Radiation Dosage of EBT Procedures

Radiologists and scientists alike agree that radiation in large doses causes cancer; the current
controversy centers on what dose should be considered "acceptable" before cancer risk begins to
increase.

Most experts ascribe to the currently accepted linear "no-threshold" theory for radiation
carcinogenesis risk, which holds that any radiation dose, no matter how small, can cause cancer,
meaning that the risk is never zero. Recently this theory has come into question, with some experts
suggesting that the risk of developing cancer after low levels of radiation exposure are overstated.
These experts believe that radiation induced cancer risk only increases after the total radiation
exposure passes a certain threshold level and that exposure to amounts of radiation below this
threshold dosage do not significantly increase the risk of developing cancer. No risk of adverse
health conditions has been established for exposures of 5,000 milli-rem (mrem) or less. The Health
Physics Society recommends against quantitative estimation of health risk for individual exposures
of 5,000 mrem in one year or 10,000 mrem lifetime. The threshold dose of radiation above which
the risk of developing cancer begins to increase is proposed to be about 10,000 mrem.

CT scanning is a relatively high dose procedure that is becoming much more common worldwide.
In the mid-1990s, CT scanning accounted for only 4% of the total X-ray procedures done but 40%
of the collective dose from all diagnostic X-ray. The introduction of helical, fluoroscopic, and
multi-slice CT technology has increased the usage of CT while doing nothing to diminish the
radiation dosage. In US hospitals today, CT scanning accounts for about 15% of imaging
procedures and 75% of radiation exposure. When multiple CT scans are performed on the same
patient, the cumulative absorbed radiation doses rise to the range at which small but statistically
significant increases in cancer have been found in the atomic bomb survivors.

Because CT procedures involve far higher radiation exposures than those received in conventional
x-ray exams, there is growing worry that such exposure could contribute to the development of a
radiation-induced cancer later in life. The FDA is currently investigating this situation. Effective
radiation doses from conventional diagnostic CT procedures range from 100 to 4,000 millirem, not
much less than the lowest doses of 500 to 2000 mrem received by Japanese survivors of atomic
bombs, who were shown to have a small but increased relative risk for cancer mortality due to
radiation exposure. A typical conventional CT scan of the abdomen delivers up to 1000 mrem of
radiation, equivalent to 500 chest x-rays. Marconi (Marconi Medical Systems, Inc. 595 Miner
Road, Cleveland, OH 44143) reportedly has calculated the typical patient dose received when
performing their non-FDA approved cardiac calcium scoring protocol when performed on their
single slice spiral CT scanner using the Win Dose program. In their cardiac calcium scoring
protocol (130 kV, 200 mA, Spiral, 1.25 pitch, 77 images) the effective patient radiation dose
delivered to the patient was 4,300 mrem, equivalent to over 200 chest x-rays. It would take more
than three years to absorb this amount of radiation from the natural background radiation people
receive from the sun and the soil. In contrast, the Electron Beam CT Scanner delivers only
about 70 mrem of radiation to the patient when acquiring images for the coronary calcium
scoring exam. A low risk location's background radiation exposure is about 240 mrem/year.
Background radiation varies substantially from location to location depending on elevation, soil and
latitude. For example, a resident of Denver, CO experiences about double the dose of background
radiation due to the higher altitude than someone living at sea level.
As a general rule, the electron beam CT scanner will deliver about 20% of the radiation to the
patient that a conventional CT scanner would. The primary explanation for this is that the
Electron Beam CT scanner is essentially a fast shuttered camera only turning on for brief periods of
50 to 100 msec as needed to acquire the images. Conventional CT Scanners have an X-ray emitter
on one side of the patient and the detector on the opposite side. In this configuration, the X-ray
emitter is always on during the acquisition of the image data.

When it comes to using radiation for screening or diagnostic purposes, the key is to decide whether
its use is justified, then optimize it.

Estimates of radiation exposure are given in rem (radiation equivalent man) which is based on the
total amount of X-ray expected to be absorbed by the patient during an average study. (100,000
millirem = 1 milliSievert)

Baseline Radiation Exposure Types:

Annual whole body dose from natural causes........................... 300 mrem

Cross Country Plane Trip......................................................... 6 mrem
One Week ski vacation.............................................................. 1-2 mrem
Two View Chest x-ray............................................................ 10 mrem
Lateral lumbar spine x-ray......................................................... 70 mrem
Mammogram............................................................................ 45 mrem
DXA, hip or spine................................................................... 1-6 mrem
DXA, writs or heel.................................................................... <1 mrem

Conventional Coronary Angiogram...................................... up to 2000 mrem

Electron Beam CT (EBT) Exams:

Coronary Artery Calcium Score......................................... 50-63 mrem

Lung Scan..................................................................... 125-158 mrem
Body Scan (chest/abdomen/pelvis).................................... 320 mrem
QCT bone density.............................................................. 10 mrem
EBT Coronary Angiography............................................... 80-105 mrem

Conventional CT Exams:

Chest (Multi Detector).................................................. 300 - 400 mrem

Body Scan (Chest/abdomen/pelvis)................................ 600 - 1,000 mrem
CT Angiography.......................................................... 350 - 1,000 mrem
 Radiation Exposure during Virtual Colonoscopy
Male Female
Barium Enema 70 mrem 70 mrem
SingleDetector CT (Harra, Radiology 2001) 4,400 mrem 6,700 mrem
MultiDetector CT (Harra, Radiology 2001) 4,700 mrem 6,700 mrem
MultiDetector CT (Macari, Radiology 2002) 5,000 mrem 7,800 mrem
MultDetector CT (van Gelder, Radiology
3,600 mrem 3,600 mrem
2002)
New Italian Ultra Low Dose MDCT Protocol
1,800 mrem 2,400 mrem
(unpublished)
Electron Beam CT 800 mrem 800 mrem

The estimation of radiation dosage is an inexact science, so these numbers listed should be
considered as best approximations.

Radiation Exposures--- CT Scanners

University of Iowa
Coronary Artery Calcium Scan
Radiation Exposure Summary**

Helical CT Helical CT Electron Beam CT

Single Detector Ring Multi (4) Detector
EBCT
(SDCT) Ring (MDCT)

Entrance Skin Dose 1900 mrad 8303 mrad 1100 mrad

Effective Dose Equivalent 480 mrem 1104 mrem 260 mrem

1.7 months 7.5 months

Comparison w/ Background Radiation 1 month background
background background

** All calculations based upon 3mm contiguous slice thicknesses encompassing the entire heart
HCT Exposure: 135 Kv, 300mAs Measurements from CDTI phantoms scanned at University of
Iowa: MultiDetector (MD) CT: Measurements used non-helical scan modes but scanning 4 detector
rings/exposure. State of art scanners without modifications: MDCT radiation exposure were about
2.3x SD CT radiation exposures which were about 1.8x EBCT exposures. SDCT and MDCT were
Toshiba Aquilion 500ms scanners