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Establishment of typical adult CT dose indicators for PET-CT scans in

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 Journal of Radiological Protection

J. Radiol. Prot. 41 (2021) 552–563 (12pp) https://doi.org/10.1088/1361-6498/ac025a

Establishment of typical adult CT dose

indicators for PET-CT scans in Slovenia
Jelena Perić1, Nejc Mekiš2 and Dejan Žontar3,4,∗
1
Institute of Oncology Ljubljana, Nuclear medicine department, Zaloška cesta 2,
Ljubljana, Slovenia
2
University of Ljubljana, Faculty of Health Sciences, Medical Imaging and
Radiotherapy Department, Zdravstvena pot 5, Ljubljana, Slovenia
3
Slovenian Radiation Protection Administration, Ajdovščina 4, Ljubljana, Slovenia
4
Jožef Stefan Institute, Jamova 39, Ljubljana, Slovenia

E-mail: [email protected]

Received 30 March 2021; revised 4 May 2021

Accepted for publication 18 May 2021
Published 19 August 2021

Abstract
The aim was to determine typical values of diagnostic reference level (DRL)
quantities for the computed tomography (CT) part of the most common positron
emission tomography—computed tomography (PET-CT) procedures in Slov-
enia. The most common PET-CT procedures were identified, and data collated
for 565 patients imaged in all three PET-CT units in Slovenia during a time span
of 11 months. As the number of facilities is too low to establish national DRLs,
we followed ICRP recommendations and determined typical values of DRL
quantities as the median values of the pooled set of data. Mean, median, and
standard deviation of CT dose index (CTDIvol ) and total dose length product
(DLP) for the CT part of the most common PET-CT procedures were determ-
ined for pooled data as well as for each PET-CT unit. The data were compared
between all three units to identify possible outliers that would likely benefit
from optimization. Three most common CT protocols covering approximately
2/3 of all PET-CT imaging performed in Slovenia were considered: from the
base of the cranium to the middle of the femur, from the top of the head to the
middle of the femur, and for the whole-body PET-CT. The established typical
values in terms of total DLP were 295, 359, and 676 mGy∙cm, respectively;
and in terms of CTDIvol 3.05, 3.22, and 3.60 mGy, respectively. Comparing
the data between all three units showed significantly higher (p < 0.001) patient
doses on one unit, indicating a need for optimization. The results present the
first-time data on the national typical values of DRL quantities for the CT
part of most common PET-CT procedures in Slovenia. While the determined
typical values are within the DRL values established in some other countries,

∗
Author to whom any correspondence should be addressed.

© 2021 Society for Radiological Protection. Published on behalf of SRP by IOP Publishing Limited. All rights reserved
1361-6498/21/+12$33.00 Printed in the UK 552
J. Radiol. Prot. 41 (2021) J Perić et al

significant differences were found between the individual units included in the
study.

Keywords: computed tomography, NDRL, PET-CT, CT, optimization

1. Introduction

Positron emission tomography (PET) is a tomographic imaging technique that provides non-
invasive quantitative assessment of biochemical and functional processes. While it provides
valuable functional information, it offers very little information about an anatomical structure.
Hybrid systems overcome this problem and provide information for attenuation correction that
is crucial for PET image reconstruction. The most common is a combination of PET and com-
puted tomography (CT) [1]. However, adding CT imaging to a PET examination significantly
increases the radiation dose delivered to the patient [2–4]. High doses received by patients
from hybrid imaging increase the importance of proper optimization of imaging protocols [5].
The International Commission on Radiological Protection (ICRP) has implemented dia-
gnostic reference levels (DRLs) for radiological imaging procedures [5, 6]. The DRL process
has proven to be an effective tool that aids in the optimization of protection in the medical
exposure of patients for diagnostic and interventional procedures. DRLs do not represent dose
limits but are used as a tool to discover the need for exposure optimization for standardized
patients. When two imaging modalities are used for the same procedure, as in SPECT-CT and
PET-CT, it is appropriate to report values for both modalities independently [5]. DRL values
are not static and should be updated regularly, even more so when new imaging modalities
are introduced or when there is a change in technology. CT protocols in PET-CT imaging are
commonly used for attenuation correction and anatomical localization. Appropriately optim-
ized protocols for these purposes result in a different patient exposure than in diagnostic CT
imaging, justifying the establishment of a separate set of DRL values [5].
DRLs are a form of investigation level used to aid in the optimization of protection in
the medical exposure of patients for diagnostic and interventional procedures [5]. While well-
established in diagnostic radiology, in many countries, DRLs for the CT part of multi-modality
examinations in nuclear medicine were recently established or are still to be determined. Con-
sequently, the related data and reliable reference values regarding patient exposure are still
relatively scarce. The purpose of this study was to perform a national survey of CT doses in
PET-CT examinations and establish typical values of DRL quantities for the CT part of the
most common PET-CT procedures in Slovenia. This goal is in line with other nations’ trends
to identify national DRLs for CT in hybrid imaging [3, 4, 7–11]. The results were compared
with other published studies to discover a potential need for optimization.

2. Materials and methods

A retrospective study with secondary data analysis was performed. The National Medical Eth-
ics Committee approved the study, and all personal data that could lead to patient identification
were anonymized prior to the study. Data were collected from hospital records by the authors
of this study and entered into a custom Excel spreadsheet.
All three departments with PET-CT units in Slovenia, with one PET-CT unit each (two
Siemens Biograph mCT 40 units and one Siemens Biograph mCT 128 unit) were included in
the study. The units were marked as follows: Siemens Biograph mCT 40 in hospital 1 as ‘Unit
1’, Siemens Biograph mCT 128 in hospital 2 as ‘Unit 2’, and Siemens Biograph mCT 40 in

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hospital 3 as ‘Unit 3’. In total, data were collected for 565 patients imaged in the time span
from 1st of March 2109 until the 30th of January 2020.
At the beginning of the study, we performed a review of the common CT protocols used
in PET-CT procedures in Slovenia. It was found that PET-CT procedures using CT protocols
for diagnostic imaging represent a small proportion (approximately 10%) of PET-CT proced-
ures in Slovenia. Therefore, they were not included in this study. Furthermore, 18 F-FDG
imaging was found to represent the vast majority (almost 90%) of procedures. Consequently,
only 18 F-FDG imaging procedures using CT protocols for attenuation correction and anatom-
ical localization were included in the study. Three standard CT protocols used in 18 F-FDG
PET-CT were identified:

(a) base of cranium to mid-femur,

(b) cranial vertex to mid-femur and
(c) whole-body (from the top of the head to toes).

The most common indications related to the PET-CT investigations that include one of these
three CT protocols are, respectively:

(a) different types of lymphoma cancer and cancer staging in patients that already had head
CT,
(b) different types of lymphoma cancer, cancer staging, treatment response assessment, sus-
picion of paraneoplastic syndrome (PNS), origo ignota and head and neck region and
(c) different types of melanoma cancer and fever of unknown origin (FUO).

PET-CT procedures that use one of these three CT protocols account for approximately 2/3
of all PET-CT imaging performed in Slovenia. Thus, they were determined as the standard CT
protocols used in PET-CT examinations in Slovenia and included in the study.
Data were collected for patients who were older than 18 years and whose body mass ranged
from 70 to 90 kg. Patient demographics such as height and weight; CT acquisition parameters
such as acquisition type, tube voltage, reference tube current, collimation, use of automatic
exposure control, rotation time, pitch, slice thickness, and reconstruction kernel; CT dosimetry
values (total dose length product (DLP) and CT dose index (CTDIvol )) and exposure parameters
were collected for all three PET-CT units. Calibration of the DLP and CTDIvol values provided
by each PET-CT unit is regularly checked by qualified medical physicists as part of the annual
technical QC. The exposure parameters for the CT part of the examination are listed for each
device in table 1.
The same patient positioning was used on all three units: for imaging protocols from the
base of cranium to mid-femur and cranial vertex to mid-femur the patient position is supine
with the hands raised above the head, whilst for the whole-body imaging the patient is supine
with the hands placed along the body. Patients imaged in non-standard positions were excluded
from the study (approximately 3% for the whole-body protocol; approximately 7% for imaging
protocol cranial vertex to mid-femur and approximately 5% for the imaging protocol base of
cranium to mid-femur).
According to ICRP recommendations [5], national DRLs are set as the 75th percentile of the
distribution of the median values of the DRL quantity collected from a representative sample of
healthcare facilities covering an entire country. However, with only three PET-CT systems cur-
rently used in Slovenia, the acquired data sample was insufficient to establish national DRLs
according to the recommended methodology. According to ICRP, where the number of facilit-
ies is small, the ‘typical value’ of a DRL quantity is recommended to be set to encourage further

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Table 1. Scanning parameters of the protocols on each PET-CT unit.

Tube Slice
Acquisition voltage Refe-rence Collimation Rotation thickness Reconstruction
Unit Model type (kV) (mAs) (N × mm) AEC Time (s) Pitch (mm) kernel

1 Siemens Topogram 100 35 — — — — 0.6 —

Biograph Helical 100/120/140 200 16 × 1.2 mm Care 1 0.8 1.2 B19 LowDose
mCT 40 kV and (IR)
CARE
Dose4D

555
2 Siemens Topogram 120 35 — — — — 0.6 —
Biograph Helical 100/120 200 16 × 1.2 mm Care 1 0.8 1.2 B19 LowDose
mCT 128 kV and (IR)
CARE
Dose4D
3 Siemens Topogram 120 35 — — — — 0.6 —
Biograph Helical 120 200 16 × 1.2 mm CARE 1 0.8 1.2 B19 LowDose
mCT 40 Dose4D (FBP)
IR—iterative reconstruction (SAFIRE); FBP—filtered back projection.
J Perić et al
J. Radiol. Prot. 41 (2021) J Perić et al

optimization in a similar manner to DRLs. Typical values are determined as the median value
of the distribution of the values of the DRL quantity. In this study, we thus substituted national
DRLs with a determination of national typical values of the DRL quantities for the selected
procedures. They were determined as the median of the pooled distribution of the relevant
quantity (DLP and CTDIvol ) for all three PET-CT units in the country. The influence of vari-
ous methodologies and sample sizes on the DRL value was investigated by [12] and should be
considered when making comparisons with DRLs established in other countries.
To ensure that data samples from all three hospitals included in the study were comparable,
body mass index (BMI) distributions of the patients on each unit were compared to each other.
Besides establishing the typical values as medians of the pooled data, dose values (total DLP
and CTDIvol ) from all units were also compared to each other to identify important outliers
that could benefit most from optimization.
Data were analysed using IBM SPSS STATISTICS 26.0 software (IBM Corp., NY, USA).
Descriptive statistical analysis was performed, calculating the mean, standard deviation,
median, 1st and 3rd quartile for each procedure for CTDIvol and total DLP value. The collated
data for total DLP and CTDIvol values were compared between pairs of CT units to search for
outliers that might indicate a need for optimization. Shapiro-Wilk test was used to check for
normal data distribution. Kruskal–Wallis test with post hoc Dunn–Bonferroni pairwise com-
parison was used to search for differences between PET-CT units. A significance of p < 0.05
was used for all tests.

3. Results

In total, data for 565 patients imaged by CT protocols for attenuation correction and anatomical
localization were analysed. For the imaging protocol from the base of cranium to mid-femur
the total sample size was 178 (58—Unit 1, 60—Unit 2, 60—Unit 3), for whole-body protocol,
the total sample size was 190 (62—Unit 1, 61—Unit 2, 67—Unit 3), and for the imaging
protocol from the cranial vertex to mid-femur the sample size was 197 (76—Unit 1, 61—Unit
2, 60—Unit 3).
First, we have tested the BMI (the input data) to assure that the data samples from all
three hospitals are comparable and that there are no differences in dose caused by different
patient sizes. Summarized information about the BMI of the patient groups for each hos-
pital is provided in table 2. The statistical analysis (Kruskal–Wallis test) showed no statist-
ically significant differences in BMI distributions of the patients comparing all three units
for the protocols from cranial vertex to mid-femur (p = 0.492) and for the whole-body pro-
tocol (p = 0.336). Statistically significant differences were found when comparing the BMI
of the imaging protocol from the base of cranium to mid-femur (p < 0.001) in which the post
hoc Dunn-Bonferroni pairwise comparison showed a difference between Unit 1 and Unit 2
(p = 0.008) and Unit 2 and Unit 3 (p < 0.001). There were no differences in BMI comparison
between the Unit 1 and Unit 3 (p = 0.788). When we inspected the average and median values
of BMI, we found that patients for this scanning protocol on Unit 2 had by approximately 3%
lower BMI than on the other two units. While statistically significant, the difference is minimal
and is not expected to influence the validity of the findings and their interpretation.
The typical values of the DRL quantity for each of the three CT protocols included in the
study are presented in table 3 in terms of total DLP and CTDIvol . Next, we compared the values
of total DLP (table 4) and CTDIvol (table 5) values for all three units for each examination pro-
tocol separately to determine if any of the protocols on any specific unit leads to significantly
higher patient doses.

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Table 2. Mean and standard deviation values of BMI for patient groups on each PET-CT
unit.
PET-CT protocol Unit 1 Unit 2 Unit 3

Cranial vertex to mid-femur 27.09 ± 2.73 26.62 ± 3.11 26.99 ± 2.31

Whole-body 27.05 ± 2.82 26.58 ± 3.46 27.21 ± 2.90
Base of cranium to mid-femur 26.41 ± 2.57 25.02 ± 2.79 26.99 ± 2.22

The results of the statistical analysis (pairwise comparison) for total DLP and CTDIvol show
that for the imaging protocol from the cranial vertex to mid-femur differences between the
individual units are statistically significant (p < 0.001).
When examining the whole-body protocol, the pairwise comparison showed statistically
significant differences between Unit 1 and Unit 2 and for the comparison between Unit 2
and Unit 3 in both parameters examined (DLP and CTDIvol ) (p < 0.001). The comparison
between Unit 1 and Unit 3 showed no statistically significant difference in the studied para-
meters (p = 0.584—DLP; p = 0.612—CTDIvol ).
For the last protocol called base of cranium to mid-femur the statistical analysis showed
significant differences between all three units, when comparing DLP and CTDIvol; Unit 1 and
Unit 3 (p < 0.001), Unit 2 and Unit 3 (p < 0.001), Unit 1 and Unit 2 (p = 0.032; p = 0.003).
For protocol from the base of cranium to mid-femur, the lowest median value was found
on Unit 1 for both DLP (261 mGy∙cm) and CTDIvol (2.62 mGy). On Unit 2 the median values
of DLP and CTDIvol were higher by 5% and 8%, respectively. The highest values were found
on Unit 3, with both DLP and CTDIvol values higher by 80% compared to Unit 1.
For the imaging protocol from cranial vertex to mid-femur, the lowest median values were
again found on Unit 1 (297 mGy∙cm for DLP and 2.64 mGy for CTDIvol ). The values on Unit
2 were again somewhat higher, by approximately 20% for both quantities. Again, the highest
values were found on Unit 3 on which both values were approximately 70% higher compared
to Unit 1.
In the whole-body protocol, the lowest values were observed on Unit 2 (556 mGy∙cm for
DLP and 2.95 mGy for CTDIvol ). The values on Units 1 and 3 were higher by approximately
30%, with no statistically significant difference found between Units 1 and 3.

4. Discussion

This study presents the results of a systematic review of patient doses from three frequent
CT protocols for attenuation correction and anatomical localization used in 18 F-FDG PET-CT
imaging in Slovenia. It encompasses all three PET-CT units in the country, providing a good
basis for identifying the institutions where investigation of the potential for optimization would
be advisable. The procedures included in the study represent approximately 2/3 of all PET-CT
procedures performed in Slovenia.
After we determined the national typical values of the DRL quantities for each of the selec-
ted protocols to be used in the DRL process on the national scale we conducted a comparison
with the available data from other countries (table 6), paying attention to match our values with
reasonably comparable protocols. It should also be considered that due to the small number of
facilities in Slovenia our reference values were established as ‘typical doses’, i.e. as a median
of the pooled data, while national DRLs are determined as the third quartile of the distribution
of median values. Therefore, the typical values of the DRL quantities in Slovenia are expected
to be lower than the national DRL (NDRL) values in other countries.

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Table 3. Mean, standard deviation, 1st, and 3rd quartiles, and median values for total DLP and CTDIvol based on combined data from all three
PET-CT units. The median values represent the national typical values.
DLP CTDIvol

PET-CT protocol Mean [st. dev.] Median = national Mean [st. dev.] Median = national
(mGy∙cm) typical value [Q1; Q3] (mGy∙cm) typical value [Q1; Q3]

558
(mGy∙cm) (mGy∙cm)
Base of cranium to mid-femur 340 [103] 295 [262; 434] 3.45 [1.05] 3.05 [2.67; 4.52]
(n = 178)
Cranial vertex to mid-femur 389 [111] 359 [309; 451] 3.51 [1.09] 3.22 [2.74; 4.01]
(n = 197)
Whole-body (n = 190) 692 [144] 676 [596; 785] 3.75 [0.91] 3.60 [3.14; 4.25]
J Perić et al
 J. Radiol. Prot. 41 (2021)

Table 4. Comparison of mean, median, 1st and 3rd quartile values for total DLP between all three PET-CT units.

National typical
PET-CT protocol Data Unit 1 (mGy∙cm) Unit 2 (mGy∙cm) Unit 3 (mGy∙cm) value (mGy∙cm)

Base of the cranium to Average 260 287 470 295

mid-femur Median 261 275 468
Standard deviation 28 36 57
1st quartile 240 261 433
3rd quartile 277 305 504
Cranial vertex to Average 301 371 520 359

559
mid-femur Median 297 360 508
Standard deviation 36 61 87
1st quartile 271 328 446
3rd quartile 325 399 586
Whole-body Average 766 569 734 676
Median 749 556 709
Standard deviation 128 88 128
1st quartile 669 510 637
3rd quartile 854 641 810
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 J. Radiol. Prot. 41 (2021)

Table 5. Comparison of mean, median, 1st and 3rd quartile values for CTDIvol between all three PET-CT units.

National typical
PET-CT protocol Data Unit 1 (mGy) Unit 2 (mGy) Unit 3 (mGy) value (mGy)

Base of the cranium to the Average 2.60 2.94 4.78 3.05

mid-femur Median 2.62 2.84 4.73
Standard deviation 0.31 0.35 0.56
1st quartile 2.35 2.74 4.45
3rd quartile 2.82 3.12 5.23
Cranial vertex to Average 2.70 3.25 4.82 3.22

560
mid-femur Median 2.64 3.22 4.54
Standard deviation 0.38 0.42 0.94
1st quartile 2.43 2.92 4.07
3rd quartile 2.94 3.48 5.46
Whole-body Average 4.21 2.98 4.01 3.60
Median 4.04 2.95 3.84
Standard deviation 0.84 0.47 0.84
1st quartile 3.58 2.61 3.38
3rd quartile 4.58 3.37 4.43
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J. Radiol. Prot. 41 (2021) J Perić et al

Table 6. Comparison of our national typical values of DRL quantities with national
DRLs from some other countries.
PET-CT protocol Country CTDIvol (mGy) DLP (mGy.cm)

Form the base of cranium Slovenia 3.05 295

to mid-femur Australia [13] 325
From cranial vertex to Slovenia 3.22 359
mid-femur Bulgaria [9] 4.00 392
France [11, 14] 6.60 628
Swiss [8] 4.40 416
UK [10] 3.40 326
Australia [13] NA 540
Australia [4] 4.41 474
Korea [3] 4.60 429
Whole-body Slovenia 3.60 676
Australia [13] NA 985
France [11] 8.00 750
Swiss [8] 5.00 720
Korea [3] 5.96 560
New Zealand [4] 13.07 1319

For the CT part of the PET-CT protocol from the base of cranium to mid-femur, we only
found an NDRL value for a comparable protocol in Australia [13]. It can be seen that our typ-
ical value of DLP is 10% lower than the corresponding Australian NDRL. A NDRL value
in terms of CTDIvol was not provided in the available sources. While only one reference
value does not provide a basis for reliable conclusions, the typical value in Slovenia appears
adequate.
For PET/CT protocol from cranial vertex to mid-femur, the established typical values were
lower than in most other countries [3, 4, 7–11, 14]. The available NDRLs of the reviewed
countries were found to be higher than our values by a few percent up to more than twofold.
The exception was the UK [10], where the NDLR in terms of DLP was lower by 10% compared
to our typical value. It has to be noted that values from the Swiss study [8] were determined
as the 3rd quartile of the pooled data and not as the 3rd quartile of median values as proposed
by the ICRP 135 [5].
The situation is similar for the whole-body protocols, where our typical value of CTDIvol is
significantly lower than all listed NDRLs. In terms of DLP, our typical value was lower than in
most other countries [4, 7–9], except for Korea, where the NDLR in terms of DLP was lower
by 15% compared to our value [3].
The typical doses established for localization and attenuation correction protocols should
not be compared to DRLs for diagnostic CT protocols that seem to be predominantly used in
some countries, e.g. Japan [15]. When comparing DRLs, one should also consider differences
in standards for the size of the imaged area. While in Slovenia, the imaged area extends to
mid-femur or even to the knees, in many countries, the scan is extended only to the first third
of the femur. The differences have also been observed in the start position, which in Slovenia is
at cranial vertex while in some countries, the scan starts at the base of the skull. This explains
why our national typical values of DLP compare somewhat less favorably with the reviewed
NDRLs than they do in terms of CTDIvol . Regardless, one can conclude that the determined
national typical values for Slovenia are mostly below the reviewed NDRLs.

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Comparison of the DLP and CTDIvol values in the three analysed PET-CT units in Slove-
nia showed considerable differences between the institutions. All protocols on Unit 3 and the
whole-body protocol on Unit 1 were identified as clear candidates for a systematic review.
Based on the available information the high doses on Unit 3 can be partially attributed to the
use of Filtered Back Projection reconstruction algorithm instead of the Iterative Reconstruc-
tion used in units 1 and 2. The influence of the image reconstruction method on the image
quality and consequently on the patient dose has been extensively studied by other authors,
e.g. [16–19]. However, optimization should be concerned with maintaining the diagnostic
information while seeking to reduce patient exposure. A detailed assessment of specific CT
protocols in each participating hospital was beyond the scope of this study. A detailed review
of the protocols and their optimization is the responsibility of each hospital and should be
performed locally [20].
The first systematic study of the values of DRL quantities for the CT part for the most com-
mon PET-CT procedures in Slovenia was performed. Typical values of CTDIvol and DLP were
determined as a median of the pooled data of the DRL quantity using the ICRP methodology
for a small number of facilities. The findings of the statistical comparison between the included
hospitals are consistent with the comparison of the local median values with the established
national typical value for each CT protocol. This confirms the usefulness of the ‘typical value’
approach in situations where national DRLs cannot be established due to a low number of
facilities. The authors suggest that the national typical values are used as a substitute for the
national DRL values as a tool for optimization in the DRL process as defined by the ICRP.

Conflict of interest

The authors declare no conflict of interest.

ORCID iD

Nejc Mekiš  https://orcid.org/0000-0002-9438-7415

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