Establishment of Facility Diagnostic Reference Levels for Head, Chest and

Abdominal CT.
Abdul Saeed Shah [Link]., Ghulam Ghaus Shah FCPS, Aman Nawaz Khan FRCR, Umara Siddique Umer FCPS &
Hadia Abid FCPS.

Department of Radiology, Rehman Medical Institute, 5/B-2, Phase-5, Hayatabad Peshawar,

Pakistan.
Introduction.
The medical use of ionizing radiation is increasing with invention and development of advance modalities
since the discovery of X-rays in late nineteenth century. The introduction of Computerized Tomography (CT)
has become a power full diagnostic tool in medical imaging. But the radiation dose delivered to the patient
(1,2)
by CT procedure is many fold than general radiography . Although the number of CT procedures
performed annually is low but its contribution to medical radiation exposure is more as compared to other
radiological modalities (3). The high radiation doses associated with CT necessitates to avoid and reduce its
unnecessary use and protect the patients by restricting CT scan parameters without compromising image
quality in justified medical exposure applications. The International Commission on Radiological Protection
(ICRP) recommends radiation protection system for medical usage of ionizing radiations – Justification,
Optimization and Dose constraint (4). The element of Justification is taken care in the decision making stage
by the radiologists and prescribing clinicians before the actual execution of diagnostic or therapeutic
exposures. However, for a justified practice, optimization is the next step that can minimize radiation
exposure to the patient. The CT dose optimization is achieved by selecting appropriate scanning protocols
with reference to patient age, size and weight to minimize X-ray radiation doses. The Diagnostic Reference
levels (DRLs) concept was introduced by ICRP in 1990 and its implementation was recommended in the ICRP-
(5)
60 and ICRP-73 to optimize medical imaging practices . The easily and reproducibly measured dosimetry
quantities recommended for the establishment of DRLs are volumetric CT Dose Index (CTDI vol) for one slice
and Dose Length Product (DLP) for whole coverage volume (6,7). The DRLs are an advisory measure to improve
optimization of patient protection by identifying high patient dose levels which might not be justified on the
basis of image quality requirements. The DRLs do not apply to individual patients and are derived as an
arbitrary threshold from radiation metrics data obtained locally and collected nationally, regionally or
institutionally. The DRLs supplement the professional judgment and does not provide a dividing line
between good and bad medical radiation oriented practices. All individuals who had a role in medical
exposure need to be familiar with DRLs as a tool for optimization of protection.
In Pakistan Nuclear Regulatory Authority (PNRA) is responsible for setting National Diagnostic Reference
Levels (DRLs). The PNRA had recommended diagnostic reference levels for various radiology examinations (8).
The present study was conducted to determine Facility Diagnostic Reference Levels (FDRLs) for adult head,
chest and abdominal CT examinations from radiation dose parameters of routine patients and to compare it
with available national and international CT DRLs.
Material & Methods.
The data of adult patient’s head, chest and abdomen CT scans performed at RMI radiology department on
128 slice CT system (Toshiba Aquilion CX, NCB1272405) was used in this study to evaluate Facility Diagnostic
Reference Levels (FDRLs) for these examinations. The CTDI vol and DLP are radiation dose output parameters
directly taken from patient protocol and were recorded in structured format for the period from 1 st
September 2023 to 30th April 2024. The data values were confirmed where required from local picture
archive communication system (PACS). The data were saved in a Microsoft Excel spreadsheet and
categorized for the examination parameters and anthropometric parameters. Effective Dose (ED) was
(9,10)
calculated by multiplying conversion coefficient of each body region with corresponding DLP values. .
Statistical analysis was performed using IBM SPSS 20 to determine CTDI vol and DLP mean, median maximum,
minimum and standard deviation values. The 1st, 2nd and 3rd percentile CTDIvol and DLP values were
determined. Finally, the facility DRLs were determined as the third quartile of median values of CTDI vol and
DLP for the CT examinations of head, chest, and abdomen scans of adult patients.
Results.
Over all 3333 CT scans were performed during the period from 1 st September 2023 to 30th April 2024
including 503 head (15%), 204 chest (6%) and 612 abdominal scans (18%). The mean +SD age of the patients
who underwent head, chest and abdominal CT was 49.18±19.4, 51.701±7.5 and 47.6±17.6 respectively.
Median CTDIvol values were 41.9mGy (IQR, 46.35-41.9mGy) and 29.5mGy (IQR, 29.5-28.3mGy) and 29.5mGy
(IQR, 42.98-29.5mGy) for head, chest and abdomen respectively. The median DLP values determined for
head were 810 [Link] (IQR, 931.6-768.5 [Link]), chest 1220 [Link] (IQR, 1312.9-1031.45 [Link]) and
abdomen 1694.5 [Link] (IQR 22.47-1529.68 [Link]) respectively. Median ED values were as follow: head
1.7mGy (IQR, 1.96-161mGy), chest 17.08mGy (IQR, 18.38-14.44mGy) and abdomen 25.42mGy (IQR, 33.71-
22.95mGy). The first, second and third quartile values determined for sample CTDI vol, DLP and ED are listed in
Table1-3).
The CTDIvol value determined for head were lower than national, European, US, Australian and UK DRLs
values. However, the CTDIvol values found for abdomen were higher as compared to national, EU, USA,
Australian and UK DRLs values. The CTDI vol values for chest are not recommended by the national regulatory
body (PNRA) and these values were found higher than other international DRLs quoted above Table4.
Discussions.
The CTDIvol and DLP dose parameters of CT examinations are universally used for comparison with national
and international DRLs and to determine whether the facility radiation parameters are within the reference
recommended range. DRLs are established as 75th percentile of a dose distribution of patient doses for
typical ionizing radiation oriented examination. The establishment of DRLs had been proved to be useful tool
(11-
in standardization and optimization of radiation doses received from common medical imaging protocols
16)
. The data for CT examinations DRLs in Pakistan is scare and national regulatory authority had
recommended DRLs for some CT investigations (8,17).
This is an initial study for the description of facility DRLs for head, chest and abdomen procedures. Statistical
values of CTDIvol, DLP and ED used for comparison are Median and Third Quartile, because they are the
mostly commonly statistical variables used in current the literature. The evaluated FDRLs for head CTDI vol and
DLP are in agreement with the National, European, USA, and Australian DRLs. The facility DRLs determined
for chest and abdomen are higher than the UK, European, USA and Australian DRLs for these examinations
Table 4. The CTDIvol FDRL for abdomen are higher than the national DRL while DRL for chest and abdomen
DLP are not recommended by the national regulatory body to date. The determined DRLs do not provide a
dividing line between good and bad practice. Neither indicate or suggest an ideal dose for a particular
procedure nor an absolute upper dose limit. The initial national surveys carried out in United Kingdom and
other European countries reported variations by a factor of 20 or more (18,19).
The effective doses determined are relatively high, necessitating optimization of chest and abdomen CT
examinations Table 5. The comparison of effective dose values has been provided as it is more commonly
understood dose metric as compared to DLP and CTDI vol. However, CTDIvol and DLP are more easily and
reproducibly measured metrics in CT investigations.
The establishment of these facility DRLs will provide a base lines for future dose reduction strategies used for
standardization and radiation doses optimization in CT imaging protocols. This study will also help in
promoting local and national data base for benchmarking CT radiation doses. We expect with improved
optimization and adjusting scanning parameters we will be able to observe dose reduction in future
radiation dose audits in the facility adults.
 Tables

Table 1 Calculated Median and Percentile CTDIvol (mGy) values for various Investigations.
Investigation Median 1st quartile 2nd quartile 3rd quartile (FDRLs)

Head 41.9 41.9 41.9 47.55

Chest 29.5 28.3 29.5 29.5

Abdomen 29.5 28.3 29.5 29.5

Table 2 Calculated Median and Percentile DLP ([Link]) values for various Investigations.
Investigation Median 1st quartile 2nd quartile 3rd quartile (FDRLs)

Head 810 765.5 810.4 931.6

Chest 1220.1 1045.2 1212.8 1302

Abdomen 1694.45 1385.1 1556.9 1673.8

Table 3 Calculated Median and Percentile ED (mSv) values for various Investigations.
Investigation Median 1st quartile 2nd quartile 3rd quartile (FDRLs)

Head 1.7 1.61 1.7 1.96

Chest 17.08 19.98 16.98 18.23

Abdomen 25.42 20.60 23.25 25.11

 Table 4 Facility DRLs Comparison with National, International DRLs
Investigation RMI FDRLs National DRLs (PNRA) European DRLs USA DRLs Australian DRLs UK DRLs

CTDIvol DLP ED CTDIvol DLP* ED* CTDIvol DLP ED CTDIvol DLP ED CTDIvol DLP ED CTDIvol DLP ED
(mGy) ([Link]) (mSv) (mGy) ([Link]) (mSv) (mGy) ([Link]) (mSv) (mGy) ([Link]) (mSv) (mGy) ([Link]) (mSv) (mGy) ([Link]) (mSv)

Head 47.55 931.6 2.01 50 - - 60 1000 1.9 62 1120 3 52 880 1.9 47 790 0.98

Chest 29.5 1302 18.23 - - - 10 400 6.6 17 610 13 10 390 5.7 8.5 290 4.1

Abdomen 29.5 1673.8 25.11 25 - - 25 800 11.3 17 810 16 13 600 9.7 10 530 7.4

*not given
Table 5 Facility Effective Doses VS Worldwide Effective Doses Data
Investigation Facility ED Worldwide ED Data
(mSv) (mSv)
Head 6.16 1.7

Chest 17.08 7.0

Abdomen 25.42 6.8

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