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La radiologia medica

, Volume 123, Issue 11, pp 818–826 | Cite as

Less radiation, same quality: contrast-enhanced multi-detector computed tomography investigation of thoracic lymph nodes with one milli-sievert

  • Ullrich G. Mueller-Lisse
  • Larissa Marwitz
  • Amanda Tufman
  • Rudolf M. Huber
  • Hanna A. Zimmermann
  • Annemarie Walterham
  • Stefan Wirth
  • Marco Paolini
CHEST RADIOLOGY
  • 80 Downloads

Abstract

Purpose

Mediastinal, hilar, and peripheral pulmonary lymphadenopathy is a hallmark sign of different benign and malignant diseases of the chest. Contrast-enhanced (CE) chest CT is a test frequently applied to examine thoracic lymph node zones. We attempted to find out whether mediastinal, hilar, and peripheral lymph nodes delineate equally in CE chest CT with reduced dose (CE-LDCT, about 1 mSv) when compared with accepted standard CE chest CT (CE-SDCT).

Materials and methods

In this ethics committee-approved, mono-institutional, retrospective (20 months) matched case–control study, two independent, blinded observers compared measurable lymph node delineation (yes–no) in six different International Association for the Study of Lung Cancer (IASLC) zones (upper mediastinal, aortopulmonary, subcarinal, lower mediastinal, hilar, peripheral) between 62 CE-LDCT cases and 124 CE-SDCT controls (respective tube charge, 100, 120 KVp, computed tomography dose index, 1.66 ± 0.51, 5.36 ± 2.24 mGy, automatic exposure control-modulated 64-row multi-detector chest CT with iterative image reconstruction). Individual matching for gender (53% female), age (53 ± 19 years), body height, weight, anterior–posterior and transverse diameters of chest and lung ruled out pre-test confounders. Lymph node size (cut-off value, 1 cm) was a potential post-test confounder. Two-tailed T test and Chi-square test were significant for p < 0.05.

Results

Measurable lymph nodes delineated equally in cases (261/372 IASLC zones, 70%; 280/372, 75%) and controls (528/744, 71%; 519/744, 70%; no significant differences, power 90%). One observer delineated significantly more peripheral zone lymph nodes in cases (35/62) than in controls (43/124); there were no significant differences otherwise. Lymph node size did not differ significantly; effective dose was 1.0 ± 0.3 mSv in cases and 3.4 ± 1.5 mSv in controls.

Conclusion

CE-LDCT with about 1 mSv demonstrated equal delineation of thoracic lymph nodes when compared with accepted standard CE-SDCT.

Keywords

Chest CT Low dose Contrast media Lymph node delineation IASLC classification 

Abbreviations

AEC

Automatic exposure control

BMI

Body mass index

CE

Intravenous contrast enhancement or intravenously contrast-enhanced

CE-LDCT

Contrast-enhanced highly dose-saving computed tomography of the chest

CE-SDCT

Contrast-enhanced computed tomography of the chest with standard dose

CT

Computed tomography

CTDI

Computed tomography dose index

DLP

Dose length product

ED

Effective dose

EK

Conversion factor of EUR 16262 EN

IASLC

International Association for the Study of Lung Cancer

IIR

Iterative image reconstruction

LDCT

Highly dose-saving computed tomography of the chest

MDCT

Multi-detector row-computed tomography

PACS

Picture archiving and communication system

SD

Standard deviation

SDCT

Computed tomography of the chest with standard dose

Notes

Acknowledgements

This manuscript includes results of doctoral thesis work in preparation by Larissa Marwitz at the Faculty of Medicine of the University of Munich (“Ludwig-Maximilians-Universität”, LMU), Germany. Authors acknowledge the kind support of their research activities by Professors Maximilian F. Reiser and Jens Ricke, Directors of the Department of Radiology of the Faculty of Medicine of the University of Munich (“Ludwig-Maximilians-Universität”, LMU), Germany.

Compliance with ethical standards

Conflict of interest

All authors declare that there is no conflict of interest.

Ethical standards

This was a retrospective study. It was performed in accordance with the Declaration of Helsinki and approved by the local ethics committee. This article does not contain any studies with animals.

References

  1. 1.
    Foley SJ, McEntee MF, Rainford LA (2012) Establishment of CT diagnostic reference levels in Ireland. Br J Radiol 85:1390–1397CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Shrimpton PC, Hillier MC, Meeson S et al (2014) Doses from computed tomography (ct) examinations in the UK—2011 review. Public Health England, Centre for Radiation, Chemical and Environmental Hazards, September, 2014. PHE publications gateway number: 2014179. www.gov.uk/phe. Accessed 16 May 2016
  3. 3.
    Mayo JR, Aldrich J, Muller NL et al (2003) Radiation exposure at chest CT: a statement of the Fleischner Society. Radiology 228:15–21CrossRefPubMedGoogle Scholar
  4. 4.
    Federal Office for Radiation Protection (2015) Radiation topics: X-ray diagnosis—harmful or useful? Salzgitter, Germany: Federal Office for Radiation Protection; September, 2015. https://www.bfs.de/SharedDocs/Downloads/BfS/DE/broschueren/ion/stth-roentgen.pdf. Accessed 16 May 2016 (in German)
  5. 5.
    Kanal KM, Butler PF, Sengupta D et al (2017) U.S. diagnostic reference levels and achievable doses for 10 adult CT examinations. Radiology 284:120–133CrossRefPubMedGoogle Scholar
  6. 6.
    Bundesministerium fuer Umwelt, Naturschutz, Bau und Reaktorsicherheit (2015) Umweltradioaktivitaet und Strahlenbelastung Jahresbericht 2013. BMUB, Bonn, Germany (in German, Summary in English, French, and German) Google Scholar
  7. 7.
    Söderberg M, Gunnarsson M (2010) Automatic exposure control in computed tomography–an evaluation of systems from different manufacturers. Acta Radiol 51:625–634CrossRefPubMedGoogle Scholar
  8. 8.
    Mueck FG, Michael L, Deak Z et al (2013) Upgrade to iterative image reconstruction (IR) in MDCT imaging: a clinical study for detailed parameter optimization beyond vendor recommendations using the adaptive statistical iterative reconstruction environment (ASIR) part 2: the chest. Rofo 185:644–654CrossRefPubMedGoogle Scholar
  9. 9.
    Coppenrath E, Mueller-Lisse UG, Lechel U et al (2004) Low-dose spiral CT of the lung in the follow-up of non-malignant lung disease. RoFo Fortschr auf dem Gebiete der Rontgenstrahlen und der Nukl 176:522–528CrossRefGoogle Scholar
  10. 10.
    Deutsche Gesetzliche Unfallversicherung (DGUV) (2011) Falkensteiner Empfehlung - Empfehlung für die Begutachtung asbestbedingter Berufskrankheiten. Berlin, Germany. http://publikationen.dguv.de/dguv/udt_dguv_main.aspx?FDOCUID=25466. Accessed 16 May 2016 (in German)
  11. 11.
    Bongartz G, Golding SJ, Jurik AG et al (2004) Appendix B—European field survey on MSCT. In: European guidelines for multislice computed tomography. Funded by the European Commission, Contract number FIGM-CT2000-20078-CT-TIP. http://www.msct.eu/CT_Quality_Criteria.htm. Accessed 16 May 2016
  12. 12.
    Friberg EG, Widmark A, Ryste Hauge ICH (2009) National collection of local diagnostic reference levels in Norway and their role in optimization of X-ray examinations. Norwegian Radiation Protection Authority, ØsteråsGoogle Scholar
  13. 13.
    Federal Office for Radiation Protection (2015) Notice of diagnostic reference levels for radiology and nuclear medicine examinations. Federal Office for Radiation Protection, Salzgitter, Germany. https://www.bfs.de/SharedDocs/Downloads/BfS/DE/fachinfo/ion/drw-roentgen.pdf. Accessed 16 May 2016 (in German)
  14. 14.
    Buty M, Xu Z, Wu A et al (2017) Quantitative image quality comparison of reduced- and standard- dose dual-energy multiphase chest, abdomen, and pelvis CT. Tomography 3:114–122CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Ebner L, Knobloch F, Huber A et al (2014) Feasible dose reduction in routine chest computed tomography maintaining constant image quality using the last three scanner generations: from filtered back projection to sinogram-affirmed iterative reconstruction and impact of the novel fully integrated detector design minimizing electronic noise. J Clin Imaging Sci 4:38.  https://doi.org/10.4103/2156-7514.137826 CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Suwatanapongched T, Gierada DS (2006) CT of thoracic lymph nodes. Part II: diseases and pitfalls. Br J Radiol 79:999–1000CrossRefPubMedGoogle Scholar
  17. 17.
    Sharma A, Fidias P, Hayman LA et al (2004) Patterns of lymphadenopathy in thoracic malignancies. Radiographics 24:419–434CrossRefPubMedGoogle Scholar
  18. 18.
    Paolini M, Wirth K, Tufman A et al (2016) Thoracic lymph node delineation at dose-reduced (1 mSv) dose-modulated contrast enhanced MDCT: a retrospective pilot study. Radiol Med 121:644–651CrossRefPubMedGoogle Scholar
  19. 19.
    von Elm E, Altman DG, Egger M et al (2007) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med 4:e296.  https://doi.org/10.1371/journal.pmed.0040296 CrossRefGoogle Scholar
  20. 20.
    Menzel HG, Schibilla H, Teunen D (eds.). European guidelines on quality criteria for computed tomography. EUR 16262 EN. http://www.drs.dk/guidelines/ct/quality/mainindex.htm. Accessed 16 May 2016
  21. 21.
    Rusch VW, Asamura H, Watanabe H et al (2009) The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer. J Thorac Oncol 4:568–577CrossRefPubMedGoogle Scholar
  22. 22.
    Kim JH, van Beek EJR, Murchinson JT et al (2015) The international association for the study of lung cancer lymph node map: a radiologic atlas and review. Tuberc Respir Dis 78:180–189CrossRefGoogle Scholar
  23. 23.
    Jawad H, Sirajuddin A, Chung JH (2013) Review of the international association for the study of lung cancer lymph node classification system: localization of lymph node stations on CT imaging. Clin Chest Med 34:353–363CrossRefPubMedGoogle Scholar
  24. 24.
    Hulley SB, Cummings SR, Browner WS et al (2007) Estimating sample size and power: applications and examples. In: Hulley SB, Cummings SR, Browner WS, Grady DG, Newman TB (eds) Designing clinical research, chapter 6, 3rd edn. Lippincott Williams and Wilkins, Philadelphia, pp 65–96Google Scholar
  25. 25.
    Glantz SA (1997) How to analyze rates and proportions. In: Glantz SA (ed) Primer of biostatistics, chapter 5, 4th edn. McGraw-Hill Health Professions Division, New York, St. Louis, San Francisco, Auckland, Bogota, Caracas, Lisbon, London, Madrid, Mexico City, Milan, Montreal, New Delhi, San Juan, Sydney, Tokyo, Toronto, pp 108–150Google Scholar
  26. 26.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Glantz SA (2012) The special case of two groups: the t-test. In: Glantz SA (eds) Primer of biostatistics, chapter 4, . 7th edn. McGraw-Hill Medical, New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto, pp 49–72Google Scholar
  28. 28.
    Jaffe TA, Yoshizumi TT, Toncheva G et al (2009) Radiation dose for body CT protocols: variability of scanners at one institution. AJR Am J Roentgenol 193:1141–1147CrossRefPubMedGoogle Scholar
  29. 29.
    Nambu A, Kato S, Motosugi U et al (2010) Thin-section CT of the mediastinum in preoperative N-staging of non-small cell lung cancer: comparison with FDG PET. Eur J Radiol 73:510–517CrossRefPubMedGoogle Scholar
  30. 30.
    Bundesamt für Strahlenschutz (2016) Diagnostic reference values for diagnostic and interventional X-ray applications. Salzgitter, Germany, BAnz AT 15.07.2016 B8. https://www.bfs.de/SharedDocs/Downloads/BfS/DE/rsh/rsh/A25-Roentgen-DRW.pdf;jsessionid=17BC3192738EDB6864E5A4D1BFB14504.1_cid391?__blob=publicationFile&v=1. Accessed 11 October 2016 (in German)
  31. 31.
    Khawaja RD, Singh S, Gilman M et al (2014) Computed tomography (CT) of the chest at less than 1 mSv: an ongoing prospective clinical trial of chest CT at submillisievert radiation doses with iterative model image reconstruction and iDose4 technique. J Comput Assist Tomogr 38:613–619CrossRefPubMedGoogle Scholar
  32. 32.
    Yamada T, Ono S, Tsuboi M et al (2004) Low-dose CT of the thorax in cancer follow-up. Eur J Radiol 51:169–174CrossRefPubMedGoogle Scholar
  33. 33.
    Dinkel HP, Sonnenschein M, Hoppe H et al (2003) Low-dose multislice CT of the thorax in follow-up of malignant lymphoma and extrapulmonary primary tumors. Eur Radiol 13:1241–1249PubMedGoogle Scholar
  34. 34.
    Vorwerk H, Beckmann G, Bremer M et al (2009) The delineation of target volumes for radiotherapy of lung cancer patients. Radiother Oncol 91:455–460CrossRefPubMedGoogle Scholar

Copyright information

© Italian Society of Medical Radiology 2018

Authors and Affiliations

  • Ullrich G. Mueller-Lisse
    • 1
    • 3
  • Larissa Marwitz
    • 1
  • Amanda Tufman
    • 2
    • 3
  • Rudolf M. Huber
    • 2
    • 3
  • Hanna A. Zimmermann
    • 1
  • Annemarie Walterham
    • 1
  • Stefan Wirth
    • 1
  • Marco Paolini
    • 1
    • 3
  1. 1.Department of Radiology, Klinikum der Universität MünchenLMU - University of MunichMunichGermany
  2. 2.Department of Pneumology, Klinikum der Universität MünchenLMU - University of MunichMunichGermany
  3. 3.Member of the German Centre for Lung Research (DZL) – CPC-MMunichGermany

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