Optimisation in CT

18 JUNE 2014

OPTIMISATION IN CT

Venue: Royal Society of Edinburgh CPD: 5 CREDITS

BIR Annual Congress 2014: 22-23 October, London

Welcome and thank you for coming to the ‘Optimisation in CT’ event organised by the British Institute of Radiology.

This booklet contains the abstracts and biographies for each speaker.

This meeting has been awarded 5 RCR category I CPD credits.

CPD certificates will be distributed by email within two weeks of the meeting once the online delegate survey has been completed.

Please complete the online delegate survey using the below link. We will use your valuable feedback to improve future conferences. https://www.surveymonkey.com/s/OptimisationinCT We hope you find the day interesting and enjoyable.

Matthew Dunn Meeting Organiser Radiation Protection SIG, BIR

We are most grateful to

for supporting this conference

Programme 09:30 Registration and refreshments 10:00 Justification and optimisation in CT - the good, the bad and the ugly

Dr Matthew Dunn, Head of Radiology Physics, Nottingham University

Hospitals NHS Trust 10:30 CT images: a radiologist’s wants and needs

Dr John Murchison, Consultant Radiologist, Royal Infirmary of Edinburgh 11:00 Dose metrics in CT - from 100 to infinity in 15 minutes

Ms Sue Edyvean, Specialist Radiation Protection Scientist, Public Health England 11:15 Image quality: an objective assessment

Mr Nicholas Keat, CT Physicist, Imanova Ltd, London 11:30 Where do I start? Optimisation for beginners

Dr Matthew Dunn, Head of Radiology Physics, Nottingham University

Hosptals NHS Trust 12:10 Discussion 12:30 Lunch 13:15 Dose surveys - the big picture

Ms Sue Edyvean, Specialist Radiation Protection Scientist, Public Health England 13:30 Dose audit - size matters

Dr Elly Castellano, Consultant Physicist, Royal Marsden Hospital, London 13:45 mA modulation - what the technology offers

Mr Nicholas Keat, CT Physicist, Imanova Ltd, London 14:00 mA modulation - what the patient gets

Mr Gareth Iball, Consultant Clinical Scientist, Leeds Teaching Hospitals

NHS Trust

14:20 The potential for kV modulation

Dr Elly Castellano, Consultant Physicist, Royal Marsden Hospital, London 14:35 Iterative reconstruction

Mr Nicholas Keat, CT Physicist, Imanova Ltd, London 14:50 Refreshments 15:10 Paediatrics - a minor problem

Dr Elly Castellano, Consultant Physicist, Royal Marsden Hospital, London 15:30 Switching scanners

Mr Gareth Iball, Consultant Clinical Scientist, Leeds Teaching Hospitals

NHS Trust 15:45 Patient shielding in CT - is it a cover up?

Mr Gareth Iball, Consultant Clinical Scientist, Leeds Teaching Hospitals

NHS Trust 16:00 Discussion 16:15 Close of meeting

Please remember to complete the online delegate survey using the below link: https://www.surveymonkey.com/s/OptimisationinCT Your certificate of attendance will be emailed to you within the next two weeks once these have been completed.

BIR Annual Congress 2014: 22-23 October, London

Speaker profiles Dr Elly Castellano Consultant Physicist, Royal Marsden Hospital, London Dr Elly Castellano is a Consultant Clinical Scientist working at The Royal Marsden NHS Foundation Trust as Head of the Diagnostic Radiology Physics Group. Elly was educated in physics and medical physics at the universities of Oxford, Surrey and London. She trained at St Mary’s Hospital, London, in nuclear medicine, radiotherapy and diagnostic radiology physics, and thereafter specialised in the latter. She is a registered clinical scientist, chartered scientist and chartered radiation protection professional. She is a corporate member of the IPEM, a corporate member of the SRP, and a member of the BIR. She has chaired the CT Users Group, the Diagnostic Radiology Special Interest Group at IPEM and is currently deputy director of IPEM’s Science Board.

In addition to her clinical work Elly is active in research with over 20 publications to date. Her main research interests are in CT dosimetry and CT optimisation, although she has several published papers in the fields of mammography and fluoroscopy. She runs the advanced x-ray and CT imaging module of the MSc Clinical Sciences (Medical Physics) at King’s College, London, and lectures extensively in the UK and abroad. She is a contributing author to several text books and handbooks on CT and patient radiation dosimetry.

Dr Matthew Dunn Head of Radiology Physics, Nottingham University Hospitals NHS Trust Matthew Dunn is currently the Head of Radiology Physics at Nottingham University Hospitals NHS Trust. He is Radiation Protection Adviser to a range of NHS and independent healthcare providers and a Medical Physics Expert in diagnostic radiology. He has a research interest in the physics and clinical application of computed tomography.

Ms Sue Edyvean Specialist Radiation Protection Scientist, Public Health England Ms Sue Edyvean is currently the Head of the Medical Dosimetry Group at Public Health England based in Chilton, Oxfordshire. Her responsibilities include national radiation patient dose surveys, Monte Carlo dosimetry, and specialises in CT both in terms of dose and image quality. She is a Medical Physicist and has worked for most of her career in the field of Computed Tomography (CT), leading the ImPACT (Imaging Performance Evaluation of CT) group at St George’s Hospital, London. This group produced many technical reports on CT, the widely used ‘ImPACT CTDosimetry’ calculator, and extensive educational material including their successful course for radiology professionals. Sue has presented extensively at many conferences and courses, sat on various international committees (IEC and ICRU), is a contributor to two IAEA (International Atomic Energy Authority) reports on CT and a co-author of the ICRU Report on CT Image Quality and Dose. She has also spent a short time at the Royal Marsden, as well as undertaking free-lance speaking and contract educational work.

Mr Gareth Iball Consultant Clinical Scientist, Leeds Teaching Hospitals NHS Trust Gareth is Lead Clinical Scientist in Radiological Physics in Leeds Teaching Hospitals NHS Trust where he has been employed for the last 14 years. Having obtained his Medical Physics MSc in 2001 Gareth completed the IPEM Medical Physics training scheme in 2003. Gareth has now been a state registered Clinical Scientist for ten years and his main areas of interest are in CT, patient dosimetry and optimisation and, more recently, PET-CT. His extensive research in CT physics lead to him being named the British Institute of Radiology Young Investigator of the Year in 2011. Presently Gareth is also a member of the IPEM Diagnostic Radiology Special Interest Group and is involved in a number of IPEM working parties including the revision of the Medical and Dental Guidance Notes.

He has authored more than 20 scientific articles in international journals and conferences and was recently an invited speaker at the Royal College of Radiologist’s Annual Radionuclide Meeting where he spoke on CT Optimisation in Hybrid Imaging and at the International Conference of Medical Physics where he spoke on CT Acceptance and Quality Control Testing.

Mr Nicholas Keat CT Physicist, Imanova Ltd, London Nick Keat is a Physicist at the Imanova Centre for Imaging Sciences (formerly GlaxoSmithKline Clinical Imaging Centre) in West London, providing support for their PET-CT imaging activities using novel PET tracers for research and pharmaceutical development. Previously, he was employed at the ImPACT group providing expertise and assessments of CT scanners for the Department of Health. His research interests include image quality optimisation in quantitative research CT and PET and new reconstruction techniques for clinical CT. Dr John Murchison Consultant Radiologist, Royal Infirmary of Edinburgh Dr John Murchison is a Consultant Radiologist at Edinburgh Royal Infirmary and a Part-time Honorary Senior lecturer at Edinburgh University Medical School. His main interest is thoracic radiology, with particular interests in thrombo-embolic disease, emphysema, interstitial lung disease, lung cancer and bronchiectasis.

John is a previous member of the RCR scientific committee and a past FRCR Part 2 Examiner.

Abstracts Justification and optimisation in CT - the good, the bad and the ugly Dr Matthew Dunn The use of CT in the UK continues to increase. The doses from CT scanning account for at least 67% of medical radiation to the public in the UK and when compared with other countries there remains significant potential for expansion. The use of CT has revolutionised medicine and has very clear clinical benefits which in most cases outweigh the risks. However the clinical benefits should not prevent the optimisation of scans to give doses that are consistent with the ALARP principle. Public and professional interest in other countries, particularly the US, has prompted more awareness of radiation dose. Evidence of effects in those scanned has also begun to emerge. So there has never been a greater need to optimise CT scans.

CT images: a radiologist’s wants and needs Dr John Murchison A radiologist’s job is to look at the evidence and make a diagnosis. The tools that he has are imaging techniques. CT scanning is one of the radiologists most useful tools, and its use and functionality have improved greatly with the advent of volumetric and particularly with multi-slice CT such that it is now the imaging investigation of choice for many clinical scenarios.

The radiologist needs the imaging protocol employed to be appropriate for the clinical questions posed. Depending on the clinical setting, that may involve the use of IV or oral contrast. I would want contrast administration and timing selected in such a way as to optimise scan information. I would want a scan of high enough quality to give a definitive opinion. That means clear images with good tissue differentiation and absence of interpretation limiting artefacts. I want appropriate reconstruction algorithms to be used and the ability to window and speedily review images with multi-planar reconstructions.

Ready access to old images for comparison is very important and I would like the ability to compare and quantify abnormalities on sequential scans, preferably automated or semi-automatically. I would like speedy user friendly computer aided detection for my lung nodules and polyps. I would also like disease quantified. In my role as a chest radiologist this would include emphysema, pulmonary emboli and interstitial lung disease pattern quantification. Identification of risk of incidental findings would also be of help.

Dose metrics in CT - from 100 to infinity in 15 minutes Ms Sue Edyvean The learning objectives of this presentation are to: • Understand the dose distribution in CT scanning compared to conventional X-ray • Review the concepts of the various dose metrics used in CT • Review specific CT dose metrics: the volume computed tomography dose index (CTDIvol) and the dose length product (DLP) • Understand what these metrics represent, and what they do not represent • Demonstrate how these values can be measured using a 100 mm ion chamber, and how they are presented on the scanner console • Discuss how the DLP can be used to give an estimate for effective dose • Outline the limitation of the measurement of CTDIvol for wide beam scanners • Present the modified definition of CTDIvol (as given by the IEC CT standard) for wider beams, and how it can be measured • Discuss how new smaller ionisation chambers can be used in the measurement paradigm of CTDI • Briefly outline the SSDE (size specific dose estimate) metric Image quality: an objective assessment Mr Nicholas Keat This talk discusses methods for measurement of objective image quality parameters in relation to clinical imaging tasks. Parameters of interest include contrast, noise, spatial resolution and artefacts and low contrast detectability.

The effect of changing scan and reconstruction settings upon image quality will also be covered.

Where do I start? Optimisation for beginners Dr Matthew Dunn The IRMER regulations require the employer to put in place written protocols for every radiodiagnostic practice IR(ME)R Reg 4. The employer is also required to ensure that these protocols are optimised IR(ME)R Reg 7.

The employer also has a duty under IRMER (reg 4 ) to set diagnostic reference levels (DRL’s). The employer needs to monitor doses to ensure that DRL’s are not exceeded e.g. dose monitoring.

Optimisation can be a daunting process to start. In practice the simplest interventions have the greatest effect. When determining the priorities the main factors to consider are the number of scans performed per year, the average dose and the potential for optimisation. The potential for optimisation can be determined by comparison of dose data with national dose data and variation between scanners at an institution. In many centres with multiple scanners the protocols are not matched or national guidance on CT protocols followed.

Successful optimisation is a team sport. A CT protocol may have over 100 data points to fully define it. A radiologist, radiographer and medical physicist are all essential components when optimising protocols. Each member brings different skills and point of view. The process for developing and issuing protocols will be explored.

Dose surveys - the big picture Ms Sue Edyvean The learning objectives of this presentation are to: • Discuss the need for dose surveys (audits) - locally and nationally • Outline the historical perspective - and the use of dose surveys in producing local and national Diagnostic Reference Levels (DRLs) • Outline the requirements for undertaking surveys • Review the advantages and disadvantages of the various methods of dose data collection: paper, spread sheets, and electronically through inhouse or commercial systems • Discuss the local and national perspective of these various approaches; both currently, and with an eye to the future Dose audit - size matters Dr Elly Castellano The learning objectives of this presentation are to: • Appreciate the limitations of CT dose audits without patient size information in characterising CT scanner performance for optimisation purposes • Understand how CT dose audits which include patient size information can provide a fuller picture of CT scanner performance which is useful for optimisation purposes • Interpret typical features of the behaviour of dose indicators with patient size, for example rate of change with patient size, saturation of the dose indicators and the location of the mA modulation operating point (if applicable) • Establish where and how to obtain patient size information, e.g. from the Radiology Information System or the CT scanner itself • Identify the potential for producing exposure charts to aid the users in confirming correct prescription of exposure parameters mA modulation - what the technology offers Mr Nicholas Keat Tube current (mA) modulation has become available on all new CT scanners over the last decade. This talk explores the need for these systems, their aims and their methods of operation. The benefits of mA modulation will be explained in terms of image quality normalisation and the potential for dose reduction, as well as their limitations.

mA modulation - what the patient gets Mr Gareth Iball Following on from the previous session which described the mA modulation systems provided by the major CT manufacturers, this session will describe the practical implementation of tube current modulation systems into clinical practice. This will include demonstrations of how dose and image quality vary with patient size and weight for a range of manufacturers systems and a range of examinations. Differences in dose and image quality will be explained in terms of the fundamental design and functionality differences between the mA modulation systems. The effect of modulation type (longitudinal, rotational and combined), image quality metric (noise index, quality reference mAs, etc), and other scan parameters on both patient dose and image quality will be presented. Finally, tips on how to avoid potential pitfalls of mA modulation systems will be shared, specifically in terms of patient set up geometry, careful protocol building and the importance of understanding the finer details of how each system operates.

The potential for kV modulation Dr Elly Castellano The learning objectives of this presentation are to: • Review why most CT imaging has traditionally been carried out at 120kVp • Understand the advantages and disadvantages of lowering the kVp; • Appreciate how lowering the kVp with and without adjusting the mAs affects contrast-to-noise ratios • Identify techniques for lowering the kVp without impacting on clinical diagnostic confidence • Determine how to establish new operating points according to clinical requirements • Understand how the CT manufacturers implement automatic kV selection Iterative reconstruction Mr Nicholas Keat For the majority of its clinical history, clinical CT reconstruction has been based upon filtered back projection. More recently, iterative reconstruction methods have been implemented, and are now available from all vendors.

These methods use a feedback loop to converge on an optimal image through comparing measured attenuation values with those simulated from the forward projection of the current image iteration. Forward projection methods will be discussed. The effect upon image quality and potential for dose reduction will also be covered.

Paediatrics - a minor problem Dr Elly Castellano The learning objectives of this presentation are to: • Understand why characterising the performance of and optimising paediatric CT protocols is particularly difficult • Recognise that dedicated, size-specific paediatric protocols are essential; • Appreciate that CT doses to children are lowest at specialist paediatric hospitals • Describe how to carry out paediatric dose audits when patient numbers are small • Evaluate the relative merits of various optimisation strategies including transferring CT protocols from a specialist paediatric centre • Appreciate that good radiographic technique is essential for delivering the expected dose and image quality benefits from optimised CT scan protocols Switching scanners Mr Gareth Iball When a CT scanning department replaces the existing scanner with one from a different manufacturer, or purchases an additional scanner, one of the most difficult tasks is that of ensuring that all scan protocols are consistent between the two systems. This is a non-trivial task, especially when it is unclear whether dose, image quality or both are required to be consistent!

There are some ‘basic’ settings that can be translated between almost any scanners, however it is the more complex aspects which the physicist may be asked to take on. On modern scanners the most complex issues are likely to be the set up of the automatic exposure control system and the use of iterative reconstruction.

This session will present a process for ensuring that the basic aspects of scan protocols are consistent and then describe a step by step methodology for tackling the complexities of AEC and iterative reconstruction settings.

NB: This is not a “golden elixir” and clinical and staff should be aware that it will be virtually impossible to identically match every aspect of any scan protocol on a different manufacturer’s scanner.

Patient shielding in CT - is it a cover up?

Mr Gareth Iball In recent years there have been many publications championing the use of patient shielding in CT. Given the recent focus on CT dose reduction patient shielding has been presented as an ‘easy win’ in the fight to reduce patient doses without adversely affecting image quality. The majority of the published work has focussed on breast shielding but eye and thyroid shielding have also been discussed along with specific applications such as shielding in paediatrics and during pregnancy. Should these shielding ‘solutions’ be considered in the process of ensuring that patient doses

are ‘as low as reasonably practicable’? Are they simply useful for patient reassurance? Are they of any use at all? Are there alternative non-shielding solutions? The published literature is often confusing and it can be difficult for imaging staff to steer a clear path through the minefield of peer reviewed publications, commentaries and marketing claims.

This session will attempt to answer the “to shield or not to shield” question by drawing on the published literature and highlighting the benefits and drawbacks of each potential shielding solution. Both in-plane and out of plane shielding will be discussed and wherever possible, alternative solutions will be presented.

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