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ARTICLE INFORMATION Received: 25 October 2012 Revised: 8 January 2013 Accepted: 22 January 2013

© 2013 The Authors

doi: 10.1259/bjr.20120551

Cite this article as: Tyan Y-S, Li Y-Y, Ku M-C, Huang H-H, Chen T-R. The effective dose assessment of C-arm CT in hepatic arterial embolisation therapy. Br J Radiol 2013;86:20120551.

The effective dose assessment of C-arm CT in hepatic arterial embolisation therapy


Y-S TYAN, MD, PhD, 2Y-Y LI, BS, 2M-C KU, MD, 2H-H HUANG, MD and 2,3T-R CHEN, PhD

School of Medicine, Chung Shan Medical University, Taichung, Taiwan Department of Medical Imaging, Chung Shan Medical University Hospital, Taichung, Taiwan 3 School of Medical Imaging and Radiological Sciences, Chung Shan Medical University, Taichung, Taiwan

Address correspondence to: Dr Tou-Rong Chen E-mail:

Objective: To assess the effective dose of the liver C-arm computed tomography (CT) scan during hepatic arterial embolisation surgery with clinical dose–area product (DAP) data from Taiwan. Methods: The experiment used two kinds of phantoms: RANDO® Man and RANDO Woman (The Phantom Laboratory, Salem, NY), embedded with thermoluminescent dosemeters at locations according to the International Commission on Radiological Protection 103 report. The conversion factors of DAP to effective doses for males and females, respectively, were obtained. The clinical DAP data of liver C-arm CT scan during hepatic arterial embolisation surgery were collected in a hospital in Taiwan. Results: There were 125 liver transarterial embolisation therapy cases, including 94 males and 31 females, from February 2009

to June 2010. C-arm CT was used 38 times for males and 17 times for females. The corresponding average and standard deviation of clinical DAP were 61.06 6.6 Gy cm2 and 52.26 8.3 Gy cm2, respectively. Conclusion: The DAP of RANDO Man and RANDO Woman phantoms simply scanned by C-arm CT are much lower than that of patients. After consideration of the clinical DAP of patients, the effective doses of a liver C-arm CT scan recommended for males and females in Taiwan are 11.562.3 mSv and 11.363.0 mSv, respectively. Advances in knowledge: The conversion factors of DAP to effective doses for males and females are 0.1960.03 mSv Gy21 cm22 and 0.2260.05 mSv Gy21 cm22. Only if the actual DAP value of a patient scan is multiplied by the conversion factor can the correct effective dose be determined.

2 mSv [5–7]. the catheter is guided from the groin artery to hepatoma vascular structures using a perspective view from fluoroscopic images. the cone beam X-ray tube and the image plate mounted on the ends of a C-arm fluoroscope cone beam X-ray detector can also produce CT images [2. Thermoluminescent dosemeter TLDs.8-mm thick. are constructed with a natural human skeleton cast inside a soft-tissue-simulating material. since the vessel path is sometimes extremely complex. The lungs are moulded to fit the contours of the natural rib cage. Transarterial embolisation (TAE). LiF:Cu. To achieve treatment. but the mortality rate is the second highest. C-arm CT angiography still requires the radiation dose.P (GR-200A. Forchheim. RANDO® phantom In our study. and the mortality rate is the sixth highest. However. liver cancer is ranked seventh. RANDO Man. chemotherapy drugs are injected through the catheter to poison the tumour and embolise the vascular supply of nutrition to the tumour. neck and stem bronchi are duplicated. Germany) equipped with a 40330 cm CsI flat detector. Each phantom is sliced at 2. we used two RANDO phantoms: RANDO Man (RAN 110) and RANDO Woman (RAN 100) produced by the Phantom Laboratory (Salem. the fluoroscope must be projected from different angles to distinguish overlapping tissues or organs. an invasive treatment. A cone beam 3D CT reconstruction is produced from the acquisition of twodimensional projection images by rotating the C-arm with the X-ray tube and image receptor around the patient. M-C Ku et al According to global cancer statistics.5 mm in diameter and 0.7 females diagnosed with liver cancer per 100 000 people [1].5 kg.6–9. The air spaces of the head. with a scan range from right anterior oblique (RAO)100° to left anterior oblique (LAO)111°. with averages of 35. Y-Y Li. 175 cm tall and weighing 73. Asia has the highest incidence of liver cancer in the world. Both phantoms. were 2 of 8 bjr. after the catheter is guided to a specific artery location. in females. NY). liver cancer is the fifth most common form of cancer in males. three-dimensional (3D) images from CT or the axial plane (axial view) will increase surgical success and shorten the fluoroscopy time. and this approach is not always successful. involves the insertion of a catheter from the groin artery and the release of a contrast agent from time to time to reveal the location of the intravascular catheter. China). Although the application of C-arm CT may shorten the surgical time and radiation dose of fluoroscopy. Holed grid patterns can be drilled into the sliced sections for the insertion of thermoluminescent dosemeters (TLDs). and it is relatively larger than the dose in general diagnosis photography.Mg. RANDO Woman. The 3D and CT-like axial images were reconstructed from these 419 images. 163 cm tall and weighing 54 kg.5 males and 12. When the blood path is tortuous. Solid Dosimetric Detector and Method Laboratory. respectively. similar to the dose of multidetector computed tomography (MDCT). However. This C-arm CT can provide real-time 3D or axial cross-sectional images. Such an effective dose is considerable. DynaCT has two modes of auto-exposure control (AEC) protocols: 8 s and 20 s of scan time.5-cm intervals into a total of 35 sliced sections. The effective dose of a C-arm CT body scan is about 6. which have no arms or legs. and then to determine the correct positions of the blood vessels. METHODS AND MATERIALS Angiography system The angiography system is a Siemens Axiom Artis dBA (Siemens Healthcare. The 8-s mode.birjournals. Such images can help physicians to judge the directions of the blood vessels and increase the chances that hepatic chemoembolisation surgery will be successful [4]. was used to simulate a male adult [8]. With recent advancements in computers and image plates.86:20120551 . includes 211° and a total of 419 exposure images. These images are hereinafter referred to as C-arm CT images.3]. This study investigates the effective dose for male and female anthropomorphic phantoms scanned by C-arm CT in liver embolisation Br J Radiol. The abdomen C-arm CT scan adopts the 8-s mode for clinical patients in the hospital. The CT-like images from the Siemens angiography system are named DynaCT. The DAP data of clinical TAE surgery scanned by a liver C-arm CT protocol were collected in a hospital in Taiwan. circular chips 4. We obtained the effective doses of clinical liver C-arm CT scans of patients via the conversion factors of male and female phantoms. To be consistent with the “as low as reasonably possible” (ALARA) principle. was used to simulate a female adult. The dose–area product (DAP) conversion to effective dose factors was estimated for male and female phantoms. physicians should be cautious in applying C-arm CT. Beijing.Y-S Tyan.

012 1.001 0.005 0.040 0. not applicable. number of TLDs. having no arms.005 0.010 0.006 0.040 0.015 0. 3 of 8 bjr.000 9–10 8–16 19–23 31–33 2–5 6–8 NA 6–32 1–2 7 12 11 12–13 13–19 28–29 33 8–9 12–19 23–27 29–30 17–18 12–13 5–9 23 22–23 21–23 22–23 23–26 24–27 31 34 1–34 Bone marrow (red)c Rib Os Coxae Femoral head and neck Vertebrae (cervical) Vertebrae (thoracic) Vertebrae (lumbar) Sacrum Heart Thymus Extrathoracic region Gallbladder Pancreas Remainder Spleen Adrenals Kidneys Small intestine Uterus/cervix Prostate Sum NA. slice location of TLDs and male and female tissue weighting factors according to the International Commission on Radiological Protection 103 report Tissues Lung Stomach Colon Breast Gonads Thyroid Oesophagus Liver Bladder Brain Salivary glands Bone surface Skin b Locations Lung Stomach Colon Breast Gonads Thyroid Oesophagus Liver Bladder Brain Salivary glands Bone surface Skin Cranium Mandible Scapulae Clavicles Sternum Number of TLDs 18 12 12 4 4 4 6 12 4 5 4 NA 8 3 2 3 2 3 6 4 2 2 5 5 4 6 6 5 2 3 5 2 6 5 4 2 180 Slice location 13–18 20–22 24–32 17 34/30 a Male 0.006 0. Therefore.040 0.010 0.120 0.012 0.004 0.010 0.86:20120551 . the proportion of 1.040 0. thermoluminescent dosemeter (TLD) locations.9% for the humerus is based on the proportions allocated to the other 12 kinds of bones.120 0.012 0.027 0.012 0.012 0.120 0.120 0.012 Br J Radiol.birjournals.080 0.12.012 0.040 0.120 0.120 0.012 0.012 0.012 0. The total tissue-weighting factor of bone marrow (red) is 0. has no humerus position available for insertion of TLDs.012 0.01. c The weighting factors for each kind of bone are according to mass distribution and percentage of bone marrow (red) in the bone [16].012 0.000 Female 0.017 0.012 NA 1.010 0.010 0.002 0.017 0.120 0. The RANDO® phantom.015 0.010 0.013 0.040 0.012 0.017 0.002 0.010 0.Liver C-arm CT dose Table 1.027 0.120 0. a Male gonads located in the 34th slice and female gonads located in the 30th slice of the phantom.001 0.010 0. b The tissue weighting factor of the bone surface is 0.040 0.012 NA 0.003 0.013 0.040 0.012 0. The tissues.012 0.004 0.012 0.012 0.010 0. We adopted the average dose of 12 types of bones for the absorbed dose calculation of bone marrow (red) in our study as the absorbed dose of the bone surface.017 0.003 0.012 0.010 0.080 0.

body mass index.8) or tissue (Z57. The X-ray dose was identified by a solid detector (Barracuda MDP. The TLD irradiations were repeated three times using a 137Cs source (beam code: INER-1002.864.2. RTI Electronics. TLDs with uncertainties of response of . TLD distribution method The numbers and locations of TLDs in the RANDO phantom were decided mainly according to the tissueweighting factor of the International Commission on Radiological Protection (ICRP) 103 report and the size of the organ [15].268. The irradiation process was repeated three times.3–32.663.0 (92–104) 61. from February 2009 to June 2010. M¨ olndal.0–75. i.55 times per person. there were 125 cases of liver TAE surgery. Its unique features make it an ideal environmental.463.6) 95.14]. electric charge (nC) transfers to the absorbed dose (mGy). Hamburg.5) BMI. The dose response of each TLD was read out from a Harshaw model 3500 reader (Thermo Fisher Scientific. A total of 180 TLDs were used to directly measure the radiation doses of the RANDO phantom being X-ray scanned. tube voltage and DAP of patient population who undergo the C-arm CT scan February 2009 to June 2010 Persons (TAE) Frequency (DynaCT) Age (y) Height (cm) Weight (kg) BMI (kg m ) kVp DAP (Gy cm ) 2 22 Malea 94 38 5968 (42–73) 16566 (156–177) 6469 (52–94) 23. IA).12].6) 95. and 17 times among 31 females. a Data are given as number or mean 6 standard deviation (range). dose–area product. Philips Medical Systems.063. height.4 (18.3 (41.5) Femalea 31 17 54613 (20–68) 15764 (150–164) 57610 (46–69) 23. All TLDs were pre-annealed at 240 °C for 10 min using a Barnstead/Thermolyne 47900 Furnace (Barnstead/ Thermolyne Corp.6–66. for an average of 0.4) [11.86:20120551 . tube voltage and DAP of the C-arm CT scan are shown in Table 2. The number of clinical investigations.066. which has an extremely low detection threshold (. TAE. transarterial embolisation therapy.9) 93. the TLD chips were then calibrated by an 85 kVp X-ray (Philips X-ray tube. Y-Y Li.birjournals.40 times per person.Y-S Tyan. for an average of 0. locations. The age. type: RO 1750. Taiwan) with an air kerma rate of 6. Clinical scan data collection The clinical data of C-arm CT liver scans in TAE surgery were collected from a medical centre located at central Taiwan. frequency. 4 of 8 bjr. Sweden) calibrated by the Institute of Nuclear Energy Research in Taiwan. The number of TAE patients.. The conversion factors obtained from the experiment of TLDs and RANDO phantoms were used to calculate effective doses of the 55 clinical DAP data.. age.2 (90–100) 52.5% were selected for the experiment.163.12 mGy h21 to obtain the mean responses and their uncertainties.363. height. OH). Each chip had its own sensitivity correction factor. Dubuque. Inc. tube housing assembly inherent filtration 2. Institute of Nuclear Energy Research.16]. weight. including 94 males and 31 females.9) Total or meana 125 55 57611 (20–73) 16367 (150–177) 63610 (46–94) 23. BMI. Marietta. After sorting.3 (18. is nearly equivalent to air (Z57. DAP.368.6–75. personal and medical dosemeter [13.e. number of TLDs and tissue-weighing factors for the male and the female are shown in Table 1 [ Br J Radiol. M-C Ku et al used to evaluate the dose in the environment and in the RANDO phantoms [9.mGy level) and an effective atomic number (Z) of 8. C-arm CT scans were used 38 times among 94 males. weight and body mass index (BMI) of the patient population for males and females are also shown in Table 2.2 (41.5 mmAl.10].3 (19. and a mean response (nC) was obtained for each chip. The computer system of the C-arm instrument calculates the tube current and the tube voltage of the C-arm CT applications according to the information from the scan Table 2.3–32. The GR-200 series TLD.9 (90–104) 58. The tissues. In total.1–27. frequency.6 (47. Germany) to correct the energy dependence of TLDs. RESULTS The scan projection radiography is imaged before routine performance of the C-arm CT scan.

as determined by AEC mode.13 Br J Radiol. In actual clinical scans of patients.03 0.01 0.05 0.00 0.3 ms 25.59 SD 0.5 cm.35 RANDO Woman (mSv) Mean 0.32 0.0 kg m22 and 20. Table 4. 0.89 0.03 0.77 0.00 0. the tube current for an obese person is much greater than that for a slim person.00 5.36 8. scan parameter and dose–area product (DAP) of liver C-arm CT for two kinds of RANDO phantom ® Parameters Height (cm) Weight (kg) BMI (kg m22) kV mAs DAP (Gy cm ) 2 RANDO® Man 175 73.01 0.61 0.03 0. but the phantoms used to simulate the patient had no arms. in the liver layer.04 0. respectively.02 0. it is clear that the BMIs of phantoms fall within the BMI range of mean 6 1 standard deviation of the patient population. Hence.17 Table 3.0 kg m22).00 0. The effective dose and standard deviation of RANDO Man and RANDO Woman as assessed by 180 TLDs scanned by C-arm CT are shown in Table 4.35 0.3 kg m22).7 times.00 0.11 0. The abdomens of RANDO Man and RANDO Woman are quite different.01 0.18 0. body mass index (BMI). weight. Generally. but the tube current varies greatly in the AEC mode of the Siemens C-arm CT scan. The lack of arms of the RANDO phantom is offset by the C-arm CT having the AEC function to 5 of 8 bjr.5 Gy cm2 and 25. the tube voltage remains the same. The organ doses and International Commission on Radiological Protection (ICRP) 103 effective dose and standard deviation of two kinds of phantoms on liver C-arm CT scan Tissues RANDO Man (mSv) Mean SD 0. standard deviation. the reason why the DAP values of phantoms are far less than the clinical DAP of patients may not only be owing to the differences in BMI between RANDO phantoms and patients but also to certain design features of the phantoms. Table 3 shows the height.00 0. of RANDO Man and RANDO Woman are also quite different.1 kg m22.7 Similarly.00 0. the DAP of a human.5 RANDO Woman 163 54.04 0. which is also less than that of RANDO Woman (20.69 0. the DAP of the C-arm CT scan for RANDO Man is much greater than that of RANDO Woman.57 1. However. 24. From Tables 2 and 3.40 0.83 0. The BMIs. The DAP values of RANDO Man and RANDO Woman.6 Gy cm2) corresponds to a female patient with a BMI of 19. For example.birjournals. DISCUSSION AND ANALYSIS The assessed effective doses of RANDO phantoms scanned by C-arm CT are often taken to directly represent the effective doses for humans. or even approach. we cannot find its relevance to the clinical DAP data.3 ms 43.44 1.00 0.0 and 18. The differences in thickness and BMI resulted in a difference in the applied tube current of almost 1. which is less than the BMI of RANDO Man (24.37 0.00 0.03 0.03 0.17 0.23 1.7 Gy cm2. respectively.86 0. weight.19 0.Liver C-arm CT dose projection image.0 90 370 mA34.00 0.3 90 223 mA34.00 0.02 0.58 2.32 0.20 1. the patients’ arms are included.0 20. with thicknesses of 23.02 0.5 24.01 0.3 kg m22. in comparison with the BMIs of phantoms.20 1.00 0. The simulated height.08 0.15 Lung Stomach Colon Breast Gonads Thyroid Oesophagus Liver Bladder Brain Salivary glands Bone surface Skin Bone marrow (red) Remainder Total SD. the minimum DAP value (41. 43. Therefore.86:20120551 .40 0. Although clinical data show that a greater BMI increases the value of the DAP in the C-arm CT scan.83 0. One is the presence or absence of arms.13 0. BMI of RANDO Man and RANDO Woman and the parameters and DAP of liver C-arm CT scans for both phantoms.04 0. are even less than the minimum clinical DAP data for males and females.7 kg m22 (47.00 0. The clinical minimum DAP value corresponds to a male patient with a BMI of 20.38 1. respectively.12 0.0 Gy cm2). Tables 2 and 3 show that the DAP of a RANDO phantom scanned by C-arm CT does not reflect.38 1.02 0.

as they are only 71% and 49% of the clinical DAP values of Taiwanese males and females.2260. respectively. C-arm CT.1761. Of course. dose–area product (DAP) and DAP-effective dose conversion factors (f) of RANDO® Man and RANDO Woman scanned by liver C-arm CT calculated by the DAP values in Table 3 and the effective doses in Table 4.21860. male and female. WI. thermoluminescent dosimeter.05 0. The conversion factors of RANDO Man and RANDO Woman are 0. which are based on a single gender of phantom. Netherlands) are RAO103. Waukesha. Y-Y Li. ® 6 of 8 bjr. c TLDs1RANDO Woman phantom. Waukesha. The angle and rotation range of the Philips Allura Xper DF20/10 (Philips Medical Systems.29/0. the effective dose must include the clinical DAP data in this study.6 0. the effective dose obtained simply from RANDO phantom data cannot represent the effective doses for real persons in clinical scans. while it could also be lack of arms. GE Innova 4100 by GE Healthcare. f RANDO Woman phantom1radiophotoluminescent glass dosemeters. the more clearly defined scan region is the liver organ. The angle and rotation range of the GE Innova 4100 (GE Healthcare. scanned region and methods C-arm CTa Siemens Artis dBA Siemens Artis dBA Siemens Artis dTA GE Innova 4100 Philips Allura Xper D20/10 Philips XperCT Scanned region Liver (male) Liver (female) Abdomen Abdomen Abdomen Lung f (mSv Gy21 cm22) 0. The distances from source to image plane are 120. e Radiophotoluminescent glass dosemeter equipped with the RANDO-woman phantom.15 25.5961. b TLDs1RANDO Man phantom. The fact that the phantoms have no arms is a limitation of our study. two kinds of phantom. 118 and 120 cm. respectively. Comparison of the conversion factors. Unlike the data from others. in our study. The effective doses. Best.32d 0. Table 6 compares our data with that of others [17–19]. Netherlands.18/0. d The conversion factors correspond to the methods of the experiment and Monte Br J Radiol.Y-S Tyan.03 mSv Gy2 1 cm2 2 and 0. The detector plane dimensions of the Philips. This lack of arms could greatly affect the assessment of the conversion factor and the effective dose. WI) are RAO103–LAO91° and a range of 194°.03 0. respectively [17].5 0. Therefore. The reason why the DAP of RANDO phantoms is smaller than the clinical DAP could be the relatively small BMI of RANDO Woman.5° and a range of 207°. Although the scan modes of different manufacturers do differ slightly. range 211°) are similar to those of other C-arm CT.38/0. M-C Ku et al Table 5. These possibilities are worthy of further study. Forchheim. most of the exposure angles and rotations Phantom Effective dose (mSv) DAP (Gy cm2) f (mSv Gy 21 22 RANDO Man 8.86:20120551 . For correct and complete assessment.18860. respectively.5–LAO103.18] Suzuki et al [17] Hwang et al [19] Methods Experimentb Experimentc Experimente/Monte Carlo Experimente/Monte Carlo Experimente/Monte Carlo Experimentf TLD. respectively.35 43. Best.045 cm ) reduce the exposure current. 40340 and 40330 cm. GE and Siemens are 38330. Germany.226 0.196 0. thereby resulting in a lower DAP. were used to evaluate the effective doses.1960. The exposure angle and rotation range of the Siemens Artis dBA C-arm CT (RAO100–LAO111°.05 mSv Gy2 1 cm2 2. The DAP values of RANDO Man and RANDO Woman are seriously underestimated. Another possibility is the materials and structural design of the RANDO phantoms.27 Author This study This study Suzuki et al [17] Suzuki et al [17. a Siemens Artis dBA is manufactured by Siemens Healthcare.032 RANDO Woman 5.birjournals. Table 5 shows the DAP effective dose conversion factors (f ) of RANDO Man and RANDO Woman as Table 6.15d 0.45d 0. and Philips Allura Xper D20/10 and Philips Xper CT by Philips Medical Systems. The conversion factors in the study were assessed from both phantoms without arms.

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