bone densitometry radiation dose: what you need to...

John Damilakis, PhDAssociate Professor and Chairman

University of Crete, Iraklion, Crete, GREECE

Bone DensitometryRadiation dose: what you need to know

Estimation of bone status using X-rays

Assessment of low energy fractures

Dual-energy X-ray absorptiometry (DXA)

Quantitative Computed Tomography (QCT)

High Resolution CT imaging

Peripheral QCT (pQCT)

Spinal Radiography

Spinal radiography is used for identification of vertebral fractures

Vokes T et al (2006) J Clin Densitom 9:37-46

The dose from a lateral radiograph of the thoracic and lumbar

spine is about 600 µSv

Vertebral Fracture Assessment

VFA is a low dose technique with doses reported

to be from 1 to about 50 µSv

Ferrar L et al (2005) Osteoporos Int 16:717-28

Eff

ectiv

e D

ose

(µSv

)

1.15

2.25

PAVA LVA

Multi-Detector CT

Fracture assessment of the spine is possible

without any additional radiation burden by

routinely performing sagittal reformations

in 3D CT of the thorax and abdomen which

have been performed for other clinical

indications.

Damilakis J et al (2007) Eur Radiol 17: 1591 - 1602

Bauer JS et al (2006) Osteoporos Int 17:608-15

Estimation of bone status using X-rays

Assessment of low energy fractures

Dual-energy X-ray absorptiometry (DXA)

Quantitative Computed Tomography (QCT)

High Resolution CT imaging

Peripheral QCT (pQCT)

Dual energy X-ray absorptiometry

For the first generation pencil-beam

devices the patient effective dose

was negligible i.e. up to 1 µSv for

for a spine and femur DXA.

For fan-beam DXA devices, patient

effective doses vary between systems

of different models and manufacturers

depending on a number of variables

Damilakis J, Adams J, Guglielmi G, Link T (2010) Eur Radiol 20: 2707 - 14

Effective dose from spine DXA

Hologic DXA scanners (scan lengths adjusted to the child’s body size)

Age at time of DXA (yr)5 10 15 20

Eff

ectiv

e d

ose

(µSv

)

10

20

30

Array

Fast

Express

Blake G et al, Bone 38:935-42, 2006

9-27 µSv

4-13 µSv

Effective dose from hip DXA

Hologic DXA scanners (scan lengths adjusted to the child’s body size)

Age at time of DXA (yr)5 10 15 20

Eff

ectiv

e d

ose

(µSv

)

10

20

30

Array

Fast

Express

Blake G et al, Bone 38:935-42, 2006

5-22 µSv

3-9 µSv

Physical phantoms and TLDs

Radiation dose from DXA

Mazess et al (2011) Osteoporos Int 11:158-166

GE-Lunar makes use of a fan-beam

with a 4.50 angle orientated parallel to

the longitudinal body axis.

A filter splits the X-ray spectrum into

high- and low-energy components and

provides energies of 38 keV and

70 keV.

Radiation dose from DXA

Hologic uses a linear fan-beam

with a detector array sufficiently

wide to image an entire vertebral

column in a single sweep.

Hologic uses rapid switching

between high and low tube

potentials e.g. from 70 to 140 kVp

Effective dose from DXA: Comparison with other examinations

ED

(µ

Sv)

30

6

18

Spine + hipDXA (Hologic)

Intra-oralradiography

Dental panoramicradiography

Chest radiography

Spine + hipDXA (GE)

SourceSource : BEIR VII: BEIR VII

Risk coefficients for cancer

Age at acute exposure (yr)

Ris

k p

er U

nit

Dos

e (%

per

Sv)

10 20 30 40 50 60 70 80

3

6

9

12

15

7.4 % per Sv

Risks for cancer

50-year-old female patient

Dose per screening: 20 µSv (Hologic)

Risk = 0.074 x 20 x 10-6 = 1.48x10-6

1.5 cases of cancer / 1 million patients (Hologic)

Effective doses from DXA and potential risks are

negligible compared with the benefits

20 µSv 40-50 µSv

Exposure during flights

The worldwide average effective dose from natural Bg radiation is 2.4 mSv/y

J. Damilakis et al, Osteoporos Int (2002) 913:716-22

Conceptus dose from DXAC

once

ptus

Dos

e (µ

Gy)

1

7

6

5

Spine

Hip

Photo by L. Nilsson

Fetus at 13 weeks:

Arm and leg bones

begin to calcify.

First Trimester Second Trimester Third Trimester

DXA: How to reduce patient dose

Patient preparation is important for reducing the radiation dose

Avoid patient movement during imaging

Select the most appropriate acquisition protocol

Use dose reduction tools such as SmartScan©

The length of the DXA should take into account patient’s body size

Estimation of bone status using X-rays

Assessment of low energy fractures

Dual-energy X-ray absorptiometry (DXA)

Quantitative Computed Tomography (QCT)

High Resolution CT imaging

Peripheral QCT (pQCT)

QCT using body CT

Adams J, EJR (2009) 71:415-24

Radiation dose from QCTE

ffec

tive

Dos

e (m

Sv)

0.5

3.5

3.0

2.5

2D QCT Spine

3D MDQCT Spine

3D MDQCT Hip

3D MDQCT Radius

Huda W et al, BJR (1996) 69:422-25

0.06 <0.01

Estimation of bone status using X-rays

Assessment of low energy fractures

Dual-energy X-ray absorptiometry (DXA)

Quantitative Computed Tomography (QCT)

High Resolution CT imaging

Peripheral QCT (pQCT)

High-Resolution CT imaging

Ito M et al, (2005) J Bone Miner Res 20:1828-36

Important information can be

obtained from structure analysis

of high-resolution image data.

Effective dose of about 3 mSv

Parameters that affect CT dose

kV, mAs

Filtration

Beam shaping filter Collimation

Detection system efficiency

Scanning length, scanner geometry, beam collimation, rsw, pitch, algorithms, dose reduction tools

-10 0 10 20 30 40 500.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

0.16

0.18

0.20

Distance (cm)

Nor

mal

ized

Con

cept

us D

ose

The body is not irradiated uniformly

Patient-specific MC SimulationAllows machine-specific and patient-specific

calculations of the dose distributions

J. J. DamilakisDamilakis et al, Radiology 257:483et al, Radiology 257:483--9, 20109, 2010

J. J. DamilakisDamilakis et al, Medical Physics 37:6411 et al, Medical Physics 37:6411 –– 6420, 20106420, 2010

Estimation of bone status using X-rays

Assessment of low energy fractures

Dual-energy X-ray absorptiometry (DXA)

Quantitative Computed Tomography (QCT)

High Resolution CT imaging

Peripheral QCT (pQCT)

Peripheral QCT

Isotropic voxel size in the order of 80 µm

which allows direct or indirect evaluation

of cortical and trabecular bone architecture

Effective dose lower than 3 µSv

Link T et al, (2010) Skeletal Radiol 39:943-55

Burrows M et al, (2010) Osteoporos Int 21:515-20

Occupational doses and shielding

Dose rates at 1m from the central axis of the imaging table range

from about 0.01 µSv/h to about 5 µSv/h, depending on the model.

Examine isodose curves provided by the manufacturer!

Radiation doses associated with DXA are very lowPencil beam : less than 1 µSv/scan Fan beam : up to 25 µSv/scan

VFA is associated with considerably l ower exposurethan lateral spine radiography (1-50 µSv vs. 600 µSv)

Messages to take home

Emphasis must be on dose optimization, especially forpaediatric examinations

Protocols used to examine vertebral microstructure using HR MDCT provide an effective dose of 3 mSv

2D QCT of the lumbar spine is a low-dose techniquewith doses reported to be from 60 to about 90 µSv

Messages to take home

The effective dose from pQCT is negligible i.e. from 3 to 10 µSv

Examine isodose curves provided by the manufacturer

Thank you !

Ευχαριστώ !