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AAM keport No.


Slze-Speclflc uose LsLlmaLes (SSuL) ln edlaLrlc
and AdulL 8ody C1 LxamlnaLlons

keport of AAM 1ask Group 204, deve|oped |n co||aborat|on w|th the
Internat|ona| Comm|ss|on on kad|at|on Un|ts and Measurements (ICkU)
and the Image Gent|y campa|gn of the A|||ance for kad|at|on Safety
|n ed|atr|c Imag|ng

ulSCLAlML8: 1hls publlcaLlon ls based on sources and lnformaLlon belleved Lo be rellable, buL Lhe
AAM, Lhe auLhors, and Lhe publlsher dlsclalm any warranLy or llablllLy based on or relaLlng Lo Lhe
conLenLs of Lhls publlcaLlon.

1he AAM does noL endorse any producLs, manufacLurers, or suppllers. noLhlng ln Lhls publlcaLlon
should be lnLerpreLed as lmplylng such endorsemenL.

lS8n: 978-1-936366-08-8
lSSn: 0271-7344

2011 by Amerlcan AssoclaLlon of hyslclsLs ln Medlclne

All rlghLs reserved.

ubllshed by
Amerlcan AssoclaLlon of hyslclsLs ln Medlclne
Cne hyslcs Llllpse
College ark, Mu 20740-3846

Slze-Speclflc uose LsLlmaLes (SSuL) ln edlaLrlc
and AdulL 8ody C1 LxamlnaLlons

keport of AAM 1ask Group 204

!ohn M. 8oone1* (Co-Chalr)
1be uolvetslty of collfotolo, uovls

kelLh !. SLrauss11 (Co-Chalr)
cbllJteos nospltol, 8ostoo

ulanna u. Cody1
M.u. AoJetsoo coocet ceotet, noostoo

CynLhla P. McCollough1*
Moyo cllolc, kocbestet

Mlchael l. McnlLL-Cray1*
1be uolvetslty of collfotolo, los Aoqeles

1homas L. 1oLh1
Ceoetol lecttlc neoltbcote, wookesbo

Marllyn !. Coske1, M.u.
clocloootl cbllJteos nospltol MeJlcol ceotet, clocloootl, On

uonald . lrush1, M.u.
uoke uolvetslty, uotbom

1Amerlcan AssoclaLlon of hyslclsLs ln Medlclne (AAM)
*lnLernaLlonal Commlsslon on 8adlaLlon unlLs and MeasuremenLs (lC8u), C1 CommlLLee
1lmage CenLly campalgn of Lhe Alllance for 8adlaLlon SafeLy ln edlaLrlc lmaglng


1. Introduct|on ...................................................................................................................... 1
2. Methods ............................................................................................................................ 2
2.1 MeLhods for ulfferenL Croups ..................................................................................... 3
2.1.1. hyslcal MeasuremenLs uslng AnLhropomorphlc hanLoms
(McCollough and colleagues Mc") .................................................................... 6
2.1.2. hyslcal MeasuremenLs uslng Cyllndrlcal MMA hanLoms
(1oLh and SLrauss 1S") ...................................................................................... 6
2.1.3. MonLe Carlo MeasuremenLs on voxellzed hanLoms
(McnlLL-Cray and colleagues MC")................................................................... 6
2.1.4. MonLe Carlo MeasuremenLs on Slmple Cyllndrlcal hanLoms
(Zhou and 8oone Z8") ....................................................................................... 7
3. kesu|ts............................................................................................................................... 8
4. D|scuss|on.......................................................................................................................... 13
S. L|m|tat|ons......................................................................................................................... 13
6. Nomenc|ature ................................................................................................................... 16
7. Step-by-Step Lxamp|e of Usage......................................................................................... 17
8. kecommendat|ons for kad|o|og|st keport|ng.................................................................... 18
9. Summary ........................................................................................................................... 19
Append|x A: ert|nent Lquat|ons ........................................................................................... 20
keferences and Cther kead|ng............................................................................................... 21

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 1
1. Introduct|on
1here are approxlmaLely 80 mllllon C1 examlnaLlons performed ln Lhe unlLed SLaLes annually. AbouL
7 mllllon of Lhese occur on chlldren (MeLLler 2000). ln response Lo Lhls, Lhe SocleLy for edlaLrlc
8adlology (S8) sponsored a conference on Lhls Loplc ln 2001 (Slovls 2002, 8erdon 2002) whlch was
followed by a conference ln 2002 sponsored by Lhe naLlonal Councll on 8adlaLlon roLecLlon and
MeasuremenLs (LlnLon 2003). ln 2008, Lhe Alllance for 8adlaLlon SafeLy ln edlaLrlc lmaglng
(Alllance") was founded by Lhe Amerlcan AssoclaLlon of hyslclsLs ln Medlclne (AAM), Lhe Amerlcan
College of 8adlology (AC8), Lhe Amerlcan SocleLy of 8adlologlc 1echnologlsLs (AS81) and Lhe SocleLy
for edlaLrlc 8adlology (S8) Lo address Lhe unlque needs of lmaglng chlldren when uslng lonlzlng
radlaLlon. CurrenLly, Lhe Alllance represenLs over 60 afflllaLed organlzaLlons (aL leasL 20 are
lnLernaLlonal) represenLlng over 730,000 people worklng ln medlcal lmaglng. 1he Alllance promoLes
radlaLlon proLecLlon for chlldren Lhrough an awareness, educaLlon, and advocacy-based soclal
markeLlng campalgn (lmage CenLly). 1he Alllance sLrlves Lo fosLer [usLlflcaLlon (examlnaLlon
lndlcaLed) and opLlmlzaLlon (approprlaLe balance beLween radlaLlon dose and sLudy quallLy) for every
pedlaLrlc C1 examlnaLlon. ln order Lo achleve Lhls balance, pedlaLrlc radlologlsLs, medlcal physlclsLs
and radlologlc LechnologlsLs need user-frlendly compuLaLlonal Lools Lo esLlmaLe radlaLlon dose durlng
pedlaLrlc C1 examlnaLlons. 1he meLhods provlded ln Lhls documenL are deslgned Lo provlde such
Lools, noL only for pedlaLrlc C1, buL for C1 examlnaLlons of paLlenLs of any slze.

CurrenL C1 scanners dlsplay Lhe volume compuLed Lomography dose lndex (C1ul
) and Lhe dose
lengLh producL (uL) dose lndlces (Shope 1981, ulxon 2003, 8oone 2007, McCollough 2008, McnlLL-
Cray 2002, AAM 2008), boLh before and afLer Lhe C1 scan ls performed. 1hls has been requlred of
manufacLurers slnce 2002 (lLC 2002). C1ul
was developed Lo provlde a sLandardlzed meLhod Lo
compare toJlotloo ootpot levels beLween dlfferenL C1 scanners uslng a reference phanLom. uL,
whlch ls Lhe producL of C1ul
(mCy) and scan lengLh (cm), ls relaLed Lo Lhe LoLal lonlzlng energy
lmparLed Lo Lhe reference phanLom. 8oLh C1ul
and uL are senslLlve Lo changes ln scan
parameLers such as Lube volLage, Lube currenL, ganLry roLaLlon Llme, plLch, and bowLle fllLer, buL are
lndependenL of paLlenL slze. 1he C1ul
ls deLermlned for elLher a 16 cm or 32 cm dlameLer
polymeLhyl meLhacrylaLe (MMA) cyllndrlcal reference phanLom, ofLen called Lhe head" or body"
C1ul phanLom, respecLlvely.

lor a glven paLlenL's C1 scan, Lhe C1ul
and Lhe relaLed uL are dlsplayed for a reference phanLom
(l.e., head or body C1ul phanLom), Lhe dlameLer of whlch (l.e., 16 cm or 32 cm) ls selecLed by Lhe
scanner. ln general, for exams uslng a head bow-Lle fllLer or head scan proLocol, Lhe 16 cm dlameLer
phanLom ls used. lor exams of Lhe Lorso, when a body bow-Lle fllLer or body scan proLocol ls used,
Lhe 32 cm dlameLer phanLom ls used. AL presenL, for pedlaLrlc body C1 proLocols, some
manufacLurers use Lhe 16 cm dlameLer phanLom and some use Lhe 32 cm dlameLer phanLom as Lhe
reference for calculaLlng C1ul
and uL. 1o accuraLely lnLerpreL C1ul
or uL for an lndlvldual
paLlenL, or Lo compare Lo oLher reporLed values, Lhe phanLom dlameLer used for a speclflc scoooet
moJel ooJ softwote vetsloo musL be known. ln mosL cases, Lhe phanLom dlameLer used ls now
dlsplayed on Lhe user console along wlLh C1ul
and uL, or ls presenL ln Lhe ulCCM uose 8eporL.
Clder scanner models and sofLware verslons, however, may lack Lhls lnformaLlon ln a readlly
accesslble place and Lhe scanner manufacLurer represenLaLlve should be consulLed ln such case.

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 2
1he dose recelved by a paLlenL from a C1 scan ls dependenL on boLh paLlenL slze and scanner
radlaLlon ouLpuL. C1ul
provldes lnformaLlon regardlng ooly Lhe scanner ouLpuL. lL does noL address
paLlenL slze, and hence does noL esLlmaLe paLlenL dose (McCollough 2011). 1hls ls a concern, becoose
fot smollet peJlottlc potleots, lotetptetloq tbe JlsployeJ c1ul
(ot ull) os potleot Jose-wltboot
tecoqolzloq tbe Jlstloctloo betweeo tbe two-coolJ leoJ to ooJetestlmotloq potleot Jose levels by o
foctot of 2-J lf tbe J2 cm lMMA pbootom wos oseJ fot tefeteoce.

1hls Lask group was charged wlLh developlng converslon facLors LhaL can be applled Lo Lhe dlsplayed
dose lndex Lo allow pracLlLloners Lo be able Lo esLlmaLe paLlenL dose. 1hese facLors Lake lnLo
accounL paLlenL slze, and hence are especlally lmporLanL for pedlaLrlc C1 or when small adulLs are
scanned. 1he work presenLed here was speclflcally moLlvaLed by Lhe needs of Lhe Alllance (SLrauss
2009), buL also reflecLs ongolng, lndependenL research performed by a number of research groups
around Lhe unlLed SLaLes. 1he scope of Lhls Lask group ls llmlLed Lo esLlmaLlng paLlenL dose uslng
scanner ouLpuL (C1ul
) and facLors assoclaLed wlLh paLlenL slze. CLher dlfferences beLween Lhe
currenL C1 scanner radlaLlon ouLpuL lndlces and paLlenL dose esLlmaLes due Lo Lhe use of shorL"
phanLoms (13 cm along Lhe z-axls) for C1ul
measuremenLs (ulxon 2003, 2006, 8oone 2007) are noL
addressed by Lhls Lask group.

2. Methods

1he C1ul
ls Lhe parameLer whlch ls used Lo normallze Lhe converslon facLors Lo as descrlbed ln Lhls
documenL, and so we sLarL wlLh a deLalled descrlpLlon of how Lhe C1ul
ls compuLed.

I|gure 1. 1he general meLhodology for Lhe assessmenL of
ls lllusLraLed. 1he 100 mm long pencll chamber ls
placed elLher aL Lhe cenLer or aL Lhe perlphery of a
polymeLhyl meLhacrylaLe dose phanLom. 1here are Lwo
sLandard MMA phanLoms, 16 cm and 32 cm ln dlameLer
and boLh are 13 cm ln lengLh. unused holes are plugged
wlLh MMA rods. 1he C1ul
meLhods are used Lo
compuLe C1ul
, as descrlbed ln Lhe LexL.

uefinitions: c1ul

1he C1ul
parameLer dlsplayed on mosL C1 scanner consoles ls measured followlng sLandard
proLocols (McCollough 2008, 8auhs 2008). 1he C1ul
ls deflned as:

( )
z mm
CTDI D z dz

LquaLlon 1

1he measuremenL approach ls lllusLraLed ln llgure 1. C1ul
can be measured aL Lhe cenLer of Lhe
phanLom and aL Lhe perlphery, resulLlng ln
CTDI for Lhe cenLer and
CTDI for Lhe
perlpheral measuremenL. lL ls emphaslzed LhaL Lhe quanLlLy measured for C1ul
deflned ln Lhls
documenL ls alr kerma, represenLed ln Lhe unlLs of mCy. 1here ls no converslon Lo dose ln Llssue or ln
MMA uslng f-facLors or Lhelr Sl equlvalenL, as prescrlbed ln earller deflnlLlons of C1ul (e.g., C1ul

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 3
Powever, for measuremenLs made ln unlLs of exposure (roenLgen), a converslon from exposure Lo alr
kerma (mCy) ls requlred: Lxposure (8) x 8.73 = Alr kerma (mCy).

1he welghLed C1ul,

, ls compuLed as:

100 100
1 2
3 3
center periphery
LquaLlon 2

8ecognlzlng LhaL dose ln C1 ls lnversely relaLed Lo hellcal (splral) plLch, Lhe C1ul
ls deflned as:

= ,
LquaLlon 3

where plLch ls deflned as Lhe raLlo of Lhe Lable feed (ln mm) per 360 ganLry roLaLlon Lo Lhe nomlnal
colllmaLed beam wldLh (nT ln LquaLlon 1, ln mm).

uefinitions: 5ite re/oted porometers

I|gure 2. 1he anLerlor posLerlor (A)
and laLeral dlmenslon, along wlLh
effecLlve dlameLer are lllusLraLed ln
Lhls flgure. 1he laLeral dlmenslon
can be deLermlned from a A or A
C1 radlograph, and Lhe A dlmenslon
can be deLermlned by a laLeral C1
radlograph. 1he effecLlve dlameLer
corresponds Lo a clrcle havlng an
area equal Lo LhaL of Lhe paLlenL's
cross secLlon on a C1 lmage. Some
lnvesLlgaLors have also used paLlenL
perlmeLer (clrcumference) as a
meLrlc of paLlenL slze.

llgure 2 lllusLraLes several of Lhe parameLers dlscussed ln Lhls secLlon. 1he C1 radlograph ls Lhe
scanned pro[ecLlon radlography used ln C1 Lo prescrlbe Lhe scan range (also called ScouL`,
1opogram` and Scanogram` by varlous manufacLurers).

Lotero/ uimension: 1he laLeral (LA1) dlmenslon ls Lhe slde-Lo-slde (lefL Lo rlghL) dlmenslon of Lhe
body parL belng scanned. 1hls dlmenslon can be assessed uslng elecLronlc callpers on Lhe sLandard A
C1 radlograph LhaL ls acqulred ln mosL cases prlor Lo a C1 scan. ln Lhe absence of a C1 radlograph, Lhe
laLeral dlmenslon could be deLermlned uslng physlcal paLlenL callpers, whlch are someLlmes avallable
ln a radlology faclllLy.

4P uimension: AnLerlor-posLerlor dlmenslon ls Lhe Lhlckness of Lhe body parL of Lhe paLlenL belng
scanned ln Lhe anLerlor-posLerlor dlmenslon, for example from Lhe surface of Lhe sLomach Lo Lhe
surface of Lhe back. 1o measure Lhe A dlmenslon from a C1 radlograph, a laLeral pro[ecLlon would
be necessary. 1he A dlmenslon can be easlly measured uslng dlglLal callpers on a convenLlonal

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions
laLeral C1 radlograph, whlch ls acqulred prlor Lo Lhe C1 scan under some clrcumsLances. ln Lhe
absence of a measuremenL from a C1 radlograph, physlcal callpers can be used Lo make Lhls

4P + Lot dimension: 1hls parameLer ls Lhe sum of Lhe laLeral and A dlmenslons. 1he analyses
performed for Lhls reporL have shown LhaL Lhe sum of Lhese Lwo orLhogonal dlmenslons ls llnearly
relaLed Lo Lhe effecLlve dlameLer.

ffective uiometer: 1he effecLlve dlameLer represenLs Lhe dlameLer of Lhe paLlenL aL a glven locaLlon
along Lhe z-axls of Lhe paLlenL (ln Lhe cranlalcaudal dlmenslon), assumlng LhaL Lhe paLlenL has a
clrcular cross secLlon. Whlle some body parLs approxlmaLe a clrcular secLlon, many do noL. 1he
effecLlve dlameLer can be LhoughL of as Lhe dlameLer of Lhe clrcle whose ls Lhe same as LhaL of
Lhe paLlenL cross secLlon (llgure 2). 1o calculaLe Lhls from Lhe known A and laLeral dlmenslons, Lhe
paLlenL ls assumed Lo be elllpLlcal ln cross secLlon, wlLh Lhe radll r
and r

r =
LquaLlon 4.1

r = .
LquaLlon 4.2

1he area, , of Lhe elllpse ls compuLed uslng:

1 2
A r r = . LquaLlon 3

lrom Lhe area of Lhe paLlenL's cross secLlon, , Lhe effecLlve dlameLer ls compuLed as:

effective diameter

= .
LquaLlon 6

Comblnlng LquaLlons 4 Lhrough 6, lL can be seen LhaL:

effective diameter AP LAT = .
LquaLlon 7

Overo// 4pprooch
lL has been shown LhaL a paLlenL slze-dependenL facLor can be used Lo esLlmaLe paLlenL dose from
scanner ouLpuL lndlces (e.g. C1ul
) for paLlenLs of dlfferenL slzes. 1he slze dependenL facLor can be
used over a range of paLlenL slzes, and exLends Lo large paLlenLs as well as small paLlenLs. 8ecause of
Lhe general avallablllLy of Lhe C1ul
parameLer on Lhe C1 console, Lhe meLhods employed by Lhe
varlous lnvesLlgaLors all rely on normallzaLlon by C1ul
, as convenLlonally measured uslng elLher Lhe
16 or 32 cm dlameLer MMA phanLoms. 1hls normallzaLlon process facLors ouL mosL dlfferences
beLween lndlvldual scanners and Lube poLenLlal seLLlngs (1urner 2010, 2011). Slnce mosL modern C1
scans can dlsplay C1ul
Lo Lhe C1 scan of a glven paLlenL, Lhe proposed facLors can be used by
Lhe C1 LechnologlsL aL Lhe C1 console Lo esLlmaLe dose Lo Lhe C1 scan.

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age S
2.1 Methods for D|fferent Groups

1he varlous Lools used by Lhe four lndependenL research groups are lllusLraLed llgure 3.

I|gure 3. 1he varlous Lools used by Lhe four lndependenL research groups: (A) McCollough and colleagues (Mc)
performed physlcal dose measuremenLs uslng a serles of elghL anLhropomorphlc Llssue-equlvalenL phanLoms. (8) 1oLh
and SLrauss (1S) used Lwo exlsLlng cyllndrlcal MMA phanLoms, Lhe 16 and 32 cm dlameLer C1ul phanLoms, and a Lhlrd
10 cm dlameLer phanLom. (C) McnlLL-Cray and colleagues (MC) performed MonLe Carlo dose calculaLlons uslng a serles of
seven anLhropomorphlc maLhemaLlcal phanLoms, of whlch Lhree are shown here. (u) 8oone and colleagues (Z8) used
MonLe Carlo calculaLlons on a serles of cyllnders of dlfferenL dlameLer wlLh dlfferenL composlLlons.

lor Lhls reporL, we have comblned daLa from four dlfferenL groups of lnvesLlgaLors who have
lndependenLly been sLudylng Lhe poLenLlal of paLlenL slze-dependenL facLors Lo esLlmaLe paLlenL dose
from C1ul
. Whlle Lhls compendlum of resulLs ls noL a meLa-analysls , Lhe excellenL
conslsLency beLween Lhe resulLs of Lhe lndependenL research groups suggesLs a level of confldence ln
Lhe derlved facLors greaLer Lhan lf only one group produced Lhe daLa. SerendlplLously, Lwo of Lhe
groups made use of MonLe Carlo-based measuremenLs, whlle Lhe oLher Lwo engaged ln physlcal
measuremenLs on phanLoms, and Lhls broadens Lhe experlmenLal meLhodology used Lo arrlve aL Lhe
recommended converslon facLors.

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 6
2.1.1. hys|ca| Measurements us|ng Anthropomorph|c hantoms (McCo||ough and co||eagues
McCollough eL al., aL Lhe Mayo Cllnlc (8ochesLer, Mn) used a seL of elghL Llssue-equlvalenL
anLhropomorphlc Lorso phanLoms (Cl8S, norfolk, vA) spannlng a range of slzes from newborn (LA1
dlmenslon 9 cm) Lo large adulL (LA1 dlmenslon 39 cm, llgure 3A). WlLh Lhe excepLlon of Lhe newborn
phanLom, Lhe aspecL raLlos of Lhese phanLoms were very slmllar. 1o represenL paLlenLs wlLh dlfferenL
body shapes (e.g. more round Lhan oval), Lhree addlLlonal phanLoms were creaLed by addlng Llssue-
equlvalenL maLerlal on Lop of Lhe Cl8S phanLoms: a rounder new born, 13 years old, and large adulL.
A and laLeral dlmenslons, perlmeLer, and area were deLermlned for each of Lhe 11 phanLoms.

hanLoms were scanned uslng four dlfferenL C1 scanner models: SensaLlon 16 and ueflnlLlon
(Slemens PealLhcare, lorchhelm, Cermany) and LlghLSpeed ulLra and vC1 (CL PealLhcare, Mllwaukee,
Wl). Lxposure was measured accordlng Lo Lhe meLhods of AAM 1C-111 (AAM 2010) uslng a 0.6cc
lon chamber (8adcal, Monrovla, CA) and converLed Lo dose Lo Llssue (mCy) uslng an f-facLor of 1.073
mCy [dose] / mCy [alr kerma] or 9.37 mCy/8.

uose ln C1 depends on Lhe amounL of scaLLer produced wlLhln Lhe scanned ob[ecL. Pence, Lhe use of
phanLoms havlng only a 13 cm lengLh along Lhe z-axls would underesLlmaLe Lhe dose Lo acLual
paLlenLs. 1o provlde a reallsLlc scaLLerlng envlronmenL, a human Lorso was slmulaLed by placlng
addlLlonal phanLoms wlLh slmllar aLLenuaLlon properLles dlrecLly ad[acenL Lo Lhe Cl8S phanLom along
Lhe longlLudlnal dlrecLlon. 1he scan lengLh for an abdomlnal C1 scan for each Lorso phanLom was
esLlmaLed based upon cllnlcal experlence, and each phanLom was scanned uslng hellcal (splral), axlal
(sequenLlal), and clne (perfuslon) scan proLocols. MeasuremenLs were made aL Lhe cenLer of Lhe
fleld-of-vlew and four perlpheral poslLlons, and a mean dose over Lhe fleld-of-vlew calculaLed uslng a
1/3 cenLer and 2/3 perlpheral average approach (l.e., Lqn 2). Mean dose was dlvlded by C1ul
every paLlenL slze.

2.1.2. hys|ca| Measurements Us|ng Cy||ndr|ca| MMA hantoms (1oth and Strauss "1S")
1oLh and SLrauss (1S) used x-ray aLLenuaLlon, expressed ln Lerms of a waLer-equlvalenL dlameLer
(Puda 2000, Menke 2003) Lo descrlbe paLlenL slze for Lhe sLandard 13 cm long, 16 cm dlameLer, and
32 cm dlameLer MMA phanLoms, and a 13 cm long, 10 cm dlameLer MMA cyllnder (llgure 38).

1oLh and SLrauss measured sLandard C1ul
for 16- and 64-sllce C1 scanners from hlllps, CL, 1oshlba,
and Slemens across a range of kv values from 80 kv Lo 140 kv. 8egresslon models of Lhe C1ul

measuremenLs, normallzed Lo Lhe 16 and 32 cm dlameLer phanLom measuremenLs, were obLalned as
a funcLlon of Lhe phanLom's waLer-equlvalenL dlameLer. 1he waLer-equlvalenL dlameLers for a cohorL
of head, chesL, and body pedlaLrlc paLlenLs were also deLermlned from C1 radlographs and C1 lmages
as well as measuremenL of Lhe paLlenL's laLeral dlmenslon uslng elecLronlc callpers. uslng Lhe
regresslon models, Lables of normallzed C1ul
as a funcLlon of paLlenL laLeral dlmenslon were
developed. 1he resulL ls a seL of scale facLors LhaL esLlmaLe Lhe dose for a 13 cm long phanLom
havlng Lhe same waLer-equlvalenL x-ray aLLenuaLlon as Lhe paLlenL.

2.1.3. Monte Car|o Measurements on Voxe||zed hantoms (McN|tt-Gray and co||eagues "MG")
1he McnlLL-Cray laboraLory aL uCLA used MonLe Carlo slmulaLlon Lechnlques Lo sLudy Lhe effecLs of
paLlenL slze on organ dose for abdomlnal C1 exams (1urner 2011). MulLl-deLecLor C1 (MuC1)

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 7
scanners from each of Lhe ma[or manufacLurers were slmulaLed uslng Lhe equlvalenL source"
meLhod descrlbed by 1urner eL al. (1urner 2009). A cohorL of elghL voxellzed paLlenL models, known
as Lhe CSl paLlenL models (eLoussl-Penss 2003) were used Lo represenL a range of slzes from
newborn Lo large adulL LhaL lncluded males and females. SlmulaLed abdomlnal C1 exams were
performed for all paLlenL models on each scanner model. 1he scan lengLh slmulaLed was proporLlonal
Lo Lhe scan lengLh Lyplcal for each body slze slmulaLed, and Lhls ranged from 13 cm Lo 33 cm. All
organ doses were obLalned uslng a prevlously descrlbed MuC1 slmulaLlon approach (ueMarco 2003)
bullL on Lhe MCnx (MonLe Carlo n-arLlcle exLended v2.7.a) radlaLlon LransporL code (WaLers 2002,

1he scanner-speclflc organ doses were normallzed by correspondlng C1ul
values and averaged
across scanners Lo obLaln scanner-lndependenL organ dose per C1ul
coefflclenLs for each paLlenL
model. 1o obLaln a meLrlc for paLlenL slze, Lhe ouLer perlmeLer of each paLlenL was measured aL Lhe
cenLral sllce of Lhe abdomlnal scan reglon. 1hen, Lhe relaLlonshlp beLween organ dose per C1ul

coefflclenLs and paLlenL perlmeLer was lnvesLlgaLed for organs LhaL were dlrecLly lrradlaLed by Lhe
abdomlnal scan.

2.1.4. Monte Car|o Measurements on S|mp|e Cy||ndr|ca| hantoms (2hou and 8oone "28")
Zhou and 8oone aL Lhe unlverslLy of Callfornla uavls used Lhe SlL88A MonLe Carlo code sysLem,
developed by 8oone (8oone 2000A) and prevlously reporLed (Zhou 2008) Lo compuLe dose Lo
lnflnlLely long cyllnders of dlfferenL composlLlons (waLer, MMA, and polyeLhylene) wlLh dlameLers
ranglng from 1 cm Lo 30 cm, ln 22 dlfferenL lncremenLs. 1he geomeLry and bow Lle fllLers of Lhe
CL LlghLspeed 16 scanner were used ln Lhe slmulaLlons. 1he monoenergeLlc slmulaLlon daLa (8 kev-
140 kev) were lncorporaLed lnLo several spreadsheeL calculaLlon Lools (Lxcel, MlcrosofL CorporaLlon,
8edmond, WA). A specLral model (8oone 1997) was lncorporaLed lnLo Lhe calculaLlon Lool as well,
allowlng Lhe user Lo ad[usL Lhe specLrum from 40 kv Lo 140 kv, and puL ln any amounL of added
alumlnum or copper fllLraLlon. 1he polyenergeLlc specLrum was produced by specLrally welghLlng Lhe
monoenergeLlc daLa complled ln Lhe spreadsheeL. ln Lhls sLudy, x-ray specLra aL 80, 100, 120, and
140 kv were slmulaLed wlLh 9.8 mm of added Al fllLraLlon. 1hese specLra dellvered half-value layers
(ln Al) of 3.8 mm, 7.1 mm, 8.0 mm, and 8.8 mm for 80 kv, 100 kv, 120 kv, and 140 kv, respecLlvely.

1he spreadsheeL allows Lhe compuLaLlon of dose ln Lhe maLerlal (waLer, MMA, or polyeLhylene) aL
Lhe cenLer and Lhe perlpheral holes ln Lhe maLhemaLlcal cyllndrlcal phanLom. 1he daLa used a waLer-
equlvalenL phanLom and were comblned uslng a 1/3 cenLer and 2/3 perlpheral average (l.e., Lqn 2),
Lo esLlmaLe Lhe absorbed dose Lo Lhe paLlenL. 1he sLudy reporLed ln Lhe llLeraLure (Zhou 2008) only
dlscussed a scaLLer lnLegraLlon lengLh of 100 mm, however separaLe spreadsheeL Lools were also
developed for a 10 mm scaLLer lnLegraLlon wldLh as well as an lnflnlLe scaLLer lnLegraLlon wldLh. 1o
slmulaLe Lhe dose for reallsLlc scan lengLhs ln Lhls sLudy, Lhe 100 mm scan lengLh daLa were averaged
wlLh Lhe lnflnlLe scan lengLh daLa, and Lo esLlmaLe Lhe dose Lyplcal for a 20-30 cm scan lengLh, whlch
ls slmllar Lo Lhe values used by Lhe oLher conLrlbuLors ln Lhls reporL.

lor normallzaLlon, Lhe MonLe Carlo deLermlned alr kerma values for Lhe 16 cm and 32 cm MMA
phanLoms were used, ldenLlcal Lo Lhe proLocol for physlcally measurlng C1ul
as dlscussed
prevlously. 1he dose ln waLer (or Llssue) was compuLed as a funcLlon of cyllndrlcal dlameLer and was
normallzed (dlvlded) by Lhe C1ul
compuLed (or measured) ln alr. Pence, Lhe f-facLor for waLer (or

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 8
Llssue) was lmpllclLly lncluded ln Lhese resulLs. 1hls essenLlally ls an f-facLor of approxlmaLely 1.073
mCy [dose] / mCy [alr kerma] or 9.37 mCy / roenLgen.

3. kesu|ts

I|gure 4. 1he normallzed dose coefflclenL for Lhe 32 cm
MMA C1ul
phanLom ls shown as a funcLlon of effecLlve
dlameLer. 1he lndlvldual daLa polnLs correspond Lo four
lndependenL research groups, as lndlcaLed ln Lhe key.
(Mc=McCollough, MC=McnlLL-Cray, 1S=1oLh/SLrauss,
Z8=Zhou/8oone). Scanners represenLed are also lndlcaLed
ln Lhe key (CL=Ceneral LlecLrlc, Sl=Slemens, h=hllllps,
1o=1oshlba, Mx=Mlxed Scanner manufacLurers).
I|gure S. 1he normallzed dose coefflclenL for Lhe 32 cm
MMA C1ul
phanLom ls shown as a funcLlon of effecLlve
dlameLer. Symbols correspond Lo a range of x-ray Lube
volLages from 80 kv Lo 140 kv. 1he besL flL (blue) curve ls
shown. 1he besL flL curve from llgure 4, represenLlng 120
kv only, ls superlmposed on Lhls ploL (red, as labeled). Cood
correspondence ls seen beLween Lhese Lwo curves. 8efer
Lo llgure 4 for legend descrlpLlons.

llgure 4 lllusLraLes Lhe comblned daLa from Lhe four groups, where Lhe 32 cm dlameLer MMA
phanLom was used for Lhe C1ul
normallzaLlon. 1he daLa shown ln Lhls flgure are for 120 kv only.
1he daLa from each group are lndlcaLed by a dlfferenL symbol, as lndlcaLed ln Lhe key and capLlon.
All ploLLed daLa polnLs were comblned and used ln Lhe compuLer flL assumlng an exponenLlal
relaLlonshlp (? = a
) beLween Lhe normallzed dose coefflclenL and effecLlve dlameLer. 1he
compuLer flL ls seen Lo accommodaLe mosL of Lhe lndlvldual polnLs qulLe well, wlLh a correlaLlon
coefflclenL (r
) of 0.942. 1he dashed verLlcal llnes correspond Lo Lhe effecLlve dlameLers of chlldren of
dlfferenL ages, as lndlcaLed on Lhe flgure. 1he daLa polnLs correspondlng Lo Lhe 10 cm locaLlon on
llgure 4 demonsLraLe sllghLly more varlaLlon Lhan elsewhere on Lhe curve. lor Lhls very small
phanLom, Lhe lncreased varlablllLy may be due Lo lncreased dependency on specLral dlfferences
across scanner manufacLurers.

1he daLa complled and demonsLraLed ln llgure 4 represenL Lhe efforLs of four groups, buL prlmarlly
on abdomlnal/pelvlc C1 geomeLrles where Lhe Lorso dlmenslons are comprlsed mosLly of sofL Llssue.
ln regards Lo Lhoraclc C1, however, we refer Lo Lhe work by Puda and coworkers (Puda 2000). ln LhaL
work, paLlenLs who ranged ln effecLlve dlameLer from 12.2 cm Lo 28.6 cm were evaluaLed, and Lhe
correcLlon facLors compuLed from LhaL daLa (6 daLa polnLs) showed an average dlfference of 3.3 ln
comparlson Lo Lhe flL curve shown ln llgure 4. 1he maxlmum dlfference was +16 for Lhe smallesL
paLlenL (12.2 cm). 1hls comparlson ls made Lo demonsLraLe LhaL Lhe converslon facLors presenLed
here are reasonably appllcable Lo chesL, abdomen, and pelvlc C1 sLudles.

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions

llgure 3 lllusLraLes Lhe normallzed dose coefflclenL as a funcLlon of effecLlve dlameLer for Lhe
1oLh/SLrauss (1S) and Zhou/8oone (Z8) daLa. 1he daLa polnLs ln llgure 3 cover x-ray Lube volLages
ranglng from 80 kv Lo 140 kv. 1he Z8 daLa represenL compuLer slmulaLlons for a CL LlghLspeed 16
scanner across 11 dlfferenL cyllnder dlameLers, whlle Lhe 1S daLa are lndlcaLlve of physlcal
measuremenLs made aL 3 dlfferenL phanLom dlameLers buL across a LoLal of 18 dlfferenL C1 scanner
makes and models. 1he besL-flL curve across all daLa polnLs resulLs ln a correlaLlon coefflclenL of 0.973.
Superlmposed on Lhls flgure ls Lhe besL-flL curve from llgure 4, whlch represenLs Lhe daLa polnLs from
all four groups buL for only 120 kv. 1here ls generally good agreemenL beLween Lhe Lwo curves,
however Lhere ls some dlvergence Loward smaller effecLlve dlameLers. 1he equaLlons and flL
coefflclenLs for all perLlnenL graphs are presenLed ln Appendlx A.

Averaged over all daLa polnLs, Lhe average percenL dlfference for Lhe absoluLe value of Lhe
dlfferences beLween Lhe Lwo curves ln llgure 3 ls 3.1. lor Lhe daLa ranglng beLween an effecLlve
dlameLer of 10 cm and 32 cm, Lhe average percenL dlfference ls 4.3. 8ecognlzlng LhaL a mlnorlLy of
pedlaLrlc C1 paLlenLs are below one year of age, lf we ellmlnaLe daLa for effecLlve dlameLers below 13
cm, and lnclude daLa for pedlaLrlc paLlenLs ranglng from 13 cm Lo 32 cm ln effecLlve dlameLer, Lhe
average percenL dlfference beLween Lhe Lwo curves ls only 3.1. 1he small dlfference beLween Lhe
curves deLermlned aL 120 kv and curves deLermlned across all relevanL C1 kv's suggesLs LhaL only one
seL of slze-dependenL facLors ls necessary across Lube volLage and scanner manufacLurer and model
Lo esLlmaLe paLlenL dose from C1ul
. ConsequenLly, lL was felL LhaL Lhe curve lllusLraLed ln llgure 4 ls
sufflclenLly robusL Lo provlde a slngle seL of facLors across boLh scanner Lype and Lube poLenLlal. 1he
flL for daLa from llgure 4 was used lnsLead of LhaL of llgure 3, because lL represenLs a broader cross
secLlon of daLa from four lndependenL groups. 1he flL coefflclenLs for Lhe curves seen ln llgure 4,
Lherefore, were used Lo generaLe Lhe correcLlon facLors found ln 1able 1.

llgure 6 lllusLraLes Lhe normallzed dose coefflclenL for Lhe 16 cm MMA C1ul
daLa as a funcLlon of
effecLlve dlameLer aL 120 kv, and lncludes daLa from Lhree lndependenL groups. Llke Lhe 32 cm
phanLom daLa seen ln llgure 4, Lhe besL-flL curve across all daLa polnLs ln llgure 6 also shows
excellenL agreemenL, wlLh a correlaLlon coefflclenL of 0.967. uue Lo Lhls excellenL flL, and for Lhe
same reasons dlscussed ln Lhe above paragraph, Lhls flL daLa was used Lo generaLe Lhe dose
correcLlon coefflclenLs approprlaLe Lo Lhe 16 cm MMA phanLom. 1hese daLa seLs are presenLed ln
1able 2.

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 10
1ab|e 1. 1hls Lable provldes converslon facLors based on Lhe use of Lhe 32 cm dlameLer MMA
phanLom for C1ul
. 1able 1A shows Lhe converslon facLor as a funcLlon of Lhe sum of Lhe laLeral and
A dlmenslons. 1able 18 shows converslon facLors as a funcLlon of Lhe laLeral dlmenslon, and 1able
1C ls for Lhe A dlmenslon. 1able 1u provldes converslon facLors as a funcLlon of effecLlve dlameLer.
lL ls essenLlal LhaL Lhese daLa be used when Lhe C1ul
reporLed ls known Lo be based on Lhe 32 cm
dlameLer body doslmeLry phanLom.

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 11
1ab|e 2. 1hls Lable provldes converslon facLors based on Lhe use of Lhe 16 cm dlameLer MMA
phanLom for C1ul
. 1able 2A shows Lhe converslon facLor as a funcLlon of Lhe sum of Lhe laLeral and
A dlmenslons. 1able 28 shows converslon facLors as a funcLlon of Lhe laLeral dlmenslon, and 1able
2C ls for Lhe A dlmenslon. 1able 2u provldes converslon facLors as a funcLlon of effecLlve dlameLer.
lL ls essenLlal LhaL Lhese daLa be used when Lhe C1ul
reporLed ls known Lo be based on Lhe 16 cm
dlameLer body doslmeLry phanLom.

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 12

I|gure 6. 1he normallzed dose coefflclenL ls
shown as a funcLlon of effecLlve dlameLer, here
for C1ul
measuremenLs made uslng Lhe 16 cm
d|ameter MMA C1ul
phanLom aL 120 kv. lor
Lhe smaller phanLom, Lhe magnlLude of Lhe
converslon coefflclenLs ls smaller. 1hls ls because
for Lhe same scanner ouLpuL, C1ul

measuremenLs made uslng Lhe smaller 16 cm
dlameLer phanLom resulL ln a numerlcally larger
values for C1ul

llgures 4, 3, and 6 all use Lhe effecLlve dlameLer as Lhe dependenL varlable, however Lhe acLual
effecLlve dlameLer ls usually noL known prlor Lo Lhe C1 scan. lrom Lhe C1 radlograph, however, elLher
Lhe A dlmenslon or Lhe laLeral dlmenslon can be deLermlned from Lhe dlglLal callpers on Lhe C1
scanner console. AlLernaLely, Lhe A or laLeral dlmenslon of Lhe paLlenL can be physlcally measured
uslng callpers deslgned for Lhls purpose. 8ecause of Lhe general avallablllLy of elLher Lhe A
dlmenslon or Lhe laLeral dlmenslon (or boLh) from Lhe C1 radlograph, lL ls useful Lo undersLand Lhe
relaLlonshlp beLween Lhese dlmenslons and Lhe effecLlve dlameLer.

I|gure 7. 1he effecLlve dlameLer as a funcLlon of A
dlmenslon ls lllusLraLed. 1he daLa polnLs from Lhree
sources were used, as lndlcaLed ln Lhe key. A sllghL
downward curvaLure ls seen ln Lhls relaLlonshlp.
I|gure 8. 1he effecLlve dlameLer as a funcLlon of laLeral dlmenslon
of Lhe paLlenL ls lllusLraLed ln Lhls flgure. Pere, a sllghL upward
curvaLure ls seen.

llgure 7 lllusLraLes Lhe effecLlve dlameLer of Lhe abdomen as a funcLlon of Lhe A dlmenslon of Lhe
paLlenL, over a large range of paLlenL slzes. 1he daLa ln Lhls flgure come from Lhree sources: LabulaLed
daLa from lC8u 74, daLa measured from C1 lmages ln a pedlaLrlc hosplLal seLLlng (klelnman 2010),
and daLa measured by 8oone (8oone 20008) uslng C1 lmages ln an adulL lmaglng envlronmenL. 1he
besL-flL curve uslng a second order polynomlal across all daLa polnLs demonsLraLes an excellenL

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 13
correlaLlon coefflclenL of r
= 0.993. lor Lhese daLa, Lhe slope of Lhe curve sllghLly decreases as a
funcLlon of A dlmenslon, resulLlng ln a sllghL downward curvaLure ln Lhe ploL.

llgure 8 lllusLraLes Lhe effecLlve dlameLer as a funcLlon of laLeral dlmenslon, from Lhe same Lhree
daLa sources as lndlcaLed for llgure 7. Pere, a second order polynomlal flLLlng funcLlon also shows
excellenL flL wlLh r
= 0.989. ln Lhls case, however, Lhe slope of Lhe llne lncreases as a funcLlon of
laLeral dlmenslon, resulLlng ln a sllghL upward curvaLure ln Lhe graph.

I|gure 9. 1he effecLlve dlameLer ls shown as a funcLlon of
Lhe sum of Lhe anLerlor posLerlor and laLeral dlmenslons
of Lhe paLlenL. 1he upward and downward curvaLures
lllusLraLed ln llgures 7 and 8 apparenLly compensaLe for
each oLher, resulLlng ln Lhe llnear relaLlonshlp seen here.
I|gure 10. 1he effecLlve dlameLer (ln cm) ls shown as a funcLlon of
age (years). 1hese daLa were compuLer flL uslng Lhe daLa provlded
ln lC8u 74. 1hese daLa are llsLed ln 1able 3 as well.

ln Lhe evenL LhaL boLh Lhe A and laLeral dlmenslons of Lhe paLlenL are known, Lhe sum of Lhese Lwo
dlmenslons can be used Lo esLlmaLe effecLlve dlameLer. 1hls relaLlonshlp ls lllusLraLed ln llgure 9.
uslng daLa from Lhree sources as dlscussed prevlously, a llnear relaLlonshlp ls observed wlLh an
excellenL correlaLlon coefflclenL of 0.999. lL ls lnLeresLlng Lo noLe LhaL Lhls parameLer demonsLraLes a
decldedly llnear relaLlonshlp wlLh Lhe effecLlve dlameLer. 1hus, Lhe upward curvaLure assoclaLed wlLh
Lhe laLeral dlmenslon (llgure 8) comblnes wlLh Lhe downward curvaLure assoclaLed wlLh Lhe A
dlmenslon (llgure 7) Lo produce Lhls llnear relaLlonshlp.

1he flL equaLlons shown ln llgures 7-9 were used Lo generaLe 1ables 1 and 2, where one can use any
of Lhe four dlfferenL lnpuL varlables (Lhe sum of Lhe A and laLeral dlmenslons, Lhe A dlmenslon, Lhe
laLeral dlmenslon, or Lhe effecLlve dlameLer) Lo esLlmaLe Lhe slze-dependenL converslon facLor.

When Lhe paLlenL dlmenslons are noL known, elLher from Lhe cross-secLlonal C1 lmages or a C1
radlograph, Lhe paLlenL age may be known. llgure 10 provldes Lhe lC8u 74 daLa showlng Lhe
relaLlonshlp of paLlenL effecLlve dlameLer Lo age. 1hese daLa can be used Lo converL age Lo effecLlve
dlameLer, whlch ln Lurn can be used ln 1able 1u or 2u Lo esLlmaLe Lhe slze-dependenL facLor Lo
esLlmaLe paLlenL dose from C1ul
. Whlle age may be used as an approxlmaLlon, dose esLlmaLes
based on paLlenL slze are consldered more accuraLe and should be used when slze lnformaLlon ls

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 14
1ab|e 3. 1hls Lable provldes Lhe ablllLy Lo esLlmaLe effecLlve dlameLer as a funcLlon of paLlenL age
(lC8u 74). 8ecause Lhere ls large varlablllLy ln paLlenL slze aL Lhe same age, age should be used only
when slze-based varlables (provlded ln 1ables 1 and 2) are noL avallable. When uslng age, flnd Lhe
correspondlng effecLlve dlameLer ln Lhls Lable, and Lhen refer LhaL Lo elLher 1able 1u (body phanLom)
or 1able 2u (head phanLom) Lo flnd Lhe mosL approprlaLe converslon facLor.

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 1S
4. D|scuss|on
1wo Lables of converslon facLors have been generaLed as a resulL of Lhls work, 1ables 1 and 1able 2.
1able 1 provldes slze-dependenL facLors Lo be applled Lo C1ul
, when Lhe operaLor knows LhaL Lhe
reference phanLom used for reporLlng LhaL C1ul
value ls measured uslng a 32 cm dlameLer MMA
C1ul phanLom. 1able 2 ls Lo be used when Lhe 16 cm MMA dose phanLom ls used. ln general, Lhe
facLors are greaLer Lhan unlLy for effecLlve dlameLers smaller Lhan Lhe reference phanLom (l.e., 32 cm
ln 1able 1, 16 cm ln 1able 2), and are lower Lhan unlLy for larger paLlenLs. lor boLh 1able 1 and 2,
Lhere are secLlons A Lhrough u, allowlng Lhe user Lo deLermlne whlch meLrlc Lo use Lo descrlbe Lhe
approxlmaLe slze of Lhe paLlenL-Lhe LA1 dlmenslon can be used, Lhe A dlmenslon, Lhe sum of A
and laLeral dlmenslons, or Lhe effecLlve dlameLer dlrecLly-whlch Lable ls used depends on whaL daLa
are avallable Lo Lhe user.

lL ls recommended LhaL Lhe Lable Lo be used should be deLermlned by Lhe radlologlsLs and or medlcal
physlclsLs worklng aL an lnsLlLuLlon, and once Lhe proLocol ls deLermlned, Lhe larger Lables should be
Lrlmmed Lo only lnclude Lhe parameLers of lnLeresL aL a glven lnsLlLuLlon-for example, lf Lhe
sLandard proLocol for pedlaLrlc body C1 aL an lnsLlLuLlon ls Lo acqulre a A C1 radlograph, Lhen only
Lhe laLeral dlmenslon lnformaLlon would be avallable Lo Lhe C1 LechnologlsL uslng Lhe dlglLal callpers
on Lhe scanner-ln Lhls example, perhaps only 1able 18 and 28 should be avallable aL Lhe scanner
console, so LhaL Lhe lncorrecL Lable ls noL lnadverLenLly used ln Lhe busy cllnlcal seLLlng.

lurLher, for a glven scanner model and sofLware verslon, lL should be deLermlned wheLher LhaL
scanner uses a 16 cm or 32 cm dlameLer MMA phanLom for lLs C1ul
reporLlng for each C1 proLocol
-lf ln doubL, conLacL Lhe scanner manufacLurer Lhrough Lhelr servlce represenLaLlve and flnd ouL.
Cnce Lhe correcL reference phanLom slze ls deLermlned for each scanner aL Lhe lnsLlLuLlon, use only
one Lable-able 1 for Lhe case of Lhe 32 cm dlameLer phanLom, and 1able 2 for Lhe 16 cm dlameLer
phanLom, for LhaL scanner. ln general, mosL scanners use Lhe 32 cm MMA for C1ul
reporLlng on
all (adulL and pedlaLrlc) body proLocols, buL a few scanner Lypes use Lhe 16 cm daLa for pedlaLrlc body

S. L|m|tat|ons
1he daLa used Lo generaLe Lhe curves correspondlng Lo Lhe daLa ln 1ables 1 and 2 were complled
from four dlfferenL lndependenL research groups. uesplLe Lhe relaLlvely good agreemenL beLween Lhe
daLa, sllghLly dlfferenL meLhods were uLlllzed ln each of Lhe lndependenL groups. Whlle Lhe Lables
address paLlenL cross-secLlonal slze, all of Lhe daLa leadlng Lo 1ables 1 and 2 were generaLed uslng C1
scan lengLhs ln Lhe range from 13 cm Lo 30 cm for phanLoms of dlfferlng dlmenslons along Lhe
longlLudlnal axls (paLlenL helghL). 8ecause C1 dose ls a funcLlon of scan lengLh and paLlenL helghL, Lhe
acLual paLlenL dose resulLlng from slgnlflcanLly dlfferenL scan lengLhs or paLlenL helghLs may dlffer
from LhaL esLlmaLed uslng Lhe accompanylng Lables. 1he meLhods descrlbed ln Lhls documenL elLher
speclflcally modeled Lhe abdomlnal reglon or used homogeneous cyllnders, however comparlsons
wlLh Lhoraclc C1 daLa from Puda (Puda 2000) show LhaL Lhe resulLs provlded here are conslsLenL wlLh
Lhoraclc C1 as well as abdomlnal and pelvlc C1 geomeLrles.

1hls reporL descrlbes a meLhod Lo paLlenL dose from C1ul
LhaL ls reasonable for use ln C1
examlnaLlons of Lhe Lorso (chesL-abdomen and or pelvls). 1hls reporL also dld noL address radlaLlon
dose assoclaLed wlLh Lhe C1 radlograph. ln addlLlon, errors may occur ln regards Lo how Lhe paLlenL

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 16
dlmenslons are deLermlned. lor example, lf Lhe laLeral dlmenslon ls deLermlned from Lhe C1
radlograph, a paLlenL closer Lo Lhe x-ray source wlll pro[ecL a larger lmage Lhan lf poslLloned farLher
from Lhe x-ray source, due Lo magnlflcaLlon lssues. 1hus, values derlved from use of Lhe facLors ln
1ables 1 and 2 should always be consldered as esLlmaLes of paLlenL dose, and wlll be mosL accuraLe
when Lhe paLlenL ls cenLered ln Lhe ganLry.

Many C1 lmaglng proLocols requlre Lhe use of lnLravenous conLrasL agenLs. CfLen mulLlple scans are
made aL Lhe same Llme on Lhe same paLlenL-for lnsLance, pre-and posL-conLrasL lmaglng. 1he
radlaLlon dose Lo Lhe same reglon of Lhe paLlenL ls Lhe sum of Lhe dose from all Lhe C1 scans coverlng
LhaL reglon. Cf course, Lhe absorbed dose from ad[acenL C1 procedures (e.g., abdomen and pelvls)
do nC1 add.

1he dose esLlmaLes uslng C1ul
, coupled wlLh Lhe converslon facLors provlded ln 1ables 1 or 2,
provldes an esLlmaLe of Lhe dose aL Lhe cenLer of Lhe scanned reglon (along z) ln Lhe paLlenL. 1hls
value wlll be sllghLly hlgher Lhan Lhe dose averaged over Lhe enLlre Llssue volume scanned. 1he dose
ls lower aL Lhe beglnnlng of Lhe scan volume, rlses Lo a peak ln Lhe cenLer of Lhe scan volume, and
Lhen decllnes agaln aL Lhe end of Lhe scan volume, Lherefore Lhe average of Lhe enLlre scan ls sllghLly
lower Lhan Lhe peak value esLlmaLed uslng Lhe provlded Lables, whlch occurs aL Lhe mlddle of Lhe
scan volume.

6. Nomenc|ature
1hls reporL represenLs Lhe recommendaLlons of AAM 1ask Croup 204, as well as Lhe C1 reporL
commlLLee of Lhe lnLernaLlonal Commlsslon on 8adlaLlon unlLs and MeasuremenLs (lC8u) and Lhe
Alllance for 8adlaLlon SafeLy ln edlaLrlc lmaglng (parenL group for Lhe lmoqe Ceotly campalgn). lL
was felL necessary LhaL speclflc nomenclaLure be suggesLed ln regards Lo Lhe proposed slze-
dependenL converslon facLors and Lhe esLlmaLed doses LhaL are produced from Lhese facLors. 1he
lnLenL ls Lo permlL conclse reference Lo doses" LhaL are esLlmaLed uslng Lhe meLhods ouLllned ln Lhls
reporL. ln Lhe cllnlcal envlronmenL (such as ln Lhe radlologlsL's dlcLaLed reporL), non-Lechnlcal
language ls necessary. Powever, ln Lhe medlcal physlcs communlLy, speclflc Lermlnology ls essenLlal
Lo clearly deflne Lhe dose measuremenL meLhodology. We address boLh needs ln Lhls secLlon.

1he site-specific dose estimote (SSuL) ls deflned ln Lhls reporL as a paLlenL dose esLlmaLe whlch Lakes
lnLo conslderaLlon correcLlons based on Lhe slze of Lhe paLlenL, uslng llnear dlmenslons measured on
Lhe paLlenL or paLlenL lmages. 1he SSuL values dlscussed ln Lhls reporL are speclflcally based on Lhe
reporLed on C1 scanners, however fuLure modlflcaLlons may lnclude SSuL correcLlon facLors
based on oLher perLlnenL phanLom measuremenLs. lor example, C1 measuremenLs performed on
dlfferenL classes of C1 phanLoms (e.g., AAM 1C-200) and measuremenL proLocols (e.g., AAM
8eporL 111) may provlde Lhe basls from whlch fuLure SSuLs are bullL upon (AAM 2010). ln all cases,
Lhe SSuL should correspond Lo Llssue doses, noL alr kerma or oLher quanLlLles. 1hus, Lhe f-facLors (alr
kerma Lo Llssue dose correcLlon values, formerly known as 8oenLgen Lo 8ad converslon facLors)
should expllclLly be a parL of Lhe SSuL meLrlc.

1able 1 provldes Lhe slze-dependenL facLors perLlnenL Lo Lhe 32 cm dlameLer C1ul
phanLom, Lhese facLors can be represenLed as
f , where Lhe \ refers Lo Lhe speclflc measure of
slze used, where \ = 5 for Lhe sum of A and laLeral dlmenslon, l for laLeral, A for A, and u for

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 17
effecLlve dlameLer. 1hus, Lhe superscrlpLs and correspond Lo Lhe converslon facLors ln
1ables 1A, 18, 1C, or 1u, respecLlvely. So Lhe nomenclaLure
f refers Lo Lhe facLor where a speclflc
laLeral dlmenslon was used wlLh 1able 18 Lo assess Lhe numerlcal value of Lhe slze-dependenL facLor.
When spoken, we recommend Lhe Lerm f-s coefflclenLs" ln referrlng Lo Lhe converslon facLors. lL ls
noLed LhaL flL equaLlons are provlded ln Appendlx A, whlch also allow compuLaLlon of Lhe numerlcal
values glven ln 1ables 1A-u and 2A-u.

When Lhe 16 cm dlameLer C1ul
reference phanLom ls used, Lhe facLors are drawn from 1able 2 and
can be represenLed as
f , where ls deflned as above.

1he speclflc formula Lo esLlmaLe paLlenL dose for a speclflc paLlenL slze ls glven by:

32 32 X
size vol
size specific dose estimate SSDE f CTDI = = ,
LquaLlon 8a

for Lhe 32 cm dlameLer C1ul
reference phanLom, and

16 16 X
size vol
size specific dose estimate SSDE f CTDI = =
LquaLlon 8b

for Lhe 16 cm dlameLer C1ul
reference phanLom.

lor cllnlcal appllcaLlons lL ls noL suggesLed LhaL Lhe equaLlons above be used, buL raLher LhaL Lhe Lerm
site-specific dose estimote or lLs acronym 55u be used Lo lndlcaLe LhaL paLlenL slze was Laken lnLo
accounL accordlng Lo Lhe meLhods descrlbed ln Lhls reporL Lo esLlmaLe paLlenL dose from Lhe
reporLed scanner ouLpuL (C1ul

1he SSuL should noL be used Lo compuLe a modlfled dose lengLh producL (uL). uL = Scan LengLh
(cm) C1ul
(mCy), and should noL be used Lo compuLe effecLlve dose L uslng -facLors.

7. Step-by-Step Lxamp|e of Usage

llgure 11 shows Lwo examples, lllusLraLlng Lhe use of Lhe slze-dependenL facLors provlded ln Lhls

Lxamp|e 1: Dose est|mate after the C1 scan: llgure 11A lllusLraLes a pedlaLrlc paLlenL who was
already scanned, and Lhe dose esLlmaLe afLer Lhe C1 scan should be performed from Lhe C1 lmages, lf
avallable, as C1 lmages have greaLer dlmenslon accuracy compared Lo Lhe C1 radlographs. uslng Lhe
dlglLal callpers ln Lhe lcLure Archlvlng and CommunlcaLlons ln Medlclne (ACS) sysLem, Lhe LA1
dlmenslon was measured Lo be 12.3 cm and Lhe A dlmenslon was 9.9 cm. 1hese Lwo values sum Lo
22.2 cm. 1he C1ul
for Lhls C1 scan was reporLed as 3.40 mCy for a 32 cm reference phanLom.
1able 1 ls used when Lhe reference phanLom dlameLer ls 32 cm. lor a 22 cm sum of Lhe A and
laLeral dlmenslons, 1able 1A shows a correcLlon facLor (
f ) of 2.3. 1herefore, Lhe slze-speclflc dose
esLlmaLe (SSuL) for Lhls paLlenL ls calculaLed as:

5.40 2.50 13 mGy mGy = .

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 18

I|gure 11. 1wo cases used Lo lllusLraLe slze-speclflc dose esLlmaLlon ln C1. llgure 11A lllusLraLes measuremenL of boLh
Lhe laLeral and A dlmenslons, and so Lhe sum of Lhese values ls used wlLh 1able 1A Lo flnd Lhe approprlaLe facLor. ln
llgure 118, Lhe laLeral dlmenslon measured from Lhe A C1 radlograph ls used Lo flnd Lhe converslon facLor ln 1able 28.

Lxamp|e 2: Dose est|mate pr|or to the C1 scan: A A C1 radlograph was acqulred (llgure 118) and
Lhe dlglLal callpers were used on Lhe A C1 radlograph Lo measure a laLeral dlmenslon of abouL
16.8 cm. 1hls measuremenL was made aL Lhe cenLer (along Lhe z-axls, whlch ls deflned as Lhe cranlal-
caudal axls) of Lhe anLlclpaLed C1 fleld. 1he value of C1ul
llsLed on Lhe console was 9.29 mCy, and lL
ls known LhaL Lhe 16 cm dlameLer MMA phanLom was Lhe basls of Lhe C1ul
dlsplay for Lhls
proLocol. When Lhe 16 cm dlameLer MMA phanLom ls used for deLermlnlng Lhe C1ul
value, 1able
2 should be used. 1able 28 lndlcaLes LhaL for a 17 cm laLeral dlmenslon, Lhe correcLlon facLor (
f )
ls 1.08. 1hus, Lhe slze-speclflc dose esLlmaLe (SSuL) for Lhls paLlenL ls:
9.29 1.08 10 mGy mGy = .

8. kecommendat|ons for kad|o|og|st keport|ng
aLlenL dose esLlmaLes are lncluded ln Lhe radlology reporL ln some pracLlces. SuggesLed language
for descrlblng Lhe slze-speclflc dose esLlmaLes (SSuL) calculaLed uslng Lhe meLhods ln Lhls reporL ls
glven below:

1he C1ul
value reporLed on Lhe scanner for Lhe
J2 cm
16 cm
MMA phanLom was used wlLh slze-dependenL facLors obLalned from AAM 8eporL
204. 1he facLor for Lhls paLlenL was based on Lhe paLlenL's

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 19
Al Jlmeosloo
lotetol Jlmeosloo
som of tbe Al ooJ lotetol Jlmeosloo
effectlve Jlometet.
uncerLalnLles assoclaLed wlLh Lhls meLhod are approxlmaLely 20. lor Lhls paLlenL,
Lhe slze-speclflc dose esLlmaLe (SSuL) for Lhls C1 scan ls ____ mCy.

1he language above was suggesLed by pedlaLrlc radlologlsLs.

9. Summary
Clven Lhe relaLlvely good agreemenL beLween Lhe curves generaLed lndependenLly by four dlfferenL
research groups, Lhe converslon facLors provlded ln Lhe accompanylng Lables should provlde Lhe
radlologlsL, worklng wlLh Lhe C1 LechnologlsL, Lhe ablllLy Lo esLlmaLe Lhe average radlaLlon dose Lo a
volume of Llssue for a glven paLlenL ln a cllnlcal seLLlng. uslng one or more of Lhe paLlenL slze lnpuL
parameLers, lL ls anLlclpaLed LhaL Lhe slze-speclflc dose esLlmaLe (SSuL) for each paLlenL can be
esLlmaLed prlor Lo Lhe C1 scan.

lL ls recommended LhaL when ad[usLlng for Lhe slze of paLlenLs, LhaL acLual slze meLrlcs be used when
posslble. ln some cases, slze lnformaLlon ls noL avallable and only Lhe paLlenL's age ls known. ln Lhls
case, lL ls consldered adequaLe Lo lmprove Lhe dose esLlmaLe uslng Lhe daLa shown ln llgure 10,
whlch lllusLraLes effecLlve dlameLer as a funcLlon of (average) paLlenL age. 1able 3 provldes Lhls same
lnformaLlon ln Labular formaL. Powever, lL should be recognlzed LhaL Lhere are wlde varlaLlons ln Lhe
slze of chlldren aL Lhe same age, and so Lhe dose converslon facLors may be less accuraLe uslng Lhls

1he meLhods provlded ln Lhls documenL do noL allow Lhe esLlmaLlon of organ doses pet se, and ln Lhe
absence of organ dose daLa lL ls noL posslble Lo lnfer effecLlve dose (ln mSv) from Lhe meLhods
descrlbed. lor example, lL ls very lmporLanL LhaL Lhe slze speclflc dose esLlmaLe (SSuL) nC1 be used
when esLlmaLlng effecLlve dose ln mSv uslng k-facLors, uslng L (mSv) = k uL = k Scan LengLh
. 1he k-facLors are based upon Lhe uose LengLh roducL (uL), whlch ln Lurn lncludes C1ul
Lhe producL. 1he esLabllshed k-facLors (e.g., AAM 8eporL 96) (AAM 2008) are based on compuLed
organ dose daLa ln adulLs, and lL ls llkely LhaL Lhe organ dose dlsLrlbuLlon wlll be dlfferenL ln smaller
paLlenLs-due Lo self aLLenuaLlon lssues and dlfferences ln how Lhe beam shaplng fllLer lnfluences
organ doses as a funcLlon of paLlenL dlameLer. 1he SSuL meLrlc lmproves Lhe accuracy of Lhe average
dose esLlmaLe, buL lL does noL correcL for dlfferences ln Lhe organ dose dlsLrlbuLlon. 1herefore, Lhe
compuLaLlon of effecLlve dose ls beyond Lhe scope of Lhls efforL. ln addlLlon, Lhe concepL of effecLlve
dose was never lnLended Lo be applled on an lndlvldual paLlenL basls. lf rlsk assessmenL of a speclflc
lndlvldual ls requlred and Lhe organ doses can be esLlmaLed, Lhen Lhe meLhods descrlbed ln Lhe
8Ll8 vll reporL (8Ll8 vll) are recommended for rlsk esLlmaLlon.

1he prlmary purpose of Lhls Lask group and Lhls reporL was Lo glve lmaglng provlders, medlcal
physlclsLs, and C1 LechnologlsLs Lhe ablllLy Lo esLlmaLe radlaLlon dose Lo paLlenLs, Laklng lnLo accounL
paLlenL slze, and uslng elLher Lhe C1ul
lnformaLlon on Lhe scanner console or ln Lhe paLlenL dose
reporL. An lmprovemenL ln doslmeLry accuracy wlll resulL from Lhe use of Lhe accompanylng Lables,

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 20
compared Lo use of scanner ouLpuL as a surrogaLe for paLlenL dose. Powever, Lhe resulLlng dose
values musL sLlll be recognlzed as esLlmaLes only. lL ls llkely LhaL even when paLlenL slze ls Laken lnLo
accounL, Lhe acLual dose Lo any glven paLlenL may dlffer from Lhe value calculaLed uslng Lhls reporL by
10 Lo 20. 8ecause of Lhls, lL ls essenLlal Lo refer Lo Lhe numbers generaLed uslng Lhls documenL as
dose estlmotes, and noL as dose colcolotloos. users are also remlnded Lo use an approprlaLe number
of slgnlflcanL flgures ln reporLlng dose esLlmaLes. Speclflcally, lL ls suggesLed LhaL for dose esLlmaLes
above 3 mCy (e.g., 8 or 17 mCy) only lnLeger values of dose esLlmaLes be reporLed and for dose
esLlmaLes below 3 mCy (e.g., 3.6 or 4.7 mCy) only one dlglL beyond Lhe declmal polnL be reporLed.

Append|x A: ert|nent Lquat|ons

1here are several perLlnenL equaLlons LhaL descrlbe Lhe resulLs of Lhls work.

lor llgures 4, 3, and 6, Lhe exponenLlal equaLlon ls glven by:

y a e

= ,
LquaLlon A-1

where Lhe coefflclenLs are glven ln Lhe Lable below:

I|gure Number k parameter parameter a b
4 Lff. ulameLer (cm) Converslon lacLor 3.704369 0.03671937
3 Lff. ulameLer (cm) Converslon lacLor 4.378094 0.04331124
6 Lff. ulameLer (cm) Converslon lacLor 1.874799 0.03871313

lor llgures 7, 8, and 9, a second order polynomlal equaLlon ls used. (1he equaLlon ln llgure 9 ls
acLually a flrsL order polynomlal equaLlon-l.e., a llnear flL). 1he equaLlon ls glven by:

y a bx cx = + + ,
LquaLlon A-2

where Lhe values of Lhe a, b, and c coefflclenLs are glven ln Lhe Lable below:

I|gure Number
k parameter parameter a b c
7 A dlam (cm) Lff. ulameLer (cm) -3.744838L0 1.671734L0 -1.338933L-2
8 LA1 dlam (cm) Lff. ulameLer (cm) 3.899298L0 3.270494L-1 9.978896L-3
9 A + LA1 dlam (cm) Lff. ulameLer (cm) -2.03128eL-1 4.938912L-1 0

1he daLa shown ln llgure 10 show Lhe effecLlve dlameLer as a funcLlon of paLlenL, age, compuLed
from lC8u 74. 1he compuLer flL for Lhls relaLlonshlp was glven by:

1.5 0.5 x
y a b x c x d e

= + + +
LquaLlon A-3

a = 18.788398
b = 0.19486433
c = -1.060036
d = -7.6244784.

44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions age 21
keferences and Cther kead|ng
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8eporLlng and ManagemenL of 8adlaLlon uose ln C1 (8eporL #96). AAM 1ask
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8auhs 2008 8auhs !A, vrleze 1!, rlmak An, 8ruesewlLz M8, McCollough CP. C1 doslmeLry:
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44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions
Puda 2000 Puda W, ScalzeLLl LM, 8oskopf M. LffecLlve doses Lo paLlenLs undergolng
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McnlLL-Cray 2002 McnlLL-Cray Ml. AAM/8SnA hyslcs 1uLorlal for 8esldenLs: 1oplcs ln C1.
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44PM keport 204: 5ite-5pecific uose stimotes {55u) in Pediotric ond 4du/t c1 xominotions
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