Optimizing CT Radiation Doses Across Institutions Leads to Dose Reductions

This excellent research from UCSF documents that education about best CT dose practices has a significant impact. The authors state, “The project strategy was to collectively define metrics, assess radiation doses, and move toward dose standardization. This article presents the results of our efforts using a combination of facility-level audit and collaborative efforts to share best practices.”


Ureteral Stones: Reduced-Dose CT Protocol in the Emergency Department

This recent article from Radiology reports the use of an 80% reduced dose CT protocol for assessing moderate to high risk patients for ureteral stones in an ED environment.

Reduced dose CT was correct for stone versus no stone in 100% of 108 patients. Dose reduction was achieved by lowering both the mAs and the kVp and adding iterative reconstruction.

Low-dose CT enterography

This article pretty well confirms what many have felt: model-based iterative reconstruction (MBIR) lowers radiation dose by 70-80% compared to adaptive statistical iterative reconstruction (ASIR), without loss of diagnostic power/information. While the images do indeed look different because there is much less noise and because of a slightly different pattern in the remaining noise, all the findings are there. Further, the anatomy and the findings are displayed as well or better.

So, in a young patient (under age 45) – especially if they are likely to be getting multiple exams – use of model-based iterative reconstruction is well worth the longer reconstruction time.

(To read more about CT enterography, Radiologyinfo.org is a great resource for patients.)

Reducing dose for CT pulmonary angiography

Paying attention to limiting Z axis coverage yields big dose saving dividends! See this article for results of this study designed to assess the safety and efficacy of radiation dose reduction in hospitals lacking iterative reconstruction.

Gentle and wise use of CT radiation dose

This comprehensive article demonstrates the importance of CT dose monitoring and utilizing strategies to achieve ALARA (as low as reasonably achievable) doses while maintaining image quality for optimal clinical diagnosis. The authors also describe how the use of technology can improve the radiation dose efficiency of CT scanners.

Radiation Dose Management in CT: Is it easy to accomplish?

Guest blog by Kalpana M. Kanal, PhD, Direc­tor of Diag­nos­tic Physics Sec­tion and Asso­ciate Pro­fes­sor in the Depart­ment of Radi­ol­ogy at Uni­ver­sity of Washington

At the AHRA conference in Las Vegas recently, Dr. Pizzutiello, a medical physicist, discussed the complexity of CT radiation management and monitoring in diagnostic imaging. With the growing use of CT exams being performed and radiation dose in CT being a hot topic in the radiology community, it is imperative to monitor radiation dose from the CT exams as well as observe trends over time. Regulations now require that CT dose has to be documented and available on demand, CT protocols be revisited on an annual basis and incidents with high dose CT exams be reviewed. Several states around the US have CT regulations or are in the process of regulation implementation. It is a monumental task to monitor and manage dose, especially for large hospitals.

There are several dose management software products available that can help in managing the dose. Dose management is, however, a team effort and it is not possible to do this effectively without a team of radiologists, technologists, and medical physicists participating in this important task.

At our institution, we have been managing dose using a commercial product, Dose Watch (General Electric Healthcare) and also have a radiation safety committee within the department to review dose trends and make intelligent decisions based on our dose data. We have also been participating in the ACR CT Dose Index Registry since its inception and review our trends and benchmark values to our peer institutions. This is definitely a good idea if one is unaware of dose trends at their institution and how it compares to others around the nation.

Dose monitoring is complex but a necessary patient safety tool and, if well planned, can be accomplished and maintained with the help of dedicated professionals who understand the importance of the task.

Low dose CT Revolution scanner

Seattle King5 TV’s Jean Enerson reported recently on UW Medical Center’s installation of the GE Revolution CT scanner.

Revolution CT scanner

The new technology of the Revolution features the following:

  • Much longer and wider detector
    • (16 cm vs. 4 cm)
  • Much faster rotation speed and scanning
    • (0.28 seconds – 70 G’s centrifugal force)
  • Much better radiation dose lowering technology
    • ASIR-V, auto kVp, density modulated auto mA

16 cm wide-detector array: Whole organ scanning on one 0.2 second rotation

Currently, the Revolution CT scanner is being used at UW Medicine for scans of the heart, blood vessels, and organs that involve more than one pass and the evaluation of transplanted organs. In the future, we intend to expand further into:

    • TAVR
    • All aortograms
    • Cardiac
      • coronaries, perfusion, congen., ablation
    • All misc. vascular studies
      • Renal arteries, HA, runoffs, carotids, COW, grafts/stents, venograms
    • Non-Dual-Energy multi-pass exams
      • Liver, pancreas, IVP
    • Perfusion (brain, transplants, tumor)
    • Workhorse (CAP, KUB, brain, spine)


Low radiation dose without compromise of image quality

This article illustrates that Radiologists’ perceptions of image quality and content change as they become accustomed – over time –  to the different noise pattern of the various types of iterative reconstruction.

In fact, no spatial resolution or low contrast resolution is lost with iterative reconstruction techniques – and diagnostic power is maintained.

Our work here at UW Medicine agrees with this report.

And it is important to know this because iterative reconstruction can result in 30%-60% dose reduction for all types of CT, without loss of diagnostic power.

Educating patients about radiation dose

The ultimate goal is to have a fully informed and well educated patient – this will result in best personalized healthcare and outcomes.

So as far as radiation dose from individual CT exams is concerned, it is good for patients to know what they received – but it is not enough. Patients also need to be educated about the meaning and risk of their radiation dose.

Educating patients about extremely low risk is difficult – as would be true about any very low risk. But, it should be coupled with educating patients about the potential health and healthcare benefits from their CT exam.

This is because what they really need to know is their risk/benefit ratio – from each CT exam. An educated patient who understands their risk/benefit ratio from CT will be a truly informed healthcare consumer.

Who should educate patients about risk and benefit? All of us – all providers. The primary care physician, the subspecialist, the radiologist, the CT technologist, the radiology nurse, PA’s and LPN’s – everyone who contacts the patient can help advance this education and this understanding.

MDCT 2014 speakers weighed in on this subject at the ISCT Symposium in early June.

Significant radiation dose reduction without sacrificing image quality

At the 2014 ISCT-sponsored MDCT meeting in San Francisco – dose reduction was a key theme during all four days.

Iterative reconstruction was a common theme of an overall dose reduction program. While adaptive statistical iterative reconstruction (ASIR) now has been well-shown to reduce average doses by up to 40% without impact on image quality, the hot topic was model-based iterative reconstruction (MBIR) in its various forms.

Consensus is now developing around MBIR being capable of 50-70% dose reductions incremental to adaptive statistical iterations. While image appearance may be somewhat different from that of filtered back projection, it is now pretty clear that such different appearance does not compromise diagnostic power. Indeed, with experience, some radiologists have developed a preference for the image appearance of MBIR.

Study Offers Promising Benefits for Iterative Reconstruction

At UW, we are outspoken for our support of adaptive statistical iterative reconstruction (ASIR).  As a big proponent of the method, I find this write-up from Radiology to be a landmark article, and the research it highlights, very impressive work.

A team of researchers recently confirmed that iterative reconstruction allows significant CT radiation dose reductions for patients undergoing urolithiasis imaging, without unintended decreased image quality or diagnostic confidence.

Urolithiasis is a common condition, with high likelihood (estimated at 75 percent) of recurrence amongst individuals diagnosed. Therefore, imaging scans are a regularity for those patients with the disease. It is important to treat these patients with the lowest radiation dose possible, as to alleviate fear of potentially excessive radiation.

For the 25 patients involved in the study, image quality was significantly boosted by adding iterative reconstruction, while dose was reduced by about 85 percent, thanks to the ultra-low dose. While previous studies report substantial degradations in imaging quality, 80 percent of the images acquired in this study had suboptimal image quality.

This study is just further evidence of the promising benefit of ASIR. I firmly believe that every imaging site with access to the protocol should use it regularly as to lower dose by 80 percent in frequently performed exams.

To learn more about iterative reconstruction, please click here!

New Research Further Dispels Fear of Over Diagnosis in CT Screening

According to a new study based on the International Early Lung Cancer Action Program (I-ELCAP), lung cancers identified in low-dose CT screening programs are similar to those identified by non- screening means. The research results, which were released on March 27 in Radiology, further alleviate concerns that cancers detected through low- dose CT screening are less aggressive than those found through other means, and therefore demand less attention and resources.  In fact, the frequency of small-cell carcinoma and adenocarcinoma were similar for cancers detected through screening programs and outside the screening setting.

This study is another brick in the wall of evidence building for the value of low radiation dose CT lung cancer screening in high risk asymptomatic smokers. Regardless of whether nodules are solid or “ground glass” (non-solid), growth occurs that is similar in the screened populations and in those detected of having lung cancer due to symptoms.

While it is true we do not yet have a data-based analysis of costs versus quality life years saved, the evidence that screening is worthwhile continues to become stronger. “The CT scanners we have now are really phenomenal,” with resolution that continues to improve as the radiation dose falls, “so that the amount of information you can get out of them for emphysema, for coronary artery risks, and so on, continues to increase,” says Dr. Claudia Henschke, lead author of this study.

She goes on to point out that cancers detected via low dose CT screening “are real cancers that would kill you if they weren’t discovered early, so it kind of underscores again the data that we had shown in ELCAP and that NLST (National Lung Screening Trial) has shown — that screening for lung cancer saves lives.” And that is the key takeaway.

Lung CT Screening a Top Cancer Advancement of 2011!

As the war on cancer continues, a group of U.S. oncologists picked its “Top Five” most essential advances in cancer care, as reported by HealthDay news. I’m pleased to announce that CT-based lung cancer screening is listed as one of the major advances for 2011.

The report, published in the Journal of Clinical Oncology, placed only targeted drug therapy above CT-based lung cancer screening. Both advancements will be major game changers for cancer care. The report confirms that the U.S. National Cancer Institute found that screening smokers and former smokers with a CT chest scan was “dramatically better than the chest X-ray.”

There now is no question about this! In high risk heavy smoker populations, low dose CT- lung cancer screening saves lives… and quite a few. The challenge now is getting our healthcare delivery systems to incorporate this approach into routine preventative medical practices….but only for high risk individuals. We need to make these scans easy to obtain, fast to perform, very low in radiation, covered in health plans, and inexpensive.

The good news is that all of these things are possible. Turning CT-lung cancer screening into a regular practice for in-need individuals is very do-able!

NCCN Confirms Importance of Lung Cancer Screening

Recently, the National Comprehensive Cancer Network has come forward in favor of lung cancer screening with low-dose CT. The NCCN is the first professional organization to perform the comprehensive review and update their recommendations to promote lung cancer screening.

This update further validates the key concept that high risk patients benefit from screening. High risk patients for lung cancer diagnoses are those who are multiple pack year smokers for 25 of more years. For these individuals, low- dose CT screening reduces the number of lung cancer deaths by 20 percent.

While we don’t really know the full cost of a screening program – such as the costs of working up false positive CT findings,  the benefit in lives saved seems to justify considering screening now.

Fortunately, the CT technique for screening is low dose and involves low radiation dosage.

RSNA 2011 Relections

RSNA (Radiological Society of North America) is the largest annual trade show in the world, with about 55,000 people in attendance for the 6 day event in Chicago, Illinois. The expo includes a large number of presentations and courses on science and modern radiology.

RSNA 2011’s two main themes were lower radiation dose in diagnostic radiology imaging (especially CT) and new technology. For lower dose, there was much material on tailoring a CT scan exactly to an individual patient – based on their body size, their cardiac output, their disease process, or the type of diagnostic challenge. Additionally, a lot about new iterative reconstructions in CT – both statistical and model based, was presented. Either method lowers dose a lot, but model based results in lowered radiation exposure by up to 80%.

New technology presentations and courses covered a range of topics including dual energy CT for better tissue characterization, and the combination of imaging modalities in one platform – like SPECT/CT, or PET/MR. These combined modalities may provide a better combination of disease identification plus precise localization.

In all, RSNA 2011 offered great insights and interesting presentations. Did you attend? Share your thoughts below!