Developing and implementing a multi-modality imaging optimization study in paediatric radiology: Experience and recommendations from an IAEA coordinated research project.

Optimization of imaging examinations is a key requirement of both the International and European Basic Safety Standards, and the focus of much international activity. Although methodologies are well established in principle, there continues to be a variety of practical issues both in collecting and interpreting dose and image quality data and in making successful interventions to optimize exposures. A Coordinated Research Project, involving institutes from ten different countries, was established by the IAEA to assess the efficacy of recommended optimization methodologies in the field of paediatric radiology and to derive practical guidance on their implementation. The steps followed in this process were identification of the imaging process to be investigated (abdomen and chest x-rays, micturating cysto-urethrograms, and brain & thorax CT scans); collection of dose and image quality data; evaluation and comparison of the data between institutes and to standards; identification and implementation of interventions for optimization; and re-evaluation of dose and image quality parameters. The project succeeded both in achieving effective interventions for optimization of specific imaging tasks in individual institutes and in identifying key issues with potential to handicap this process. The main area in which problems were encountered was in the collation of reliable dose and image quality data. The reasons for this were explored and a series of recommendations have been made, summarized into 'ten practical tips' for optimization to assist institutes, particularly those in the early stages of addressing optimization issues.

Paediatric nuclear medicine practice: an international survey by the IAEA.

PURPOSE: The International Atomic Energy Agency (IAEA) decided to initiate a survey to evaluate the current status of the practice of paediatric nuclear medicine worldwide, with the focus mainly on low and middle-income countries specifically in Latin America, Eastern Europe, Africa and Asia. This investigation sought to determine if the practice in paediatric nuclear medicine in these countries differed from that indicated by the survey of the Nuclear Medicine Global Initiative (NMGI) and if nuclear medicine practitioners were following established paediatric nuclear medicine guidelines. METHODS: A total of 133 institutes took part in the survey from 62 different IAEA member states within Africa (29), Asia (39), Europe (29) and Latin America (36). The four most frequent conventional (single-photon) nuclear medicine procedures were 99mTc labelled MDP, DSMA, MAG3 and pertechnetate thyroid scans. In addition, 46 centres provided data on FDG PET/CT, including exposure data for the CT component. Nearly half of the sites (48%) perform less than 200 paediatric nuclear medicine studies per year, while 11% perform more than 1000 such studies per year. RESULTS: Administered activities largely exceeded the recommendations for most of the sites for DMSA, MAG3 and pertechnetate, while compliance with international standards was somehow better for MDP studies. For FDG PET, the results were more uniform than for conventional nuclear medicine procedures. However, the use of CT in PET/CT for paediatric nuclear medicine revealed a high variability and, in some cases, high, dose-length product (DLP) values. This observation indicates that further attention is warranted for optimizing clinical practice in FDG PET/CT. CONCLUSIONS: Overall, in most parts of the world, efforts have been undertaken to comply either with the EANM dosage card or with the North American Consensus Guidelines. However, variability in the practice of paediatric nuclear medicine still exists. The results of this survey provide valuable recommendations for a path towards global standardization of determining the amount of activity to be administered to children undergoing nuclear medicine procedures.

Moving beyond quality control in diagnostic radiology and the role of the clinically qualified medical physicist.

Quality control (QC), according to ISO definitions, represents the most basic level of quality. It is considered to be the snapshot of the performance or the characteristics of a product or service, in order to verify that it complies with the requirements. Although it is usually believed that "the role of medical physicists in Diagnostic Radiology is QC", this, not only limits the contribution of medical physicists, but is also no longer adequate to meet the needs of Diagnostic Radiology in terms of Quality. In order to assure quality practices more organized activities and efforts are required in the modern era of diagnostic radiology. The complete system of QC is just one element of a comprehensive quality assurance (QA) program that aims at ensuring that the requirements of quality of a product or service will consistently be fulfilled. A comprehensive Quality system, starts even before the procurement of any equipment, as the need analysis and the development of specifications are important components under the QA framework. Further expanding this framework of QA, a comprehensive Quality Management System can provide additional benefits to a Diagnostic Radiology service. Harmonized policies and procedures and elements such as mission statement or job descriptions can provide clarity and consistency in the services provided, enhancing the outcome and representing a solid platform for quality improvement. The International Atomic Energy Agency (IAEA) promotes this comprehensive quality approach in diagnostic imaging and especially supports the field of comprehensive clinical audits as a tool for quality improvement.

The effect of a combined tube current modulation system on dose delivered to patients undergoing thoracic and abdominal CT with a 128-slice scanner.

Combined tube current modulation techniques (such as Care Dose4D used in this study) during computed tomography (CT) procedures bring together the benefits of the angular and z-axis modulation techniques, measuring X-ray attenuation profile in the z-axis together with the data from the perpendicular x-y direction with a sophisticated algorithm. The purpose of this study was to investigate the radiation dose, in terms of computed tomography dose index (CTDI(vol)), delivered to patients during thoracic and abdominal CT using this technique and compare it with the corresponding CTDI(vol) of the fixed tube current CT technique. The results revealed a 5-32% dose reduction for chest CT and a dose reduction of 7.6-60% for the three-sequence abdominal CT scan of normal and overweight patients. In the case of obese patients a 15.4-18.7% dose increase for chest CT and a (-1.5) - (26.3)% dose increase for the three-stage abdominal examinations for females and males, respectively, was revealed.

Monte Carlo simulation of breast imaging using synchrotron radiation.

PURPOSE: Synchrotron radiation (SR), being the brightest artificial source of x-rays with a very promising geometry, has raised the scientific expectations that it could be used for breast imaging with optimized results. The "in situ" evaluation of this technique is difficult to perform, mostly due to the limited available SR facilities worldwide. In this study, a simulation model for SR breast imaging was developed, based on Monte Carlo simulation techniques, and validated using data acquired in the SYRMEP beamline of the Elettra facility in Trieste, Italy. Furthermore, primary results concerning the performance of SR were derived. METHODS: The developed model includes the exact setup of the SR beamline, considering that the x-ray source is located at almost 23 m from the slit, while the photon energy was considered to originate from a very narrow Gaussian spectrum. Breast phantoms, made of Perspex and filled with air cavities, were irradiated with energies in the range of 16-28 keV. The model included a Gd(2)O(2)S detector with the same characteristics as the one available in the SYRMEP beamline. Following the development and validation of the model, experiments were performed in order to evaluate the contrast resolution of SR. A phantom made of adipose tissue and filled with inhomogeneities of several compositions and sizes was designed and utilized to simulate the irradiation under conventional mammography and SR conditions. RESULTS: The validation results of the model showed an excellent agreement with the experimental data, with the correlation for contrast being 0.996. Significant differences only appeared at the edges of the phantom, where phase effects occur. The initial evaluation experiments revealed that SR shows very good performance in terms of the image quality indices utilized, namely subject contrast and contrast to noise ratio. The response of subject contrast to energy is monotonic; however, this does not stand for contrast to noise ratio, since there is a range of optimal performance for SR (18-21 keV). In comparison to conventional mammography, SR shows improved subject contrast for energies lower than the mean energy of each spectrum. CONCLUSIONS: The comparison of the results of the two models, conventional and SR, proved that SR exhibits better performance in the majority of cases. The proposed simulation model offers the possibility to perform exhaustive search to evaluate the performance of SR in clinical applications such as breast imaging.

Can electronic zoom replace magnification in mammography? A comparative Monte Carlo study.

Magnification, which is considered to be a relatively high "dose cost" mammographic technique, is a complementary examination performed on women exhibiting breast complaints or abnormalities. Particular attention is given to the imaging procedure as the primary aim is to confirm the existence of suspected abnormalities, despite the additional dose. The introduction of post-processing capabilities and the widespread use of digital mammography promoted some controversy in the last decades on whether electronic zoom performed on the derived initial screening mammogram can effectively replace this technique. This study used Monte Carlo simulation methods to derive simulated screening mammograms produced under several exposure conditions, aiming to electronically magnify and compare them to the corresponding magnification mammograms. Comparison was based on quantitative measurements of image quality, namely contrast to noise ratio (CNR) and spatial resolution. Results demonstrated that CNR was higher for geometric magnification compared to the case of electronic zooming. The percentage difference was higher for lesions of smaller radius and achieved 29% for 0.10 mm details. Although spatial resolution is maintained high in the zoomed images, when investigating microcalcifications of 0.05 mm radius or less, only with geometric magnification can they be visualised.

Monte Carlo studies on the influence of focal spot size and intensity distribution on spatial resolution in magnification mammography.

Magnification is a special technique applied in mammography in cases where breast complaints have already been noticed, aiming to examine a specific area of the breast. Small-sized focal spots are essential in such techniques in order to reduce the resultant geometrical unsharpness. The x-ray intensity distribution of the focal spot is another crucial parameter for such a technique as it affects the mammographic resolution. In this study a Monte Carlo simulation model is utilized, in order to examine the effect of a wide range of focal spot sizes and three representative intensity distributions on spatial resolution under magnification. A thick sharp edge consisting of lead, non-transparent to x-rays was imaged under various conditions for this purpose, and the corresponding spatial resolution was calculated through the modulation transfer function (MTF). Results demonstrate that focal spots larger than 0.10 mm can mainly be used for low degrees of magnification, especially when combined with double peak Gaussian intensity distribution of the focal spot (sum of two single peak Gaussian distributions with different centers), as the resultant spatial resolution is not as high as the corresponding from smaller foci or uniform and single peak Gaussian distributions. Moreover, for the degrees of magnification usually utilized in clinical practice they do not reach the acceptable limit of 12 lp mm(-1). The replacement of the x-ray tube when the focal spot starts being destroyed is very crucial as the possible alteration of single peak Gaussian distribution to double peak Gaussian results in the degradation of spatial resolution. A focal spot of 0.10 mm or smaller, combined with single peak Gaussian intensity distribution, can be considered appropriate even for higher degrees of magnification and its use can contribute in the effort to optimize the magnification views in mammography.

Dose and image quality optimization in neonatal radiography.

In a special care baby unit, neonates, mainly premature, encounter serious to life-threatening diseases, the timely diagnosis and treatment of which may require a large number of radiographs. Increased neonatal radiosensitivity and longer life expectancy increase the risk of radiation-induced cancer, which emphasizes the importance of minimizing dose while maintaining clinically satisfactory image quality. An optimization study on radiation dose and image quality in neonatal radiography is presented. Neonates were categorized into four groups depending on birthweight. For a total of 378 chest and chest-abdomen radiographs, exposure parameters were recorded. Entrance surface dose (ESD) was estimated and dose-area product (DAP) was measured. Image quality evaluation was performed by two observers and was based on the visibility of certain anatomical features and catheters placed during treatment using a five-grade scale. ESD values increased with neonatal weight and demonstrated wide variation (16.4-76.9 microGy, mean 38.2 microGy). A wide variation was also observed in DAP values (1.2-15.0 mGycm2, mean 7.2 mGycm2). Image quality evaluation revealed the feasibility of achieving a diagnostically satisfactory image (score >70%) using both low and high tube voltage techniques, with the latter resulting in reduced ESDs. The majority of estimated ESDs are in accordance with the reference level of 50 microGy recommended by the National Radiological Protection Board for neonatal radiography. The results suggest that the use of high tube voltage techniques could result in further reductions in neonatal dose, without image quality degradation, underlying the requirement for establishing standard examination protocols for neonatal radiography with respect to neonatal weight.

Contrast-to-noise ratio in magnification mammography: a Monte Carlo study.

Magnification views are a common way to perform a secondary examination when suspicious abnormalities are found in a screening mammogram. The visibility of microcalcifications and breast lesions is restricted by the compromise between the image quality and the absorbed dose. In this study, image quality characteristics in magnification mammography were evaluated based on Monte Carlo techniques. A breast phantom was utilized, simulating a homogeneous mixture of adipose and glandular tissue in various percentages of glandularity, containing inhomogeneities of various sizes and compositions. The effect of the magnification degree, breast glandularity, tube voltage and anode/filter material combination on image quality characteristics was investigated in terms of a contrast-to-noise ratio (CNR). A performance index PI(nu) was introduced in order to study the overall performance of various anode/filter combinations under different exposure parameters. Results demonstrate that CNR is improved with the degree of magnification and degraded as the breast glandularity is increased. Degree of magnification 1.3 offers the best overall performance for most of the anode/filter combinations utilized. Under magnification conditions, the role of dose is demoted against the image quality, as magnification views are secondary, diagnostic examinations and not screening procedures oriented to non-symptomatic women. For decreased image quality weighting, some anode/filter combinations different from Mo/0.030 mmMo can be utilized as they offer a similar performance index. However, if the desired weighting for the image quality is high, the Mo/0.030 mmMo combination has the best overall performance.

Suitability of new anode materials in mammography: dose and subject contrast considerations using Monte Carlo simulation.

Mammography is the technique with the highest sensitivity and specificity, for the early detection of nonpalpable lesions associated with breast cancer. As screening mammography refers to asymptomatic women, the task of optimization between the image quality and the radiation dose is critical. A way toward optimization could be the introduction of new anode materials. A method for producing the x-ray spectra of different anode/filter combinations is proposed. The performance of several mammographic spectra, produced by both existing and theoretical anode materials, is evaluated, with respect to their dose and subject contrast characteristics, using a Monte Carlo simulation. The mammographic performance is evaluated utilizing a properly designed mathematical phantom with embedded inhomogeneities, irradiated with different spectra, based on combinations of conventional and new (Ru, Ag) anode materials, with several filters (Mo, Rh, Ru, Ag, Nb, Al). An earlier developed and validated Monte Carlo model, for deriving both image and dose characteristics in mammography, was utilized and overall performance results were derived in terms of subject contrast to dose ratio and squared subject contrast to dose ratio. Results demonstrate that soft spectra, mainly produced from Mo, Rh, and Ru anodes and filtered with k-edge filters, provide increased subject contrast for inhomogeneities of both small size, simulating microcalcifications and low density, simulating masses. The harder spectra (W and Ag anode) come short in the discrimination task but demonstrate improved performance when considering the dose delivered to the breast tissue. As far as the overall performance is concerned, new theoretical spectra demonstrate a noticeable good performance that is similar, and in some cases better compared to commonly used systems, stressing the possibility of introducing new materials in mammographic practice as a possible contribution to its optimization task. In the overall optimization task in terms of subject contrast to dose ratio, tube voltage was found to have a minor effect, while with respect to the filter material, a lesion specific performance was noticed, with Al filtered spectra showing improved characteristics in case of the inhomogeneities simulating microcalcifications, while softer k-edge filtered spectra are more suitable for the discrimination of inhomogeneities simulating masses.

Monte Carlo generated conversion factors for the estimation of average glandular dose in contact and magnification mammography.

Magnification mammography is a special technique used in the cases where breast complaints are noted by a woman or when an abnormality is found in a screening mammogram. The carcinogenic risk in mammography is related to the dose deposited in the glandular tissue of the breast rather than the adipose, and average glandular dose (AGD) is the quantity taken into consideration during a mammographic examination. Direct measurement of the AGD is not feasible during clinical practice and thus, the incident air KERMA on the breast surface is used to estimate the glandular dose, with the help of proper conversion factors. Additional conversion factors adapted for magnification and tube voltage are calculated, using Monte Carlo simulation. The effect of magnification degree, tube voltage, various anode/filter material combinations and glandularity on AGD is also studied, considering partial breast irradiation. Results demonstrate that the estimation of AGD utilizing conversion factors depends on these parameters, while the omission of correction factors for magnification and tube voltage can lead to significant underestimation or overestimation of AGD. AGD was found to increase with filter material's k-absorption edge, anode material's k-emission edge, tube voltage and magnification. Decrease of the glandularity of the breast leads to higher AGD due to the increased penetrating ability of the photon beam in thick breasts with low glandularity.

DOSIS: a Monte Carlo simulation program for dose related studies in mammography.

Dosimetric studies in mammography are addressed by means of a Monte Carlo simulation program. The core of this program (DOSIS: dosimetry simulation studies) is a simulation model developed using FORTRAN 90, enriched with a graphical user interface developed in MS Visual Basic. User defined mammographic technique parameters affecting breast dose are imported to the simulation model and the produced results are provided by means of both absolute (surface dose, exposure at detector plane) and relative quantities (percentage depth dose, isodose curves). The program functionality has been demonstrated in the evaluation of various mammographic examination techniques. Specifically, the influence of tube voltage and filtration on the surface dose and the exposure at detector plane has been studied utilizing a water phantom. Increase of tube voltage from 25 to 30 kVp for a Mo/Mo system resulted in a 42% decrease of the surface dose for a thick breast (6 cm), without changing the exposure at the detector plane. Use of 1.02 mm Al filter for a W anode system operating at 30 kVp resulted in a 19.1% decrease of the surface dose delivered to a 5 cm water equivalent breast. Overall, W/Al systems appear to have improved dosimetric performance, resulting up to a 65% decrease of surface dose compared to Mo/Mo systems, for identical exposures at the detector plane and breast thicknesses.