assess group differences with respect to the proportion of breast tissue and glandular tissue inside the angle of reduced x-ray beam, we followed a two-step approach: first, tissue percentages were compared in both groups by univariate two-sample Welch t test assuming unequal variances. Because the distributions of both outcome measures were heavily skewed, logit transformations were applied [6]. Second, to assess the group effect adjusted for the possible confounding variables of age and cup size of participants, we performed multifactorial analysis of variance. The logit-transformed proportions of breast and glandular tissues inside the x-ray beam served as response variables, whereas the group variable, category, and cup size entered the model as explanatory factors. To account for nonadditive simultaneous effects of the group factor and age category or cup size on the outcome measures, we also included the corresponding interaction terms. Model diagnostics in terms of residual analysis (normal-quantile plots) were used to investigate whether model assumptions were fulfilled. Significance of effects was assessed by likelihood ratio tests applying a two-sided significance level of.5. All statistical analyses were conducted using the statistical computing environment R (version 2.13., The R Foundation) [7]. Results Several different brassiere types were used. None, including the ones with metallic appliances or clips, caused artifacts influencing the diagnostic value of the study (Figs. 1 and 2). Interrater agreement was perfect (κ = 1). No relevant artifacts impairing the assessment of breast tissue or chest wall were found. Univariate analysis of the data showed statistically significant differences (p <.1) between the two groups (group A vs group B) for both outcomes (proportion of breast tissue and glandular tissue affected by angledependent tube current modulation; Fig. 3). Although in group A, on average 91.3% (SD, 9.36%) of breast tissue and 96% (SD, 6.73%) of glandular tissue was contained inside the Chest CT All patients from group A were examined with a single-source 128-MDCT system (Definition AS+, Siemens Healthcare; 1 kv, 11 reference mas, pitch factor of.9, rotation time of.5 Fig year-old woman with malignant melanoma. Images were obtained with patient wearing (right) and not wearing (left) brassiere. W448 AJR:2, May 14

3 Reduction of CT Radiation Dose to Female Breast Downloaded from by on 1/12/18 from IP address Copyright ARRS. For personal use only; all rights reserved Fig year-old woman with sarcoidosis. Images were obtained with patient wearing (right) and not wearing (left) brassiere. Breast Tissue Inside Angle (%) 1 8 With Bra Without Bra Glandular Tissue Inside Angle (%) With Bra Without Bra Fig. 3 Distribution of percentages of breast tissue (left) and glandular tissue (right) inside angle of reduceddose x-ray beam for patients wearing and not wearing brassiere during CT scanning. Thick solid lines within boxes denote median, circles denote outliers, box indicates interquartile range (IQR), and thin horizontal lines denote 1.5 IQR.. Breast Tissue Inside Angle (%) Age Categories (y) Glandular Tissue Inside Angle (%) Age Categories (y) Fig. 4 Percentages of breast tissue (left) and glandular tissue (right) inside angle of reduced-dose x-ray beam, according to patient age group. Dashed lines and open circles represent average values for group wearing brassiere, whereas solid lines and circles refer to control group not wearing brassiere during CT scanning. 1 8 angle, these values decreased to.4% (SD, 24.66%) and 67.1% (SD, 25.28%), respectively, in group B. In the 16- to -year-old age group, the percentage of breast tissue affected by angledependent tube current modulation increased from 76.9% to 94.2%, and the percentage of glandular tissue increased from 81.5% to 96.2%. In the 41- to 65-year-old age group, the percentage of breast tissue increased from 55.3% to 92.1%, and the percentage of glandular tissue increased from 62.2% to 96.2%. Finally, in the 66- to 89-year-old age group, the percentage of breast tissue affected by angle-dependent tube current modulation increased from 52.7% to 88.3%, and the percentage of glandular tissue increased from.7% to 95.4%. Confounder-adjusted multifactorial analysis of variance also resulted in a significant effect of the grouping variable (positive effect of wearing a brassiere, p <.1) for both outcome measures. Older age categories had a negative effect on the outcome measures (p <.1). An interaction of the age category and the grouping variable showed an increased negative effect for not wearing a brassiere inside the CT scanner for older women (p <.5 for breast tissue and p <.1 for glandular tissue; Fig. 4), so the age of patients potentiates the effect of wearing the brassiere in a positive way. The effect of wearing a brassiere seems to have a smaller effect on the percentage of breast and glandular tissue affected by angle-dependent tube current modulation in younger patients, although the young women in group B also had high percentages of breast tissue located in the angle of 1, without wearing special clothes. Regarding the effect of cup size, the effect of wearing a brassiere seems to have a larger impact in patients with larger cup sizes (p <.1; Fig. 5). The best results were achieved by patients with cup size A wearing a brassiere. In this group, 97.5% of breast and 98.1% of glandular tissue was inside the region of tube current reduction. The highest effect of wearing a brassiere could be seen in women with cup size E. In this group, only 3.% of breast tissue and 31.8% of glandular tissue was affected by angle-dependent tube current modulation without a brassiere, but 83.3% and 9.% of tissue, respectively, was affected with a brassiere. Discussion Dose reduction has become a major concern in CT. Sensitivity to radiation varies be- AJR:2, May 14 W449

4 Seidenfuss et al. Downloaded from by on 1/12/18 from IP address Copyright ARRS. For personal use only; all rights reserved Breast Tissue Inside Angle (%) 1 8 A B C D E Cup Size tween different tissues. Of particular concern is dose to the glandular tissue of the breast, especially in younger women [8, 9]. The International Commission on Radiological Protection [3] estimates glandular breast tissue to be more radiosensitive than previously recognized, making it one of the most radiosensitive organs in the body. Several strategies have been proposed to reduce the dose to radiosensitive organs consistent with the as low as reasonably achievable principle. Foley et al. [1] showed that displacing the breast cranially outside the direct x-ray beam has potential as a method of reducing direct radiation exposure to the sensitive tissue in cardiac CT. This may be applicable in coronary CT angiography but does not work in chest CT [1], and our findings indicate that placement of breast improves the effect of dose reduction using angle-dependent tube current modulation. Such angle-dependent tube current modulation techniques have been proposed and validated in different phantom experiments [4, 5, 11, 12], which found that significant dose reduction can be achieved without sacrificing image quality. Vollmar and Kalender [4] measured a relative difference of breast dose values of 42.8% for bismuth shields, 44.7% for angle-dependent tube current modulation, and 9.4% for attenuation-based tube current modulation as compared with a scan without dose modulation. Ketelsen et al. [5] used a similar commercially available angle-dependent tube current modulation algorithm in a phantom study and calculated a 35.2% dose reduction to the female breast. Glandular Tissue Inside Angle (%) A B C D E Cup Size Fig. 5 Percentages of breast tissue (left) and glandular tissue (right) inside angle of reduced-dose x-ray beam, grouped by brassiere cup size. Dashed lines and open circles represent average values for group wearing brassiere, whereas solid lines and circles refer to control group not wearing brassiere during CT scanning. 1 8 Although phantom measurements are necessary for direct measurement of glandular tissue exposure, they only represent an idealized anatomy. We therefore sought to evaluate the percentage of breast tissue and glandular tissue that potentially profits from such a technique by reviewing chest CT examinations of a large patient cohort. We found that wearing a brassiere increases the percentage of breast tissue within the region of reduced tube current and therefore improves the performance of an angle-dependent tube current modulation technique (Fig. 6). We found an age-dependent correlation of the effects, with less improvement in the youngest patients. We consider this group to be the most important because they are at the highest risk of radiation-induced cancer. Regarding brassiere cup size effect, a correlation between breast size and the percentage of breast and glandular tissue located in the angle of dose-reduced beam has been shown. The best results were achieved by patients with small cup size wearing a brassiere, whereas women with big cup size benefit the most from wearing a brassiere while undergoing CT examination. We have shown that wearing a brassiere positively influences the effectiveness of angle-dependent tube current modulation in all age groups and body size groups (Figs. 1 and 2), with the greatest effect in women with large breasts. Overweight women had smaller percentages of breast tissue located in the region of tube current reduction. It has also been shown that this patient group has a higher risk for tumor recurrence and a higher mortality compared with slim people [13]. Hauner et al. [14] found a significant positive association between body mass index and mortality associated with breast Fig year-old woman. Images show color-coded dose distribution while patient was wearing brassiere (top) and not wearing brassiere (bottom) in previous examination performed 6 months earlier. Images on left side show dose distribution with angle-dependent tube current modulation, and images on right side show dose distribution without angle-dependent tube current modulation. Dose values shown at right are in milligrays. W45 AJR:2, May 14

5 Reduction of CT Radiation Dose to Female Breast Downloaded from by on 1/12/18 from IP address Copyright ARRS. For personal use only; all rights reserved cancer. Angel et al. [15] studied the effects of tube current modulation during routine chest CT with Monte-Carlo simulations and showed that dose reduction (17% on average) with tube current modulation has a linear relationship with body perimeter. In obese women, tube current modulation negatively affected radiation exposition (the dose increased by 41%) compared with a fixed tube current protocol, although image quality was improved [15]. The link between radiation exposure and induction of neoplasms has been proposed in a number of studies. Perisinakis et al. [16] reported an almost twofold total radiation-induced cancer risk estimated for female patients than for male patients undergoing cardiac CT. Faletra et al. [17] calculated the lifetime attributable risk for women at age years to be 1 in 1283 after a single radiation exposure, whereas for women in their 8s, the risk is 1 in 12,658. Einstein et al. [9] estimated the cancer risk associated with standard cardiac scans to be 1 in 143 for a -year-old woman and 1 in 3261 for an 8-year-old woman, with breast cancer being the leading cancer type. The relative risk of developing breast cancer for women in their s after a single scan of the heart and aorta can be reduced from 28.6 to 18.6 if tube current modulation is used [9]. These data support the need for rigorous dose reduction in young women because they seem to bear the greatest risk of developing radiation-induced breast cancer during the course of their lifetimes. Cancer induction linked to x-ray exposure may play a minor role for women 65 years old and older, but our data show that no degradation of the diagnostic value occurs when the patient is wearing a brassiere, and more breast and glandular tissue profit from the reduced direct exposure to x-rays. As an alternative to angle-dependent tube current modulation, bismuth layers could be placed over the radiosensitive organs to shield the female breast (or the eye lenses) from direct radiation exposure. Yilmaz et al. [18] calculated that a chest CT of an average-sized woman results in.2.5 Gy of absorbed radiation in breast tissue, equivalent to 1 25 two-view mammograms or more than 1 chest radiographs, and the skin dose could be reduced by % using a bismuth shield. The glandular dose was 7.7 versus 9.4 mgy in their phantom study, indicating a dose reduction of 17% [18]. Geleijns et al. [19] also found that shielding markedly reduces dose to the breast (3%) and the lung (15%) but at the cost of a substantial increase in noise and beam-hardening artifacts. Vollmar and Kalender [4] showed that bismuth shielding and angle-dependent tube current modulation had comparable effects in dose reduction, but the image noise level was increased by 28% with bismuth shielding, whereas tube current modulation and angle-dependent tube current modulation only marginally influenced the image noise level (7.1% and 7.8%, respectively). Bismuth shielding was found to reduce the dose to the surface of the breasts (by 46 57%, depending on breast size), but also introduced artifacts, significantly decreased image signal and contrast (contrast-to-noise ratio,.9%), and increased image noise in coronary CT angiography []. For those reasons, the authors did not recommend the use of such shields in coronary CT angiography. McCollough et al. [21] strictly discouraged the use of bismuth shields for three reasons: bismuth shields negatively interfere with automated exposure control techniques, shields degrade image quality, and shields not only reduce dose to the breast but also absorb photons exiting the patient, photons that would otherwise reach the detector and improve the signal-to-noise ratio. In conclusion, we have shown in a large patient cohort that placement of the female breast by keeping a brassiere on during chest CT dose not negatively influence image quality but increases the effect of dose reduction of angle-dependent tube current modulation algorithms. References 1. Kuefner MA, Grudzenski S, Schwab SA, et al. DNA double-strand breaks and their repair in blood lymphocytes of patients undergoing angiographic procedures. Invest Radiol 9; 44: Löbrich M, Rief N, Kühne M, et al. In vivo formation and repair of DNA double-strand breaks after computed tomography examinations. Proc Natl Acad Sci USA 5; 12: International Commission on Radiological Protection. The 7 recommendations of the International Commission on Radiological Protection: ICRP publication 13. Ann ICRP 7; 37: Vollmar SV, Kalender WA. Reduction of dose to the female breast in thoracic CT: a comparison of standard-protocol, bismuth-shielded, partial and tube-current-modulated CT examinations. Eur Radiol 8; 18: Ketelsen D, Buchgeister M, Fenchel M, et al. Automated computed tomography dose-saving algorithm to protect radiosensitive tissues: estimation of radiation exposure and image quality considerations. Invest Radiol 12; 47: Ashton WD. The logit transformation with special reference to its uses in bioassay. New York, NY: Hafner Publishing, R Development Core Team. R: a language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing, Preston DL, Mattsson A, Holmberg E, Shore R, Hildreth NG, Boice JD Jr. Radiation effects on breast cancer risk: a pooled analysis of eight cohorts. Radiat Res 2; 158: Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA 7; 298: Foley SJ, McEntee MF, Achenbach S, Brennan PC, Rainford LS, Dodd JD. Breast surface radiation dose during coronary CT angiography: reduction by breast displacement and lead shielding. AJR 11; 197: Duan X, Wang J, Christner JA, Leng S, Grant KL, McCollough CH. Dose reduction to anterior surfaces with organ-based tube-current modulation: evaluation of performance in a phantom study. AJR 11; 197: Wang J, Duan X, Christner JA, Leng S, Yu L, Mc- Collough CH. Radiation dose reduction to the breast in thoracic CT: comparison of bismuth shielding, organ-based tube current modulation, and use of a globally decreased tube current. Med Phys 11; 38: Chlebowski RT, Aiello E, McTiernan A. Weight loss in breast cancer patient management. J Clin Oncol 2; : Hauner D, Janni W, Rack B, Hauner H. The effect of overweight and nutrition on prognosis in breast cancer. Dtsch Arztebl Int 11; 18: Angel E, Yaghmai N, Jude CM, et al. Monte Carlo simulations to assess the effects of tube current modulation on breast dose for multidetector CT. Phys Med Biol 9; 54: Perisinakis K, Seimenis I, Tzedakis A, Papadakis AE, Damilakis J. Triple-rule-out computed tomography angiography with 256-slice computed tomography scanners: patient-specific assessment of radiation burden and associated cancer risk. Invest Radiol 12; 47: Faletra FF, D Angeli I, Klersy C, et al. Estimates of lifetime attributable risk of cancer after a single radiation exposure from 64-slice computed tomographic coronary angiography. Heart 1; AJR:2, May 14 W451

6 Seidenfuss et al. Downloaded from by on 1/12/18 from IP address Copyright ARRS. For personal use only; all rights reserved 96: Yilmaz MH, Albayram S, Yaşar D, et al. Female breast radiation exposure during thorax multidetector computed tomography and the effectiveness of bismuth breast shield to reduce breast radiation dose. J Comput Assist Tomogr 7; 31: Geleijns J, Salvadó Artells M, Veldkamp WJ, López Tortosa M, Calzado Cantera A. Quantitative assessment of selective in-plane shielding of tissues in computed tomography through evaluation of absorbed dose and image quality. Eur Radiol 6; 16: Einstein AJ, Elliston CD, Groves DW, et al. Effect of bismuth breast shielding on radiation dose and image quality in coronary CT angiography. J Nucl Cardiol 12; 19: McCollough CH, Wang J, Gould RG, Orton CG. Point/counterpoint: the use of bismuth breast shields for CT should be discouraged. Med Phys 12; 39: FOR YOUR INFORMATION This article is available for CME and Self-Assessment (SA-CME) credit that satisfies Part II requirements for maintenance of certification (MOC). To access the examination for this article, follow the prompts. W452 AJR:2, May 14

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