Imaging Radiation Risk:

Perception and Reality

Lung Cancer Workshop VII
Bethesda, MD - May 13, 2010

Lawrence N. Rothenberg, Ph.D.

Dept. of Medical Physics
Memorial Sloan-Kettering Cancer Center
New York, NY

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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

UCSF Group in Arch of Int Med Articles Dec 2009

NY Times articles on radiation doses and accidents

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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

Effective Dose, E (mSv)

For comparison to other radiation procedures
Same Probability of Occurrence of Cancer and Genetic
Effects as for Whole Body Uniform Dose
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Standard CT Dose Phantom:
It does not look much like a chest!
MAXIMUM

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)

Head 0.0021 (mSv / mGy-cm)

Neck 0.0059
Chest 0.014
Abdomen 0.015
Pelvis 0.015

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UK 2003 Lung CT Doses

Shrimpton PC, Hillieer MC, Lewis MA. BJR 2006; 79:968-980

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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

From Brenner & Hall

NEJM 2007
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CT Dose Reduction Techniques
Caution: Effect on image quality must be known before use
Lower mA
Lower kVp
Reduce rotation or total exposure time
Increase helical pitch
Increase section thickness
Increase section spacing
Decrease scan length
Utilize automatic dose reduction techniques, if available
Indirect effects of reconstruction algorithms, image filters

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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

From Gierada DS, Garg K, Nath H, et al. AJR 2009; 193:419-424

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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

Procedure Effective Dose Natural Background

CT Chest 7 mSv 2 Years
Low Dose CT Chest 1.5 mSv 6 Months
Radiography-Chest 0.1 mSv 10 Days

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:

“Patients should follow their doctor’s recommendations for receiving CT

scans. While unnecessary radiation exposure should be avoided, a
medically needed CT scan has benefits that outweigh the radiation risks.”

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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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