Simplified size adjusted dose reference levels for adult CT examinations: A regional study

Cumulative radiation exposure from multimodality recurrent imaging of CT, fluoroscopically guided intervention, and nuclear medicine

OBJECTIVES

To assess cumulative effective dose (CED) over a 4-year period in patients undergoing multimodality recurrent imaging at a major hospital in the USA.

METHODS

CED from CT, fluoroscopically guided intervention (FGI), and nuclear medicine was analyzed in consecutive exams in a tertiary care center in 2018-2021. Patients with CED ≥ 100 mSv were classified by age and body habitus (underweight, healthy weight, overweight, obese), as per body mass index percentiles < 5th, 5th to < 85th, 85th to < 95th, and ≥ 95th (age 2-19 years), and its ranges < 18.5, 18.5-24.9, 25-29.9, and ≥ 30 (≥ 20 years), respectively.

RESULTS

Among a total of 205,425 patients, 5.7% received CED ≥ 100 mSv (mean 184 mSv, maximum 1165 mSv) and their ages were mostly 50-64 years (34.1%), followed by 65-74 years (29.8%), ≥ 75 years (19.5%), 20-49 years (16.3%), and ≤ 19 years (0.29%). Body habitus in decreasing occurrence was obese (38.6%), overweight (31.9%), healthy weight (27.5%), and underweight (2.1%). Classification by dose indicated 172 patients (≥ 500 mSv) and 3 (≥ 1000 mSv). In comparison, 5.3% of 189,030 CT patients, 1.6% of 18,963 FGI patients, and 0.19% of 41,401 nuclear-medicine patients received CED ≥ 100 mSv from a single modality.

CONCLUSIONS

The study of total dose from CT, FGI, and nuclear medicine of patients with CED ≥ 100 mSv indicates major (89%) contribution of CT to CED with 70% of cohort being obese and overweight, and 64% of cohort aged 50-74 years.

CLINICAL RELEVANCE STATEMENT

Multimodality recurrent exams are common and there is a lack of information on patient cumulative radiation exposure. This study attempts to address this lacuna and has the potential to motivate actions to improve the justification process for enhancing patient safety.

KEY POINTS

• In total, 5.7% of patients undergoing multimodality recurrent imaging (CT, fluoroscopically guided intervention, nuclear medicine) incurred a dose of ≥ 100 mSv. • Mean dose was 184 mSv, with 15 to 18 times contribution from CT than that from fluoroscopically guided intervention or nuclear medicine. • In total, 70% of those who received ≥ 100mSv were either overweight or obese.

Relationships of Radiation Dose Indices with Body Size Indices in Adult Body Computed Tomography

We investigated the relationships between radiation dose indices and body size indices in adult body computed tomography (CT). A total of 3200 CT scans of the thoracic, abdominal, abdominopelvic, or thoraco-abdominopelvic regions performed using one of four CT scanners were analyzed. Volume CT dose index (CTDIvol) and dose length product (DLP) were compared with various body size indices derived from CT images (water-equivalent diameter, WED; effective diameter, ED) and physical measurements (weight, weight/height, body mass index, and body surface area). CTDIvol showed excellent positive linear correlations with WED and ED. CTDIvol also showed high linear correlations with physical measurement-based indices, whereas the correlation coefficients were lower than for WED and ED. Among the physical measurement-based indices, weight/height showed the strongest correlations, followed by weight. Compared to CTDIvol, the correlation coefficients with DLP tended to be lower for WED, ED, and weight/height and higher for weight. The standard CTDIvol values at 60 kg and dose increase ratios with increasing weight, estimated using the regression equations, differed among scanners. Radiation dose indices closely correlated with body size indices such as WED, ED, weight/height, and weight. The relationships between dose and body size differed among scanners, indicating the significance of dose management considering body size.

How Do Cancer-Specific Computed Tomography Protocols Compare With the American College of Radiology Dose Index Registry? An Analysis of Computed Tomography Dose at 2 Cancer Centers

BACKGROUND

Little guidance exists on how to stratify radiation dose according to diagnostic task. Changing dose for different cancer types is currently not informed by the American College of Radiology Dose Index Registry dose survey.

METHODS

A total of 9602 patient examinations were pulled from 2 National Cancer Institute designated cancer centers. Computed tomography dose (CTDI vol ) was extracted, and patient water equivalent diameter was calculated. N-way analysis of variance was used to compare the dose levels between 2 protocols used at site 1, and three protocols used at site 2.

RESULTS

Sites 1 and 2 both independently stratified their doses according to cancer indications in similar ways. For example, both sites used lower doses ( P < 0.001) for follow-up of testicular cancer, leukemia, and lymphoma. Median dose at median patient size from lowest to highest dose level for site 1 were 17.9 (17.7-18.0) mGy (mean [95% confidence interval]) and 26.8 (26.2-27.4) mGy. For site 2, they were 12.1 (10.6-13.7) mGy, 25.5 (25.2-25.7) mGy, and 34.2 (33.8-34.5) mGy. Both sites had higher doses ( P < 0.001) between their routine and high-image-quality protocols, with an increase of 48% between these doses for site 1 and 25% for site 2. High-image-quality protocols were largely applied for detection of low-contrast liver lesions or subtle pelvic pathology.

CONCLUSIONS

We demonstrated that 2 cancer centers independently choose to stratify their cancer doses in similar ways. Sites 1 and 2 dose data were higher than the American College of Radiology Dose Index Registry dose survey data. We thus propose including a cancer-specific subset for the dose registry.

Establishing diagnostic reference levels for pediatric fluoroscopic examinations in a tertiary hospital

BACKGROUND

Diagnostic reference levels (DRLs) identify unusually high patient radiation exposures and are required for dose optimisation. DRLs for pediatric fluoroscopic examinations are not widely determined in Australia.

OBJECTIVE

Our objectives were to establish DRLs for pediatric fluoroscopic examinations in a South Australian tertiary hospital and compare these to previously published data and to explore relationships between patient dose area product (DAP), age and fluoroscopy times.

MATERIALS AND METHODS

Dose data from 365 pediatric patients undergoing 5 fluoroscopic examinations were retrospectively collected for a 3-year period commencing January 2018 to develop local DRLs. Relationships between DAP, age and fluoroscopy time were explored using scatterplots, Spearman's correlation, and regression analyses.

RESULTS

Local DRLs were significantly lower than data published previously, possibly reflecting technological and procedural advancements. Each 1-year increase in patient age was associated with a 0.77 μGy·m² increase in DAP for barium meal and follow-through studies (95% confidence interval [CI]=0.055, 1.48) (P=0.04), and a 1.37 μGy·m² increase in DAP for barium swallow studies (95% CI=0.61, 2.12) (P<0.001). A low correlation was demonstrated between DAP and fluoroscopy time for micturating cystourethrography studies (r=0.35, 95% CI=0.15, 0.51, P<0.001) and barium meal and follow-through studies (r=0.37, 95% CI= -0.011, 0.65, P=0.05). Age and fluoroscopy time were not significantly related.

CONCLUSION

This study provides updated Australian pediatric fluoroscopic DRLs, with the intention of promoting a national database for benchmarking pediatric doses. The local DRLs can be used for dose comparisons and optimisation between facilities.

T-shirt size as a classification for body habitus in computed tomography (CT) and development of size-based dose reference levels for different indications

PURPOSE

To examine the impact of patient size on dose indices and develop size-based reference levels (50th and 75th percentiles) for 20 body CT exams for routine and organ-specific clinical indications.

METHODS

Based on effective diameter estimated from adult body CT, each acquisition was classified into T-shirt size as XXS, XS, S, M, L, XL, and XXL. Radiation dose indices for each size and each exam type were correlated.

RESULTS

About 0.93 million CT exams from 256 CT facilities in the United States were analysed. Taking T-shirt size M as a reference, the CTDI_vol for other sizes were: XXS (∼60%), XS (∼65%), S (∼75%), L (∼130%), XL (∼165%), XXL (∼210%), or grossly small patients received about 60% of the dose as compared to M sized patients and XXL required doubling the dose. Taking ratio of the dose indices of the largest to smallest size, it was evident that SSDE variation was much less (about 50%) than that in CTDI_vol, but there was still nearly 40 to 220% variation in SSDE across the range of t-shirt sizes. The 50th and 75th percentile values are presented for CTDI_vol, SSDE and DLP for each of the 20 CT exams and for each of the seven T-shirt sizes.

CONCLUSIONS

A novel approach expressing body habitus in terms of T-shirt size is not only simple and intuitive, but it also provides a tool to have a perception of differences in dose metrices among patients of different body build.

Establishment of national diagnostic reference levels for percutaneous coronary interventions (PCIs) in Thailand

PURPOSE

To establish national diagnostic reference levels (DRLs) for percutaneous coronary intervention (PCI) in Thailand for lesions of different complexity.

METHODS

Radiation dose quantity as kerma-area-product (KAP) and cumulative air-kerma at reference point (CAK) from 76 catheterization labs in 38 hospitals in PCI registry of Thailand was transferred online to central data management. Sixteen months data (May 2018 to August 2019) was analyzed. We also investigated role of different factors that influence radiation dose the most.

RESULTS

Analysis of 22,737 PCIs resulted in national DRLs for PCI of 91.3 Gy.cm² (KAP) and 1360 mGy (CAK). The NDRLs for KAP for type C, B2, B1 and A lesions were 106.8, 82.6, 67.9, and 45.3 Gy.cm² respectively and for CAK, 1705, 1247, 962, and 790 mGy respectively. Thus, as compared to lesion A, lesion C had more than double the dose and B2 had nearly 1.6 times and B1 had 1.2 times CAK. Our DRL values are lower than other Asian countries like Japan and Korea and are in the middle range of Western countries. University hospital had significantly higher dose than private or public hospital possibly because of higher load of complex procedures in university hospitals and trainees performing the procedures. Transradial approach showed lower doses than transfemoral approach.

CONCLUSIONS

This large multi-centric study established DRLs for PCIs which can act as reference for future studies. A hallmark of our study is establishment of reference levels for coronary lesions classified as per ACC/AHA and thus for different complexities.