Use of Multiphase CT Protocols in 18 Countries: Appropriateness and Radiation Doses.

PURPOSE: To assess the frequency, appropriateness, and radiation doses associated with multiphase computed tomography (CT) protocols for routine chest and abdomen-pelvis examinations in 18 countries. MATERIALS AND METHODS: In collaboration with the International Atomic Energy Agency, multi-institutional data on clinical indications, number of scan phases, scan parameters, and radiation dose descriptors (CT dose-index volume; dose-length product [DLP]) were collected for routine chest (n = 1706 patients) and abdomen-pelvis (n = 426 patients) CT from 18 institutions in Asia, Africa, and Europe. Two radiologists scored the need for each phase based on clinical indications (1 = not indicated, 2 = probably indicated, 3 = indicated). We surveyed 11 institutions for their practice regarding single-phase and multiphase CT examinations. Data were analyzed with the Student t test. RESULTS: Most institutions use multiphase protocols for routine chest (10/18 institutions) and routine abdomen-pelvis (10/11 institutions that supplied data for abdomen-pelvis) CT examinations. Most institutions (10/11) do not modify scan parameters between different scan phases. Respective total DLP for 1-, 2-, and 3-phase routine chest CT was 272, 518, and 820 mGy·cm, respectively. Corresponding values for 1- to 5-phase routine abdomen-pelvis CT were 400, 726, 1218, 1214, and 1458 mGy cm, respectively. For multiphase CT protocols, there were no differences in scan parameters and radiation doses between different phases for either chest or abdomen-pelvis CT (P = 0.40-0.99). Multiphase CT examinations were unnecessary in 100% of routine chest CT and in 63% of routine abdomen-pelvis CT examinations. CONCLUSIONS: Multiphase scan protocols for the routine chest and abdomen-pelvis CT examinations are unnecessary, and their use increases radiation dose.

Optimization of paranasal sinus CT procedure: Ultra-low dose CT as a roadmap for pre-functional endoscopic sinus surgery.

OBJECTIVE: To assess image quality and radiation dose associated with ultra-low dose CT protocol for patients with benign paranasal sinus diseases undergoing functional endoscopic surgery (FESS). METHODS: We scanned the head portion of Alderson RANDO phantom on a second generation, dual-source, multidetector-row CT scanner (Siemens Definition Flash) using standard-dose and five low-dose protocols. Two radiologists assessed the image quality for each protocol to determine best ultra-low-dose protocols for imaging patients with benign paranasal sinus diseases undergoing FESS. The ultra-low-dose CT protocols were then used for scanning. Thereafter, 40 adult patients (age range 18-54 years, M:F 23:17) were scanned with the four low dose scanning protocols (10 patients per protocol). On both transverse and coronal reformatted CT images, two radiologists assessed visibility of key anatomic landmarks for FESS on a 2-point scale (1 = clear and complete visualization; 2 = suboptimal visualization). Data were analyzed with descriptive statistics and Cohen's kappa coefficient for interobserver agreement. RESULTS: In phantom study, the lowest dose scan protocol (CTDIvol 2.1 mGy, 70 kV, 75 mAs) was unacceptable due to poor image quality. For patient studies, both radiologists gave acceptable image quality scores for ultra-low-dose scan protocol with axial scan mode, automatic tube potential selection and tube current modulation (CTDIvol 2.2 mGy; DLP 22.9 mGy.cm) with up to 60% lower dose compared to prior standard-dose CT (CTDIvol 5.3 mGy; DLP 73.5 mGy.cm). CONCLUSIONS: Ultra-low-dose CT protocol provides sufficient image quality for scanning patients undergoing functional endoscopic surgery for benign paranasal sinus diseases.

National survey to set diagnostic reference levels in nuclear medicine single photon emission imaging in Croatia.

PURPOSE: In order to introduce the concept of diagnostic reference levels (DRLs) in the national nuclear medicine practice a survey was proposed and completed through all nuclear medicine departments in Croatia. An additional aim was to increase the awareness of importance and full implementation of a comprehensive quality program that includes devices used in the nuclear medicine chain. METHODS: Data were collected for more than 30 nuclear medicine single photon emission procedures. National DRLs (NDRLs) as administered activity and also as administered activity per unit mass were calculated in accordance to International Commission on Radiological Protection (ICRP) recommendations. Additionally, effective doses were estimated using conversion factors published by the ICRP. RESULTS: NDRLs for nuclear medicine single photon emission procedures were proposed. For procedures performed in only one department typical values were presented as reference. Effective doses related to applied radiopharmaceuticals were calculated to estimate radiation risk related to respective nuclear medicine procedure in more detail. CONCLUSION: This work presents results of the first national survey on DRLs of nuclear medicine single photon emission procedures and proposes reliable NDRLs that represent an actual status of nuclear medicine practice in Croatia. Results have motivated departments to introduce and set their own typical values to be used, as one of the tools, for further optimization process. One of the drawbacks of the DRL concept in nuclear medicine is the lack of the image quality parameters involved. For this reason, a quantity that considers both radiation protection and image quality should be introduced.

IMPLEMENTATION OF QUALITY ASSURANCE PROGRAM IN RADIOGRAPHY-2-YEAR EXPERIENCE OF COLLABORATION WITH PUBLIC HEALTH INSTITUTIONS IN WEST REGION OF CROATIA.

Quality Assurance program on using ionizing radiation is mandatory in all EU member states but this is still not implemented in most facilities in Croatia mostly because of a lack of medical physicists in diagnostic radiology. Since public health institutions in Croatia do not employ medical physicists in diagnostic radiology, collaboration between these institutions in west region of Croatia with Clinical Hospital Center Rijeka (CHC) was initiated during the year 2015. Physicists from CHC Rijeka performed periodical Quality Control (QC) tests and were included in optimization process. Results of QC tests during the period of 2 years showed a lot of improvements-equipment is maintained more frequently, some old units were replaced with new ones and all institutions acquired QC equipment so radiographers could perform daily and monthly QC tests. All these activities showed that medical physics support in radiology departments is necessary and can improve clinical practice.

Reinforcing of QA/QC programs in radiotherapy departments in Croatia: results of treatment planning system verification.

Implementation of advanced techniques in clinical practice can greatly improve the outcome of radiation therapy, but it also makes the process much more complex with a lot of room for errors. An important part of the quality assurance program is verification of treatment planning system (TPS). Dosimetric verifications in anthropomorphic phantom were performed in 4 centers where new systems were installed. A total of 14 tests for 2 photon energies and multigrid superposition algorithms were conducted using the CMS XiO TPS. Evaluation criteria as specified in the International Atomic Energy Agency Technical Reports Series (IAEA TRS) 430 were employed. Results of measurements are grouped according to the placement of the measuring point and the beam energy. The majority of differences between calculated and measured doses in the water-equivalent part of the phantom were in tolerance. Significantly more out-of-tolerance values were observed in "nonwater-equivalent" parts of the phantom, especially for higher-energy photon beams. This survey was done as a part of continuous effort to build up awareness of quality assurance/quality control (QA/QC) importance in the Croatian radiotherapy community. Understanding the limitations of different parts of the various systems used in radiation therapy can systematically improve quality as well.

Dosimetric verification of compensated beams using radiographic film.

INTRODUCTION: External photon beam modulation using compensators in order to achieve a desired dose distribution when brachytherapy treatment is followed by external beam radiation is a well-established technique. A compensator modulates the central part of the beam, and the dose beneath the thickest part of the compensator is delivered mostly by scattered, low energy photons. A two-dimensional detector with a good spatial resolution is needed for the verification of those beams. In this work, the influence of different types of detectors on the measured modulated dose distributions was examined. MATERIALS AND METHODS: Dosimetric verification was performed using X-Omat V, Eastman Kodak radiographic films at different depths in a solid water phantom. The film measurements were compared with those made by ionization chambers. Photon beams were also modelled using EGSnrc Monte Carlo algorithm to explain the measured results. RESULTS: Monte Carlo calculated over-response of the film under the thickest part of the compensator was over 15%, which was confirmed by measurements. The magnitude of over-response could be associated with changes in the spectra of photon energy in the beam. CONCLUSIONS: The radiographic film can be used for the dosimetry of compensated high energy photon beams, with limitations in volumes where photon spectra are hardly degraded.

Survey of equipment quality control in radiotherapy centres in croatia: first results.

Implementation of advanced radiation therapy techniques in clinical practice can greatly improve tumour control and normal tissue sparing. An important part of this implementation is quality control (QC) of every part of the radiotherapy process, as it helps to detect errors and provides instant remedy. This increases the probability of successful radiation treatment and ensures patient radiation safety. Every radiotherapy quality assurance (QA) programme is based on quality control of radiotherapy equipment. The aim of our survey was to review QC practices in a number of radiotherapy centres in Croatia. As a first step, we defined a set of tests to check different parameters of linear accelerators and simulators in these centres. The tests were defined and performed according to protocols developed at two university hospitals. Test results varied largely between the centres. This calls for harmonisation of QC protocols.