Abstract
Purpose.
Radiological risk is a combination of radiation and clinical risk (likelihood of not
delivering a proper diagnosis), which together may be characterized as a total risk
index (TRI). While many strategies have been developed to ascertain radiation risk,
there has been a paucity of studies assessing the clinical risk. This knowledge gap
makes impossible to determine the total radiological procedure risk and, thus, to
perform a comprehensive optimization. The purpose of this study was to develop a mathematical
model to ascertain TRI and to identify the minimum TRI (mTRI) in a clinical CT population.
Materials and Methods.
This IRB approved study included 21 adults abdomen exams performed on a dual-source
single energy CT at two different dose levels (84 CT series). Virtual liver lesions
were inserted into projection data to simulate localized stage liver cancer (LSLC).
The detectability index (d') was calculated in each series and converted to percentage
of correct observer answers (AUC) in a two-alternative forced-choice model. The AUC
was converted into the loss of 5-year relative survival rate (SEER, NCI), considering
an upper bound on patient's risk for a misdiagnosis of LSLC (false positive + false
negative). Concerning radiation risk, organ doses were estimated using a Monte Carlo
method and the Risk Index was calculated and converted in 5-year relative survival
rate for cancer. Finally, the two risks were weighted equally into a combined TRI
curve per each patient as a function of CTDIvol. The analytical minimum of each TRI
curve provided the patient mTRI.
Results.
The mTRI for LSLC patients that underwent an abdominal CT exhibited a rapid rise at
low radiation dose due to enhanced clinical risk of under-dosed examinations. Increasing
dose offered less risk with mortality per 100 patients between 2.1 and 6.5 (mean 4.5)
at CTDIvol=5mGy, between 1.1 and 5.9 (mean 3.5) at CTDIvol=10mGy and between 0.5 and
5.4 (mean 3.0) at CTDIvol=20 mGy.
Conclusion.
The clinical risk seems to play a more dominant factor in designing optimum CT protocols.
The TRI may provide an objective and quantifiable metric of the interplay of radiation
and clinical risks during the optimization of the CT technique for individual patients.
Clinical Relevance statement.
CT risk-based optimization can be made possible by first quantifying both radiation
and clinical risk using comparable units, then calculating an overall risk, and finally
minimizing the total risk.
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