RADIATION DOSE FOR PEDIATRIC AND YOUNG ADULT CT: A SURVEY TO ESTABLISH AGE-BASED REFERENCE LEVELS OF 2015-2016 IN KOREA

Paediatric diagnostic reference levels for common computed tomography procedures: A systematic review

BACKGROUND

Previous paediatric diagnostic reference levels (PDRL) literature reviews for commonly performed procedures of the brain, chest and abdomen revealed wide DRL variation and deviation of scanning protocols across CT centres. The current review went further to determine the extent and possible factors of DRL variation in the same procedure, age or weight group, between scanners and CT centres for the standardisation of CT practice globally.

METHODS

The preferred reporting items for systematic reviews and meta-analysis (PRISMA) flow chart was used to screen articles in Science Direct, Medline, Academic Search Complete via EBSCOhost, PubMed, and CINAHL via EBSCOhost including the Google search engine.

RESULTS

A total of 6573 articles were retrieved and screened against the established criteria and finally, 52 articles were selected and synthesised narratively.

CONCLUSION

The findings of this review show variation of brain PDRLs up to a factor of 2 fold for the same examination and age group. Factors attributable to dose variations noted in this review were largely related to the setting of the scan protocols such as the use of different phantom sizes, dose parameters, and age groups. This indicates the need to standardise methods of establishing PDRLs and alignment with the European Commission and ICRP recommended guidelines are proposed.

IMPLICATION FOR PRACTICE

The review highlights different methods for establishing PDRLs and their implication which could guide radiographers and medical physicists in future PDRLs establishment for dose optimization.

Patient size as a parameter for determining Diagnostic Reference Levels for paediatric Computed Tomography (CT) procedures

INTRODUCTION

The paediatric radiation dose has never been studied in Sri Lanka, nor has a national diagnostic reference level (NDRL) established. Therefore, the primary aim of this study was to propose diagnostic reference levels (DRL) and achievable dose (AD) values for paediatric CT examinations based on size.

METHODS

A total of 658 paediatric (0-15 years) non-contrast-enhanced (NC) studies of head, chest and abdomen regions performed during six months in two dedicated paediatric hospitals (out of the three such institutions in the country) were included. For head examinations, the dose indexes were analysed based on age, while for body examinations, both age and effective diameter (D_eff) were used. The median and the third quartile of the pooled dose distribution were given as AD and NDRL, respectively.

RESULTS

The AD ranges for the head, chest and abdomen regions based on CTDI_vol were 45.8-57.2 mGy, 2.9-10.0 mGy and 3.8-10.3 mGy. The corresponding NDRL ranges were 45.8-95.8 mGy, 3.5-14.1 mGy and 4.5-11.9 mGy. The AD ranges based on SSDE_deff and d_eff were 3.5-9.6 mGy and 4.1-10.3 mGy in chest and abdomen regions. The corresponding NDRL were 4.5-14.1 mGy and 6.1-10.6 mGy.

CONCLUSION

Other institutions can use the present study DRLs as a reference dose for paediatric CT. The AD values can be used as a baseline for target dose optimisations, reducing doses up to 90%.

Sample Size and Estimation of Standard Radiation Doses for Pediatric Brain CT

Estimation of the standard radiation dose at each imaging facility is required for radiation dose management, including establishment and utilization of the diagnostic reference levels. We investigated methods to estimate the standard dose for pediatric brain computed tomography (CT) using a small number of data. From 980 pediatric brain CT examinations, 25, 50, and 100 examinations were randomly extracted to create small, medium, and large datasets, respectively. The standard dose was estimated by applying grouping and curve-fitting methods for 20 datasets of each sample size. For the grouping method, data were divided into groups according to age or body weight, and the standard dose was defined as a median value in each group. For the curve-fitting methods, logarithmic, power, and bilinear functions were fitted to plots of radiation dose against age or weight, and the standard dose was calculated at the designated age or weight using the derived equation. When the sample size was smaller, the random variations of the estimated standard dose were larger. Better estimation of the standard dose was achieved with the curve-fitting methods than with the grouping method. Power fitting appeared to be more effective than logarithmic and bilinear fittings for suppressing random variation. Determination of the standard dose for pediatric brain CT by the curve-fitting method is recommended to improve radiation dose optimization at facilities performing the imaging procedure infrequently.

U.S. Diagnostic Reference Levels and Achievable Doses for 10 Pediatric CT Examinations

Background Diagnostic reference levels (DRLs) and achievable doses (ADs) were developed for the 10 most commonly performed pediatric CT examinations in the United States using the American College of Radiology Dose Index Registry. Purpose To develop robust, current, national DRLs and ADs for the 10 most commonly performed pediatric CT examinations as a function of patient age and size. Materials and Methods Data on 10 pediatric (ie, patients aged 18 years and younger) CT examinations performed between 2016 and 2020 at 1625 facilities were analyzed. For head and neck examinations, dose indexes were analyzed based on patient age; for body examinations, dose indexes were analyzed for patient age and effective diameter. Data from 1 543 535 examinations provided medians for AD and 75th percentiles for DRLs for volume CT dose index (CTDI_vol), dose-length product (DLP), and size-specific dose estimate (SSDE). Results Of all facilities analyzed, 66% of the facilities (1068 of 1625) were community hospitals, 16% (264 of 1625) were freestanding centers, 9.5% (154 of 1625) were academic facilities, and 3.5% (57 of 1625) were dedicated children's hospitals. Fifty-two percent of the patients (798 577 of 1 543 535) were boys, and 48% (744 958 of 1 543 535) were girls. The median age of patients was 14 years (boys, 13 years; girls, 15 years). The head was the most frequent anatomy examined with CT (876 655 of 1 543 535 examinations [57%]). For head without contrast material CT examinations, the age-based CTDI_vol AD ranged from 19 to 46 mGy, and DRL ranged from 23 to 55 mGy, with both AD and DRL increasing with age. For body examinations, DRLs and ADs for size-based CTDI_vol, SSDE, and DLP increased consistently with the patient's effective diameter. Conclusion Diagnostic reference levels and achievable doses as a function of patient age and effective diameter were developed for the 10 most commonly performed CT pediatric examinations using American College of Radiology Dose Index Registry data. These benchmarks can guide CT facilities in adjusting pediatric CT protocols and resultant doses for their patients. © RSNA, 2021 An earlier incorrect version appeared online. This article was corrected on October 29, 2021.

Paediatric diagnostic reference levels in computed tomography: a systematic review

This study aims to review the existing literature on diagnostic reference levels (DRLs) in paediatric computed tomography (CT) procedures and the methodologies for establishing them. A comprehensive literature search was done in the popular databases such as PubMed and Google Scholar under the key words 'p(a)ediatric DRL', 'dose reference level', 'diagnostic reference level' and 'DRL'. Twenty-three articles originating from 15 countries were included. Differences were found in the methods used to establish paediatric CT DRLs across the world, including test subjects, reference phantom size, anatomical regions, modes of data collection and stratification techniques. The majority of the studies were based on retrospective patient surveys. The head, chest and abdomen were the common regions. The volume computed tomography dose index (CTDI_vol) and dose-length product (DLP) were the dosimetric quantities chosen in the majority of publications. However, the size-specific dose estimate was a growing trend in the DRL concept of CT. A 16 cm diameter phantom was used by most of the publications when defining DRLs for head, chest and abdomen. The majority of the DRLs were given based on patient age, and the common age categories for head, chest and abdomen regions were 0-1, 1-5, 5-10 and 10-15 years. The DRL ranges for the head region were 18-68 mGy (CTDI_vol) and 260-1608 mGy cm (DLP). For chest and abdomen regions the variations were 1.0-15.6 mGy, 10-496 mGy cm and 1.8-23 mGy, 65-807 mGy cm, respectively. All these DRLs were established for children aged 0-18 years. The wide range of DRL distributions in chest and abdomen regions can be attributed to the use of two different reference phantom sizes (16 and 32 cm), failure to follow a common methodology and inadequate dose optimisation actions. Therefore, an internationally accepted protocol should be followed when establishing DRLs. Moreover, these DRL variations suggest the importance of establish a national DRL for each country considering advanced techniques and dose reduction methodologies.

Diagnostic Reference Level of Radiation Dose and Image Quality among Paediatric CT Examinations in A Tertiary Hospital in Malaysia

Pediatrics are more vulnerable to radiation and are prone to dose compared to adults, requiring more attention to computed tomography (CT) optimization. Hence, diagnostic reference levels (DRLs) have been implemented as part of optimization process in order to monitor CT dose and diagnostic quality. The noise index has recently been endorsed to be included as a part of CT optimization in the DRLs report. In this study, we have therefore set local DRLs for pediatric CT examination with a noise index as an indicator of image quality. One thousand one hundred and ninety-two (1192) paediatric patients undergoing CT brain, CT thorax and CT chest-abdomen-pelvis (CAP) examinations were analyzed retrospectively and categorized into four age groups; group 1 (0-1 year), group 2 (1-5 years), group 3 (5-10 years) and group 4 (10-15 years). For each group, data such as the volume-weighted CT dose index (CTDIvol), dose-length product (DLP) and the effective dose (E) were calculated and DRLs for each age group set at 50th percentile were determined. Both CT dose and image noise values between age groups have differed significantly with p-value < 0.05. The highest CTDIvol and DLP values in all age groups with the lowest noise index value reported in the 10-15 age group were found in CT brain examination. In conclusion, there was a significant variation in doses and noise intensity among children of different ages, and the need to change specific parameters to fit the clinical requirement.

Procedure-specific CT Dose and Utilization Factors for CT-guided Interventional Procedures

Purpose To present procedure-specific radiation dose metric distributions and define quantitative CT utilization factors for CT-guided interventional procedures. Materials and Methods This single-center, retrospective study collected dictation reports and radiation dose data from 9143 consecutive CT-guided interventional procedures in adult patients from 2012 to 2017. Procedures were sorted into four major interventional categories: ablation, aspiration, biopsy, and drainage, each of which was further divided into subcategories. After exclusion, a total of 8213 procedures (4391 in men and 3822 in women) were divided into 21 subcategories. The mean patient age at examination for men was 62 years ± 15 (standard deviation; age range, 19-114 years), and for women it was 61 years ± 15 (age range, 19-113 years). Distributions of dose metrics and CT usage-related parameters were analyzed by category with descriptive statistic outcomes. Quantitative CT utilization factors (which measure average CT usage) for each interventional subcategory were derived by using total scan length, acquisition count, and number of images. Results Interventional CT scans have distinctly different dose metric characteristics from diagnostic CT scans. Wide variations of dose metrics were observed among subcategories, even within the same major category. For the most frequently performed CT-guided interventional procedures within each major category, liver ablation, chest aspiration, liver biopsy, and single abdominal drainage, the median dose-length product was 2351, 657, 1175, and 1125 mGy ∙ cm, respectively. Procedure-specific CT utilization factors ranged between 0.6 and 3.6. Conclusion This study provides procedure-specific CT dose metric distributions and quantitative CT utilization factors on the basis of a large number of procedures and categorization of CT-guided interventional procedures. © RSNA, 2018.