Excessive Dosage from Cone Beam

CT's in Radiation Therapy

The Development of Current Imaging Protocols within Radiotherapy and
Methods of LAR Improvement
Ashley Lady
RADSCI 4489
 What is a Cone beam
CT (CBCT)? 1

• Medical imaging technique that utilizes a divergent

set of X-rays, forming a cone shape
• Provides a 3D image of anatomical areas of
interest
• Specialized focus on soft tissue visualization
• Clinical applications include endodontics,
orthodontics, oral surgery, IR and IGRT in
radiation therapy
 CBCT in Radiation
Therapy 1

• Golden standard of imaging for tumor

localization during the radiation treatment
process
• Dose of radiation delivered to a larger
portion of the body than the tumor
volume to assist in image matching
around the area of interest
• Assists with IMRT treatments to direct
and conform the treatment dose toward
the primary treatment volume (PTV)
• Most patients will receive at least 1
CBCT per day each day of their
treatment
 Different Arcs in CBCT's

Pelvis/Abdomen/Chest/
Head and Neck/Brain:
Extremity:
Spotlight Conebeam
Full Conebeam
(160 degrees)
(360 degrees)
 So...what's the problem?2

Excess
CBCT Radiation
Dose

• Although CBCT's are a medical imaging technique, they still provide a dose
of radiation that many people are not aware of
• Average CBCT can put an extra 40-60 mGy of dose onto a patient, on top
of the radiation treatment they are already receiving
 Should we be concerned? 3

• ANY amount of radiation can create damage to DNA of normal tissue

• Stochastic effect
• The dose from an imaging procedure may be much lower than that from a
treatment dose but...
• How much normal tissue is exposed?

• What age is the patient?

• How often are they receiving these conebeams?

 Goal of this Research 4

• Determine if the excess dose from a CBCT could affect a patients LAR of
secondary malignancy
What is LAR?

Lifetime Attributable Risk=

The proportion of cancer in a given population that can be ascribed
to a certain risk factor

In this case, that risk factor is secondary radiation exposure from a

CBCT
Literature Review
 Abuhaimed and Martin et al. 5

• Monte carlo experiment that tested the organ doses and effective doses of a full conebeam
on two water phantoms
• Average male size and average female size
• One scan completed on head protocol, thorax protocol and pelvis protocol on both the
male and female phantoms
• Comparison of organ and effective doses between the new CBCT protocol (V2.5) and the old
protocol (V1.6) Effective Dose =
Organ Dose = Tissue weighted sum of all organ
Dose toward a specific doses, provides a more accurate
organ in question representation of overall health risk
Organ Dose Results 5

• Head protocol (3-13%) • Thorax protocol (10-77%) • Pelvis protocol (13-21%)

 Effective Dose
Results5
• Head – 14% increase
• Thorax – 17% increase
• Pelvis – 16% increase
 Kim and Yoshizumi et al.6
• Danger from excessive CBCT dosage was measured utilizing a 5-year old anthropomorphic
phantom
• Experiment was split into 3 phases:
• Phase one – measuring the absorbed organ dose
• Two scans performed on abdominopelvic region with 125 kVp
• One standard dose mode with tube current of 80 mA and 25 milliseconds of exposure time
• One low dose mode with tube current of 40 mA and 10 milliseconds of exposure time
• Phase two – measuring the effective dose
• Phase three – measuring the LAR and RR (relative risk) of the patient
 Results from the 3 phases 6
• Phase 1: • Phase 3:
• LAR and RR
• Highest absorbed dose
was in the following • Standard dose mode =
organs: • The LAR of cancer
• Phase 2: incidence ranged from 23
• - Skin • Effective Dose increase:
to 144 cases per 100,000
exposed persons
• - Colon • Standard dose scan = • Low dose mode =
• - Stomach • 37.8 ± 0.7 (SD) • The LAR of cancer
incidence ranged from 31
mSv cases per 100,000 exposed
persons for the low-dose
• Low dose scan = mode
• 8.1 ± 0.2 (SD)
mSv
 Carlin and Artioli et al. 7

• Investigated the cellular effects of CBCT's on 19 healthy adults, specifically in buccal mucosa
cells by employing the micronucleus test and looking at other nuclear alterations
• Micronuclei – arise from acentric fragments or whole chromosomes not originally included in the nucleus
• Each patient was placed through one dentomaxillofacial CBCT
• Every patient was a non-smoker and in average healthy weight/condition
• A sample of buccal mucosal cells were taken before and after the scan in order to compare the
extent of damage
• Right before CBCT and 10 days after the scan was complete
• Limitation: only looking at the acute effects of radiation onto these cells
 Results of the • No statistically relevant change in the
Micronuclei Test 7
presence of micro-nucleated cells
(0.04%)
• Significant increase in the number of
other nuclear alterations
• Nuclear fading (Karyolysis)
• Nuclear shrinkage (Pyknosis)
• Nuclear fragmentation (Karyorrhexis)
• Repetition of these alterations could
lead to the potential of chronic cell
injury, abnormal cell proliferation
and possible tumor development

Pyknosis Karyolysis Karyorrhexis

 Kim DW et al. 8
• Also based their research on imaging dose and the risk of developing a secondary
malignancy
• Performed a single CBCT scan on three separate anatomical areas of interest on an
anthropomorphic phantom
• Head and neck, thorax/chest and pelvis
• Utilized a glass dosimeter in order to calculate dose toward organs near the center of the
region that was being tested
• After dose was measured, the LAR was calculated based on the imaging dose and on average
how often each patient would be given a CBCT of this region during treatment
 Dosimeter Results 8

• Average primary in-field doses at the center of the phantom:

• 1.9 cGy (H&N), 5.1 cGy (thorax/chest) and 16.7 cGy (Pelvis)
• Multiply that by common fractionation for each patient to find a total imaging dose over the
course of their treatment

LAR Results
• In order to determine LAR, researchers utilized the BEIR VII models
• Originally based on data from the Japanese Atomic
Bomb survivors in 1945
• LAR was most severe for the pelvic region – If a patient were to receive
30 CBCT's during their treatment, the lifetime secondary malignancy
risk for major organs could affect 400 per 100,000 persons
Methods
 Overview
• Performed in the training linac of the James Comprehensive Cancer Center with the
assistance of physics residents
• A total of three CBCT scans with OBI imagers on a Linear Accelerator would be performed
on anthropomorphic water phantoms on different anatomical regions
• Head and neck (spotlight conebeam), chest/thorax and pelvis (full conebeam)
• Diagnostic dosimeter dose detectors would be placed on the phantoms in order to measure
the dose that is being received
• Each has a thickness of 0.5-1.0 mm in order to mimic the thickness of skin, spaced equally apart on surface
• Dose will be calculated to the proper number of CBCT's a patient would receive in clinic
 Three Wings of the Study
Head and Neck: Chest/Thorax: Pelvis:

• Standard Immobilization • Standard Immobilization • Standard Immobilization

• 4-6 marked diodes placed • 10 marked diodes placed • 10 marked diodes placed in
in arc-like manner on the around the Xiphoid arc-like manner on lower
isocenter marks process area pelvic region
• Spotlight conebeam • Full conebeam performed • Full conebeam performed
performed (40 degrees to (180 degrees to 180E (180 degrees to 180E
180E degrees) degrees) degrees)
• Dose is measured • Dose is measured • Dose is measured
• Calculated to mimic 30-33 • Calculated to mimic 25- • Calculated to mimic 28-33
fractions 30 fractions fractions
 Limitations

Accuracy of patient
Do all clinics utilize
size/age with
the same CBCT's?
phantoms?

What dose is truly being

Repeated CBCT's?
measured?
Discussion
 Wrapping it up
• Most studies have come to the consensus that CBCT's do provide a extra dose of radiation that
has the potential to cause cellular effects
• Is it to the point that it could create a second malignancy?
• Important to think about the size and the age of the patient, the type and extent of the cancer
that they currently have and how often they are receiving excess scans
• As a therapist or any radiation oncology professional, you have the responsibility to be aware of
the dose that the patients are getting from repeat CBCT's during the treatment process
• Very important when treating pediatric patients or younger patients, who are more at risk for
developing a secondary malignancy later in their lives
Questions?
 References
1. Gianfaldoni, S., Gianfaldoni, R., Wollina, U., Lotti, J., Tchernev, G. and Lotti, T. (2019). An Overview on Radiotherapy: From Its History to Its Current Applications in
Dermatology.
2. DW, K. (2019). Imaging doses and secondary cancer risk from kilovoltage cone-beam CT in radiation therapy. - PubMed - NCBI. Ncbi.nlm.nih.gov.
3. Anon, (2019). Health Risks from Exposure to Low Levels of Ionizing Radiation.
4. Newhauser, W. and Durante, M. (2019). Assessing the risk of second malignancies after modern radiotherapy.
5. Abuhaimed, A. (2019). A Monte Carlo study of organ and effective doses of cone beam computed tomography (CBCT) scans in radiotherapy. Journal of Radiological
Protection.
6. Kim, S. (2019). Radiation Dose From Cone Beam CT in a Pediatric Phantom: Risk Estimation of Cancer Incidence : American Journal of Roentgenology: Vol. 194, No. 1
(AJR). Ajronline.org.
7. Carlin, V., Artioli, A., Matsumoto, M., Filho, H., Borgo, E., Oshima, C. and Ribeiro, D. (2019). Biomonitoring of DNA damage and cytotoxicity in individuals exposed
to cone beam computed tomography.
8. DW, K. (2019). Imaging doses and secondary cancer risk from kilovoltage cone-beam CT in radiation therapy. - PubMed - NCBI. Ncbi.nlm.nih.gov.