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13th South-East Asian Congress of Medical Physics 2015 (SEACOMP) IOP Publishing
Journal of Physics: Conference Series 694 (2016) 012030 doi:10.1088/1742-6596/694/1/012030

A fully automated calculation of size-specific dose estimates

(SSDE) in thoracic and head CT examinations

C Anam1,2, F Haryanto2, R Widita2, I Arif2 and G Dougherty3

1
Department of Physics, Faculty of Mathematics and Sciences, Diponegoro
University, Indonesia
2
Department of Physics, Faculty of Mathematics and Natural Science, Institut
Teknologi Bandung, Indonesia
3
California State University (CSU) Channel Islands, California, USA

E-mail: [email protected]

Abstract. The purpose of this study is to automatically calculate and then investigate the size-
specific dose estimate (SSDE) in thoracic and head CT examinations undertaken using
standard imaging protocols. The effective diameter (Deff), the water equivalent diameter (DW),
and the SSDE were calculated automatically from patient images. We investigated sixteen
adult patients who underwent a CT head examination and thirty adult patients who underwent a
CT thorax examination. Our results showed that the DW value in the thoracic region was 4.5%
lower than the value of Deff, while the DW value in the head region was 8.6% higher than the
value of Deff. The relationships between diameter (Deff and DW) and CTDIvol were distinctive. In
the head region, decreasing the patient diameter resulted in a constant CTDIvol due to the tube
current modulation (TCM) being off, while in the thoracic region decreasing the patient
diameter resulted in a decrease in value of CTDI vol due to TCM being on. In the head region,
decreasing the patient diameter resulted in an increase in the value of SSDE, while in the
thoracic region decreasing the patient diameter resulted in a decrease in the value of SSDE.

1. Introduction
The radiation dose from CT examinations is greater than other radiological modalities [1, 2].
Therefore, it is very important to accurately estimate the patient dose and to reduce it to as low as
possible. In order to estimate and compare CT radiation doses received by patients, the medical
community uses volume CT dose index (CTDIvol) as an indicator [3]. The CTDIvol is measured using a
standard phantom made from polymethylmethaacrylate (PMMA) with a diameter of 32 cm to
represent the patient’s body and 16 cm to represent the patient’s head and a 100 mm pencil ionization
chamber [3]. The CTDIvol depends on exposure parameters, e.g., tube voltage, tube current, pitch, and
so on. However, CTDIvol is considered to be an output dose indicator only and not a patient dose
indicator, because the dose to the patient not only depends on output dose but also depends on the
patient’s characteristics [4, 5]. The patient dose indicator which takes into account both output dose
and patient characteristics is the size-specific dose estimate (SSDE) [6].
The most obvious patient characteristic is the effective diameter (Deff) [6]. But this alone is not
sufficient to determine the patient characteristic because different parts of the patient are composed of
different materials [7-9]. Air (lung) is the biggest contributor in the thoracic region, and soft tissue is

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13th South-East Asian Congress of Medical Physics 2015 (SEACOMP) IOP Publishing
Journal of Physics: Conference Series 694 (2016) 012030 doi:10.1088/1742-6596/694/1/012030

the biggest contributor in the abdominal region. Therefore, although the thorax and abdomen may
have the same effective diameter, the dose received by each of them will not be the same. The revised
descriptor for patient characterization is the water equivalent diameter (DW) [7, 10].
To reduce the patient dose, new methods and techniques have been introduced, one of which is the
tube current modulation (TCM) technique. TCM changes the tube current continuously to deliver an
approximately constant noise level for the complete scan range [11]. In TCM, the user selects a noise
level instead of a tube current value. The scan is started with a pre-selected tube current value which
ensures an adequately recorded signal for the most attenuating region, and then the tube current is
reduced in the regions where the attenuation is lower [12]. It was reported that the patient dose was
significantly decreased using TCM compared to non-TCM approaches [11, 12].
This study will automatically calculate effective diameter (Deff), water equivalent diameter (DW),
and size-specific dose estimate (SSDE). We will investigate the relationship between Deff and DW in
the thoracic and head examinations. We will also investigate the relationships between patient
diameter (Deff and DW) and dose (CTDIvol and SSDE) in the thoracic and head CT examinations using
standard imaging protocols.

2. Method

2.1. The patient images

In this study, we calculated the Deff, DW and SSDE of thirty adult patients who underwent thoracic
examinations and sixteen adult patients who underwent head examinations. The patients were scanned
using a 128-slice multi-detector CT (Aquilion 128, Toshiba, Japan) installed at Kensaras Hospital,
Semarang, Central Java, Indonesia. We used standard protocols both for thoracic and head
examinations. The standard protocol for the thoracic examinations used a voltage of 120 kVp, a pitch
of 1.438, a collimation beamwidth 0.5 mm × 64, and 3D tube current modulation. The standard
protocol for the head examinations used a voltage of 120 kVp, a tube current of 300 mA, an exposure
of 225 mAs, a pitch of 0.688, and a collimation beamwidth 0.5 mm × 32. The tube current modulation
(TCM) was switched off for the head examinations.

2.2. The automated Deff and DW calculation

The first step to automate the calculation of Deff and DW is to contour the patients automatically. The
algorithm used a combination of basic segmentation techniques and specific information about the
border of the patient body [13]. The first step was thresholding using a HU value of -200. However,
thresholding alone was not be able to contour the patient accurately because of the presence of objects
inside the patient with HU values lower than -200. To overcome this problem, we used edge detection
to identify these objects and labeled them using their areas. The largest area identified was considered
to be the border of the patient.
After automated contouring, Deff and DW could be calculated. The calculation of Deff was completed
in several steps. The first step was the determination of the center position of the patient. The second
step was the determination of the diameters in the anterior-posterior (AP) and lateral (LAT) directions.
And the final step was the calculation of the effective diameter from the root of the product of the AP
and LAT dimensions.
Deff  AP LAT (1)

The calculation of DW was also completed in several steps. The results of the automated contouring
were used to crop the original images, and the area of the cropped image and the average HU value of
the patient were calculated. DW was then computed using equation (2):
 1 A
D 2  HU  1 (2)
W 1000 

2
13th South-East Asian Congress of Medical Physics 2015 (SEACOMP) IOP Publishing
Journal of Physics: Conference Series 694 (2016) 012030 doi:10.1088/1742-6596/694/1/012030

where A is the area of the patient after cropping.

2.3. The SSDE calculation

The values of CTDIvol were extracted from the DICOM header with the tag [0018, 9345]. The SSDE
was calculated by multiplying the value of volume CT dose index (CTDIvol) with the appropriate
conversion factors (f).
SSDE  CTDIvol  f (3)
The conversion factor (f) depends on the diameter of the patient (Deff and DW,) based on AAPM
report 204 [6]. To calculate the SSDE value for the head, we used the conversion factor from a PMMA
phantom 16 cm in diameter, and for the thoracic region, we used a conversion factor from a PMMA
phantom 32 cm in diameter.

3. Results

3.1. The relationship between Deff and DW

The relationship between Deff and DW in the thoracic CT examinations is shown in figure 1a. DW has a
strong linear correlation (R2 = 0.93) with Deff. On average the DW value in the thoracic region is 4.5%
smaller than the value of Deff. The relationship between Deff and DW in the head CT examinations is
shown in figure 1b. DW is also linearly correlated with Deff, but not as strongly (R2 = 0.73). The DW
value in the head region is on average 8.6% greater than the value of Deff.
34 19.5

32 19
DW  0.882  Deff  3.424
30 18.5
R 2  0.73
28
DW=Deff 18

26
17.5
DW (cm)

DW(cm)

24
17

22 DW  0.994  Deff  31.014 DW=Deff

16.5
20 R 2  0.93
16
18
15.5
18 20 22 24 26 28 30 32 15.5 16 16.5 17 17.5 18
Deff (cm) Deff (cm)

Figure 1. (a) The relationships between Deff and DW for the thoracic examinations, (b) for the head
examinations.

3.2. Relationship between diameter (Deff and DW) and dose (CTDIvol and SSDE)
The relationship between Deff and dose (CTDIvol and SSDE) for the thoracic examinations are shown
in figure 2a, and the relationships between DW and dose (CTDIvol and SSDE) are shown in figure 2b.
Figure 2a shows that the value of CTDIvol increases with increasing diameters (Deff and DW). The
increased CTDIvol leads to an increase in SSDE. From figures 2a and 2b, it seems that the correlation
between diameters (Deff and DW) and CTDIvol is stronger (with R2 about 0.8) than the correlation
between diameters (Deff and DW) and SSDE (with R2 about 0.5). This is due to the calculation of
CTDIvol being directly based on the average mAs which fluctuates along the z-axis in the TCM mode.
Thus, the correlation between diameters (Deff and DW) and CTDIvol is strong. CTDIvolwas converted
into SSDE using a conversion factor (f), which reduced the correlation between diameters and SSDE
in the TCM mode.

3
13th South-East Asian Congress of Medical Physics 2015 (SEACOMP) IOP Publishing
Journal of Physics: Conference Series 694 (2016) 012030 doi:10.1088/1742-6596/694/1/012030

From figures 2a and 2b, SSDE seems to be highest at 24 cm then drops when the diameters (Deff
and DW) increase. This is most likely due to the exponential nature of the conversion factor (f), whose
value decreases with increasing diameters (Deff and DW).
The relationships between Deff and dose (CTDIvol and SSDE) for the head examinations are shown
in figure 3a, and the relationships between DW and dose (CTDIvol and SSDE) are shown in figure 3b.
The value of CTDIvol is constant with increasing diameters (Deff and DW). The constant value of
CTDIvol and the increasing diameters (resulting in decreasing f values) make the value of SSDE
decrease. Figure 3a shows a cross-over value of Deff between 16 and 16.5 cm. When Deff is smaller than
the cross-over value the SSDE value is greater than CTDIvol, and vice versa. On the other hand, all the
SSDE values based on DW are smaller than the CTDIvol values.
35 35
(a) (b)
30 30
SSDE  1.069  DW  4.421
SSDE  1.149  Deff  8.65
R 2  0.50
25 R  0.60
2
25
Dose (mGy)

20 Dose (mGy) 20

15 15

10 CTDIVOL  1.275  Deff  17.93 10 CTDIVOL  1.213  DW  14.92

R  0.80
2
R 2  0.80
5 5
SSDE SSDE
CTDIvol CTDIvol
0 0
18 20 22
D24eff (cm)
26 28 30 32 16 18 20
D22W (cm)
24 26 28 30 32

Figure 2. (a) Relationship between Deff and SSDE; Deff and CTDIvol, (b) DW and SSDE; and DW and
CTDIvol for the thoracic examinations.
75 75
(a) (b)

CTDIvol =69.4
CTDI 69.(mGy)
4 (mGy) CTDI= 69.4 (mGy)
CTDIvol 69.4 (mGy)
VOL VOL
70 70
Dose(mGy)

Dose(mGy)
Dose (mGy)

Dose (mGy)

( 0.04  Deff )
SSDE  136.1 e
65 SSDE = 136.1*exp(-0.04*Deff) 65

( 0.03  DW )
SSDE
SSDE  122.7  e
= 122.7*exp(-0.03*Dw)

60 60

SSDE SSDE
CTDIvol CTDIvol
55 55
15.5 16 16.5 17 17.5 18 17 17.5 18 18.5 19
Deff (cm) Dw (cm)
Deff (cm) DW (cm)

Figure 3. (a) Relationship between Deff and SSDE; and Deff and CTDIvol, (b) DW and SSDE; and DW
and CTDIvol for the head examinations.

4. Discussion
We have developed software for the automated estimation of Deff, DW, and SSDE. The software works
without any user intervention.
Figure 1a shows that in thoracic examinations, the value of DW is smaller than Deff. This is due to
the presence of the lung in the thorax. The HU value for air in the lung is approximately -1000. The
presence of air in the lung makes the value of DW smaller, whereas the value of Deff is calculated only
from the effective diameter and it is assumed that the patient composition is close to water with an HU
value around 0. On the other hand, figure 1b shows that in head examinations, the value of DW is

4
13th South-East Asian Congress of Medical Physics 2015 (SEACOMP) IOP Publishing
Journal of Physics: Conference Series 694 (2016) 012030 doi:10.1088/1742-6596/694/1/012030

greater than Deff. This is because the biggest contributors to the head are soft tissue with HU value
around 0 and bone with HU value around 1000+.
Since DW considers not only the diameter of the patient, but also the composition of the patient, DW
is considered to be more appropriate than Deff. However, the calculation of DW is more difficult than
Deff. In practice, the value of DW can be estimated from Deff using equation 4 and 5 for thoracic and
head examinations, respectively.
DW  0.994 Deff  31.014 (4)

DW  0.882 Deff  3.424 (5)

The relationships between patient diameters (Deff and DW) and CTDIvol are very interesting. Figure
2a shows that CTDIvol increases with increasing Deff. This reflects the effect of TCM. In the TCM
technique, if the diameter decreases, the tube current will proportionally decrease and this will reduce
CTDIvol. In contrast, with a non-TCM technique CTDIvol is constant with decreasing or increasing
diameters (Deff and DW) because the tube current is constant and independent of the diameter of the
patient.
For the head examinations, figure 3a shows that although CTDIvol is constant with increasing Deff,
SSDE decreases with increasing Deff. We know from the AAPM table, the conversion factor (f)
decreases with an increase of Deff, therefore SSDE will decrease with an increase of Deff in the case of
a constant CTDIvol value. The cross-over value at Deff between 16 and 16.5 cm is based on the AAPM
conversion factor (f). Figure 3b shows that all SSDE values are lower than CTDIvol values.
Figure 3a and 3b show that the CTDIvol is constant with either decreasing or increasing diameter
(Deff and DW). This is because TCM was not activated in the standard protocol for adult head
examinations. Activating TCM in a head examination would not result in a high variation of dose due
to the small variation in head diameter for our patients (Deff between 15.96 and 17.60 cm, and DW
between 17.21 and 18.97 cm). However, activating TCM for the standard head protocol will decrease
the dose (SSDE), and thus improve patient safety.

5. Conclusions
We have proposed an algorithm for the automated calculation of Deff, DW, and SSDE. We conclude that
for thoracic examinations, the radiation dose (SSDE) decreases with a decrease in patient diameter
when TCM is activated. For examinations of the head, the radiation dose (SSDE) increases with a
decrease in patient diameter, if TCM is not activated.

References
[1] Slovis T L 2002 CT and computed radiography: The picture are great, but is the radiation dose
greater than required? Am. J. Roentgenol. 179 39-41
[2] Dawson P 2004 Patient dose in multislice CT: Why is it increasing and does it matters? Br. J.
Radiol. 77 S10-S13
[3] Bauhs J A, Vrieze T J, Primak A N, Bruesewitz M R and McCollough C H2008 CT dosimetry:
comparison of measurement techniques and devices RadioGraphics 28 245-253
[4] McCollough C H, Leng S, Lifeng Y, Cody D D, Boone J M and McNitt-Gray M F 2011 CT
dose index and patient dose: they are not the same thing Radiology 259 311–316
[5] Brink J A and Morin R L 2012 Size-specific dose estimation for CT: how should it be used and
what does it mean? Radiology 265 666–668
[6] AAPM 2011 Size-specific dose estimates (SSDE) in pediatric and adult body CT examinations
(College Park: AAPM)
[7] Wang J, Duan X, Christner J A, Leng S, Yu L and McCollough C H 2012 Attenuation-based
estimation of patient size for the purpose of size-specific dose estimation in CT. I.
Development and validation of methods using the CTimage Med. Phys. 39 6764-6771

5
13th South-East Asian Congress of Medical Physics 2015 (SEACOMP) IOP Publishing
Journal of Physics: Conference Series 694 (2016) 012030 doi:10.1088/1742-6596/694/1/012030

[8] Wang J, Christner J A, Duan Y, Leng S, Yu L and McCollough C H 2012 Attenuation-based

estimation of patient size for the purpose of size-specific dose estimation in CT. II.
Implementation on abdomen and thorax phantoms using cross sectional CT images and
scanned projection radiograph images Med. Phys. 39 6772-6778
[9] Bostani M, McMillan K, Lu P, Kim H J, Cagnon C H, Demarco J J, McNitt-Gray M F 2015
Attenuation-based size metric for estimating organ dose to patients undergoing tube current
modulated CT exams Med. Phys. 42 958-968
[10] AAPM 2014 Use of Water Equivalent Diameter for Calculating Patient Size and Size-specific
Dose Estimates (SSDE) in CT (College Park: AAPM)
[11] Kalender W A, Wolf H and Suess C 1999 Dose reduction in CT by anatomically adapted tube
current modulation II: phantom measurements Med. Phys. 26 2248–2253
[12] McCollough C H 2005 Automatic exposure control in CT: are we done yet? Radiology 237 755-
756
[13] Anam C, Haryanto F, Widita R, Arif I 2015 Automated estimation of patient’s size from 3D
image of patient for size-specific dose estimates (SSDE) Adv. Sci. Eng. Med. 7 892-896

Acknowledgements
This work was supported by the Research and Innovation Program, Bandung Institute of Technology
(ITB) 2015, No. 237h/I1.C01/PL/2015. The authors would like to thank Mr. Sanggam Ramantisan
from Kensaras Hospital, Semarang, Indonesia.