Radiation and Computed Tomography in Children
Download
Report
Transcript Radiation and Computed Tomography in Children
Radiation and Computed
Tomography in Children…
Is there still a cause for ALARAm?
Nikhil B. Shah, M.D.
Assistant Professor of Pediatrics
Division of Pediatric Emergency Medicine
Weill Cornell Medical Center
Disclosure
I have no potential, apparent, or real conflict
of interest to disclose and DO NOT INTEND
to discuss off-label or investigational use of
products or services.
Outline
Overview
Risks of radiation in children
Initiatives to reduce radiation exposure in
children
Outline
Overview
Risks of radiation in children
Initiatives to reduce radiation exposure in
children
Question
What is the relative radiation dose of a CT
compared to a chest x-ray (CXR)?
a. CT = CXR
b. CT = 1-10 CXR
c. CT = 10-100 CXR
d. CT = 100-250 CXR
e. CT ≥ 500 CXR
Lee et al Radiology April 2004
Question
What is the relative radiation dose of a CT
compared to a chest x-ray (CXR)?
a. CT = CXR
b. CT = 1-10 CXR
c. CT = 10-100 CXR
d. CT = 100-250 CXR
e. CT ≥ 500 CXR
Why is this issue important?
Diagnostic imaging in the pediatric
emergency department is increasing
Up to 1/3 of studies may not contribute to
patient management
The primary concern is the radiation risk of
unnecessary diagnostic imaging
Picano E, BMJ 2004, 328:578-580
Why is this issue important?
Unnecessary imaging:
Adds to the costs of medical care
Puts the child at risk of discovering an
“incidentaloma”
Subjects the child to unnecessary
radiation which increases the lifetime risk
for fatal cancers
Pierce and Preston, Radiat Res, 2000
Advent of CT
1974 – 1st CT scans
performed
CT has evolved into an
invaluable diagnostic
tool
2010 – > 6000 scanners
in use
Impact of CT
700% increase in CT
use over past
decade
CT use continues to
increase; growth
rate 10% per year
Brenner, et al, NEJM 2007
Impact of CT
More than 70 million CT scans performed
annually in US
11% in children (~10 million)
Relatively young technology whose risks
are not yet fully quantified
Why the recent upsurge in CT
utilization?
Increased availability
Advances in CT technology (ie, helical CT
and MDCT)
Faster scanning - sometimes < 1 second
Decreased need for sedation
Too good to be true?
Despite the many benefits of CT, the
radiation exposure associated with this
modality has come under increasing
scrutiny
Dose Contribution of CT
CT
15%
All other
imaging
modalities
85%
% of Imaging Studies
Utilizing Ionizing Radiation
All other
imaging
modalities
30%
CT
70%
% of Total Radiation Dose
from Medical Imaging
Comparison of Effective Radiation
Doses from X-ray and CT
Imaging Study
Chest X-ray
Effective Dose
(mSv)
0.02
Equivalent number
of chest x-rays
1
Head CT
4
200
Abdominal CT
5
250
Chest CT
3
150
Adapted from Brody, et al, Pediatrics 2007
Societally-Relevant Low Dose
Radiation Exposures
Source
Estimated effective dose (mSv)
Natural background radiation
3 mSv/yr
Airline passenger (cross country)
0.04 mSv
Radiation worker exposure limit
20 mSv/yr
Single screening mammogram
3 mSv
Radiological bomb (20 block radius)
3-30 mSV
Chest X-ray (2 views)
0.1 mSv
Head CT
4 mSv
Chest CT
3 mSV
Abdominal CT
5 mSV
Outline
Overview
Risks of radiation in children
Initiatives to reduce radiation exposure in
children
AJR Feb 2001
AJR February 2001
Brenner, et al 2001
Most institutions do not adjust dose settings
for children
Recommended dose reduction in pediatric CT
Lifetime cancer mortality risk attributable to
CT is considerably higher in children
Estimated 1:500 radiation-induced cancer
deaths
Unique Considerations in Children
Rapidly dividing cells more sensitive to the
effects of radiation
10-fold increase in neoplastic potential
compared to equivalent dose in an adult
Particularly true for thyroid, breast, and
gonadal tissue
Longer lifetime during which malignant
transformation may occur
Hall Pediatric Radiology Apr 2002 pg 226
If we know all this, why is this an
issue?
CT scans are generally not tailored to the
smaller size of children
Therefore, children receive a higher
radiation dose per unit of tissue compared
to an adult for a given study
The numbers
1 in 500 to 1:1000 children who have had a
CT scan will develop a radiation-induced
fatal cancer in their lifetime
This correlates to a 0.35% increase over the
expected baseline lifetime risk for cancer
Does not account for non-fatal cancer
Radiation and Public Health
Radiation risk to the individual is small
Risk to the population as a whole is
considerable given the sheer number of CTs
30% will have more than one scan
Dose is cumulative
A Risk Comparison
Activity
Risk
Driving 7,500 miles
1:1000 (accident risk)
Motorcycling for 1,000 miles
1:1000 (accident risk)
Abdominal CT scan
1:1000 (risk of radiationinduced cancer)
Radiation and Public Health
NCRP reports an increase in effective dose
per individual in the US
3.6 mSv in early 1980s to 6.2 mSv in 2006
Indiscriminate use of CT has the potential to
become a public health problem
Radiation and Public Health
DHHS (2005) -Diagnostic medical radiation
added to list of known human carcinogens
2005 BEIR VII report - Diagnostic radiation
substantially increases cancer risks
Ongoing – Large NCI cohort study evaluating
cancer incidence in children who have had CT
Emerging Human Cohorts
Chernobyl
Airline personnel
Nuclear industry workers
Radiation therapy patients
2011 Japanese tsunami/earthquake
Outline
Overview
Risks of radiation in children
Initiatives to reduce radiation exposure in
children
ALARA
‘As Low As Reasonably Achievable’
Reducing the amount of radiation a child is
exposed to while maintaining efficiency and
reliability of the diagnostic modality
Doses could be reduced by > 30-50% to
obtain essentially the same information
ALARA
ALARA
for the radiologist
for the clinician
ALARA: for the radiologist
Develop weight-based protocols
Improve shielding
Focused/limited-view studies when feasible
Discourage repeat CT studies
Consider alternative non-radiation
modalities such as MRI or ultrasound
Shah & Platt Curr Opin Pediatr 2008
Alternative Imaging Modalities:
Ultrasound
Advantages
No radiation
Inexpensive
Disadvantages
Operator-dependent
Impaired diagnostic efficacy in the obese
and in retrocecal appendix
Alternative Imaging Modalities:
MRI
Sparse current literature
One report found MRI accurately identified
100% of acute appendicitis in 20 patients
MRI may be a valuable imaging technique
particularly in children and pregnancy
Alternative Imaging Modalities:
MRI
Improvement in MRI technology needed
Barriers to routine use of MRI in children
Cost
Availability
Need for sedation
Rapid Brain MRI
Short shunt/hydrocephalus protocol
Useful to look at ventricles, but can also see
midline shifts or mass effect
Entails sagittal, coronal & axial SSFSE and
diffusion weighted sequences
Very rapid – approximately 3 minutes
AFARA ? for the Clinician
AFARA – “As Few As Reasonably
Achievable” ?
10-30% of all CT scans may be
‘unnecessary’
Limiting the number of CTs to only those
that are clinically indicated
Adopting a selective imaging strategy
So how do we know which
patients to scan?
Identify patients at high- or low-risk for a
particular outcome of interest using:
Clinical decision rules
Scoring systems
Clinical practice guidelines
What about when the diagnosis is
uncertain?
AFARA: for the clinician
Role of the pediatric care provider is
paramount
Responsible for ordering & providing
indications and justifications for CT
exams
Principle source of information about
imaging studies, including potential risks
AFARA: for the clinician
Educating clinicians about judicious CT use
may have the most impact in reducing
radiation exposure in children
Educating patients about risks, benefits and
radiation doses for CT scans
AFARA: for the clinician
Explore alternative options and consider
true need for a study
Role of pediatric radiologist cannot be
overemphasized in this decision-making
BUT….
….aren’t most
institutions
following these
practices already?
A century of progress…
1896
2011
Current Barriers to Selective CT
Utilization in the ED
Unique demands of ED setting often justify
prompt and accurate diagnosis
Represents a challenge to all clinicians who
care for children
Increased potential for litigation
May tilt perceived risk-benefit balance
towards overuse of CT in children
www.imagegently.org
Alliance for Radiation
Safety in Pediatric
Imaging in 2007
Goal is to raise
awareness of the
opportunities to lower
radiation dose in the
imaging of children
Summary
When medically indicated, the benefits of
CT far outweigh the individual risks
Recent evidence underscores the
importance of judicious utilization of CT
Public awareness & education are essential
Clinicians and radiologists should present a
unified team, who together advocate safe
practice in children
Questions?