Paediatric CT dose: a multicentre audit of subspecialty practice in Australia and New Zealand

Age-based diagnostic reference levels and achievable doses for paediatric CT: a survey in Shanghai, China

Computed tomography (CT) is extensively utilised in medical diagnostics due to its notable radiographic superiority. However, the cancer risk associated with CT examinations, particularly in children, is of significant concern. The assessment of cancer risk relies on the radiation dose to examinees. Diagnostic reference levels (DRLs) and achievable doses (ADs) were used to assess the level of radiation dose in CT examinations widely. Although the national DRLs of paediatric CT have been explored in China, few local DRLs at the city level have been assessed. To set up the local DRLs and ADs of paediatric CT, we investigated the radiation dose level for paediatric CT in Shanghai. In this survey, a total of 3061 paediatric CT examinations underwent in Shanghai in 2022 were selected by stratified sampling, and the dose levels in terms of volume CT dose index (CTDIvol) and the dose-length product (DLP) were analysed by 4 age groups. The DRLs and ADs were set at the 75th and 50th percentile of the distribution and compared with the previous studies at home and abroad. The survey results revealed that, for head scan, the DRLs of CTDIvolwere from 25 to 46 mGy, and the levels of DLP were from 340 to 663 mGy·cm. For chest, the DRLs of CTDIvolwere from 2.2 to 8.3 mGy, and the levels of DLP were from 42 to 223 mGy·cm. For abdomen, the DRLs of CTDIvolwere from 6.3 to 16 mGy, and the levels of DLP were from 181 to 557 mGy·cm. The ADs were about 60% lower than their corresponding DRLs. The levels of radiation doses in children-based hospitals were higher than those in other medical institutions (P< 0.001). In conclusion, there was still potential for reducing radiation dose of paediatric CT, emphasising the urgent need for optimising paediatric CT dose in Shanghai.

Revising and exploring the variations in methodologies for establishing the diagnostic reference levels for paediatric PET/CT imaging

PET-computed tomography (PET/CT) is a hybrid imaging technique that combines anatomical and functional information; to investigate primary cancers, stage tumours, and track treatment response in paediatric oncology patients. However, there is debate in the literature about whether PET/CT could increase the risk of cancer in children, as the machine is utilizing two types of radiation, and paediatric patients have faster cell division and longer life expectancy. Therefore, it is essential to minimize radiation exposure by justifying and optimizing PET/CT examinations and ensure an acceptable image quality. Establishing diagnostic reference levels (DRLs) is a crucial quantitative indicator and effective tool to optimize paediatric imaging procedures. This review aimed to distinguish and acknowledge variations among published DRLs for paediatric patients in PET/CT procedures. A search of relevant articles was conducted using databases, that is, Embase, Scopus, Web of Science, and Medline, using the keywords: PET-computed tomography, computed tomography, PET, radiopharmaceutical, DRL, and their synonyms. Only English and full-text articles were included, with no limitations on the publication year. After the screening, four articles were selected, and the review reveals different DRL approaches for paediatric patients undergoing PET/CT, with primary variations observed in patient selection criteria, reporting of radiation dose values, and PET/CT equipment. The study suggests that future DRL methods for paediatric patients should prioritize data collection in accordance with international guidelines to better understand PET/CT dose discrepancies while also striving to optimize radiation doses without compromising the quality of PET/CT images.

Comparison of Application Value of Different Radiation Dose Evaluation Methods in Evaluating Radiation Dose of Adult Thoracic and Abdominal CT Scan

Objective

To explore the differences among volumetric CT dose index (CTDI_vol), body-specific dose assessment (SSDE_ED) based on effective diameter (ED), and SSDE_WED based on water equivalent diameter (WED) in evaluating the radiation dose of adult thoracic and abdominal CT scanning.

Methods

From January 2021 to October 2021, enhanced chest CT scans of 100 patients and enhanced abdomen CT scans of another 100 patients were collected. According to the body mass index (BMI), they can be divided into groups A and D (BMI < 20 kg/m²), groups B and E (20 kg/m² ≤ BMI ≤ 24.9 kg/m²), and groups C and F (BMI > 24.9 kg/m²). The CTDIvol, anteroposterior diameter (AP), and the left and rght diameter (LAT) of all the patients were recorded, and the ED, water equivalent diameter (WED), the conversion factor (f _size,ED), (f _{size, WED}), SSDE_ED, and SSDE_WED were calculated. The differences were compared between the different groups.

Results

The AP, LAT, ED, and WED of groups B, E, C, and F were higher than those of groups A and D, and those of groups C and F were higher than those of groups B and E (P < 0.05). The f _size,ED and f _{size, WED} of groups B, E, C, and F are lower than those of groups A and D, and those of groups C and F are lower than those of groups B and E (P < 0.05). CTDI_vol, SSDE_ED, and SSDE_WED in groups B, E, C, and F are higher than those in groups A and D, and those in groups C and F are higher than those in groups B and E (p < 0.05). In the same group, patients with chest- and abdomen-enhanced have higher SSDE_WED and SSDE_ED than CTDI_vol, patients with chest-enhanced CT scans have higher SSDE_WED than SSDE_ED, and patients with abdomen-enhanced CT scans have higher SSDE_ED than SSDE_WED (P < 0.05).

Conclusion

CTDIvol and ED-based SSDEED underestimated the radiation dose of the subject exposed, where the patient was actually exposed to a greater dose. However, SSDE_WED based on WED considers better the difference in patient size and attenuation characteristics, and can more accurately evaluate the radiation dose received by patients of different sizes during the chest and abdomen CT scan.

National diagnostic reference levels: What they are, why we need them and what's next

Diagnostic reference levels (DRLs) are an optimisation tool for medical imaging procedures using ionising radiation. They give an indication of the expected radiation dose received by an average-sized patient undergoing a given imaging procedure. Comparison of typical (median) exposure levels for common imaging procedures with DRLs helps imaging facilities identify procedures that may be amenable to further optimisation. Undertaking comparisons with published DRLs is a requirement for medical imaging facilities under the Code for Radiation Protection in Medical Exposure and for their access to Medicare rebates under the Diagnostic Imaging Accreditation Scheme (DIAS). The Australian Radiation Protection and Nuclear Safety Agency has created the National Diagnostic Reference Level Service to facilitate the collection of data for the establishment of national DRLs in Australia and to assist imaging facilities in comparing their typical doses with the national DRLs. National DRLs have been established in computed tomography, nuclear medicine, and for image-guided and interventional procedures. DRLs must be subject to ongoing review and revision by the national authority to ensure they reflect current practice. This ongoing cycle of assessment and review helps to ensure that the ratio of benefit to risk for patients is maximised.

Establishment of Local Diagnostic Reference Levels of Pediatric Abdominopelvic and Chest CT Examinations Based on the Body Weight and Size in Korea

OBJECTIVE

The purposes of this study were to analyze the radiation doses for pediatric abdominopelvic and chest CT examinations from university hospitals in Korea and to establish the local diagnostic reference levels (DRLs) based on the body weight and size.

MATERIALS AND METHODS

At seven university hospitals in Korea, 2494 CT examinations of patients aged 15 years or younger (1625 abdominopelvic and 869 chest CT examinations) between January and December 2017 were analyzed in this study. CT scans were transferred to commercial automated dose management software for the analysis after being de-identified. DRLs were calculated after grouping the patients according to the body weight and effective diameter. DRLs were set at the 75th percentile of the distribution of each institution's typical values.

RESULTS

For body weights of 5, 15, 30, 50, and 80 kg, DRLs (volume CT dose index [CTDIvol]) were 1.4, 2.2, 2.7, 4.0, and 4.7 mGy, respectively, for abdominopelvic CT and 1.2, 1.5, 2.3, 3.7, and 5.8 mGy, respectively, for chest CT. For effective diameters of < 13 cm, 14-16 cm, 17-20 cm, 21-24 cm, and > 24 cm, DRLs (size-specific dose estimates [SSDE]) were 4.1, 5.0, 5.7, 7.1, and 7.2 mGy, respectively, for abdominopelvic CT and 2.8, 4.6, 4.3, 5.3, and 7.5 mGy, respectively, for chest CT. SSDE was greater than CTDIvol in all age groups. Overall, the local DRL was lower than DRLs in previously conducted dose surveys and other countries.

CONCLUSION

Our study set local DRLs in pediatric abdominopelvic and chest CT examinations for the body weight and size. Further research involving more facilities and CT examinations is required to develop national DRLs and update the current DRLs.

Assessment of computed tomography radiation doses for paediatric head and chest examinations using paediatric phantoms of three different ages

INTRODUCTION

With the rapid development of computed tomography (CT) scanners, the assessment of the radiation dose received by the patient has become a heavily researched topic and may result in a reduction in radiation exposure risk. In this study, radiation doses were measured using three paediatric phantoms for head and chest CT examinations in Najran, Saudi Arabia.

METHODS

Thirteen scanners were included in the study to estimate the CT radiation doses using three phantoms representing three age groups (1-, 5-, and 10-year-old patients).

RESULTS

The volume CT dose index (CTDI_vol) estimated for each phantom ranged from 6.56 to 41.12 mGy and 0.292 to 11.10 mGy for the head and chest examinations, respectively. The estimation of lifetime attributable risk (LAR) indicated that the cancer risk could reach approximately 0.02-0.16% per 500 children undergoing head and chest CT examinations.

CONCLUSION

The comparison with the published data of the European Commission (EC) and countries reported in this study revealed that the mean CTDI_vol for the head examinations was within the recommended dose reference levels (DRLs). Meanwhile, chest results exceeded the international DRLs for the one-year-old phantoms, suggesting that optimisation work is required at a number of sites.

IMPLICATIONS FOR PRACTICE

The variation among CT doses reported in this study showed that substantial standardisation is needed.

Dose monitoring in pediatric and young adult head and cervical spine CT studies at two emergency duty departments

PURPOSE

As the number of pediatric computed tomography (CT) imaging is increasing, there is a need for real-time radiation dose monitoring and evaluation of the imaging protocols. The aim of this study was to present the imaging data, patient doses, and observations of pediatric and young adult trauma-and routine head CT and cervical spine CT collected by a dose monitoring software.

METHODS

Patient age, study date, imaging parameters, and patient dose as volume CT dose index (CTDI_vol) and dose length product (DLP) were collected from two emergency departments' CT scanners for 2-year period. The patients were divided into four age groups (0-5, 6-10, 11-15, and 16-20 years) for statistical analysis and effective dose determination. The 75th percentile doses were evaluated to be used as local diagnostic reference levels (DRLs).

RESULTS

Six hundred fifteen trauma head, 318 routine head, and 592 trauma cervical spine CT studies were assessed. All mean CTDI_vol values were statistically lower in hospital B (40.3 ± 12.3, 30.03 ± 11.1, and 6.9 ± 3.1 mGy, respectively) than in hospital A (53.0 ± 12.9, 43.2 ± 8.7, and 18.3 ± 7.3 mGy, respectively). Statistically significant differences were observed on scanning length between hospitals and between CTDI_vol values when protocol was updated. The 75th percentiles of trauma cervical spine in hospital B can be used as local DRL. Non-optimized protocols were also revealed in hospital A.

CONCLUSION

Dose monitoring software offers a valuable tool for evaluating the imaging practices and finding non-optimized protocols.

Imaging of the temporal bone in children using low-dose 320-row area detector computed tomography

INTRODUCTION

The aim of this study was to compare the image quality obtained using low-dose and standard-dose 320-row temporal bone computed tomography (CT) in paediatric patients.

METHODS

Thirteen low-dose CT (120 kV/50 mAs) and nine standard-dose CT (120 kV/100 mAs) images from children up to 5 years of age were compared for their image quality. The noise and signal-to-noise ratio for bone, fat and air were measured. Two observers assessed the overall image quality and ability to visualize 14 small anatomic structures using a 5-point scale, with a score of 3-5 indicating imaging of diagnostic quality.

RESULTS

Noise was significantly higher and the signal-to-noise ratio was significantly lower with low-dose CT. Although the overall image quality and visibility of several structures on low-dose CT were significantly reduced when compared with standard-dose CT, all the image quality scores were 3 or >3. The dose-length products for low-dose CT and standard-dose CT were 59.6 mGy·cm and 119.3 mGy·cm, respectively.

CONCLUSION

Low-dose CT of the temporal bone using 320-row CT provides images of diagnostic quality for assessment of middle and inner ear anatomy, similar to that provided by the standard-dose protocol, in spite of increased image noise.

Radiation dose levels in pediatric chest CT: experience in 499 children evaluated with dual-source single-energy CT

BACKGROUND

The availability of dual-source technology has introduced the possibility of scanning children at lower kVp with a high-pitch mode, combining high-speed data acquisition and high temporal resolution.

OBJECTIVE

To establish the radiation dose levels of dual-source, single-energy chest CT examinations in children.

MATERIALS AND METHODS

We retrospectively recorded the dose-length product (DLP) of 499 consecutive examinations obtained in children <50 kg, divided into five weight groups: group 1 (<10 kg, n = 129); group 2 (10-20 kg, n = 176); group 3 (20-30 kg, n = 99), group 4 (30-40 kg, n = 58) and group 5 (40-49 kg, n = 37). All CT examinations were performed with high temporal resolution (75 ms), a high-pitch mode and a weight-adapted selection of the milliamperage.

RESULTS

CT examinations were obtained at 80 kVp with a milliamperage ranging between 40 mAs and 90 mAs, and a pitch of 2.0 (n = 162; 32.5%) or 3.0 (n = 337; 67.5%). The mean duration of data acquisition was 522.8 ± 192.0 ms (interquartile range 390 to 610; median 490). In the study population, the mean CT dose index volume (CTDIvol₃₂) was 0.83 mGy (standard deviation [SD] 0.20 mGy; interquartile range 0.72 to 0.94; median 0.78); the mean DLP₃₂ was 21.4 mGy.cm (SD 9.1 mGy.cm; interquartile range 15 to 25; median 19.0); and the mean size-specific dose estimate (SSDE) was 1.7 mGy (SD 0.4 mGy; interquartile range 1.5 to 1.9; median 1.7). The DLP₃₂, CTDI_vol32 and SSDE were found to be statistically significant in the five weight categories (P < 0.0001).

CONCLUSION

This study establishes the radiation dose levels for dual-source, single-kVp chest CT from a single center. In the five weight categories, the median values varied 15-37 mGy.cm for the DLP₃₂, 0.78-1.25 mGy for the CTDI_vol32 and 1.6-2.1 mGy for the SSDE.

Results from a phantom based multi-centre paediatric computed tomography dose survey

A computed tomography radiation dose survey was performed within our enterprise using three age-based paediatric phantoms representing a 1, 5 and 10 years old. Twenty-seven scanners were surveyed with volume computed tomography dose index and dose length product data collected for head, chest and abdomen-pelvis protocols at each age. Reconstruction method e.g. filtered back projection (FBP) or iterative (IR) was also recorded. About two-thirds of the 1 year old FBP chest scans exceeded the national Baby diagnostic reference level (DRL). A small number of scanners also exceeded the national Child DRL for the 1 and 5 years old phantoms. Only about half of the phantom protocols showed a difference of statistical significance between FBP and IR scanners. The results suggested the need for optimisation work at a number of sites. It was determined that the proposed local (i.e. enterprise-wide) DRLs are presented best in terms of weight or girth rather than age.

Reconstruction of paediatric organ doses from axial CT scans performed in the 1990s - range of doses as input to uncertainty estimates

OBJECTIVE

To assess the range of doses in paediatric CT scans conducted in the 1990s in Norway as input to an international epidemiology study: the EPI-CT study, http://epi-ct.iarc.fr/ .

METHODS

National Cancer Institute dosimetry system for Computed Tomography (NCICT) program based on pre-calculated organ dose conversion coefficients was used to convert CT Dose Index to organ doses in paediatric CT in the 1990s. Protocols reported from local hospitals in a previous Norwegian CT survey were used as input, presuming these were used without optimization for paediatric patients.

RESULTS

Large variations in doses between different scanner models and local scan parameter settings are demonstrated. Small children will receive a factor of 2-3 times higher doses compared with adults if the protocols are not optimized for them. For common CT examinations, the doses to the active bone marrow, breast tissue and brain may have exceeded 30 mGy, 60 mGy and 100 mGy respectively, for the youngest children in the 1990s.

CONCLUSIONS

The doses children received from non-optimised CT examinations during the 1990s are of such magnitude that they may provide statistically significant effects in the EPI-CT study, but probably do not reflect current practice.

KEY POINTS

• Some organ doses from paediatric CT in the 1990s may have exceeded 100 mGy. • Small children may have received doses 2-3 times higher compared with adults. • Different scanner models varied by a factor of 2-3 in dose to patients. • Different local scan parameter settings gave dose variations of a factor 2-3. • Modern CTs and age-adjusted protocols will give much lower paediatric doses.