Abstract
Computed Tomography (CT) scanning generates 3-D images of the inside structures of the body by delivering a comparative radiation dose to the patient. This requires great concern of optimization via establishing Diagnostic Reference Level (DRL). DRL values can be estimated based on reference patient percentiles (such as 90th, 75th, and 50th) dose distribution. DRL has significant uses in professional judgments by generating harmonized evidence about the radiation dose received by the patient. The primary goal of this review is to assess the practical application of DRL in CT procedures internationally. The main objective of establishing DRLs is to optimize the patient dose without compromising the image quality in order to obtain adequate diagnostic information. That means the inescapability of DRL for a country in medical diagnosis is to reduce the limitation of dose dispersion, to harmonize and expand the good practice, to narrow large dispersion of doses, and to create systematic supervision for unwanted radiological doses. The review presents that international records have a wide range of mean dose distributions due to the variation of exam protocols and technical parameters in use. Hence, this review recommends that each CT health facility are required to exercise careful dose reduction strategies by accounting for adequate image quality with sufficient diagnostic information via follow-up of concerned bodies.
Keywords: Radiation, CT, patient, dose, DRL, optimization, protection.
Graphical Abstract
[1]
UNSCEAR. Sources, effects and risks of ionizing radiation. United Nations Scientific Committee on the Effects of Atomic Radiation. Report to the general assembly with scientific annexes UN publication. 2008. Available from: https://www.unscear.org/unscear/en/publications/2008_1.html
[2]
IAEA. Dose reduction in CT while maintaining diagnostic confidence: A feasibility/demonstration study. (IAEA-TECDOC) Report No: 1621, Austria-Vienna 2009.
[3]
ICRP Publication 135: Diagnostic reference levels in medical imaging. Ann ICRP 2017; 46(1): 1-147.
[http://dx.doi.org/10.1177/0146645317717209] [PMID: 29065694]
[http://dx.doi.org/10.1177/0146645317717209] [PMID: 29065694]
[4]
Size-specific dose estimates (SSDE) in pediatric and adult body CT examinations. AAPM Report No 204 2011.
[5]
Kanal KM, Butler PF, Sengupta D, Bhargavan-Chatfield M, Coombs LP, Morin RLUS. diagnostic reference levels and achievable doses for 10 adult CT examinations. Radiology 2017; 284(1): 120-33.
[http://dx.doi.org/10.1148/radiol.2017161911] [PMID: 28221093]
[http://dx.doi.org/10.1148/radiol.2017161911] [PMID: 28221093]
[6]
Radiation protection No 154. European guidance on estimating population doses from medical X-ray procedures. Final report of contract no TREN/04/NUCL/S0739241 2008.
[8]
European guidelines on diagnostic reference levels for paediatric imaging. Directorate-General for Energy Directorate D-Nuclear Energy, Safety And ITER Unit D3—Radiation Protection And. Nucl Saf 2018; 1-122.
[9]
Graingr A. Diagnostic radiology: A textbook of medical imaging. London: Elsevier 2015; pp. 3-36.
[10]
Rehani MM, Gupta R, Bartling S, et al. Radiological protection in cone beam computed tomography (CBCT). Ann ICRP 2015; 44(1): 9-127.
[http://dx.doi.org/10.1177/0146645315575485] [PMID: 26116562]
[http://dx.doi.org/10.1177/0146645315575485] [PMID: 26116562]
[11]
McCollough CH, Primak AN, Braun N, Kofler J, Yu L, Christner J. Strategies for reducing radiation dose in CT. Radiol Clin North Am 2009; 47(1): 27-40.
[http://dx.doi.org/10.1016/j.rcl.2008.10.006] [PMID: 19195532]
[http://dx.doi.org/10.1016/j.rcl.2008.10.006] [PMID: 19195532]
[12]
Alsafi K. Radiation protection in X-ray computed tomography : Literature review. Int J Radiol Imaging Technol 2016; 2(3)
[http://dx.doi.org/10.23937/2572-3235.1510016]
[http://dx.doi.org/10.23937/2572-3235.1510016]
[13]
Siemens Health Care. AAPM computed tomography radiation dose education slides. AAPM working group on standardization of CT nomenclature and protocols. Available from: https://www.nibib.nih.gov/sites/default/files/Cody.pdf
[14]
Radiological protection of patients in diagnostic and interventional radiology, nuclear medicine and radiotherapy. Proceedings of an International Conference Held in Malaga. 26–30 March 2001; Spain. 2001; pp. 26-30.
[15]
The 2007 Recommendations of the International Commission on Radiological Protection. ICRP publication 103. Ann ICRP 2007; 37(2-4): 1-332.
[http://dx.doi.org/10.1016/j.icrp.2007.10.003] [PMID: 18082557]
[http://dx.doi.org/10.1016/j.icrp.2007.10.003] [PMID: 18082557]
[16]
Quality assurance programme for computed tomography: Diagnostic and therapy applications Human Health Series No 19. Vienna: IAEA 2012; pp. 41-53.
[17]
Council directive 2013/59/Euratom of 5 December 2013 laying down basic safety standards for protection against the dangers arising from exposure to ionising radiation, and repealing directives 89/618/Euratom, 90/641/Euratom, 96/29/Euratom, 97/43/Euratom and 2003/122/Euratom. Off J Eur Union 2014; 1-73.
[18]
Dosimetry in diagnostic radiology: An international code of practice Technical Reports Series No 457. Vienna: IAEA 2007.
[19]
Reiser M, Becker C, Nikolaou K, Glazer G. Medical radiology, diagnostic imaging. Multislice CT. Switzerland: Springer 2009; pp. 60-70.
[http://dx.doi.org/10.1007/978-3-540-33125-4]
[http://dx.doi.org/10.1007/978-3-540-33125-4]
[20]
Radiation protection and safety of radiation Sources : International basic safety standards. General safety requirements part 3, No GSR Part 3,Vienna 2014; 3: 1-303.
[21]
Yonekura Y. Diagnostic reference levels based on latest surveys in Japan – Japan DRLs. 2015. Available from: http://www.radher.jp/J-RIME/report/DRLhoukokusyoEng.pdf
[22]
McCollough C, Branham T, Herlihy V, et al. Diagnostic reference levels from the ACR CT Accreditation Program. Am Coll Radiol 2011; 8(11): 795-803.
[http://dx.doi.org/10.1016/j.jacr.2011.03.014] [PMID: 22051465]
[http://dx.doi.org/10.1016/j.jacr.2011.03.014] [PMID: 22051465]
[23]
Brink JA, Miller DL. national diagnostic reference levels: Closing the gap. Radiology 2015; 277(1): 3-6.
[http://dx.doi.org/10.1148/radiol.2015150971] [PMID: 26115453]
[http://dx.doi.org/10.1148/radiol.2015150971] [PMID: 26115453]
[24]
European Commission. Radiation protection No. 180. European Guidelines on Diagnostic Reference Levels for Paediatric Imaging. 2014. Available from: http://www.eurosafeimaging.org/wp/wp-content/uploads/2018/09/rp_185.pdf
[25]
Tsapaki V, Aldrich JE, Sharma R, et al. Dose reduction in CT while maintaining diagnostic confidence: Diagnostic reference levels at routine head, chest, and abdominal CT-IAEA-coordinated research project. Radiology 2006; 240(3): 828-34.
[http://dx.doi.org/10.1148/radiol.2403050993] [PMID: 16837668]
[http://dx.doi.org/10.1148/radiol.2403050993] [PMID: 16837668]
[26]
European commission. Study on European population doses from medical exposure (Dose Datamed 2, DDM2). DDM2 project report part 2: Diagnostic reference levels (DRL) in Europe, Contract ENER/2010/NUCL/SI2581237. 2017.
[27]
Wardlaw G, Martel N. Sci-Thur PM-colourful interactions: highlights 07: Canadian computed tomography survey-national diagnostic reference levels. Med Phys 2016; 43(8 Part 3): 4932-3.
[http://dx.doi.org/10.1118/1.4961767]
[http://dx.doi.org/10.1118/1.4961767]
[28]
Yoon S, Kim J, Lee S. Second Korean national CT diagnostic reference levels in 14 CT protocols. Eur Radiol 2018; 1-13.
[29]
Foley SJ, McEntee MF, Rainford LA. Establishment of CT diagnostic reference levels in Ireland. Br J Radiol 2012; 85(1018): 1390-7.
[http://dx.doi.org/10.1259/bjr/15839549] [PMID: 22595497]
[http://dx.doi.org/10.1259/bjr/15839549] [PMID: 22595497]
[30]
Ataç GK, Parmaksız A, İnal T, et al. Patient doses from CT examinations in Turkey. Diagn Interv Radiol 2015; 21(5): 428-34.
[http://dx.doi.org/10.5152/dir.2015.14306] [PMID: 26133189]
[http://dx.doi.org/10.5152/dir.2015.14306] [PMID: 26133189]
[31]
Saravanakumar A, Vaideki K, Govindarajan K, Devanand B, Jayakumar S, Sharma SD. Establishment of CT diagnostic reference levels in select procedures in South India. Int J Radiat Res 2016; 14(4): 1-8.
[http://dx.doi.org/10.18869/acadpub.ijrr.14.4.341]
[http://dx.doi.org/10.18869/acadpub.ijrr.14.4.341]
[32]
National diagnostic reference levels (NDRLs). 2019. Available from: https:// www.gov.uk/government/publications/diagnosticradiology-national-diagnostic-referencelevels-ndrls/ndrl
[33]
European Commission Council directive 97/43/ EURATOM of 30 June 1997 on health protection of individuals against the dangers of ionizing radiation in relation to medical exposure, and repealing directive 84/466/Euratom. Off J Eur Communities 1997; 22-7.
[34]
Yurt A, Özsoykal İ, Kandemir R, Ada E. Local study of diagnostic reference levels for computed tomography examinations of adult patients in Izmir, Turkey. Radiat Prot Dosimetry 2020; 190(4): 446-51.
[http://dx.doi.org/10.1093/rpd/ncaa121] [PMID: 32947621]
[http://dx.doi.org/10.1093/rpd/ncaa121] [PMID: 32947621]
[35]
Abdulkadir M. Determination of computed tomography diagnostic reference levels in north-central Nigeria 2015.
[36]
Korir K, Wambani S, Korir K, Tries A, Boen K. National diagnostic reference level initiative for computed tomography examinations in Kenya. Radiat Prot Dosimetry 2016; 168(2): 242-52.
[http://dx.doi.org/10.1093/rpd/ncv020] [PMID: 25790825]
[http://dx.doi.org/10.1093/rpd/ncv020] [PMID: 25790825]
[37]
Moifo B, Tapouh J, Guena M, Ndah TN, Samba RN, Simo A. Diagnostic reference levels of adults CT-Scan imaging in Cameroon: A pilot study of four commonest CT-protocols in five radiology departments. Open J Med Imaging 2017; 07(01): 1-8.
[http://dx.doi.org/10.4236/ojmi.2017.71001]
[http://dx.doi.org/10.4236/ojmi.2017.71001]
[38]
Semghouli S, Amaoui B, El-Kharras A, et al. Establishment of a diagnostic reference level for brain ct procedures in Moroccan Hospitals. J Adv Res 2017; 5(5): 319-24.
[39]
Ekpo EU, Adejoh T, Akwo JD, et al. Diagnostic reference levels for common computed tomography (CT) examinations: Results from the first Nigerian nationwide dose survey. J Radiol Prot 2018; 38(2): 525-35.
[http://dx.doi.org/10.1088/1361-6498/aaaaf8] [PMID: 29376504]
[http://dx.doi.org/10.1088/1361-6498/aaaaf8] [PMID: 29376504]
[40]
Inkoom S, Boadu M, Schandorf C, Emi-reynolds G. A survey of patient dose management in computed tomography with special emphasis to paediatric patients in Ghana. Radiol Nucl Med 2010; 47(7): 1-8.
[41]
Muhogora E, Ngatunga B, Mboya G, et al. Patient doses during radiography and CT examinations in Tanzania: Preliminary results. Radiography and CT patient doses in Tanzania. Int Nucl Inf Syst 2010; 47(6): 1-6.
[42]
Khelassi-Toutaoui N, Merad A, Tsapaki V, et al. Adult CT examinations in Algeria: Towards updating national diagnostic reference levels. Radiat Prot Dosimetry 2020; 190(4): 364-71.
[http://dx.doi.org/10.1093/rpd/ncaa116] [PMID: 32885243]
[http://dx.doi.org/10.1093/rpd/ncaa116] [PMID: 32885243]
[43]
Nyathi M, Shivambu I. Local diagnostic reference levels for common computed tomography procedures at a tertiary Hospital in South Africa. Iran J Med Phys 2019; 16(5): 1-6.
[44]
Monnehan G, Silue K, Djagouri K, et al. Determination of diagnostic reference levels in Côted’Ivoire : Case of the adult skull computed tomography in the district of Abidjan. Int J Sci Res 2017; 6(8): 2015-8.
[45]
Muhogora WE, Ahmed NA, Beganovic A, et al. Patient doses in CT examinations in 18 countries: Initial results from International Atomic Energy Agency projects. Radiat Prot Dosimetry 2009; 136(2): 118-26.
[http://dx.doi.org/10.1093/rpd/ncp144] [PMID: 19687134]
[http://dx.doi.org/10.1093/rpd/ncp144] [PMID: 19687134]
[46]
National protocol for patient dose measurements in diagnostic radiology. 1992. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/337175/National_Protocol_for_Patient_Dose_Measurements_in_Diagnostic_Radiology_for_website.pdf
[47]
La C, Vodovatov A, Golikov V, Zvonova I, Bernhardsson C. Potential for the establishment of national CT diagnostic reference levels in the Russian Federation. International Conference on Radiation Protection in Medicine. 1-3.
[48]
Li Z, Zhang J, Xia C, et al. Radiation doses in CT examinations from the West China Hospital, Sichuan University and setting local diagnostic references levels. Ann Transl Med 2020; 8(16): 1010.
[http://dx.doi.org/10.21037/atm-20-5443] [PMID: 32953810]
[http://dx.doi.org/10.21037/atm-20-5443] [PMID: 32953810]
[49]
Mohammed A, Lina K, Ghida A, et al. National diagnostic reference levels have a lot of potential but a long way to go. A systematic review on the current status of adult diagnostic reference levels in head, chest and abdominopelvic computed tomography. J Radiol Prot 2020; 40(3): 2-28.
[http://dx.doi.org/10.1088/1361-6498/ab826f]
[http://dx.doi.org/10.1088/1361-6498/ab826f]
[50]
Abuzaid M, Elshami W, Tekin O, et al. Insights into imaging. Springer Open 2020; 11: 4-10.
[http://dx.doi.org/10.1186/s13244-020-00891-6] [PMID: 32748218]
[http://dx.doi.org/10.1186/s13244-020-00891-6] [PMID: 32748218]
[51]
Goo HW. CT radiation dose optimization and estimation: An update for radiologists. Korean J Radiol 2012; 13(1): 1-11.
[http://dx.doi.org/10.3348/kjr.2012.13.1.1] [PMID: 22247630]
[http://dx.doi.org/10.3348/kjr.2012.13.1.1] [PMID: 22247630]
[52]
National diagnostic reference levels (NDRL) computed tomography (CT) – adult. Adult 2020; 1: 1-4.
[53]
Sera V, Choirul A, Asep W, Rusmanto Ida P. The establishment of the national dose reference level (DRL) for head-CT examination in Indonesia. J Phys Conf Ser 2020; 3-9.
[54]
Tavakoli M, Heydari K, Jafari S. Evaluation of diagnostic reference levels for CT scan in Isfahan. Glob J Med Res Stud 2014; 1(4): 130-4.
[55]
American Association of Physicists in Medicine. Report No. 096 - The Measurement, Reporting, and Management of Radiation Dose in CT (2008). 2008. Available form: https://www.aapm.org/pubs/reports/detail.asp?docid=97
[56]
Campeloa M, Silvab M, Terini R. CTDI versus new AAPM metrics to assess doses in CT: A case study 2016; 4(2): 1-15.
[http://dx.doi.org/10.15392/bjrs.v4i2.194]
[http://dx.doi.org/10.15392/bjrs.v4i2.194]
[57]
European guidelines on quality criteria for computed tomography Report EUR 16262 EN. Luxembourg: Office for Official Publications of the European Communities 1996.
[58]
Conference of Radiation Control Program Directors. Part F (diagnostic x-rays and imaging systems in the healing arts). Suggested state regulations for control of radiation, ionizing radiation. Frankfort: SSRCR. 2015. Available from: https://cdn.ymaws.com/www.crcpd.org/resource/collection/521FA608-6D06-4E4C-88F1-48A321CF2F90/CRCPD_Brochure_Rev_Feb_27_2020.pdf
Article Metrics
21
4