CT Imaging • Original Research

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Schindera et al.
MDCT Tube Current Modulation

CT Imaging
Original Research

Effect of Patient Size on Radiation

Dose for Abdominal MDCT
with Automatic Tube Current
Modulation: Phantom Study
Sebastian T. Schindera1,2 OBJECTIVE. The purpose of this study was to evaluate in a phantom study the effect of
Rendon C. Nelson2 patient size on radiation dose for abdominal MDCT with automatic tube current modulation.
Thomas L. Toth 3 MATERIALS AND METHODS. One or two 4-cm-thick circumferential layers of fat-
Giao T. Nguyen 4 equivalent material were added to the abdomen of an anthropomorphic phantom to simulate
Greta I. Toncheva4 patients of three sizes: small (cross-sectional dimensions, 18 × 22 cm), average size (26 × 30
cm), and oversize (34 × 38 cm). Imaging was performed with a 64-MDCT scanner with com-
David M. DeLong2
bined z-axis and xy-axis tube current modulation according to two protocols: protocol A had
Terry T. Yoshizumi2,4 a noise index of 12.5 H, and protocol B, 15.0 H. Radiation doses to three abdominal organs
Schindera ST, Nelson RC, Toth TL, et al. and the skin were assessed. Image noise also was measured.
RESULTS. Despite increasing patient size, the image noise measured was similar for pro-
tocol A (range, 11.7–12.2 H) and protocol B (range, 13.9–14.8 H) (p > 0.05). With the two
protocols, in comparison with the dose of the small patient, the abdominal organ doses of the
average-sized patient and the oversized patient increased 161.5–190.6% and 426.9–528.1%, re-
spectively (p < 0.001). The skin dose increased as much as 268.6% for the average-sized patient
and 816.3% for the oversized patient compared with the small patient (p < 0.001).
CONCLUSION. Oversized patients undergoing abdominal MDCT with tube current
modulation receive significantly higher doses than do small patients. The noise index needs
to be adjusted to the body habitus to ensure dose efficiency.

T
he effectiveness of automatic tube
Keywords: automatic tube current modulation, CT, current modulation to reduce radi-
image quality, obesity, radiation dose ation dose and improve image
quality has been discerned for ab-
DOI:10.2214/AJR.07.2891 dominal CT [1–5]. With the technique, tube
Received July 18, 2007; accepted after revision
current is automatically adjusted to the X-ray
September 10, 2007. attenuation of the patient section being scanned
to keep the radiation exposure as low as possi-
1
Department of Diagnostic Radiology, University Hospital ble and to obtain images with a constant speci-
of Bern, Bern, Switzerland.
fied image quality [6]. Various types of auto-
2
Department of Radiology, Duke University Medical matic tube current modulation, including z-axis
Center, Box 3808, Erwin Rd., Durham, NC 27710. modulation, xy-axis modulation, and combined
Address correspondence to R. C. Nelson z- and xy-axis modulation, have been intro-
(rendon.nelson@duke.edu).
duced. State-of-the-art MDCT scanners in-
3
GE Healthcare Inc., Waukesha, WI. clude xyz-axis tube current modulation, where-
by tube current is modulated to patient-specific
4
Division of Radiation Safety, Duke University Medical attenuation in all three planes.
Center, Durham, NC. In automatic tube current modulation for ab-
WEB dominal CT, the radiation dose is increased for
This is a Web exclusive article. a larger body habitus [1, 3, 4]. With the advent
of high-output X-ray tubes, which are capable
AJR 2008; 190:W100–W105 of producing peak tube currents up to 800 mA,
0361–803X/08/1902–W100
it is technically feasible to maintain constant
image quality over a wide range of patient
© American Roentgen Ray Society sizes. Thus in attempts to obtain CT images of
consistent quality, the radiation exposure can
vary substantially between a thin and a large
patient. The potential risk of very high radia-
tion doses to oversized patients when automatic
tube current modulation is used has been noted
by several authorities [2, 5, 7]. However, the
exact extent of the radiation dose received by
oversized patients undergoing high-output CT
with automatic tube current modulation has not
been investigated, to our knowledge. Because
obesity is a growing public health problem in
many countries and CT plays an important role
in the diagnostic evaluation of obese patients
with abdominal comorbid conditions, more
data are needed to solve this important clini-
cal problem. The purpose of our study was to
evaluate in a phantom study the effect of patient
size on radiation dose in abdominal MDCT
performed with xyz-axis automatic tube cur-
rent modulation.
Materials and Methods
Anthropomorphic Phantom
An adult-sized whole-body anthropomorphic
phantom of a woman (model 702, CIRS) was used to

W100 AJR:190, February 2008


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Fig. 1—Photograph shows female adult anthropomorphic phantom encased with
two 4-cm-thick fat rings covering upper abdominal portion. Phantom was placed
on wooden board, which was fixed on CT examination table.
assess abdominal organ doses and image quality (Fig.
1). The phantom was fabricated of epoxy resins for
accurate simulation of the physical density and X-ray
interaction of various human tissues. The phantom
was composed of 38 2.5-cm-thick sectional slabs.
The cross-sectional diameter at the level of the upper
abdomen measured 18 cm in the anteroposterior
direction and 22 cm in the lateral direction.
To simulate patients of different sizes, the
phantom was custom fitted at the level of the upper
abdomen (T12–L3) with one or two 4-cm-thick
circumferential layers of fat-equivalent material
(Fig. 1). Each fat ring had a CT attenuation of
−80 H and measured 10 cm in the longitudinal
direction (Fig. 2). The fat rings covered four
sectional slabs of the upper abdomen. Three
types of phantom setups simulated three patients
with different body sizes: a small patient (cross-
sectional diameter of phantom setup without fat
ring, 18 × 22 cm), an average-sized patient (setup
with one fat ring, 26 × 30 cm), and an oversized
patient (setup with two fat rings, 34 × 38 cm). The
cross-sectional dimensions of the three phantom
setups were in accordance with published human
data on patient sizes [1, 8]. For example, the
abdominal anteroposterior by lateral diameter
derived from 153 patients in one study averaged
25 × 32 cm [1].
CT
The anthropomorphic phantom with its three
setups was scanned on a 64-MDCT scanner
(VCT, GE Healthcare). Two scanning protocols
(A and B) were used with xyz-axis automatic
tube current modulation, which merges z-axis
and xy-axis modulation techniques (Smart mA,
AJR:190, February 2008
MDCT Tube Current Modulation
Fig. 2—Anteroposterior scout CT image of anthropomorphic phantom shows two
10-cm-wide fat rings covering four sectional slabs of upper abdomen. Fat rings
were placed at level of upper abdomen (T12–L3).
GE Healthcare). The modulation technique for protocol. For both scanning protocols, the tube
the z-axis is an automatic tube current modulation voltage was set at 140 kVp, representing the standard
feature used to adjust tube current along the z-axis tube voltage for routine abdominal CT in our
of the patient despite the wide range of attenuation department. For protocol A, a noise index of 12.5 H
caused by changing patient size, anatomic features, was chosen, and for protocol B, 15.0 H. The selected
and tissue composition [6]. In contrast, xy-axis noise indexes were recommended by Kalra et al. [1]
modulation is used to adjust the tube current to for routine abdominopelvic CT examinations. The
minimize X-rays over angles that are less important minimum and maximum tube currents were 10 and
in reducing overall image noise. Thus for anatomic 715 mA, respectively. At 140 kVp, the maximum
features that can be highly asymmetric, such as the tube current allowed by the MDCT scanner was
shoulders, X-rays are significantly less attenuated in 715 mA. The gantry rotation time for the simulated
the anteroposterior direction than in the transverse small patient was 0.5 second, and for the simulated
direction, so the tube current can be substantially average- and oversized patients, 1.0 second. The
reduced in this direction without causing a longer gantry rotation time was selected to prevent
substantial increase in overall image noise. use of tube current settings greater than 715 mA
A single scout image was used to measure in the two phantom setups with a wider girth. All
attenuation area and oval ratio, which were used other CT parameters were kept identical for the two
to determine the tube current for the selected CT protocols (Table 1).
TABLE 1: CT Parameters
Parameter Protocol A Protocol B
Detector configuration 64 × 0.625 mm 64 × 0.625 mm
Peak kilovoltage (kVp) 140 140
Noise index (H) 12.5 15.0
Tube current range (mA) 10–715 10–715
Gantry rotation time (s)
Simulated small patient 0.5 0.5
Simulated average-sized and oversized 1.0 1.0
patient
Beam pitch 1.375 1.375
Table feed per gantry rotation (mm) 55 55
Reconstructed slice thickness (mm) 5 5
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Longitudinal scan coverage was 15 cm, which
included the four sectional slabs of the upper
abdomen encased by the 10-cm-wide fat ring plus
2.5 cm cranial and caudal to the ring (Fig. 2). To
avoid errors in radiation dose and image quality
caused by misplacement of the phantom, great effort
was made to use the scanner laser to accurately
align the phantom with the gantry isocenter.
One of the authors assessed the mean tube
current for the three phantom setups associated with
protocols A and B and then multiplied by the gantry
rotation time to acquire the mean tube current–time
product. The CT dose index was obtained from the
operator console of the scanner.
Detector Calibration Method
For measurements of the radiation dose to
the upper abdominal organs and to the skin, we
used a metal oxide semiconductor field effect
transistor (MOSFET) system (model TN-RD-60,
Thomson-Nielsen) with high-sensitivity radiology
dosimeters (TN-1002RD, Thomson-Nielsen). The
MOSFET reader was connected to a notebook
computer (Latitude, Dell), and the data were read
immediately after each CT exposure.
We calibrated the MOSFET detectors as follows.
First, we determined the thickness of copper sheets
to achieve the half-value layer (7.24 mm aluminum
at 120 kVp) of the CT scanner with a conventional
radiographic X-ray tube [9, 10]. Second, we added
0.2-mm copper sheets to the X-ray tube to obtain an
equivalent half-value layer of 7.37 mm aluminum
at 120 kVp. Third, individual MOSFET detectors
were calibrated at our clinical energy level of 140
kVp. During calibration, detectors were placed
beside an ion chamber (10x5-6, Radcal). Radiation
exposure was read with a radiation monitor (model
9015, Radcal) that had a built-in function for
automatic temperature and pressure corrections.
Conversion from exposure to absorbed dose was
computed by multiplication by an f-factor of 0.94
at 140 kVp [9].
Radiation Dose Assessment and
Statistical Analysis
To measure radiation dose to the upper
abdominal organs, 13 MOSFET dosimeters were
placed in drilled holes in the anthropomorphic
phantom at the following three abdominal organ
locations: right and left lobes of the liver (five
MOSFET detectors), stomach (five detectors),
and spleen (three detectors). To avoid scattered
radiation from beyond the fat rings, we used only
holes that were covered by the fat rings at least 3
cm in the cranial direction and 3 cm in the caudal
direction. The three phantom setups with the
MOSFET detectors were scanned twice with each
of the two protocols. For skin dose measurements,
six MOSFET detectors were placed anteriorly,
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Schindera et al.
according to the three setups, either on the surface simulated average- and oversized patients within
of the anthropomorphic phantom or on the surface protocols A and B. We applied a two-way analysis
of the fat rings. Because the helical beam pattern of of variance with the protocol and the phantom setup
MDCT exposes the detectors in a random manner, as the factors. A value of p < 0.05 was considered
we took a conservative approach to determining to indicate a statistically significant difference.
a representative skin dose by accepting the three All statistical analyses were performed with SAS
highest readings of the two CT acquisitions. software system version 9.1.3.
The mean radiation dose and its SD were
computed for each of the three abdominal organs Image Quality Assessment and
and the skin. For statistical analysis of the radiation Statistical Analysis
dose, we compared the two protocols within For image quality assessment, the three phantom
the same phantom setup and different phantom setups were scanned once with protocols A and
setups within the same protocol. For the latter, B without the MOSFET detectors to eliminate
we compared the simulated small patient with the streak artifacts. Image quality was assessed by an
Fig. 3—Diagrams of axial
CT images show simulated
patients scanned with protocols
A and B. Top, small patient
(phantom without fat ring);
middle, average-sized patient
(phantom encased by one fat
ring); bottom, oversized patient
(phantom encased by two
fat rings). As cross-sectional
diameter of phantom increases,
image quality is maintained in
protocols A and B. Left bottom
image shows region of interest
placement for image noise
measurement (circle).
TABLE 2: Mean Tube Current–Time Product, Range of the Tube Current
Product, and CT Dose Index
Mean Tube Current–Time
CT Protocol Product (mAs) Tube Current (mA) CT Dose Index (mGy)
Small patient
A 102.8 81–198 5.0
B 70.5 56–135 3.5
Average-sized patient
A 166.7 157–172 14.6
B 115.2 108–119 9.7
Oversized patient
A 576.6 468–631 47.8
B 400.1 354–438 33.2
AJR:190, February 2008
 MDCT Tube Current Modulation
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TABLE 3: Radiation Dose and Image Noise

Radiation Dose (mGy)
Protocol Liver Stomach Spleen Skin Image Noise (H)
Small patient
A 7.4 ± 0.8 6.4 ± 3.0 7.4 ± 0.8 8.6 ± 0.4 11.9 ± 0.6
B 5.2 ± 1.3 4.7 ± 1.5 5.0 ± 0.2 6.3 ± 0.5 14.1 ± 0.5
Average-sized patient
A 20.4 ± 1.2 18.6 ± 4.2 19.5 ± 0.8 31.7 ± 0.8 11.7 ± 0.7
B 13.6 ± 8.5 13.0 ± 5.4 13.5 ± 6.4 21.3 ± 2.5 13.9 ± 0.6
Oversized patient
A 41.1 ± 8.3 40.2 ± 13.1 44.5 ± 4.7 78.8 ± 4.5 12.2 ± 0.4
B 27.4 ± 5.4 26.4 ± 9.4 29.4 ± 3.7 54.7 ± 3.4 14.8 ± 0.7
Note—Values are mean ± SD.

investigator on a separate workstation (Advantage
Windows 4.2, GE Healthcare) using reconstructed
5-mm-thick transverse images. For the image
quality assessment, image noise was measured by
placement of an approximately 2,000-mm 2 region
of interest (ROI) in the center of the phantom (Fig.
3). Image noise was defined as the SD of the ROI
value. Three ROI measurements were obtained
on three axial CT images for each of the three
phantom setups scanned with the two protocols.
Mean and SD were calculated for the image
noise values, which were compared among the
two protocols and the phantom setups by means
of two-way analysis of variance. A difference of
p < 0.05 was considered statistically significant.
Results
Within protocols A and B, mean tube
current–time product, range of tube current
values, and CT dose index all increased in
relation to the size of the simulated patient
(Table 2). Despite the increasing patient size,
the two protocols had similar image noise
(p > 0.05) (Table 3). For the three patient
TABLE 4: Percentage Difference in Radiation Doses between Protocols A and
B and Patient Sizes
Patient Size Protocol Liver
Small A vs B –29.4 a
Average A vs B –33.3
Oversized A vs B –33.3
Small vs average A 175.7
B 161.5
Small vs oversized A 455.4
B 426.9
aNo statistically significant difference (p > 0.05); all other comparisons show a statistically significant
difference (p < 0.05).
sizes, the radiation dose associated with both compared with the small patient (p < 0.001).
protocols was always higher for the skin As the size of the simulated patient increased,
(range, 6.3–78.8 mGy) than for any of the the radiation dose to the skin yielded a greater
abdominal organs (range, 4.7–44.5 mGy). percentage increase than did the radiation dose
The radiation doses associated with protocol to the abdominal organs (Fig. 4).
A, which had a noise index of 12.5 H, were
26.6–34.3% higher than those associated Discussion
with protocol B, which had a noise index of With high-output CT scanners with au-
15.0 H (Table 4). At the same time, for the tomatic tube current modulation technique,
three patient sizes, the image noise increased radiologists can obtain images with constant
18.5–21.2% from protocol A to protocol B. image quality despite the size of the patient.
This increase paralleled the difference be- Because it is clinically desirable to maintain
tween the 12.5- and 15.0-H noise indexes image quality over a range of patient sizes,
(20% increase). radiologists are tempted to use a constant
Within both protocols, the lowest radiation operator-selected image quality setting (e.g.,
doses occurred in the small patient and the noise index, reference tube current–time
highest doses in the oversized patient (Table 3). product) for patients of all sizes. From a pa-
Within protocols A and B, the average-sized tient dose perspective, however, this approach
patient received 161.5–190.6% and the over- is not necessarily recommended. With a pre-
sized patient received 426.9–528.1% higher selected image quality setting, a thin patient
abdominal organ doses than did the small pa- can receive a very low radiation dose and an
tient (p < 0.001) (Table 4). The skin doses in- oversized patient, a very high dose. To the
creased up to 268.6% for the average-sized pa- best of our knowledge, the relation between
tient and up to 816.3% for the oversized patient radiation dose and patient size with the use
of automatic tube current modulation in ab-
dominal CT has not been investigated in an
anthropometric phantom study.
The CT scanner used in our study deliv-
Stomach Spleen Skin Image Noise
ered a maximum tube current of 715 mA at
a peak tube potential of 140 kVp. Because
–26.6a –32.4 a –26.7a 18.5 of the high tube current capability of the
–30.1 –30.8 –32.8 18.8 scanner, the selected noise indexes, and the
–34.3 –33.9 –30.6 21.2 adjusted gantry rotation times, xyz-axis au-
tomatic tube current modulation maintained
190.6 163.5 268.6 –1.7a
image quality for the three simulated patient
176.6 170.0 238.1 –1.4 a sizes. However, the maintenance of constant
528.1 501.3 816.3 2.5a image quality for larger patients came at the
461.7 488.0 536.0 5.0a cost of significantly increased radiation. For
the simulated oversized patient, the abdomi-
nal organ doses increased up to 528.1% and

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80
Radiation Dose (mGy)
60
40
20
0 0
20 25 30
Lateral Diameter (cm)
Fig. 4—Mean radiation dose for skin (+), spleen (), stomach (), and liver () plotted according to size of simulated patient (lateral diameter).
A and B, Graphs show doses for protocol A (A) and protocol B (B).
the skin doses up to 816.3%, compared with
the doses in small patients. Thus when auto-
matic tube current modulation is used with-
out adjustment of the noise index to patient
habitus, radiologists and technologists need
to be aware of the resultant very broad range
of radiation doses.
Operator-selected image quality settings
play a key role in the dose efficiency of au-
tomatic tube current modulation. Previous
studies [1, 11] have shown that subjective
image quality increases with patient size on
abdominopelvic CT images with constant
image noise. In other words, radiologists
tend to accept greater subjective image qual-
ity for larger patients. The increased subjec-
tive image quality for larger patients may be
explained by the increase in fat deposition
around the abdominal organs that adds to the
inherent tissue contrast between various or-
gans. This greater acceptance of higher sub-
jective image quality for large patients may
allow adjustment of the operator-selected
image quality settings in the use of auto-
matic tube current modulation. The optimal
noise indexes adjusted to patient habitus for
abdominopelvic CT still have to be evaluated
in a clinical study [1].
Selection of image quality for different-sized
patients undergoing abdominopelvic CT with
automatic tube current modulation is widely
operator dependent and thus arbitrary. No clear
reference values for patients of various sizes
have been published, to our knowledge. In an
attempt to reduce the arbitrary nature of param-
eter selection, manufacturers of CT scanners
should be encouraged to intensify research on
semiautomatic selection of image quality set-
tings dependent on patient size. Udayasankar
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Schindera et al.
80
Radiation Dose (mGy)
60
40
20
35 40
A B
et al. [12] assessed a sized-compensated tube
current modulation technique using the square-
root projection area of the patient’s scout image
to select the noise index for abdominopelvic
CT. The square root of the projection area can
be determined from scout or CT images and
is the most appropriate patient size metric for
patient-dependent protocol planning because it
is a direct measure of patient attenuation and
not merely a factor for attenuation, as are pa-
tient dimensions, weight, and body mass index.
In the study by Udayasankar et al., the prelimi-
nary results of size compensation were promis-
ing. Two radiologists graded the image quality
of all 100 abdominopelvic CT examinations
as acceptable regardless of patient size. The
applied noise indexes used for the 100 CT
examinations ranged between 9.6 and 28.7 H.
Another noteworthy finding of our study
was the greater percentage increase in skin
dose compared with abdominal organ dose
as patient size increased. A possible expla-
nation for this finding may be the greater
attenuation of the traversing photon fluence
through the wider girth of our simulated pa-
tient, resulting in lower detection of radiation
by the abdominal detectors in the center of
the phantom compared with the skin detec-
tors on the body surface. If one assumes that
the female breast can receive doses similar
to our reported skin doses, oversized women
are at risk of receiving high radiation doses
to the radiosensitive breast with automatic
tube current modulation CT. Further stud-
ies of this technique are needed to assess
exposure of the female breast to radiation in
different-sized patients.
There were limitations to our study. First,
the two fat rings covered only 10 cm of the
20 25 30 35 40
Lateral Diameter (cm)
upper abdomen instead of the entire abdo-
men and pelvis. Total coverage of the abdo-
men and pelvis was not technically feasible
because of the curvature of the phantom at the
level of the lower abdomen and pelvis. A com-
plete abdominopelvic CT examination of the
three phantom setups with the two protocols
should increase the absolute organ and skin
dose numbers but not the percentage change
between the phantom setups. Second, we used
a female phantom and did not include a male
phantom. The fat deposits of obese men tend
to be mainly in the visceral region; in obese
women, fat is present primarily in the subcu-
taneous region [13, 14]. The female phantom,
however, which had a smaller cross-sectional
diameter than that of a male phantom and did
not have extra visceral fat deposition, simulates
the worst-case radiation exposure scenario for
a large patient. Furthermore, because our sim-
ulation included an increase in subcutaneous
fat only and not an increase in visceral fat, our
abdominal organ radiation dose results have
to be considered higher than those for an actu-
al obese patient of corresponding size. Third,
we evaluated automatic tube current modula-
tion with the xyz-axis modulation technique
and did not separately evaluate z-axis and xy-
axis modulation techniques. Because clinical
studies [2, 3] have shown extra dose savings
with the combined technique, we decided to
investigate only the technique with the greater
potential for dose reduction.
With abdominal CT performed with xyz-
axis automatic tube current modulation, our
phantom study showed a wide range of radia-
tion doses due to varying patient size. As the
patient’s body habitus increased, the greatest
increase in radiation exposure was measured
AJR:190, February 2008

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in the skin. To ensure dose efficiency with
automatic tube current modulation in pa-
tients of all sizes, we recommend that the
operator-selected image quality settings be
adjusted to the patient’s habitus.
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