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Comparison of Effective Radiation Doses from X-Ray, CT, and PET/ CT in Pediatric Patients with Neuroblastoma Using a Dose Monitoring Program

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Comparison of Effective Radiation Doses from X-Ray, CT, and PET/ CT in Pediatric Patients with Neuroblastoma Using a Dose Monitoring Program Diagn Interv Radiol 2016; 22:390–394 PEDIATRIC RADIOLOGY © Turkish Society of Radiology 2016 ORIGINAL ARTICLE Comparison of effective radiation doses from X-ray, CT, and PET/ CT in pediatric patients with neuroblastoma using a dose monitoring program Yeun Yoon Kim PURPOSE Hyun Joo Shin We aimed to evaluate the use of a dose monitoring program for calculating and comparing the Myung-Joon Kim diagnostic radiation doses in pediatric patients with neuroblastoma. Mi-Jung Lee METHODS We retrospectively reviewed diagnostic and therapeutic imaging studies performed on pediatric patients with neuroblastoma from 2003 to 2014. We calculated the mean effective dose per exam for X-ray, conventional computed tomography (CT), and CT of positron emission tomography/com- puted tomography (PET/CT) from the data collected using a dose monitoring program (DoseTrack group) since October 2012. Using the data, we estimated the cumulative dose per person and the relative dose from each modality in all patients (Total group). The effective dose from PET was man- ually calculated for all patients. RESULTS We included 63 patients with a mean age of 3.2±3.5 years; 28 had a history of radiation therapy, with a mean irradiated dose of 31.9±23.2 Gy. The mean effective dose per exam was 0.04±0.19 mSv for X-ray, 1.09±1.11 mSv for CT, and 8.35±7.45 mSv for CT of PET/CT in 31 patients of the Dose- Track group. The mean estimated cumulative dose per patient in the Total group was 3.43±2.86 mSv from X-ray (8.5%), 7.66±6.09 mSv from CT (19.1%), 18.35±13.52 mSv from CT of PET/CT (45.7%), and 10.71±10.05 mSv from PET (26.7%). CONCLUSION CT of PET/CT contributed nearly half of the total cumulative dose in pediatric patients with neuro- blastoma. The radiation dose from X-ray was not negligible because of the large number of X-ray images. A dose monitoring program can be useful for calculating radiation doses in patients with cancer. adiation exposure in children may cause more serious consequences than in adults. The risk of radiation-induced cancer mortality is significantly higher per unit dose in R children than in adults because this risk increases inversely with age (1). There are sev- eral established reasons for this phenomenon. First, children are innately more vulnerable to develop secondary malignancies. For example, an infant has more than 10 times the risk of cancer induction with the same radiation dose compared with an adult (2). The risk of developing secondary fatal malignancies in children around the age of 10 years is approxi- mately 15% per Sievert (Sv), which is four times higher than that for adults in their forties (2). Second, children have a longer lifespan to develop malignancies after exposure, and most solid cancers have a latency of at least a decade (3). In addition, gonadal irradiation causes more genetic damage in children than in adults (4). Radiotherapy is the main risk factor for the development of solid second malignant neo- plasms within the irradiated body region (5, 6). However, the increasing use of diagnostic imag- From the Department of Radiology and Research ing studies with ionizing radiation in pediatric practice also raises the issue of radiation hazards Institute of Radiological Science (M.J.L. mjl1213@ yuhs.ac) Severance Children’s Hospital, Yonsei (7). The radiation dose from diagnostic computed tomography (CT) is positively correlated with University College of Medicine, Seoul, Korea. cancer induction in children (8). Moreover, compared with adult CT, pediatric CT may sharply increase the estimated risk of cancer mortality (9). In addition, the use of serial positron emis- Received 28 May 2015; revision requested 23 July 2015; last revision received 11 November 2015; sion tomography/computed tomography (PET/CT) in children with malignancies has also accepted 3 December 2015. raised concerns regarding the harmful effects of a considerable amount of radiation. Published online 14 June 2016. Neuroblastoma is the most common extracranial solid cancer in childhood (10). The cu- DOI 10.5152/dir.2015.15221 mulative radiation dose from frequent imaging studies using ionizing radiation may lead to 390 serious problems in pediatric patients with to compare the radiation dose from each factors from the National Radiological cancer. As the survival rates of pediatric pa- modality. Protection Board-R262 for X-ray and the tients with solid tumors have dramatically International Commission on Radiological increased over the last several decades Methods Protection (ICRP) 102 for conventional CT (11), the long-term consequences of radi- Patients and examinations and CT of PET/CT. The radiation dose from ation exposure from serial imaging studies The Institutional Review Board of Sever- PET was calculated by multiplying the fluo- in these patients have become more im- ance hospital approved this retrospective rodeoxyglucose activity by the dose coeffi- portant. In addition, PET/CT has emerged study and required neither patient approv- cient. The fluorodeoxyglucose activity was as an important diagnostic tool for neuro- al nor informed consent for reviewing the assumed to be 5 MBq per body weight in blastoma (12, 13). Conventional imaging patients’ images and medical records. We kg (16), and we used the tissue weighting protocols for neuroblastoma include not searched the electronic medical record in factors from ICRP 103. only CT but also PET/CT before and after our institution from January 2008 to Octo- Radiation dose data from this program treatment, on follow-up, or for evaluation ber 2014 to collect information from pediat- was available from October 2012 in our hos- of recurrence (14). Therefore, precise calcu- ric patients with pathologically diagnosed pital. For patients with exams performed lation and monitoring of the radiation dose neuroblastoma since records from 2008 after October 2012, the radiation dose was from imaging studies that use ionizing ra- were available for retrieval in the electronic calculated using the DoseTrack program diation in each neuroblastoma patient are system. We reviewed the medical records of (DoseTrack group). We collected the effec- important. However, it is difficult to manu- these children for age at the time of diagno- tive dose data by modality per patient us- ally calculate the radiation dose from each sis, gender, organ of tumor origin, and body ing the program and calculated the mean modality in each patient. weight on the day of PET or PET/CT. In ad- effective dose per X-ray, conventional CT, Recently developed dose monitoring dition, we reviewed the history of radiation and CT of PET/CT examination. For studies software collects dose information from therapy, with irradiated dose and duration. performed before October 2012, the effec- each patient, either directly from the mo- Furthermore, we reviewed the diagnos- tive dose was estimated by applying the dality or through the radiology information tic imaging studies performed on these mean dose per exam calculated by the data system, picture archiving and communica- children to collect the acquisition number from the DoseTrack group. We calculated tion system (PACS), or electronic medical of each imaging modality from 2003 to the mean cumulative radiation dose per records. Using dose monitoring programs, December 2014 because PACS (Centricity; person and the relative doses from X-ray, it is possible to calculate, report, and mon- GE Healthcare) was adopted at our hospi- conventional CT, and CT of PET/CT in all pa- itor radiation doses, including the effective tal in 2003. We included diagnostic imag- tients (Total group). dose, more easily than before (15). Howev- ing studies with ionizing radiation, such er, few studies have evaluated these pro- as X-ray, conventional CT, PET, and PET/CT, Statistical analysis grams in clinical practice. and those without ionizing radiation, such We used descriptive statistics for age, du- This study aimed to evaluate the utility of as ultrasonography and magnetic reso- ration and number of imaging studies, and a dose monitoring program for calculating nance imaging (MRI). We did not evaluate doses from diagnostic imaging studies or and monitoring the effective radiation dose the radiation dose from other nuclear med- radiotherapy. Statistical analysis was per- from diagnostic imaging studies, including icine imaging studies except PET or PET/ formed using SPSS Statistics (version 20.0, X-ray, conventional CT, and CT of PET/CT, in CT because of the different methodologies IBM Corp.) to evaluate data normality and pediatric patients with neuroblastoma and used to calculate the radiation dose in these calculate mean values with standard devi- studies and the limited clinical information ations. Relative doses between X-ray, CT, CT Main points regarding the old data. We calculated the of PET/CT, and PET were summarized using total duration of exams for each patient. simple proportions. • PET and PET/CT contributed to more than 70% of the total diagnostic radiation doses in pediatric neuroblastoma patients. Dose calculation and analysis Results • The average cumulative dose per patient We used a commercially available dose The study included 63 patients (39 males from CT of PET/CT was 18.35 mSv, which monitoring program (DoseTrack; version and 24 females) from January 2008 to Oc- accounted for 46% of the total dose and was 1.0, 2012, GE Healthcare) to calculate the tober 2014. The mean age at the time of greater than twice of the average cumulative effective dose from X-ray, conventional CT, diagnosis was 3.2±3.5 years. The organs of dose of 7.66 mSv from conventional CT. and CT of PET/CT in each patient. The pro- tumor origin were as follows: adrenal gland • Patient irradiation should be considered gram monitors radiation doses from all im- (n=44), mediastinum (n=10), retroperitone- when selecting the imaging modality and aging modalities using ionizing radiation.
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