Campbell et al.

Chest Imaging • Original Rese arch

Scanning Beyond Anatomic
Limits of the Thorax in
Chest CT
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Scanning Beyond Anatomic Limits

of the Thorax in Chest CT: Findings,
Radiation Dose, and Automatic
Tube Current Modulation
Justin Campbell1 OBJECTIVE. Our objective was to determine additional radiation dose associated with
Mannudeep K. Kalra1,2 scanning beyond the anatomic limits of the thorax in chest CT protocol and to assess the effect
Stefania Rizzo1 of z-axis modulation on the additional radiation dose associated with the scanning protocol.
Michael M. Maher3 MATERIALS AND METHODS. “Extra” images for routine chest CT were defined as
Jo-Anne Shepard1 those above lung apices (supraapical) and those caudal to the lowermost portion of lung paren-
chyma (infrapulmonary), including images obtained beyond the adrenal glands (infraadrenal).
Campbell J, Kalra MK, Rizzo S, Maher MM, One hundred and forty-eight consecutive chest CT examinations (70 men, 78 women; age
Shepard J-A range, 15–90 years) performed September 13–25, 2003, were reviewed to determine the num-
ber of supraapical, infrapulmonary, and infraadrenal extra images. All examinations were per-
formed using z-axis modulation (n = 70) or fixed tube current (n = 78). The CT dose index vol-
ume and dose–length product (DLP) values for the extra images were calculated. Two
radiologists reviewed these extra images for pathologic findings. Student’s t test was used to
perform the statistical analysis.
RESULTS. One hundred forty-four (97%) examinations had supraapical extra images and
145 (98%) had infrapulmonary extra images. A total of 31 additional findings were observed
in extra images. Most clinically important findings were identified in patients with a history of
malignancy. With z-axis modulation, the mean DLP for supraapical and infrapulmonary extra
images was 39.98 mGy·cm and 132.59 mGy·cm, respectively. With fixed tube current, the
mean DLP for supraapical and infrapulmonary extra images was 30.31 mGy·cm and 95.91
mGy·cm, respectively.
CONCLUSION. A substantial number of extra images are acquired during chest CT that
do not add clinically important information in patients with nonmalignant indications. The use
of z-axis modulation increased radiation dose for the extra images.

hen remaining scanning param- We hypothesized that “extra” images ac-

DOI:10.2214/AJR.04.1512
W eters are held constant, radia-
tion dose associated with CT
examinations is directly pro-
portional to the scan volume and can be re-
Received September 24, 2004; accepted after revision duced by limiting scanning to the area of in-
December 6, 2004. terest. Indeed, with increased use of CT and
1Department
concerns over associated radiation dose, nu-
of Radiology, Massachusetts General
Hospital, Boston, MA 02114. merous changes in scanning protocols and
technological innovations for radiation dose
2Present address: Department of Radiology, reduction have been developed [1–5]. Scan-
Emory University Hospital, 1364 Clifton Rd., Atlanta, GA ning parameters such as tube current, peak
30322. Address correspondence to M. K. Kalra
(mannudeep_k_kalra@yahoo.com).
kilovoltage, beam pitch, scan duration, and
scan volume can be adjusted to optimize ra-
3Department of Radiology, University College, diation dose to patients while maintaining
Cork, Ireland. image quality. Among the technological in-
AJR 2005; 185:1525–1530
novations, automatic tube current modula-
tion represents an important development
0361–803X/05/1856–1525
that aids in maintaining constant image qual-
© American Roentgen Ray Society ity with greater radiation dose efficiency [1].
quired with chest CT increase radiation dose
to patients without adding substantial diag-
nostic information. Therefore, the purpose of
this study was to determine the additional ra-
diation dose associated with scanning beyond
the anatomic limits of the thorax in standard
chest CT protocol and to assess the effect of
z-axis automatic tube current modulation on
the additional radiation dose associated with
the extra images.
Materials and Methods
Materials
The Human Research Committee of our institu-
tional review board approved the study for retrospec-
tive review of chest CT examinations with waiver of
informed consent. Regardless of the clinical indica-
tion for the study (benign, malignant, or indetermi-
nate), each chest CT examination (with the exception

AJR:185, December 2005 1525


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of high-resolution CT of the chest) was performed
per our routine departmental protocol, which extends
from lung apices to the lowermost portion of the ad-
renal glands. CT examinations performed with re-
quest for concomitant abdomen and pelvis or neck
examinations were not included in the study group.
Images obtained beyond the lung apices, lowermost
portions of lung parenchyma, and adrenal glands
were counted. The technologists were not aware that
the present study was being performed.
Consecutive routine chest CT examinations per-
formed at a single institution during a 13-day pe-
riod from September 13 to 25, 2003, were reviewed
to determine the number of extra images acquired
during chest CT. Supraapical, infrapulmonary, and
infraadrenal extra images were recorded separately
for each study. The study cohort was composed of
148 consecutive chest CTs (mean patient age, 57
years; age range, 15–90 years) performed with a z-
axis modulation technique (number of examina-
tions, n = 70) or fixed tube current (n = 78). There
were 70 men (mean age, 57 years; age range, 23–84
years) and 78 women (mean age, 56 years; range,
15–90 years) in the study cohort.
CT Technique
All CT examinations were performed on 4-
MDCT (LightSpeed QX/i, GE Healthcare) or 16-
MDCT (LightSpeed 4.X, GE Healthcare) scanners
using manual selection of fixed tube current (n =
78) or z-axis modulation technique (n = 70). All ex-
aminations with the z-axis modulation technique
(AutomA, GE Healthcare) were performed using
identical scanning parameters (minimum = 75 mA,
maximum = 380 mA; 15 H noise index) as per our
routine departmental protocol. The CT studies with
the fixed tube current technique were performed at
200–300 mA. Remaining scanning parameters for
both techniques were identical and included 140
kVp, 0.5–1 sec gantry rotation time, 5-mm recon-
structed slice thickness, standard reconstruction al-
gorithm, beam pitch of 1.5:1 (table speed/rotation =
15 mm/rotation) with 4-MDCT scanners, and
0.938:1 (table speed/rotation = 18.75 mm/rotation)
with 16-MDCT scanners.
Z-Axis Modulation
There is a large variation in X-ray beam attenu-
ation in different regions of the body due to changes
in size, shape, and tissue composition (density). X-
ray quantum noise in the incident beam projections,
which depends on the X-ray beam attenuation at
that position, is an important determinant of image
noise at any slice position. Quantitative image noise
is an important characteristic of image quality,
which should be maintained at an acceptable level
to acquire diagnostically acceptable image quality
at greater radiation dose efficiency.
1526
Campbell et al.
Automatic tube current modulation techniques
estimate image noise and adjust tube current to
maintain a constant image noise with lower radiation
exposure. The z-axis modulation technique automat-
ically adjusts tube current in the scanning direction
to the changing attenuation characteristics of the area
being scanned to maintain a user-specified noise
level. The z-axis modulation technique (AutomA
technique) assessed in the present study allows the
user to preselect the noise level (noise index) that
will be acceptable in the reconstructed images for a
given clinical indication. The noise index value is ap-
proximately equal to the quantitative image noise in
the central region of the image obtained from scan-
ning a uniform water phantom [1]. Selection of a
higher noise index results in higher noise in recon-
structed images but a lower radiation dose. A 5% in-
crease in the noise index results in increased image
noise with about a 10% decrease in associated radi-
ation exposure. Conversely, CT at a lower noise in-
dex results in less image noise but a higher radiation
dose. Thus, a 5% decrease in noise index typically
increases radiation exposure by 10%.
To use this z-axis modulation technique, the
technologist selects a noise index (a vendor-spe-
cific measure of desired image quality or noise)
and a range of acceptable tube currents (minimum
and maximum mA limits). The technique deter-
mines the tube current based on the patient’s lo-
calizer radiograph projection data and a set of em-
pirically determined noise prediction coefficients
for a reference technique. The reference tech-
nique has a 2.5-mm slice thickness at the selected
peak kilovoltage and 100 mAs using a standard
reconstruction algorithm. The technique then
adapts the tube current required to meet the preset
noise levels (noise index) from information avail-
able in a single localizer radiograph, which in-
cludes density, size, and shape information about
the patient. Based on this information, it adapts
tube current according to the selected noise index
and minimum and maximum mA limits. The min-
imum and maximum limits of 75 and 380 mA
used in the present study allowed the technique to
use any tube current values from 75 to 380 mA to
achieve selected noise level (noise index). Man-
ual selection of tube current for a continuous he-
lical acquisition uses the same single tube current
(mA) throughout the scan series. On the other
hand, z-axis modulation can change the tube cur-
rent from one slice position to the next (use lower
current for midchest and higher for shoulders and
abdomen) depending on the specified noise index
and size, shape, and attenuation of the area being
scanned. Although users can reduce radiation ex-
posure for smaller patients by selecting a lower
tube current value for performing CT with man-
ual selection of fixed tube current, z-axis modula-
tion automatically adapts tube current to patient
size without the need for arbitrary selection of
tube current values.
Number of Extra Images
For each examination, supraapical extra images
were defined as images obtained beyond the lung
apices. All images obtained beyond the lowermost
portion of the lung parenchyma were categorized as
infrapulmonary extra images. The infrapulmonary
extra images also included the infraadrenal extra
images, which were obtained beyond the lower-
most portion of the adrenal glands. For supraapical,
infrapulmonary, and infraadrenal extra images, a
score of zero was given for those examinations that
began at a level below the lung apices or ended
above the lowermost portions of lung parenchyma
or adrenal glands, respectively.
Clinical Indications for Chest CT
The study cohort was classified based on the clin-
ical indications for chest CT examination provided
on the requisition into benign (n = 29), indeterminate
(n = 61), or malignant (n = 58) categories. The indi-
cation was classified as malignant if the study was
performed to stage or follow a patient with a known
malignant neoplasm. An indication was classified as
benign if the study was performed to evaluate a
known disease that was not a malignant neoplasm.
For example, a patient with an indication such as
“history of scleroderma” or “evaluate for interstitial
lung disease” was classified as a benign indication.
Likewise, an indeterminate indication included pa-
tients that could not be classified as definitely malig-
nant or benign, such as “history of cough” and “sol-
itary pulmonary nodule.” All CT examinations were
reviewed in blinded fashion by two radiologists (one
with 5 years of experience and one with 3 years of
experience) and a fourth-year radiology resident, in
consensus, for pathology in the supraapical, infra-
pulmonary, and infraadrenal extra images. In addi-
tion, electronic medical records were reviewed to de-
termine clinical importance of each additional
finding. Findings were considered clinically impor-
tant if they represented new findings (i.e., not seen on
a previous imaging examination), led to a dedicated
imaging examination, or affected clinical staging of
disease or management.
Radiation Dose Associated with Extra Images
Tube current and gantry rotation time were re-
corded for each extra image in CT studies per-
formed with manual selection of tube current and z-
axis modulation technique. Tube current–time
product (mAs) was calculated by multiplying tube
current by gantry rotation time. The CT dose index
volume (CTDIvol) and dose–length product (DLP)
for CT examinations and for the extra images were
AJR:185, December 2005
 Scanning Beyond Anatomic Limits of the Thorax in Chest CT
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estimated using the manufacturer’s technical refer-
ence manual [5]. Although CTDIvol and DLP are
not the actual dose to a specific patient, they form a
standardized index of the average dose delivered
from the scan series. The technical reference man-
ual published by the vendor was used to estimate
standard dose values for the 32-cm-diameter body
phantom (CTDI100) with adjustment factors that
were used for CT examinations included in our
study [5]. The weighted CTDI (CTDIw) was esti-
mated by adding one-third of the central CTDI100 to
two-thirds of the peripheral CTDI100. Subse-
quently, CTDIvol (measured in mGy) was estimated
by dividing the CTDIw by the pitch value. The
CTDIvol represents the average dose within a scan
volume (to a standardized CT phantom) and is now
displayed on the user interface of all CT scanners.
The DLP (measured in mGy·cm) was calculated by
multiplying the CTDIvol by the length of the scan
volume (in cm). The DLP represents the integrated
dose for the scan series.
Statistical Analysis
All statistical tests were performed with Mi-
crosoft Excel software. To compare trends of extra
image acquisition in patients with different clinical
indications, Student’s t test was used to determine
significant statistical difference between the num-
bers of extra images acquired for each indication cat-
egory. A p value of less than 0.05 was considered a
statistically significant difference. Mean and median
mAs were calculated for examinations performed
with z-axis modulation and fixed tube current tech-
niques. To compare radiation dose with fixed tube
current and z-axis modulation techniques, statistical
differences between mean mAs, CTDIvol, and DLP
for examinations performed with these techniques
were determined using Student’s t test.
0.05). On average, three supraapical extra im-
ages (range, 1–18; median, 3.3) were obtained
in chest CT examinations included in our study
cohort. In patients with benign, indeterminate,
and malignant indications, the average number
of supraapical extra images was 3.0, 3.4, and
3.6, respectively. Likewise, on average, 11 in-
frapulmonary extra images (range, 2–27; me-
dian, 11.2) were acquired in the CT examina-
tions of the chest. In patients with benign,
indeterminate, and malignant indications, the
average number of infrapulmonary extra im-
ages was 12.1, 11.5, and 11.8, respectively. Of
these infrapulmonary extra images, an average
of six infraadrenal extra images per CT exam-
ination (range, 1–20; median, 6.1) were ob-
tained. In patients with benign, indeterminate,
and malignant indications, the average number
of infraadrenal extra images was 6.3, 6.1, and
6.4, respectively.
Additional Findings for Extra Images
No additional findings were identified in
the supraapical extra images. Additional find-
ings in infrapulmonary extra images were
noted in 45 CT examinations, which included
six adrenal nodules (4.1%, 6/148) and 39 non-
adrenal findings (26.4%, 39/148) (Table 1).
Nonadrenal findings included low-attenua-
tion lesions in the liver (n = 15), renal calculi
(n = 6), cholelithiasis (n = 5), fatty liver (n =
3), splenomegaly (n = 2), focal low-attenua-
tion lesions in the spleen (n = 2), abdominal
lymphadenopathy (n = 2), cirrhosis (n = 1),
pancreatic mass (n = 1), renal mass (n = 1),
and indeterminate tubular soft-tissue struc-
ture (n = 1). No additional findings were
noted in extra images acquired in patients
younger than 40 years (n = 19).
No adrenal lesions were identified in extra
images of CT examinations performed for be-
nign indications. However, nonadrenal find-
ings were noted in five examinations. These
findings were considered not clinically im-
portant and represented incidental findings.
Likewise, in extra images acquired in inde-
terminate indications, one patient had an adre-
nal nodule, whereas 19 patients had nonadrenal
additional findings. The adrenal nodule was un-
changed from a chest CT performed 6 months
earlier. Subcentimeter-sized, low-attenuation
liver lesions identified in six patients with inde-
terminate indications for chest CT were not re-
garded as clinically important, as they were sta-
ble for 6 months to 2 years in previous
abdominal CT examinations (n = 5) and most
likely represented benign lesions such as he-
patic cysts or hemangiomas. The low-attenua-
tion tubular soft-tissue structure in the upper ab-
domen noted in one patient had been stable for
several years and was most likely to represent a
congenital anomaly of cisterna chyli remnant.
CT examinations of three patients with abdom-
inal lymphadenopathy (n = 2) and splenome-
galy (n = 1) were misclassified as indeterminate
indications because known history of chronic
lymphocytic leukemia (n = 2) and metastatic
adenocarcinoma (n = 1) was not provided to the
radiologists. Among the 19 findings noted in
patients with indeterminate indications, only
two findings, cirrhosis of the liver in a 70-year-
old man and renal mass in a 64-year-old woman
(histopathology showed renal cell carcinoma)
(Fig. 1) represented new findings.

Results TABLE 1: Adrenal and Nonadrenal Additional Findings in the “Extra” Images
Extra Images Obtained for Different Indications for Chest CT Scanning
A total of 2,145 extra images were ob- Indications
tained in 147 of 148 patients, with an average Findings Benign Indeterminate Malignant
of 14.5 extra images per patient (range, 0–32;
Adrenal None Adrenal nodule (1) Adrenal nodule (5)
median, 14.5). In three examinations (2.0%,
3/148), no supraapical extra images were ac- Nonadrenal Cholelithiasis (2) Low-attenuation liver lesion (6) Low-attenuation liver lesion (9)
quired (one each for benign, indeterminate, Renal calculi (1) Renal calculi (5) Cholelithiasis (2)
and malignant indications). Likewise, no in- Fatty liver (1) Lymphadenopathy (2) Splenomegaly (1)
frapulmonary extra images were obtained in Low-attenuation Splenomegaly (1) Fatty liver (1)
three patients (two for benign indications, one splenic lesion (1)
for a malignant indication). Technologists did Cholelithiasis (1) Low-attenuation splenic lesion (1)
not include adrenal glands in eight CT exam-
Fatty liver (1) Pancreatic mass (1)
inations (5.41%, 8/148; benign indications,
Cirrhosis (1)
n = 2; indeterminate indications, n = 4; malig-
nant indications, n = 2). Renal mass (1)
There was a significant statistical difference Indeterminate tubular soft-
between the numbers of extra images acquired tissue structure (1)
for different clinical indication categories (p < Note—Numbers are number of findings.

AJR:185, December 2005 1527


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Fig. 1—Transverse CT
image of 70-year-old
man who underwent
chest CT for evaluation of
lung nodule shows
hypodense lesion in right
kidney, an important
finding in infrapulmonary
extra image of
indeterminate indication.
Histopathology showed
renal cell carcinoma.
Most clinically important findings in the
infrapulmonary extra images were found in
patients with a history of malignant disease.
Five adrenal nodules and 15 nonadrenal find-
ings were identified in extra images acquired
with CT of patients with a history of malig-
nancy. Low-attenuation lesions in the spleen
(n = 1) and pancreas (n = 1) were stable for
1.5–2 years from the previous CT studies and
hence were considered to be benign. In four
patients, low-attenuation liver lesions repre-
sented metastatic disease in subsequent dedi-
cated abdominal CT examinations.
Radiation Dose Associated
with Additional Images
Mean tube current–time products for su-
praapical extra images in examinations per-
formed with z-axis modulation technique and
fixed tube current were 154 mAs (range,
37–228 mAs; 95% confidence interval,
143–165 mAs) and 135 mAs (range, 90–250
mAs; 95% confidence interval, 130–142
mAs), respectively (p = 0.0036). A significant
statistical difference (p = 0.0271) was also
noted between the mean mAs for infrapulmo-
nary extra images in CT examinations per-
formed with z-axis modulation technique
(mean, 151 mAs; range, 37–262 mAs; 95%
confidence interval, 138–164 mAs) and man-
ual selection of fixed tube current (mean, 135
mAs; range, 90–250 mAs; 95% confidence
interval, 129–141 mAs) (Fig. 2).
For CT studies performed at fixed tube cur-
rent, CTDIvol and DLP were 18.69 mGy and
30.31 mGy·cm, respectively, for supraapical
extra images and 18.41 mGy and 95.91
mGy·cm, respectively, for infrapulmonary
1528
Campbell et al.
extra images. For extra images in examina-
tions performed with the z-axis modulation
technique, the CTDIvol and DLP were 20.90
mGy and 39.98 mGy·cm, respectively, for su-
praapical extra images and 20.29 mGy and
132.59 mGy·cm, respectively, for the infra-
pulmonary extra images.
At our institution, the typical CTDIvol and
DLP for chest CT studies performed with
fixed tube current using scanning parameters
identical to those used in the present study are
20.98 mGy and 604.57 mGy·cm, respectively.
The typical CTDIvol and DLP values for chest
CT performed with z-axis automatic tube cur-
rent modulation at our institution are 10.51
mGy and 303.52 mGy·cm, respectively.
Discussion
With the advent of single-detector helical
CT and then MDCT scanners, the clinical in-
dications for CT have increased dramatically
[1]. With the increasing number of CT exam-
inations, associated radiation dose has be-
come an important issue. Although CT exam-
inations account for 11% of X-ray-based
examinations performed in the United States,
the technique accounts for over two-thirds of
the radiation dose associated with medical
imaging [6]. In accordance with the as-low-
as-reasonably-achievable principle, strides
have been made to reduce the radiation dose
associated with CT using multiple ap-
proaches [1–5, 7–12].
Among the available methods of reducing
radiation dose associated with chest CT are
limiting imaging to the area of interest and
the use of automatic tube current modula-
tion technology. Greess et al. [9] and Tack et
al. [10] have shown substantial reduction in
the radiation dose associated with chest CT
with the use of angular modulation tech-
nique. To our knowledge, no study has spe-
cifically evaluated the prevalence of scan-
ning beyond the defined anatomic limits of
the thorax in chest CT protocol, additional
diagnostic information gained, and radia-
tion dose to patients from the extra images
in chest CT. In addition, although the effect
of angular modulation on chest CT has been
evaluated, the effect of z-axis modulation
technique on the radiation dose associated
with extra images acquired in chest CT has
not been reported [7, 9–11].
Our study shows that a substantial number
of extra images are acquired in routine chest
CT. Most extra images in routine chest CT ex-
aminations are acquired below the lowermost
portion of lung parenchyma, with an average
of 11.2 infrapulmonary extra images and 3.3
supraapical extra images. Whereas extension
of scan volume above lung apices can deliver
additional radiation dose to the radiosensitive
thyroid gland, caudal extension of scan volume
below the lowermost portion of lung paren-
chyma is associated with additional radiation
dose to upper abdominal structures. Interest-
ingly, the number of extra images did not vary
significantly with the use of manual selection
of fixed tube current versus z-axis modulation
technique or with the indication for the study
(benign, indeterminate, or malignant).
None of the findings in the extra images
acquired in patients with benign indications
changed the clinical management. Like-
wise, there were very few clinically impor-
tant additional findings in patients with in-
determinate indications for chest CT. After
excluding three findings in studies misclas-
sified into the indeterminate indications
subgroup because of unspecified history of
malignancy in the requisition, only two ex-
aminations (3.4%, 2/58) performed in pa-
tients with indeterminate indications were
considered important. Both of the examina-
tions classified as indeterminate were per-
formed in patients with lung cancer. On the
other hand, 19 patients with malignancy had
additional findings (32.8%, 19/58) and of
these, nine additional findings (five adrenal
nodules, four liver lesions) were clinically
important (15.5%, 9/58). As most clinically
important findings in the infrapulmonary
extra images were identified in patients with
a history of malignancy, we recommend that
chest CT in these patients should cover the
liver and adrenal glands. However, our find-
AJR:185, December 2005
 Scanning Beyond Anatomic Limits of the Thorax in Chest CT
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Fig. 2—Radiation doses with fixed tube current and z-axis modulation techniques are different.
A, Transverse CT image of 60-year-old woman who underwent chest CT for follow-up of pulmonary nodule using fixed tube current technique at 100 mAs.
B, Transverse CT image of 32-year-old woman who underwent chest CT for follow-up of pulmonary nodule using z-axis modulation technique with 190 mAs in supraapical
extra image.
ings underscore the importance of knowing
the history of malignancy in all patients
when deciding on the protocol for chest CT.
Indeed, the American College of Radiology
(ACR) guidelines do not recommend imaging
of the adrenal glands in routine chest CT exam-
inations [8]. However, there is general agree-
ment that CT examination of the chest per-
formed for staging of non–small cell lung
cancer should include the adrenal glands and
liver as recommended by the ACR Task Force
on Appropriateness Criteria by both the Expert
Panel on Thoracic Imaging and the Lung Can-
cer Work Group [13–15]. Our results are in
agreement with these recommendations.
Our study also shows that substantial addi-
tional radiation dose is delivered to the patients
with acquisition of extra images in chest CT.
Overall, extra images contributed a 20.9%
(126.22/604.57 mGy·cm) increase in DLP in
examinations performed with the fixed tube
current technique and 56.9% (172.57/303.52
mGy·cm) increase in DLP with the z-axis mod-
ulation technique. Most additional radiation
dose was associated with the infrapulmonary
extra images rather than supraapical extra im-
ages, as more images were acquired below the
lowermost portion of lung parenchyma com-
pared with the region above lung apices. There-
fore, substantial reduction in patient radiation
dose can be achieved by limiting the number of
images acquired below the lowermost portion
of lung parenchyma in routine chest CT.
Compared with the fixed tube current tech-
nique, the z-axis modulation technique in-
creased the radiation dose associated with the
acquisition of extra images, with an overall in-
AJR:185, December 2005
A B
crease of 36.7% ([172.57 – 126.22] / 126.22)
in DLP. Likewise, z-axis modulation increased
radiation dose by 31.9% ([39.98 – 30.31] /
30.31) for supraapical extra images and by
38.2% ([132.59 – 95.91] / 95.91) for infrapul-
monary extra images compared with the fixed
tube current technique. As described in the pre-
ceding section, the z-axis modulation tech-
nique adapts tube current to the regional cross-
sectional size, shape, and attenuation. Thus,
the increase in radiation dose associated with
the z-axis modulation technique for acquisition
of extra images with chest CT may be ex-
plained on the basis of greater X-ray beam at-
tenuation and image noise at the level of the
shoulders and abdomen compared with that
within the anatomic limits of the thorax. De-
spite this increase in radiation dose with acqui-
sition of extra images with the z-axis modula-
tion technique, the overall radiation dose for
the entire chest CT performed with z-axis mod-
ulation was substantially lower than the overall
radiation dose for the fixed tube current tech-
nique. Therefore, to achieve maximum radia-
tion dose reduction with automatic tube cur-
rent modulation, imaging should be confined
to the area of interest.
Our study has a few limitations. The major
limitation is that CT examinations included in
the study cohort were performed on different
CT scanners (4-MDCT [n = 57] and 16-
MDCT [n = 91] scanners). In addition, we did
not assess the effect of patients’ weight or re-
gional dimensions on radiation dose associ-
ated with z-axis modulation and fixed tube
current technique. An important limitation is
that we did not assess factors that lead to ac-
quisition of extra images during CT. Several
factors could have led to acquisition of extra
images, such as erroneous selection of scan
volume, a tendency to overshoot the margins
to avoid noninclusion of specified scan vol-
ume, inappropriate scanning protocols for
young patients with benign or indeterminate
indications, and lack of interest or awareness
on the part of radiologists to avoid inadvertent
exposure. Although erroneous selection of
scan volume could have led to acquisition of
extra images, especially those above the lung
apices, infrapulmonary extra images were ac-
quired due to the extended length of our chest
CT protocol. Technologists may have ac-
quired extra images due to lack of appropriate
training, lack of awareness regarding CT ra-
diation dose risks, lack of stringent guidelines
and monitoring of CT studies, and their inten-
tion to extend a little beyond defined scanning
area to ensure inclusion of defined anatomic
limits. The latter possibility may also have re-
sulted from the scanning of uncooperative,
noncompliant, or breathless patients. Further
studies may be needed to investigate steps
that can aid in minimizing acquisition of extra
images, which might include determining
better anatomic landmarks for defining region
of interest, careful training of technologists,
and monitoring of CT studies. Future studies
must also assess if extra images acquired in
our institution with its chest CT protocol are
also acquired in other CT centers.
Our study highlights some important con-
siderations in routine chest CT protocols. First,
routine chest CT protocols should take into ac-
count the indication for the study, as additional
1529

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images do not provide additional diagnostic in-
formation in most patients with nonmalignant
indications. Thus, in the absence of a specific
request or an indication for simultaneous as-
sessment of the upper abdomen, a routine chest
CT should be limited to the anatomic limits of
the thorax in most patients with benign and in-
determinate indications. Extension of scan
length beyond the lowermost portion of lung
parenchyma does add important diagnostic in-
formation in patients with malignant disease.
Second, technologists should realize that un-
less requested otherwise, scan length should
not be exceeded, to ensure that additional radi-
ation dose is not given to the patients undergo-
ing routine chest CT. This may involve retrain-
ing of the technologists and explaining and
training the patients before scanning, when ap-
propriate, about breath-holding. Scanning with
faster state-of-the-art MDCT scanners should
not facilitate carelessness in maintaining scan
length to the anatomic area of interest. Lastly,
z-axis modulation technique may be used for
routine chest CT despite increase in radiation
dose in the regions of extra images, as overall
radiation dose with z-axis modulation is sub-
stantially less than with the fixed tube current
technique.
In conclusion, a substantial number of extra
images are acquired during chest CT. Extra im-
ages acquired beyond anatomic limits of the
thorax do not contribute additional diagnostic
information in patients with benign and inde-
1530
Campbell et al.
terminate indications and are associated with
increased radiation dose. Although the z-axis
modulation technique reduces radiation for
images of the thorax compared with the man-
ual selection technique, the use of z-axis mod-
ulation results in increased radiation for the ex-
tra images acquired outside of the thorax.
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