This superb article emphasizes the very high importance of a team approach when undertaking CT dose management.
This study further validates that model-based iterative reconstruction can decrease CT exam dose by 50-80% without compromising diagnostic power. There now is a substantial accumulation of published reports of this type in multiple body areas and organs. The same is becoming true for blended types of adaptive statistical plus model based (minus the optical components) iterative reconstruction (such as ASIR-V).
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.”
In this article, the research conducted by University of Washington Radiology Fellow Dr. Achille Mileto and colleagues highlight the importance of dose monitoring, but also the challenges: “Successful efforts to reduce overall radiation doses may actually direct attention away from other critical pieces of information that have so far been underappreciated, namely the widespread variability in global radiation dose values across clinical operation volumes.” … “These data may provide a foundation for the future development of best-practice guidelines for patient-specific radiation dose monitoring.”
Dr. Achille Mileto from the University of Washington
“We are kind of obsessed with radiation dose reduction, but I think we should keep in our minds the concept of radiation dose optimization, which means trying to adjust the dose to the specific clinical task,” Mileto said. “With technology we are reducing the dose, but we are increasing the room for variability. This is great if you are consistently reducing the dose, but we really want to understand what’s going on in terms of variability. So I think the main lesson is to try to develop best-practice guidelines for patient-specific radiation dose monitoring. I think basically the scenario in the near-term future will be to create some kind of shared library for radiation doses.”
Study concludes that ultralow-dose CT may substitute for standard-dose CT in some COPD patients
There are at least three different generations of iterative reconstruction, all of which enable substantial CT dose reductions without compromise of diagnostic power. While earlier versions of IR yielded 30% dose reductions, those with model-based IR or some blend thereof can result in 50-80% patient radiation dose reductions – with even better spatial and low contrast resolution. Access the full article on this study.
All iterative reconstruction techniques powerfully reduce CT radiation dose in the 40-80% range – without compromising diagnostic power. And they all continue to be refined and to evolve, as this article illustrates. While the “look” of CT images may change from the noise removal, the diagnostic power is not compromised despite the substantial dose reduction. As radiologists, working with change is our future. The old days of nothing but filtered back projection are in our history but not in our future.
To quote the American Association of Physicists in Medicine:
- The risk from medical diagnostic radiation in doses below 50 mSv as a single dose or 100 mSv as a cumulative dose is too small to be measured and may be non-existent.
This article illustrates how much good diagnostic information can be obtained using very low CT radiation doses when screening for lung nodules.
In the screening environment, doing no harm is especially important since so many patients are screened. But detection rates cannot suffer.
Here is encouragement that we can meet both goals with very low dose CT combined with iterative reconstruction.
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.
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.
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.
This interesting paper talks about the use of iterative reconstruction to help lower the radiation dose of screening CT colonography.
Of course, as with all screening exams, the first order of priorities is to do no harm – hence the motivation to keep the radiation dose especially low.
The challenge is to lower dose without compromising diagnostic power.
For about the past two years, here at UW Medicine (Seattle) we have been using Model Based Iterative Reconstruction (VEO, GE Healthcare) for all our CT colonography exams. As recommended in this article, we also keep the kVp low – 80 or 100, which also helps to reduce the dose.
The result is a very low dose exam, but with excellent image quality and low image noise. This helps to make great coronal/sagittal reconstructions plus very nice 3D fly-through on the post-processing workstation.
Seattle King5 TV’s Jean Enerson reported recently on UW Medical Center’s installation of the GE 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:
- All aortograms
- 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)
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.
Guest blog by Kalpana M. Kanal, PhD, Director of Diagnostic Physics Section and Associate Professor in the Department of Radiology at University of Washington
How low can we go in radiation dose without affecting diagnostic confidence for detection of low-contrast liver lesions?
In a recent article we published, we studied the impact of incremental increases in CT image noise on detection of low-contrast hypodense liver lesions. Clinical CT liver exams were obtained on a 64-slice CT scanner using automatic tube current modulation at a routine clinical noise index 15. An artificial image noise addition tool was used to increase the noise level in clinical liver CT images to simulate 75% (NI 17.4), 50% (NI 21.2), and 25% patient radiation dose (NI 29.7) scanning relative to the original images (NI 15.0; 100% dose). The images were reviewed by radiologists of varying experience who subjectively scored lesion detectability on all the images, original and simulated.
We concluded that there is little loss of detection sensitivity for low-contrast liver lesion detectability of CT exams scanned with a NI at least up to 21.2 compared to a NI of 15, a patient radiation dose reduction of 50%. No significant degradation was observed when reader performance was evaluated as a function of lesion size (>10 mm) and contrast (>60 HU) at 90% sensitivity. When lesion size dropped to <10 mm or contrast was <60 HU, sensitivity did drop to 85%.
This study had some limitations, the most important of which was that this study was a simulation and not a true study of CT scanning at lower radiation dose compared to high dose scanning which would have involved scanning patients multiple times. Nevertheless, this study was important as it demonstrated that dose could be reduced by 50% without affecting diagnostic confidence for detecting low-contrast liver lesions.
Standardizing dose description parameters and metrics is an ongoing and very active area in ACR and nationwide. This will be a big help to comparing metrics between institutions and over time. The SSDE (Size Specific Dose Estimate) is a good step in that direction.
But this article also points out the large impact of exam appropriateness on dose. It is an impressive fact that a profound way to lower population dose is to avoid doing inappropriate exams. Tools such as the ACR Appropriateness Criteria or Computerized Decision Support at the point of order entry can empower appropriateness review. And every radiologist needs to increase their awareness of exam appropriateness in daily work.
This very wise philosophy for implementing iterative dose reduction in any CT program was well presented at the recent MDCT meeting of the ISCT in San Francisco in June. A key component is to have regular and measurable ways for radiologists to regularly grade or score image quality as dose is ramped down slowly with increasing amounts of iterative reconstruction. With Model Based Iterative Reconstruction (MBIR), it may be possible to drop dose up to 60% compared to otherwise low dose adaptive statistical iterative reconstruction methods (ASIR) – but not in one jump. It takes time to get accustomed to the slightly different look of images with iterative reconstruction.
At least a month’s worth of experience should accrue before passing judgment on image quality. It is also important to guard against anecdotal cases used to render judgments, so experience over time is important. But with a methodical approach, a lot of progress can be achieved in overall dose reduction.
There are some who say that iterative reconstruction should be reserved only for younger patients and not used on older cancer patients who already have serious disease.
But many patients with malignancies are younger or are being treated for cure.
This article suggests that an iterative reconstruction technique (such as model-based iterative reconstruction, MBIR) which can reduce patient radiation dose by 50% may have salubrious utility in patients with lymphomas – who often are younger, who get multiple CT scans, and who are being treated for cure.
This may apply to other malignancies as well.
“Don’t Skip the CTA” that’s the word going out to patients with advanced renal failure based on findings of researchers in Baltimore. In a study presented at June’s International Society for Computed Tomography (ISCT), Dr. Barry Daly demonstrated how CTA using moderate doses of IV contrast negatively affects only a small percentage of patients and provides valuable information that outweighs the chance of adverse effects.
However, because lower dose is better for patients, especially that small portion at risk with normal doses, Daly and his team also did a study of low-kVp, low-contrast-dose CTA in chronic renal failure patients. This technique is possible due to the advances in CT technology that have allowed radiologists the ability to get more out of smaller amounts of iodine.
While the low kVp techniques enabled much lower doses of iodinated contrast and resulted in images that looked great, the dual-energy CT technique may have accomplished this effect even better!
With dual-energy, you get the best of both worlds. You get the benefit of lower kVp effect (kEv in GE units), plus the ability to look at images which are equivalent to 100 or 120 kVp from the same CT raw data. Essentially, you still achieve substantial iodine dose reduction, but also get very dense HU enhancements in vessels and organs.
The bottom line is this: CTA isn’t something that patients with advanced renal failure should think about skipping. There is a too big a risk for going into surgery without one. The key is finding the safest technique to reduce the dosage level of iodinated contrast while getting the best images. Dual-energy CT may be the best solution out there.
I recently came across this video from RSNA. About halfway in, they ask the question, “What is the biggest advancement in CT technology this year?”
I would agree with Dr. Siegel that iterative reconstruction has stimulated thinking and conversation among radiologists about how to substantially lower CT dose without compromising the benefits of CT. Based on our 18 months of experience, we know the reduction is at least 40 percent with the current version of iterative reconstruction. And we suspect much greater reductions are coming. Some of the issues centers around radiologists’ “preferences” for how a CT images looks. But preferences can change, even dramatically, when driven by the hope of much lower patient dose.
What do you think – what do you view as the biggest advancement in CT?
One of the most exciting – and talked about – sessions at RSNA was called “Radiation Dose: Can It Be Too Low?” The expert panel had a healthy debate on radiation dose and risk, and finally reached an agreement that CT scans should be limited to “justified and optimized studies.” (HealthImaging.com has a good recap of the panel’s discussion.)
The debate about risk can go on, but when practicing medicine (radiology) with real patients, the obligation is to both minimize risk AND maximize benefit.
So the challenge for radiologists is to lower dose as much as possible without compromising the amazing diagnostic power of CT. How to accomplish this is both science and art. But we have discovered at UW that with a combination of low dose technique and low dose CT technology, you can take out up to 40 percent of the radiation dose to the patient (compared to 3 years ago) without having any negative impact on diagnosis. So that number certainly is achievable at most sites.
Could we go even further in dose reduction?