Pe d i a t r i c I m a g i n g • O r i g i n a l R e s e a r c h

Coursey et al.
Pediatric Chest MDCT with Tube Current Modulation
Pediatric Imaging
Original Research

Pediatric Chest MDCT Using

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Tube Current Modulation:

Effect on Radiation Dose with
Breast Shielding
Courtney Coursey 1 OBJECTIVE. The purpose of our study was to assess the effect on radiation dose and
Donald P. Frush1 image noise during pediatric chest 16-MDCT using automatic tube current modulation and
Terry Yoshizumi2 bismuth breast shields.
Greta Toncheva2 MATERIALS AND METHODS. Age-based chest 16-MDCT was performed on an an-
Giao Nguyen2 thropomorphic phantom representing a 5-year-old child. Two scans were obtained in each of
four sequences: first, without a shield; second, with a 2-ply bismuth shield; third, using auto-
S. Bruce Greenberg 3
matic tube current modulation with a scout image obtained after placement of the shield; and
fourth, using automatic tube current modulation with a scout image obtained before place-
Coursey C, Frush DP, Yoshizumi T, Toncheva
ment of the shield. Metal oxide semiconductor field effect transistor technology was used
G, Nguyen G, Greenberg SB
to measure the radiation dose in 20 organ locations. Effective dose was estimated using the
console dose–length product. Noise was measured by recording the SD of Hounsfield units in
identical regions of interest.
RESULTS. The bismuth breast shield reduced the dose to the breast by 26%. Shield-
Keywords: CT, CT technology, MDCT, pediatric chest CT, ing and automatic tube current modulation reduced the breast dose by 52%. Multiple organ
phantoms, radiation dose reduction, shielding doses were lowest when the shield was placed after the scout radiograph had been obtained.
When the shield was placed after the scout image was obtained, the mean noise in the range
DOI:10.2214/AJR.07.2017
of shielding increased from 11.4 to 13.1 H (superior mediastinum) and from 10.0 to 12.8 H
The bismuth material for this study was provided by (heart) (p < 0.01). Increased noise, however, was near the target noise index (measured in SD
F & L Medical Products. of Hounsfield units) of 12.0 H (SD). Using automatic tube current modulation, the effective
dose was reduced by 35% when the shield was placed after the scout and by 20% when the
D. P. Frush receives unrestricted research support from shield was present in the scout.
GE Healthcare.
CONCLUSION. The greatest dose reduction is achieved by placing the shield after
Received February 6, 2007; accepted after revision obtaining the scout image to avoid Auto mA compensation due to density of shield. With this
July 22, 2007. technique, image noise increased but remained close to the target noise index.
1
Division of Pediatric Radiology, Department of Radiology,

A
n estimated 57 million CT exami-
Box 3808, Duke University Medical Center, Durham,
NC 27710. Address correspondence to D. P. Frush
nations were performed in the
(frush943@mc.duke.edu). United States in 2000 [1]. It is
also estimated that approximately
2
Radiation Safety Division, Duke University Medical 7.1 million CT examinations were performed
Center, Durham, NC.
in pediatric patients in 2002 [2]. Because of
3
Department of Radiology, University of Arkansas for the large number of examinations and the rel-
Medical Sciences and Arkansas Children’s Hospital, atively high radiation dose delivered by CT,
Little Rock, AR. techniques should minimize the radiation
dose to the patient while still providing diag-
CME
This article is available for CME credit. See www.arrs.org
nostic quality—the ALARA (as low as rea-
for more information. sonably achievable) principle. Radiation dose
is of special concern for the pediatric patient
WEB population because the younger the child at
This is a Web exclusive article.
exposure, the greater the potential for cancer
AJR 2008; 190:W54–W61 development [3, 4].
Two techniques that have independently
0361–803X/08/1901–W54
been shown to lower CT radiation dose are
© American Roentgen Ray Society automatic tube current modulation [5–12]
and bismuth shielding [13–15]. Automatic
tube current modulation using both angular
(x,y-axis) and longitudinal (z-axis) tech-
niques has been shown to reduce patient
dose [5–12]. Shielding has also been shown
to reduce radiation dose, primarily from at-
tenuation of the primary beam.
The combined use of automatic tube cur-
rent modulation and a shielding device might
be expected to reduce radiation dose more
than either technique alone. However, it may
also be that automatic tube current modula-
tion technology that modulates in the z-axis
on the basis of the topogram (scout image)
may compensate for the presence of the
shield by increasing the tube current and
thus increasing the dose during the diagnos-
tic scan when the shield is present while the
scout image is obtained. To our knowledge,

W54 AJR:190, January 2008

 Pediatric Chest MDCT with Tube Current Modulation
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A B
Fig. 1—Phantom and shield used in this study.
A, Anthropomorphic phantom representing 5-year-old child (Atom Pediatric 5-Year-Old Phantom, model 705-D CIRS) with metal oxide semiconductor field effect transistor
(MOSFET) (Autosense MOSFET system, Best Medical Canada) detectors in place.
B, Bismuth (F & L Medical Products) breast shield (arrow) in place.

dosimetry during MDCT using the combina- TABLE 1: Organ Doses Using MOSFET During Chest MDCT in Phantom
tion of bismuth shielding and automatic tube Representing a 5-Year-Old Child
current modulation has not been reported. Dose (cGy)a
Therefore, the purpose of our study was to
Without With Shield, Scout With Scout Without
determine the effect on radiation dose and Slice, Shield or Without Shield, With Shield, With
to measure image quality (noise) of images Organ Locationb ATCM ATCM ATCM ATCM
obtained using bismuth breast shields with z- Breast (l) 12, 58 0.40 0.31 0.17 0.17
axis automatic tube current modulation dur-
Breast (r) 12, 59 0.35 0.25 0.19 0.19
ing pediatric chest MDCT.
Skin above breast 12, – 0.37 0.28 0.20 0.20
Materials and Methods Skin above sternum 12, – 0.48 0.32 0.29 0.18
An anthropomorphic phantom representing
Esophagus and heart 12, 51 0.36 0.34 0.26 0.19
a 5-year-old child (Atom Pediatric 5-Year-Old
Phantom, model 705-D, CIRS) was used (Fig. Bone marrow, sternum 11, 39 0.31 0.29 0.20 0.12
1). The specific dimensions of the phantom are Bone marrow, ribs (l) 11, 40 0.30 0.24 0.19 0.13
weight, 19 kg; height, 110 cm; thorax dimensions, Bone marrow, ribs (r) 11, 45 0.38 0.32 0.13 0.18
14 × 17 cm. This phantom was scanned using the Bone marrow, thoracic 11, 38 0.46 0.30 0.23 0.21
technique clinically used for the 5-year-old age- and lumbar spine
based chest CT protocol (16-MDCT, LightSpeed, Lung (l) (middle) 12, 53 0.41 0.37 0.27 0.19
GE Healthcare) consisting of 120 kVp, 0.5-second Lung (r) (middle) 12, 56 0.40 0.36 0.26 0.22
rotation time, 1.375 pitch, 16 × 1.25 mm effective
Lung (l) (middle) 13, 68 0.44 0.42 0.38 0.25
collimation, 5-mm slice thickness, 2.5-mm re-
Lung (r) (middle) 13, 71 0.48 0.41 0.40 0.26
construction interval, and a small scanning field
of view, with images reconstructed in a standard Thymus 12, 60 0.43 0.37 0.28 0.23
algorithm. The phantom was first scanned with Thyroid (l)c 9, 24 0.45 0.44 0.24 0.25
a fixed tube current of 65 mA without a breast Thyroid (r)c 9, 25 0.43 0.42 0.26 0.25
shield. The phantom was next scanned using the Liverc 16, 103 0.40 0.42 0.38 0.35
same parameters but with the addition of a 2-ply
Stomachc 16, 109 0.37 0.37 0.36 0.37
bismuth (1.7 g/cm 2) (F & L Medical Products)
Esophagusc 10, 35 0.40 0.36 0.24 0.23
breast shield with a 1-cm-thick foam stand-off
pad. The shield measured 9 cm in the craniocau- Kidney (l)c 16, 116 0.33 0.31 0.31 0.28
dal dimension and was designed to cover the chest Note—MOSFET = metal oxide semiconductor field effect transistor. ATCM = z-axis automatic tube
to the midaxillary line (Fig. 1). The phantom was current modulation. Dash (–) indicates detectors placed on surface of phantom.
a Average of two scans was obtained for each protocol.
then scanned using z-axis automatic tube current bOf CIRS phantom (Atom Pediatric 5-Year-Old Phantom, model 705-D).

modulation (Auto mA, GE Healthcare) with 65 cLocations not underneath breast shield.

AJR:190, January 2008 W55

 Coursey et al.

mA maximum, 10 mA minimum, and a noise in-
dex (measured in SD of Hounsfield units) of 12.0
H (SD) (all other parameters remaining the same)
with the topogram (scout) frontal and lateral ra-
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diographs obtained with the bismuth breast shield noise level (the noise index) between maximum
in place. Auto mA selects tube currents on the ba- (ceiling) and minimum levels, which are also se-
sis of patient density, size, and shape, as reflected lected [16]. The noise index approximates noise
in the localizer radiograph, to maintain the target as measured in the center of a uniform phantom

A B

C D

Fig. 2—Measurement of noise.

A–E, Regions of interest (ROIs) measuring approximately 170 mm2 were drawn
in indicated areas (circles) at level of clavicles (A), scapulae (B), superior
mediastinum (C), heart (D), and upper abdomen (E). C and D show ROIs obtained in
range of shield (arrow).
E

W56 AJR:190, January 2008

 Pediatric Chest MDCT with Tube Current Modulation
[16]. Finally, the phantom was scanned with z-
axis automatic tube current modulation using the
same parameters, but the scout radiographs were
obtained before the breast shield was placed.
The phantom is subdivided into 26 contiguous
sections, each 25-mm thick, with assignable ana-
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tomic locations for up to 19 radiosensitive internal
organs. Each section contains several 5-mm diameter
through holes, with each hole location optimized
for dosimetry of 19 internal organs. Each hole in
the phantom is labeled with an assigned number
that can be referenced to the user manual accompa-
nying the phantom [17]. Each detector was placed
in the hole at the recommended depth for these in-
ternal organs (Table 1). For skin dose, detectors
were placed on the surface of the skin. The doses at
20 organ locations were measured using metal oxide
semiconductor field effect transistor (MOSFET)
technology (Autosense MOSFET system, Best Med-
ical Canada; High-Sensitivity MOSFET dosimeter
model TN-1002RD, Best Medical Canada). When the
transistor is irradiated, the threshold voltage of the
transistor shifts. This shift can be measured and is
proportional to the absorbed radiation dose [18]. The
calibration method for MOSFET detectors has been
described in greater detail elsewhere [19, 20]. For a
typical CT dose of 1 cGy (10 mGy), the percentage of
uncertainty is approximately 10% or less. Scanning
was performed twice for each set of imaging pa-
rameters, and the average of the two recorded doses
was used for analysis. Tube current for each slice was
recorded from the annotations on the images.
Dose–length product (DLP) values were re-
corded from the console [21] using a conversion
factor of 0.021 mSv · mGy-1 · cm-1 for 5-year-old
chest MDCT. This factor was based on the fact
that the adult chest conversion factor is 0.019 mSv
· mGy-1 × cm-1 and on previous MOSFET dosime-
try determinations in our laboratory [22]. The same
scanning duration was used for each manipulation.
Noise was measured as the SD of Hounsfield
units by drawing regions of interest (ROIs) in
homogeneous-appearing areas of the scan and
recording the SD of Hounsfield units in the ROI.
The size of the ROI varied depending on the re-
gion measured but was generally a 170 mm 2 circu-
lar area. Noise was measured in identical regions
for each study at a total of 18 different locations in
five slice levels from the soft-tissue algorithm dis-
play, as shown in Figure 2. The mean noise mea-
surement was computed for each of the five slice
levels for the four different scanning paradigms in
Table 2. The relationship of these mean levels was
examined using a two-way analysis of variance.
Results
The measured radiation doses detected at
20 locations using MOSFET technology are
AJR:190, January 2008
100
90
80
Tube Current (mA)
70
60
50
40
30
20
10
0
0 10
Fig. 3—Tube current generated at each slice level for each scanning paradigm: z-axis Auto mA (GE Healthcare)
tube current modulation, shield present in scout image (purple); z-axis Auto mA tube current modulation, shield
placed after scout image was obtained (green); fixed tube current (65 mA) scanning (orange). Slice thickness was
5 mm. White rectangle indicates location of shield.
reported in Table 1. The highest detected
doses with a fixed tube current technique and
no bismuth shield were in the lungs and in the
skin above the sternum, where doses of 0.48
cGy were recorded. The breast doses with a
fixed tube current and no bismuth shield were
0.40 cGy to the left breast and 0.35 cGy to the
right breast. The lowest recorded doses with a
fixed tube current and no bismuth shield were
to the marrow of the left midthoracic ribs
(0.30 cGy), the sternum marrow (0.31 cGy),
and the left kidney (0.33 cGy) (Table 1).
With the addition of the bismuth breast
shield while keeping all other scanning pa-
rameters fixed, the measured average breast
dose was reduced by 26% (from 0.38 cGy to
0.28 cGy). Measured doses decreased at all
14 locations under the shield by an average
of 18.0% (ranging from 5% in the left lung to
35% in the bone marrow of the spine). Com-
pare these doses with those measured out-
side the shielded area where doses decreased
by an average of 4% at four locations, were
unchanged at one location, and increased by
5% at one location.
The changes in tube current that resulted
from the different scanning paradigms are il-
lustrated in Figure 3. A fixed tube current of
65 mA was used in the standard age-based
chest protocol. By comparison, when au-
20 30 40 50 60 70
Slice No.
tomatic tube current modulation was used
without the shield present in the scout im-
age, the resultant tube current was lower in
the lungs (34–37 mA) and increased through
the upper abdomen, eventually reaching the
preset tube current ceiling of 65 mA. When
automatic tube current modulation was used
with the shield present in the scout image, the
modulation compensated for the presence of
the shield by increasing tube current through
the level of the shield. The tube current was
40 mA in the first section that included the
shield and increased along the length of the
shield, reaching 62 mA in the last section that
included the shield (Fig. 3). By comparison, in
the examination with automatic tube current
modulation but with the scout image obtained
before placement of the shield, the tube cur-
rent was 36 mA in the first section that includ-
ed the shield and did not increase to more than
36 mA over the entire length of the shield.
With the implementation of tube current
modulation with the shield placed after the
scout image was obtained, measured doses
decreased (average dose decrease, 37.5%)
at 19 of the 20 (95%) locations when com-
pared with the fixed tube current scan with
the breast shield (Table 1). In the remaining
location, the measured dose in the stomach
was unchanged (Table 1).
W57

TABLE 2: Comparison of Mean Noise Values for Pediatric Chest MDCT
Noise
Fixed Tube Current,
Age-Based Chest CT,
Location No Breast Shield
Clavicles 9.17 (8.02–9.98)
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Mid scapulae 9.42 (7.65–11.31)
Superior mediastinuma 8.96 (6.80–12.24)
Heart a 8.50 (7.27–9.93)
Upper abdomen 11.4 (10.25–12.95)
Note—Numbers in parentheses are minimum–maximum SD of Hounsfield units in ≈ 170 mm 2 region of interest. ATCM = automatic tube current modulation.
aLocation in range of shielding.
With the implementation of tube current
modulation with the shield present in the scout
image, measured doses decreased at 19 of the
20 (95%) locations (average dose decrease,
25.5%) when compared with the fixed tube
current scan with the breast shield (Table 1).
In the remaining location, the measured dose
in the left kidney was unchanged (Table 1).
Comparing the examinations with au-
tomatic tube current modulation when the
shield was placed before the scout was ob-
tained versus when the shield was placed
after, measured doses were higher (average
dose increase, 48%) at 10 of 14 locations
(71.4%) under the shield, unchanged at three
locations (21.4%) under the shield, and lower
(average dose decrease, 27.8%) at one loca-
tion (7.1%) under the shield when the shield
was present in the scout image (Table 1).
Comparing the overall highest-dose scan
(fixed tube current, age-based chest CT proto-
col, no shield) with the lowest-dose scan (au-
tomatic tube current modulation and bismuth
shield with shield placed after scout image
was obtained), measured doses decreased by
an average of 51.3% in the 16 locations under
the shield, ranging from a 43.2% decrease in
TABLE 3: Effective Dose and Noise Determination for Chest MDCT in
Phantom Representing a 5-Year-Old Child
Effective
Scanning Paradigm Dosea (mSv)
Fixed tube current, age-based chest CT 2.0
Fixed tube current, age-based chest CT 2.0
plus breast shield
ATCM, with shield, shield present in 1.6
scout image
ATCM, with shield, shield placed after 1.4
scout image obtained
Note—ATCM = automatic tube current modulation in z-axis using Auto mA (GE Healthcare).
aBased on dose–length product.
bSD of Hounsfield units in ≈ 170 mm2 region of interest.
W58
Coursey et al.
Noise
Fixed Tube Current, ATCM, Shield, Shield
Age-Based Chest CT ATCM, Shield, Shield Placed After Scout
with Breast Shield p Present In Scout Obtained p
9.17 (7.59–11.05) 1.00 11.45 (10.95–12.06) 11.24 (9.85–12.69) 0.46
9.62 (7.12–12.4) 0.63 11.87 (9.05–14.38) 11.9 (9.08–14.82) 0.93
9.42 (8.14–10.56) 0.27 11.41 (9.79–13.58) 13.06 (11.20–16.86) 0.01
9.96 (8.93–11.51) 0.008 10.00 (8.00–10.82) 12.82 (11.55–14.36) 0.001
11.12 (9.90–12.68) 0.44 11.12 (9.83–11.96) 11.38 (10.06–14.06) 0.50
the left lung to a 62.5% decrease in the skin surements were 11.4 H for the fixed tube cur-
over the sternum. Of note, breast dose de- rent scan with no shield, 11.1 H for the fixed
creased by 51.6% when automatic tube cur- tube current scan with breast shield, 11.2 H
rent modulation and the bismuth shield were for automatic tube current modulation and
used with the shield placed after the scout as breast shield with shield present in the scout,
compared with the fixed tube current, age- and 11.4 H for automatic tube current modula-
based chest CT with no shield. tion and breast shield with shield placed after
Image noise was measured as described the scout (Table 3). Mean noise measurements
earlier (Table 2). For the CT images in range were not significantly different with the addi-
of the shield, average noise measurements tion of the breast shield in the fixed tube cur-
(SD of Hounsfield units) were 8.7 H for the rent scans, except in the heart, where the noise
fixed tube current scan, 9.7 H for the fixed increased from 8.50 to 9.96 H (p = 0.008)
tube current scan with breast shield, 10.6 H (Table 2). When the shield was placed after
for automatic tube current modulation and the scout was obtained with automatic tube
breast shield with shield present in the scout, current modulation, the mean noise measure-
and 12.9 H for automatic tube current modula- ment at the level of the heart was significantly
tion and breast shield with shield placed after greater (from 10.0 to 12.8 H) than when the
the scout was obtained (Table 3). Superior to shield was present in the scout (p = 0.001).
the shield, average noise measurements were Likewise, the mean noise measurement at the
9.3 H for the fixed tube current scan with no level of the superior mediastinum was sig-
shield, 9.4 H for the fixed tube current scan nificantly greater as compared with the scans
with the breast shield, 11.7 H for automatic when the shield was present in the scout (from
tube current modulation and breast shield 11.4 to 13.1 H) (p = 0.01). Average noise at the
with shield present in the scout, and 11.5 H for level of the shield was greater than the target
automatic tube current modulation and breast noise index (12.0 H [SD]) when the shield was
shield with shield placed after the scout (Table placed after the scout because automatic tube
3). Inferior to the shield, average noise mea- current modulation did not compensate for the
presence of the shield and generated a lower
tube current (34–36 mA in the range of the
shield) compared with when the shield was
present in the scout (tube current of 40–62
Noiseb mA in the range of the shield). This lower
Above At Shield Below tube current resulted in increased noise.
Shield Level Shield Using the DLP method, the effective dos-
9.3 8.7 11.4 es were 2.0 mSv using the fixed tube current
9.4 9.7 11.1 technique with and without the breast shield,
as expected because DLP is independent of
11.7 10.6 11.2 the scout, unlike with automatic tube current
modulation, in which the DLP will depend
11.5 12.9 11.4 on the scan modulation. When automatic
tube current modulation is used, the project-
ed modulations in tube current are accounted
for in the DLP. The total effective dose was
1.6 mSv using automatic tube current modu-
AJR:190, January 2008
 Pediatric Chest MDCT with Tube Current Modulation
lation with the bismuth shield present in the
scout radiograph, yielding a 20% dose reduc-
tion as compared with the fixed tube current
scans (Table 3). The total effective dose was
1.4 mSv using automatic tube current modu-
lation with the bismuth shield placed after
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the scout radiograph was obtained, yielding
a 30% dose reduction as compared with the
fixed tube current scans (Table 3).
Discussion
Managing the radiation dose during pediat-
ric chest CT is important for two reasons. First,
the potential cancer risk has been shown to in-
crease as age at radiation exposure decreases
[3, 4]. Second, radiation-sensitive tissues such
as the breasts [23–26] are directly irradiated
during chest CT. Strategies for reducing radia-
tion dose for pediatric chest CT include ap-
propriate adjustments in scanning parameters
[27], in-plane breast shielding (where the
shield is in range of CT) [14–15], and auto-
matic tube current modulation [5–12].
Bismuth breast shields have been shown to
reduce breast radiation dose by 29% in chil-
dren [14] and by 27% to 52% in adults, de-
pending on the thickness of the shield [15].
In line with these investigations, we found a
26% dose reduction to the breast in an anthro-
pomorphic phantom representing a 5-year-old
using a 2-ply bismuth breast shield. The 4%
decrease in dose at four locations not under
the shield and the 5% increase in dose at one
location not under the shield when the shield
is added is not unexpected in that the uncer-
tainty of the MOSFET system is approximate-
ly 10% or less for a typical CT dose of 1 cGy.
Three general techniques for automatic
tube current modulation are offered by the
manufacturer of the scanner used for this in-
vestigation: z-axis (longitudinal) modulation,
x,y-axis (angular) modulation, and a combi-
nation of both. With z-axis modulation, the
method used in this study, tube current is
modulated along the craniocaudal dimension
of the patient. For example, in the setting of
chest CT with z-axis modulation, a relatively
lower tube current is delivered through the
lungs, where there is less attenuation, while
a relatively higher tube current is delivered
through the upper abdomen, where there is
more soft-tissue attenuation. With x,y-axis
modulation, a relatively lower tube current is
delivered through the thinner portions of the
patient (generally the anteroposterior dimen-
sion), and a relatively higher tube current is
delivered when there is relatively more at-
tenuation (generally the lateral dimension).
AJR:190, January 2008
The algorithms used for automatic tube cur-
rent modulation differ depending on the man-
ufacturer [28]. The z-axis modulation used in
this investigation (Auto mA) requires the user
to select the noise index (SD of Hounsfield
units) and minimum and maximum tube cur-
rent values. The range between these values is
where the modulation will take place.
Automatic tube current modulation in the
z-axis has been shown to reduce tube current–
time product by 18–26% in the setting of
adult chest CT, depending on the noise index
[7]. Automatic tube current modulation in
the x,y-axis has been shown to reduce mAs
by 31–39% in the setting of pediatric chest
CT [6] and to reduce mean effective mAs by
16.9% in the setting of adult chest CT [5].
Note, however, that tube current reductions
are surrogates for the actual patient dose. The
current study provides additional insight into
the work of prior studies by also assessing the
effect on organ doses when automatic tube cur-
rent modulation is used because dosimetry was
performed, rather than recording estimated
dose changes based on alterations in tube cur-
rent. MOSFET dosimetry offers an opportu-
nity for more accurate dose determinations in
CT [19]. The 37.5% average organ dose reduc-
tion in the current anthropomorphic phantom
study with the use of Auto mA tube current
modulation with the shield placed after the
scout image, then, is slightly higher than previ-
ously reported mAs reductions in the setting of
adult chest CT with z-axis automatic tube cur-
rent modulation. This difference may reflect a
combination of different automatic tube cur-
rent modulation technologies, different noise
indexes, or automatic tube current modulation
when used in a phantom. The 25.5% average
dose reduction with Auto mA tube current
modulation with the shield present in the scout
is similar to previous investigations.
The locations (stomach and left kidney) in
which the measured dose did not change with
Auto mA were in the upper abdomen, where
tube current was the same (65 mA) in the fixed
tube current and the automatic tube current
modulation scans, likely because an equivalent
amount of tube current was necessary to main-
tain the target noise level. Noise levels in the
sections containing the stomach and left kid-
ney dosimeters were similar in the automatic
tube current modulation and fixed tube current
scans (data not shown).
The use of breast shields in combination
with automatic tube current modulation has
not been previously addressed. It is conceiv-
able that with the type of z-axis modulation
used in this investigation (combined z- and x,y-
axis modulation was not available at the time
of our study), the increased attenuation present
on the scout image due to the shield (and the
concomitant increase in tube current in this re-
gion) could negate the benefits of both shield-
ing and tube current modulation. We found
that Auto mA z-axis modulation compensated
for the density of the shield if the shield was
present in the scout radiograph by increasing
the tube current along the z-axis in the range of
the shield (Fig. 3). As seen in Figure 3, the tube
current began to increase at the leading edge of
the breast shield. The rate of rise increased dra-
matically after 15 slices, or approximately 7.5
cm beyond the leading edge of the shield. The
reason for this unexpected delay in increasing
tube current is not known. Although there is
a lag before modulation begins, it is relatively
short (80 milliseconds). Further analysis of the
data with the manufacturer did not provide an
explanation (Toth T, GE Healthcare, personal
communication).
However, if the modulation began sooner
in the upper thorax, we would have expected
an even greater dose savings with Auto mA
tube current modulation when the shield was
placed after the scout. That tube current did
not decrease beyond the shield before reach-
ing the abdomen can be explained by the fact
that the Auto mA tube current modulation
software derives the tube current on the ba-
sis of the highest attenuating structure under
the detectors at a given time. A portion of
the detectors was likely always either over
the shield or over the upper abdomen at the
end of the scanning. However, even though
Auto mA compensated for the shield when
the shield was present in the scout, the select-
ed tube currents through the positions that
included the shield (40–62 mA) still were
lower than the fixed tube current of 65 mA
used in the fixed-tube-current, age-based
scan. Therefore, some but not all of the tube
current benefit was lost when the shield was
present in the scout radiograph.
Furthermore, we postulated that placing the
shield after the scout image was obtained would
maximize dose benefits from both shielding
and Auto mA tube current modulation. In fact,
placing the shield after the scout was obtained
resulted in radiation doses (measured using
MOSFET technology) that were lower at 10
locations, unchanged at three locations (right
breast, left breast, skin over breasts), and in-
creased at one location in the range of shield-
ing. The effective dose, as expected, decreased
by 13%, from 1.6 to 1.4 mSv, when the shield
W59

was placed after the scout radiograph with
Auto mA tube current modulation.
That breast dose and skin dose superficial
to the breasts did not change when the shield
was placed after the scout was obtained while
almost all the other organ doses in the range
Downloaded from www.ajronline.org by 54.210.20.124 on 10/28/15 from IP address 54.210.20.124. Copyright ARRS. For personal use only; all rights reserved
of the shield decreased was somewhat un-
expected. One explanation is that the breast
detectors were located near the leading edge
of the shield, where the differences in tube
current were not so great (43–50 mA when
shield was present in scout image vs 34–35
mA when shield was placed after scout im-
age was obtained). Given the spiral nature of
the primary beam, it is also possible that the
position of the beam (e.g., posteroanterior vs
anteroposterior) relative to the breast detec-
tors was different in the automatic tube cur-
rent modulation runs with shield placed be-
fore and after the scout image was obtained.
A posteroanterior beam would be more at-
tenuated by soft tissues before it reaches the
breast detectors, whereas an anteroposte-
rior beam would be attenuated by the breast
shield before reaching the detectors. This
phenomenon has been reported recently with
MOSFET and breast dosimetry and is a limi-
tation of this type of surface dosimetry (un-
like more central dose locations) in helical as
opposed to axial MDCT [29].
It was also unexpected that the average
dose in the bone marrow of the right ribs
increased when the shield was placed after
the scout (Table 1). As noted earlier, all other
measured doses in the range of the shield de-
creased or were unchanged when the shield
was placed after the scout with Auto mA.
The measured doses at this location for each
of the four Auto mA runs (two with the shield
present in the scout and two with the shield
placed after the scout) were 0.12, 0.14, 0.13,
and 0.22 cGy. The 0.22-cGy value appears to
be an outlier that may have falsely elevated
the average.
Breast doses of 0.1–0.7 Gy have been
shown to be associated with an increased
risk of breast cancer [25, 26]. Although the
breast dose in our study was low (0.4 cGy
without the shield), appropriately minimiz-
ing any radiation dose, especially for breast
parenchyma in young individuals, is prudent.
In keeping with this ALARA principle, we
found that breast dose was reduced by 26%
with the breast shield alone and by 52% when
using the breast shield and automatic tube
current modulation in an anthropomorphic
phantom representing a 5-year-old child.
When measured doses decreased, image
W60
Coursey et al.
noise increased. The highest-dose scan (fixed
tube current chest CT without shielding) was
also the least noisy. The lower noise measured
in the nonmodulated examination was due, we
think, to tube current levels that were higher
than needed (such as in the lungs). For non-
modulated examinations, it is likely that pro-
tocols have evolved to maintain a minimum
noise level for diagnostic quality through
intrinsically higher attenuating areas, mean-
ing other regions will have less noise than is
needed. For example, in the nonmodulated
examinations, average noise measurements
cranial to the shield were 9.3 and 9.4 H (SD)
and caudal to the shield were 11.4 and 11.1 H
(SD) in the runs with and without the breast
shield, respectively (Table 3).
The lowest-dose scan (automatic tube
current modulation and shield, with shield
placed after the scout image was obtained)
was the noisiest scan. The increase in im-
age noise at the level of the heart and supe-
rior mediastinum (in the range of shielding)
when the shield was placed after the scout
was significantly (p < 0.01) higher compared
with when the shield was present in the scout
radiograph with automatic tube current mod-
ulation. It is unclear why the heart and not
the superior mediastinum had a significantly
higher amount of noise with nonmodulated
scanning with and without the shield. This
may represent a statistical error.
When the shield was placed after the scout
image was obtained, the measured noise in-
dex (12.9 H [SD]) in the range of shielding
was slightly higher than the selected target
noise index of 12.0 H (SD). Although this
increase in noise is statistically significant, it
does not necessarily equate to a reduction in
diagnostic quality. For example, a prior inves-
tigation (Darsie J et al., presented at the 2005
annual meeting of the Radiological Society of
North America) supports a noise index of 12.9
H (SD) to be in the acceptable range for pe-
diatric chest CT. In addition, the target noise
index was 12.0 H (SD), and the breast shields
increased noise above this level by 0.9 H (SD),
a difference that is arguably below threshold
for visual detection. In the automatic tube
current modulation runs, not unexpectedly,
noise measurements were similar both cra-
nial to and caudal to the shield. The automatic
tube current modulation algorithm modulates
tube current to maintain a constant noise level
throughout the scanning.
Limitations of our study include that only
one type of CT scanner and therefore only
one automatic tube current modulation tech-
nology was investigated. For example, not all
automatic tube current modulation products
described by McCollough et al. [28] modu-
late on the basis of the scout radiograph.
Therefore, the effect of placing the shield
before or after the scout radiograph cannot
be predicted in these settings. The use of an
anthropomorphic phantom representing a
single age is also a limitation of this study.
However, it is expected that similar dose re-
ductions would be seen with anthropomor-
phic phantoms representing different ages.
Also, because there are no respiratory or
cardiac motion artifacts in a phantom study,
the doses and image noise changes we found
may not completely translate into a patient
study. The use of the SD of Hounsfield units
in a region of interest as a proxy for image
quality is also a limitation of this study. The
effect of the combined use of bismuth shields
and automatic tube current modulation on
diagnostic quality of images needs to be as-
sessed. Finally, our conversion factor used to
compute effective dose was an estimate of a
chest CT protocol for a 5-year-old because
standards are not available for pediatric
chest 16-MDCT. Although the effective dose
would differ if another conversion factor
were used, the change in the effective dose
we determined (13% decrease) when the
shield was placed after the scout compared
with when the shield was present in the scout
is independent of the factor used.
In conclusion, the use of a bismuth breast
shield in addition to one technique for z-axis
automatic tube current modulation further re-
duces detected radiation dose as determined
in a pediatric anthropomorphic phantom.
Dose reduction is greatest when the breast
shield is placed after the scout radiograph is
obtained. Although placing the breast shield
after the scout radiograph is obtained does
result in increased image noise in the range
of the shield because the tube current is cal-
culated without factoring in the attenuation
of the breast shield, the increased image
noise is still close to the noise target level.
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