Physica Medica 71 (2020) 176–177
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Physica Medica
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Is it possible to kill the radiation risk issue in computed tomography?
Computed tomography (CT) has continued to attract public media
attention from time to time [1]. Initially, during 2001–2007, it was the
potential cancer risks in children with continuing reports inter-
mittently; then unexpected overexposures in 2008–2009 that are un-
likely to occur again; reports of over-utilization in 2007–2009 and re-
ports of inappropriate use that keep appearing from time to time [1].
These reports during the past nearly two decades have heightened in-
terest in making CT safer for patients. There have been enormous ac-
tions by all stakeholders; manufacturers of CT systems, medical physi-
cists, researchers and users in hospitals and there have been national
and international campaigns and programs. While the realization
started growing that the CT imaging has become much safer due to
significant reduction in radiation dose achieved [2,3], the recent stu-
dies are turning the table once again on the side of risk to a large
number of patients [4]. This time it is the risks from multiple CT exams
some patients undergo with high cumulative radiation dose.
Two large-scale studies just published have shown that nearly 1 out
of 100 patients (0.64% to 3.4% with an overall average of 1.33%) who
undergo a CT exam may receive high cumulative effective doses (CED)
of 100 mSv or more [4,5]. The minimum time to accrue 100 mSv was a
single day at all four institutions, an unreported finding to date [4].
They argued that, although CED is not the perfect means to quantify
partial and intermittent body exposures by recurrent CTs, nor is it that
100 mSv is the threshold for radiation effects, but values of CED more
than 100 mSv make it rather likely that various organs may receive
absorbed organ doses of more than 100 mGy. They also provide organ
dose data for a sub-set of the cohort which showed several organs with
doses over 100 mGy. An Editorial that followed the above publications
delves on potential radiation effects at the radiation levels presented in
above two papers and concurs with concerns [6]. The authors also es-
timated that nearly 0.9 million patients are likely getting into this group
every year globally [4,5]. This is totally unexpected finding in terms of
magnitude. The new finding comes in wake of tracking of previous
exposures that has become possible with modern technology in current
decade. Just on click of a button, it is now possible to know all previous
radiological exams and radiation doses, at least within the network of a
health service provider.
What should be done? The traditional approach has been to blame
overuse of CT. For the first time, it comes out that the above findings of
sizable number of patients with 100 mSv+ include data from a hospital
where there is good control mechanism in place and where imaging
request goes through the clinical decision support (CDS) system [7].
Also, the hospital has adequate control on optimization of technique
such that the typical CT doses are much below the national benchmark
[4]. Additionally, the researchers manually studied imaging appro-
priateness of a small subset in above high dose cohort of patients with
recurrent CT exams and found high level of appropriateness as assessed
by clinicians [7]. This creates a unique situation not witnessed before.
Obviously, when patients do need the imaging justifiably and the exam
https://doi.org/10.1016/j.ejmp.2020.02.017
Received 28 January 2020; Received in revised form 16 February 2020; Accepted 21 February 2020
Available online 09 March 2020
1120-1797/ © 2020 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.
T
must be performed, there is a need to analyze what can be done to help
these patients as radiation risk creates concern. The need for further
development of appropriateness criteria has already been covered by
paper by Rehani et al [7] and a recent Editorial [8] and is outside the
scope of the current paper. This paper deals with the need expressed on
CT machines as the above papers conclude that there is an urgent need
for the industry to develop CT scanners and protocols with sub-mSv
radiation dose, a goal that has been lingering [4,5,7].
Is it doable within foreseeable future? The answer appears to be
yes, very likely as indicated in a recent paper [9]. Essentially there are
six important factors of the CT system that can contribute to decrease in
radiation dose to the patient.
First, using more powerful X-ray tubes and thicker prefilters, in a
filter changer with a large variety of thicknesses will selectively remove
low energy radiation from the beam that do not make it through the
patient and thus add unnecessary radiation dose. The X-rays will be-
come more monochromatic. Currently, only one vendor provides
changeable filter thicknesses (0, 0.4 mm or 0.7 mm Sn). Second, use of
tunable tube voltage settings e.g. from 60 kV to 160 kV in steps of
10 kV, can allow the X-ray spectrum to be individually tailored to the
patient to meet the imaging task [10]. Third, automatic exposure con-
trol would not only include tube current modulation but also tube
voltage and filter thickness modulation. Apart from significant dose
reduction [10] a positive outcome would be reduced beam hardening
and metal artifacts. Fourth, adaptive bow-tie filters, which are currently
under investigation and which aim at shaping the X-ray cone’s fluence
field as a function of the patient anatomy have the potential to further
reduce the X-ray dose. For pediatric CT angiography, dose reduction up
to 70% for head, 77% for thorax, and 34% for abdomen/pelvis has been
reported [9]. Fifth, the expected introduction of photon counting de-
tector technology will boost CT image quality and dose efficiency.
Those directly converting detectors have no electronic noise, they offer
favorable photon statistics due to counting instead of integrating, they
provide improved iodine contrast, their spatial resolution is higher and,
last but not least, they intrinsically acquire spectral information [11].
For example, the combined effect of smaller detector pixels and of
photon counting versus energy integrating can yield a 40% dose re-
duction [12]. All these features can be used to provide improved CT
images or to significantly lower the X-ray dose [9].
What about the software? We all know that deep learning has
found its way into medical sciences and in particular in imaging. Sixth,
obviously, it will also be used to improve CT image formation and most
likely soon replace iterative reconstruction techniques [13]. The main
advantage of the neural network-based algorithms is that they do not
rely on handcrafted features or prior knowledge, as do the iterative
reconstruction techniques, but that they rather learn very complex
features from the data themselves. Some vendors already provide deep
learning technology to remove noise from the reconstructed images
[14]. As of today, however, no clinical studies to prove or quantify dose

reduction levels are available yet.
Conservatively assuming that each of these anticipated technolo-
gical improvements, improved spectra, improved detectors and im-
proved reconstruction software, will allow to reduce X-ray dose to, say,
one third, we will see a dose reduction of 70% in total. While sub-mSv
scanning today is possible for certain premium CT devices and selected
protocols it is foreseeable that in the future not only premium systems
will operate in this low dose domain and that they will do this on a
routine basis for nearly all patients and protocols. It is unfortunate that
the cumulative radiation doses to patients had not been assessed despite
the fact that the technology has been around to track patient doses for
the last over decade at some institutions. The latest results should create
compelling need for the industry to push for sub-mSv CTs.
It is hoped that CT imaging industry will create an agenda such that
100 mSv+ doses will not be seen anymore.
While the intent remains that users are provided with CT scanners
that can reduce the worries on radiation risks for patients who are
falling on the higher end of multiple CT exams, the need for rational
practice, which even though is always needed, will become more ser-
ious when cumulative doses are within a few tens of mSv. One can
never have a diet that can substitute calories-consciousness or a security
system that can make everyone feel 100% safe and thus continued at-
tention will be needed for reducing radiation risks to those who may
still fall in the range of few tens of mSv.
References
[1] Rehani MM. What makes and keeps radiation risks associated with CT a hot topic?
AJR Am J Roentgenol 2015;204(3):W234–5. https://doi.org/10.2214/AJR.14.
12860.
[2] McCollough CH. Computed tomography technology-and dose-in the 21st century.
Health Phys 2019;116(2):157–62. https://doi.org/10.1097/HP.
0000000000000997.
[3] Rehani MM, Szczykutowicz TP, Zaidi H. CT is still not a low-dose imaging modality.
Med Phys 2019. https://doi.org/10.1002/mp.14000.
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Corresponding author at: Radiology Department, Massachusetts General Hospital, 175 Cambridge Str., Suite 244, Boston, MA 02114, USA.
177
Physica Medica 71 (2020) 176–177
[4] Rehani MM, Yang K, Melick ER, Heil J, Šalát D, Sensakovic WF, et al. Patients
undergoing recurrent CT scans: assessing the magnitude. Eur Radiol 2019. https://
doi.org/10.1007/s00330-019-06523-y.
[5] Brambilla M, Vassileva J, Kuchcinska A, Rehani MM. Multinational data on cu-
mulative radiation exposure of patients from recurrent radiological procedures: call
for action. Eur Radiol 2019. https://doi.org/10.1007/s00330-019-06528-7.
[6] Ruehm W, Harisson RM. High CT doses return to the agenda. Radiat Environ
Biophys 2020;59:3–7. https://doi.org/10.1007/s00411-019-00827-9.
[7] Rehani MM, Melick ER, Alvi RM, Khera RD, Batool-Anwar S, Neilan TG, et al.
Patients undergoing recurrent CT exams: assessment of patients with non-malignant
diseases, reasons for imaging and imaging appropriateness. Eur Radiol 2019.
https://doi.org/10.1007/s00330-019-06551-8.
[8] Remedios D. Cumulative radiation dose from multiple CT examinations: stronger
justification, fewer repeats, or dose reduction technology needed? Eur Radiol 2020.
https://doi.org/10.1007/s00330-019-06624-8.
[9] Lell MM, Kachelriess M. Recent and upcoming technological developments in
computed tomography: high speed, low dose, deep learning, multienergy. Invest
Radiol 2020;55(1):8–19. https://doi.org/10.1097/RLI.0000000000000601.
[10] Leyendecker P, Faucher V, Labani A, Noblet V, Lefebvre F, Magotteaux P, et al.
Prospective evaluation of ultra-low-dose contrast-enhanced 100-kV abdominal
computed tomography with tin filter: effect on radiation dose reduction and image
quality with a third-generation dual-source CT system. Eur Radiol
2019;29:2107–16.
[11] Taguchi K, Iwanczyk JS. Vision 20/20: single photon counting x-ray detectors in
medical imaging. Med Phys 2013;40(10):100901.
[12] Klein L, Dorn S, Amato C, Heinze S, Uhrig M, Schlemmer H-P, Kachelriess M, Sawall
S. Effects of detector sampling on noise reduction in a clinical photon counting
whole-body CT. Invest Radiol 2020;55(2):111–9. https://doi.org/10.1097/RLI.
0000000000000616.
[13] Wang G, Ye JC, Mueller K, Fessler JA. Image reconstruction is a new frontier of
machine learning. IEEE Trans Med Imaging 2018;37(6):1289–96.
[14] Akagi M, Nakamura Y, Higaki T, Narita K, Honda Y, Zhou J, et al. Deep learning
reconstruction improves image quality of abdominal ultra-high-resolution CT. Eur
Radiol 2019;29(11):6163–71. https://doi.org/10.1007/s00330-019-06170-3.
Marc Kachelrießa, Madan M. Rehanib,
⁎
a
German Cancer Research Center (DKFZ), Heidelberg, Germany
b
Massachusetts General Hospital, Boston, MA 02114, USA
E-mail addresses: madan.rehani@gmail.com,
mrehani@mgh.harvard.edu (M.M. Rehani).