CURRENT CT DOSE METRICS: MAKING CTDI SIZE-SPECIFIC
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1 CURRENT CT DOSE METRICS: MAKING CTDI SIZE-SPECIFIC Keith Strauss, MSc, FAAPM, FACR Cincinnati Children s Hospital University of Cincinnati College of Medicine
2 Acknowledgments John Boone, PhD Michael McNitt-Grey, PhD Cynthia McCollough, PhD Dianna Cody, PhD Tom Toth, PhD G. Donald Frey, PhD
3 CT Dose Indices INTRODUCTION CTDI CTDI 100, CTDI w, CTDI vol Displayed vs Measured CTDI vol DLP Clinical Dilemma SSDE E Dose Limitations Simple Application of SSDE in the Clinic Estimating Organ Doses from SSDE
4 REAL WORLD. Radiation distribution crosses the imaged volume Peak dose Tails of dose distribution Adapted from Frey - 5 mm mm
5 CTDI = Integral under the radiation dose profile along the z-axis from a single axial scan of width nt. radiation dose profile nt nominal beam width = total nominal scan width Adapted from Frey Z
6 CT SCANNER DOSE INDICES Computed Tomography Dose Index (CTDI) Represents the average integrated absorbed dose along the z axis from a series of contiguous irradiations. CTDI 100 represents accumulated multiple scan dose at center of 100 mm scan.
7 CT SCANNER DOSE INDICES Measurement of CT Radiation Dose Plastic cylindrical phantoms: CTDI Phantoms (PMMA) 16 & 32 cm diameter Pencil chamber moved into provided holes to measure radiation dose peripheral hole Center of phantom Non measured holes plugged center hole Adapted from TG204 PMMA plug 100 mm pencil chamber
8 CT SCANNER DOSE INDICES Measurement of CT Radiation Dose Plastic cylindrical phantoms: CTDI Phantoms (PMMA) 16 & 32 cm diameter Pencil chamber moved into provided holes to measure radiation dose peripheral hole Surface of phantom Non measured holes plugged center hole Adapted from TG mm pencil chamber PMMA plug
9 CT SCANNER DOSE INDICES Measurement of CT Radiation Dose 32 and 16 cm CTDI standard phantoms positioned to measure CT doses. Images Courtesy of John Boone
10 CT SCANNER DOSE INDICES Measurement of CT Radiation Dose Dose readings at two points in phantom 1 cm below surface 100 Center Dose distribution depends on phantom diameter
11 CT SCANNER DOSE INDICES Calculation of CTDI Values Weighted CTDI: CTDI w Average CTDI across the FoV CTDI w = 1/3 CTDI 100,center + 2/3 CTDI 100,edge CTDI w = = 83 mgy for 32 cm CTDI phantom Ave Dose over x & y direction
12 CT SCANNER DOSE INDICES Measured CTDI vol Measure CTDI vol with identical scan parameters kv ma Rotation time Bow Tie Filter Use phantom 10, 16, and 32 cm diameter
13 Measured CTDI vol = 47 Measured CTDI vol = 37 Measured CTDI vol = mgy 47 mgy 38 mgy 47 mgy 35 mgy 10.8 mgy 10 cm Diameter 16 cm Diameter 32 cm Diameter Measured CTDI vol increases 2.6 times as phantom size decreases!
14 CT SCANNER DOSE INDICES Displayed CTDI vol Dose that represents distribution of dose given to crosssectional area of a slab of the CTDI phantom (16 or 32 cm diameter) Reflects changes in: High voltage to x-ray tube (kv) X-ray tube current (ma) Rotation time (sec) Pitch Bow tie filter shape, thickness, material Source to detector distance
15 CT SCANNER DOSE INDICES Displayed CTDI vol Standardized method to estimate and compare the radiation output of two different CT scanners to same phantom. Dose index of CT scanners if the fan beam width in z direction of the patient is small (< 1 cm) If fan beam width (> 1 cm), dose index addressed by AAPM TG111
16 CT SCANNER DOSE INDICES Displayed CTDI vol does not represent... Patient dose!!
17 Measured CTDI vol = 47 Measured CTDI vol = 37 Measured CTDI vol = mgy 47 mgy 47 mgy 38 mgy 35 mgy 10.8 mgy Displayed CTDI vol16 = 37 Displayed CTDI vol32 = 18 Displayed CTDI vol16 = 37 Displayed CTDI vol32 = 18 Displayed CTDI vol16 = 37 Displayed CTDI vol32 = 18
18 CTDI SHORTCOMING Same radiographic technique 32 cm CTDI Phantom Displayed CTDI vol = 18 mgy for both patients
19 CLINICAL DILEMMA Displayed CTDI vol on scanner is independent of patient size 16 cm CTDI phantom: adult dose over while pediatric dose under estimated. 32 cm CTDI phantom: adult and pediatric dose under estimated ~ 2.5 times! Propagated by DICOM Structured Reports and CT scanner dose reports.
20 CLINICAL DILEMMA CTDI Phantoms are not clinical models
21 CLINICAL DILEMMA Anthropomorphic Phantoms only approximate the human body
22 CT SCANNER DOSE INDICES Displayed Dose Length Product (DLP) DLP (mgycm) = CTDI vol * Scan Length Scan length is the length of phantom irradiated. Represents energy transferred. DLP is not a patient dose index because CTDI vol does not represent patient dose. SSDELP = SSDE * Scan Length Better estimate of energy transferred.
23 Adapted from Frey DLP = 200 mgy cm CTDIvol = 20 mgy ten 1-cm slices DLP = 400 mgy cm CTDIvol STILL = 20 mgy twenty 1-cm slices DLP represents the greater biologic risk!
24
25 Report does not: TG 204 Address correction factors for heads Correct small (< 1%) doses from scanned projection images. Correct for variation (~ 5%) in attenuation of thorax vs abdomen Correct small variation in pre and post contrast scans
26 So what is SSDE?: TG 204 Estimate of the average patient dose within the entire scan volume of patient. Adjusts for patient size and varying attenuation from overlying tissue thickness. Uses average scanner radiation output during CT scan: CTDI vol Output varies along z axis Output varies as beam rotates Output varies based on bow tie filter
27 TG 204 Data from four independent investigators studying patient size correction factors. Adapted from TG 204 Physical measurements on phantoms A. Anthropomorphic Phantoms (McCollough Laboratory Mc ) B. Cylindrical PMMA phantoms (Toth / Strauss Collaboration T-S ) Monte Carlo computer modeling C. Monte Carlo Voxelized Phantoms (McNitt-Gray Laboratory MG ) D. Monte Carlo Mathematical Cylinders (Boone Laboratory Z-B )
28 TG cm 120 kv Adapted from TG 204
29 TG cm 120 kv Adapted from TG 204
30 TG 204 What about scans performed at 80, 100, or 140 kv? from 120 kv only Combined TS / ZB: kv 1. 5% difference overall 2. 3% difference between 1 yr old (15 cm) & adult (32 cm)
31 TG 204 What about scans performed in the thorax? 1. Thorax data from Huda et al % 12 cm 3. 7% 17 cm 4. < 3% dif > 17 cm Adapted from Boone
32 TG 204 What is an effective diameter? Circle with area of patient s cross section Effective diameter can be estimated if the patient s AP or lateral dimension is known. circle of equal area AP effective diameter lateral
33 AGE vs PATENT SIZE Same age patients vary dramatically in size. Abdomens of: Largest 3 year olds and Smallest adults are the same size. Patient cross section size, not age, should be used.
34 What if I am doing retrospective dose analysis and I only know age of patient? Corrections based on patient size are more accurate. Adapted from TG 204 Effective Diameter as a function of age per ICRU 74
35 TG 204 Determining patient size Measure Lateral dimension with mechanical calipers. Measure Lateral or AP dimension from AP or Lateral projection scan. Magnification Error Measure AP or LAT dimension from axial scan view. AP or PA Projection Scan Adapted from TG204 AP or PA Projection Scan Adapted from TG204
36 TG 204 Determining size of CTDI phantom your CT scanner used to estimate CTDI vol Failure to identify correct phantom, 16 or 32 cm leads to a systematic error of up to 100%. No standard exists. Choice may depend on: Selected protocol: adult or pediatric Selected scan field of view Year of manufacture Software level Make no assumptions: contact manufacturer of your unit through their service organization.
37 SSDE Accuracy 20% TG 204 Product is an estimate of patient dose Report doses with proper number of significant digits SSDE > 5 mgy: integers only, e.g. 7 or 23 mgy SSDE < 5 mgy: one decimal point, e.g. 2.7 or 4.5 mgy
38 SAMPLE CALCULATION: POST SCAN Determine size of patient AP = 9.9 cm; LAT = 12.3 cm AP + LAT = 22.2 cm 32 cm CTDI phantom assumed Displayed CTDI vol = 5.4 mgy 5.4 mgy x 2.5 = 13 mgy SSDE Adapted from TG 204
39 Caution: Effective Dose Limitations SSDE can NOT be substituted in place of CTDI vol when using k-factors to estimate Effective Doses from CT exam.
40 Effective Dose Limitations Can Effective Dose be used to estimate: An individual patient s radiation dose? Organ doses? ABSOLUTELY NOT, despite the fact that one can find numerous published papers that make this error!!
41 Effective Dose Limitations Effective Dose was originally defined to address radiation protection concerns of occupationally exposed workers. Effective dose can be used to facilitate a comparison of biological effects between diagnostic exams of different types.
42 Effective Dose Limitations Effective Dose Recommended Reading ICRP 103 Executive Summary AD Nixon, New ICRP recommendations, J Radiol Prot CJ Martin, Effective dose: How should it be applied to medical exposures?, BJR 2007 Rational approach to the clinical use of effective dose estimates, AJR 2011.
43 CLINICAL APPLICATIONS OF SSDE Phantom 16 CTDI 32 CTDI 16/32 CTDI CTDI vol SSDE SSDE SSDE Abdomen (mgy) (mgy) (mgy) (mgy) Newborn 8 Sm Adult 12 Lg Adult 16 Setting up reference values for all size patients based on CTDI vol results in odd patient doses. \
44 CLINICAL APPLICATIONS OF SSDE Phantom 16 CTDI 32 CTDI 16/32 CTDI CTDI vol SSDE SSDE SSDE Abdomen (mgy) (mgy) (mgy) (mgy) Newborn 8 9 Sm Adult Lg Adult 16 7 Setting up reference values for all size patients based on CTDI vol results in odd patient doses. \
45 CLINICAL APPLICATIONS OF SSDE Phantom 16 CTDI 32 CTDI 16/32 CTDI CTDI vol SSDE SSDE SSDE Abdomen (mgy) (mgy) (mgy) (mgy) Newborn Sm Adult Lg Adult Setting up reference values for all size patients based on CTDI vol results in odd patient doses. \
46 CLINICAL APPLICATIONS OF SSDE Phantom 16 CTDI 32 CTDI 16/32 CTDI CTDI vol SSDE SSDE SSDE Abdomen (mgy) (mgy) (mgy) (mgy) Newborn Sm Adult Lg Adult Setting up reference values for all size patients based on CTDI vol results in odd patient doses. \
47 CLINICAL APPLICATIONS OF SSDE SSDE CTDI v16 CTDI v32 CTDI v16/32 Abdomen (mgy) (mgy) (mgy) (mgy) Newborn 9 Sm Adult 12 Lg Adult 15 Setting up reference values for all size patients based on SSDE is more straight forward. \
48 CLINICAL APPLICATIONS OF SSDE SSDE CTDI v16 CTDI v32 CTDI v16/32 Abdomen (mgy) (mgy) (mgy) (mgy) Newborn 9 8 Sm Adult Lg Adult Setting up reference values for all size patients based on SSDE is more straight forward. \
49 CLINICAL APPLICATIONS OF SSDE SSDE CTDI v16 CTDI v32 CTDI v16/32 Abdomen (mgy) (mgy) (mgy) (mgy) Newborn Sm Adult Lg Adult Setting up reference values for all size patients based on SSDE is more straight forward. \
50 CLINICAL APPLICATIONS OF SSDE SSDE CTDI v16 CTDI v32 CTDI v16/32 Abdomen (mgy) (mgy) (mgy) (mgy) Newborn Sm Adult Lg Adult Setting up reference values for all size patients based on SSDE is more straight forward. \
51 CLINICAL APPLICATIONS OF SSDE SSDE estimates patient dose for both adult and pediatric patients. can be first approximation of some organ doses Soft tissues only Organ completely in scan volume in z direction. \
52 CLINICAL APPLICATIONS OF SSDE SSDE Can be first approximation of some organ doses: Radial dose profiles Range dependent on patient diameter Pediatric vs Adult? CTDI vol (83)
53 CLINICAL APPLICATIONS OF SSDE SSDE Can be first approximation of some organ doses: Increased error for small organs depending on location. Less effect for pediatrics Adapted from McCollough 100
54 CONCLUSIONS Estimating and managing a patient s CT dose as a function of their size is facilitated by the use of SSDE provided: CTDI vol, CTDI phantom size assumed by the CT scanner, and Patient size are known.
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