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VirtualDose: a software for reporting organ doses from CT for adult and pediatric patients

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2015 Phys. Med. Biol. 60 5601

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 Institute of Physics and Engineering in Medicine Physics in Medicine & Biology

Phys. Med. Biol. 60 (2015) 5601–5625 doi:10.1088/0031-9155/60/14/5601

VirtualDose: a software for reporting organ

doses from CT for adult and pediatric
patients
Aiping Ding1, Yiming Gao1, Haikuan Liu1,2,
Peter F Caracappa1, Daniel J Long3, Wesley E Bolch3,
Bob Liu4 and X George Xu1
1
Nuclear Engineering Program, Rensselaer Polytechnic Institute, Troy, NY 12180,
USA
2
Institute of Radiation Medicine, Fudan University, Shanghai 200032, People’s
Republic of China
3
Department of Biomedical Engineering, University of Florida, Gainesville,
FL 32611, USA
4
Department of Radiology, Massachusetts General Hospital, Boston, MA 02114,
USA

E-mail: [email protected]

Received 8 September 2014, revised 2 May 2015

Accepted for publication 14 May 2015
Published 2 July 2015

Abstract
This paper describes the development and testing of VirtualDose—a software
for reporting organ doses for adult and pediatric patients who undergo
x-ray computed tomography (CT) examinations. The software is based on
a comprehensive database of organ doses derived from Monte Carlo (MC)
simulations involving a library of 25 anatomically realistic phantoms that
represent patients of different ages, body sizes, body masses, and pregnant
stages. Models of GE Lightspeed Pro 16 and Siemens SOMATOM Sensation
16 scanners were carefully validated for use in MC dose calculations. The
software framework is designed with the ‘software as a service (SaaS)’
delivery concept under which multiple clients can access the web-based
interface simultaneously from any computer without having to install
software locally. The RESTful web service API also allows a third-party
picture archiving and communication system software package to seamlessly
integrate with VirtualDose’s functions. Software testing showed that
VirtualDose was compatible with numerous operating systems including
Windows, Linux, Apple OS X, and mobile and portable devices. The organ
doses from VirtualDose were compared against those reported by CT-Expo
and ImPACT—two dosimetry tools that were based on the stylized pediatric
and adult patient models that were known to be anatomically simple. The

0031-9155/15/145601+25$33.00 © 2015 Institute of Physics and Engineering in Medicine Printed in the UK 5601
Phys. Med. Biol. 60 (2015) 5601 A Ding et al

organ doses reported by VirtualDose differed from those reported by CT-Expo

and ImPACT by as much as 300% in some of the patient models. These results
confirm the conclusion from past studies that differences in anatomical realism
offered by stylized and voxel phantoms have caused significant discrepancies
in CT dose estimations.

Keywords: CT dosimetry, dose reporting, software as a service (SaaS)

(Some figures may appear in colour only in the online journal)

1. Introduction

X-ray computed tomography (CT) has experienced tremendous technological advances

in recent years and is one of the most useful diagnostic imaging modalities today. Driven
­particularly by advanced multi-detector CT (MDCT) technologies, the number of CT scans
performed each year in the United States had reached nearly 81.2 million in 2014(IMV’s
2014 CT Market Outlook Report 2015). The potential radiation risk to the patient population,
particularly children, has led to increasing attention from the radiology community in the past
few years (Berrington de Gonzalez et al 2009, Sodickson et al 2009, Brenner 2010, Ding
et al 2010, Boone et al 2012, Pearce et al 2012). For a long time, the as low as reasonably
achievable (ALARA) principle (ICRP 1977) has been widely adopted in the radiation protec-
tion of patients undergoing diagnostic imaging including CT (Slovis 2003, Kalra et al 2004,
McCollough et al 2009, Dougeni et al 2012). In its Publication 102, the international commis-
sion on radiological protection (ICRP) emphasized the importance of managing patient dose,
particularly from repeated or multiple examinations (ICRP 2007b). Recently, several task
groups from the american association of physicists in medicine (AAPM) developed method-
ologies for the evaluation of CT doses (AAPM 2008, 2010), including the size-specific dose
algorithm for pediatric and adult CT examinations (AAPM 2011). Public campaigns such as
the dose index registry (DIR) (ACR 2012), Image Wisely (Wisely 2013), and Image Gently
(Gently 2013) have been initiated to engage the radiology community. In January of 2015,
revised elements of performance (EPs) for organizations that provide diagnostic imaging ser-
vices have been finalized by the Joint Commission and will go into effect on July 1, 2015(The
Joint Commission 2015).
Presently, three types of dosimetric quantities are used in CT dosimetry (Tack and Gevenois
2007, Mahesh 2009, Seeram 2009): 1) weighted CT dose index (CTDIw) and volume CT dose
index (CTDIvol), which provide an indication of the average absorbed dose to a cylindrical
phantom in the scan region, 2) dose-length product (DLP), which integrates the dose along
the length of the scan, and 3) effective dose (E), which is a risk-related method for comparing
whole-body patient radiation doses across different imaging procedures. To respond to the
increasing trend in CT dose, the States of California, Connecticut, and Texas in the United
States have mandated the CT dose reporting in terms of CTDIvol and DLP. However, there
are some concerns about the use of CTDIvol as a metric for patient dose, because it does not
account for the size or anatomy of the patient (Brenner 2006, Dixon 2006, McCollough 2006,
Boone 2007, McCollough et al 2011).
Radiation-induced health effects are correlated with the mean absorbed dose to organs and
tissues. The absorbed dose is determined as the quotient of mean energy imparted from any
type of radiation and the mass of any irradiated material of interest. To quantify the whole-
body risk, the ICRP recommends the effective dose as a radiation protection quantity, which
is based on the weighted sum of selected major radio-sensitive organs or tissues according to:

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E = ∑ w THT = ∑ w T ∑ w RD T,R
(1)
T T R

where DT,R is the average absorbed dose in tissue T from the radiation type R. wR is a radiation
weighting factor accounting for the relative biological damage of different types of radiation
(and is always unity for x-rays), and wT is a tissue weighting factor for T derived from that
tissue’s relative radio-sensitivity. The set of ‘tissue weighting factors’ has been revised peri-
odically to reflect the latest epidemiological information, most recently in ICRP Publication
103(ICRP 2007a) which replaces the recommendations in IRCP Publication 60 (ICRP 1991).
Although, the ICRP developed the concept of effective dose for the purpose of setting occu-
pational dose limits for radiation protection, and stated that the effective dose concept should
not be used to indicate risk for specific individuals, the quantity is still widely used by the
radiology community to compare risk for patients who undergo x-ray imaging (McCollough
and Schueler 2000, McNitt-Gray 2002, Brenner and Huda 2008). The effective dose is defined
only for the ICRP reference adult models (ICRP 2009), but the methodology has been applied
to other computational phantoms (Xu 2014).
Several CT organ dose calculation tools are currently available (Kalender et al 1999,
Stamm and Nagel 2002, CT Dose 2008, Ban et al 2011, eXposure 2012, ImPACT 2012). Most
these existing packages are based on stylized patient phantoms developed prior to the 1980s
using overly simplified anatomies. Although stylized phantoms were utilized worldwide both
for external and internal dosimetry studies, the stylized models had been found to result in
significant dose errors when compared against anatomically realistic patient models (Zanki
et al 2002, Liu et al 2010, Lee et al 2011, 2012, Xu 2014). Furthermore, most existing soft-
ware packages do not consider patient populations other than averaged-sized adults, ignoring
pediatric, pregnant, and obese patients.
This paper describes the development and testing of a new web-based software, called
‘VirtualDose’, for reporting organ doses to patients who undergo diagnostic CT examina-
tions. Funded by a grant from the national institute of biomedical imaging and bioengineering
(NIBIB) for commercial development, VirtualDose is designed to improve upon existing soft-
ware packages by considering validated CT scanner models and scanner-specific correction
factors, latest ICRP recommendations, advanced ‘software as a service (SaaS)’ delivery mode,
and a family of 25 anatomically realistic patient phantoms which includes a set of voxel phan-
toms covering median (50th percentile) adults, children at different ages, pregnant females at
three gestational stages, and obese patients of different body mass.

2. Materials and methods

2.1. Twenty-five ‘virtual patient’ models

Computational phantoms can be divided into three generations with increasing anatomical
realism and geometrical sophistication: 1) stylized phantoms developed prior to the 1980s,
2) voxel phantoms developed since the late 1980s, and 3) Boundary Representation (BREP)
phantoms developed since the mid of 2000s (Xu 2014).This study took advantage of a total of
25 whole-body BREP phantoms that were previously developed at rensselaer polytechnic insti-
tute (RPI) and the university of florida (UF). These phantoms included reference adults rep-
resenting the ICRP-89 50th percentile (median) of adults (named RPI-Adult-Male (RPI-AM)
and RPI-Adult-Female (RPI-AF)) (Zhang et al 2009b, Na et al 2010), pediatric patients at
different ages (newborn, 1-, 5-, 10-, and 15 year-old) (Bolch et al 2010), and pregnant females
at three gestational stages (named RPI-Pregnant 3-,6-, and 9 month) (Xu et al 2007). A newly

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developed set of phantoms representing overweight and obese patients (Ding et al 2012) were
also adopted for the development of VirtualDose. Figure 1 depicts these phantoms which were
originally designed in various BREP data formats that are easy to deform (Xu and Eckerman
2009). They were converted to voxel-based phantoms, as summarized in table 1, to perform
MC organ dose calculations.

2.2. CT scanner models

Two CT scanner models (the GE LightSpeed Pro 16 and Siemens SOMATOM Sensation 16)
were explicitly constructed in the Monte Carlo code, MCNPX v2.6 (Pelowitz 2005). The GE
LightSpeed Pro 16 scanner (figure 2), operated at different tube voltages (i.e., 80, 100, 120,
and 140 kVp) with different beam collimations (1.25, 5, 10, and 20 mm), was developed and
validated using a previously validated method by Gu et al (2009) that was later refined by
Ding (2012). The SOMATOM Sensation 16 was simulated by Lee et al (2011), operated at 80,
100, 120, and 140 kVp with two beam collimations of 10 and 24 mm.
It had been shown by Turner et al (2010) that organ doses normalized by CTDIvol were
practically independent of the scanner type. Therefore, CT scanners other than the scanners
validated in this study were corrected by the measured CTDIvol normalized to a tube current
of 100 mAs, as described below in section 2.4. In this way, a small number of fully validated
CT scanner models can be used to represent nearly any modern CT scanner.

2.3. Monte Carlo organ dose calculations

With detailed geometric and compositional information for dozens of well identified organs,
a computational phantom contains necessary anatomical data for radiation dose calculations
using a MC radiation transport code, such as MCNPX (Pelowitz 2005). Coupled with a model
of the radiation produced by the CT scanner, a MC radiation simulation can produce a detailed
distribution of radiation dose across various organs and tissues of the body.
For the purposes of reporting organ doses for a particular patient undergoing a specific CT
scan, the scan range was first deconstructed into the individual tube rotations or slices of the
scan. A series of separate axial scans from head to toe (as shown in figure 3), were succes-
sively simulated by using each specific tube voltage and each transverse beam width in the
MCNPX code. For each slice simulated, the direct dose within the scan volume and the scat-
tered radiation dose outside of the scan volume were calculated. The procedure was repeated
for pediatric, pregnant female, and adult male/female phantoms, over a very large number
of simulations. The MCNPX code can handle voxels efficiently using MCNPX’s ‘repeated
structures’ feature, therefore an in-house voxelization algorithm (Zhang et al 2009b) was
developed to convert these BREP phantoms into a voxel-based data. The number of source
photons was selected to ensure that the calculated organ doses had an acceptable level of sta-
tistical uncertainty—relative errors of  <1% in most organs near the primary beam and  <5%
for organs with very small volumes or located at large distances from the primary beam. Dose
to skin and also bone surfaces and red marrow were handled using the methods demonstrated
in previous studies (Zhang et al 2009b, Johnson et al 2011).
The MC simulation results provided organ dose in units of MeV per gram per source
particle and they must be adjusted according to the integrated x-ray tube current, which was
expressed as the product of tube current (mA) and the exposure time (s). The proprietary
nature of the x-ray tube and bowtie filter assembly makes it difficult to quantify the x-ray
photon output directly. As a result, an empirical conversion factor (CF) was used to convert
the tally output to absorbed dose per unit integrated tube current (in units of mGy/100 mAs).

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Figure 1. 3D rendering of whole-body BREP phantoms used in this study: (a) UF

pediatric male and female patients at different ages (newborn, 1-, 5-, 10-, and 15 year-
old), (b) RPI adult male and female patients matching with the 50th percentile of
population, (c) RPI pregnant female patients at three gestational stages (3-,6-, and
9 month), and (d) RPI obese patients.

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Table 1. Phantom parameters and body mass index (BMI) of the voxel-based ‘Virtual
Patient’ models used in VirutalDose.
Mass Height BMI Voxel size
(kg) (cm) (kg m−2) (mm3)
Pediatric patient models
Newborn male 3.27 47.8 14.3 2   ×   2  ×  2
Newborn female 3.27 47.8 14.3 2   ×   2  ×  2
1 year male 9.39 76.6 16.0 3   ×   3  ×  3
1 year female 9.39 76.6 16.0 3   ×   3  ×  3
5 year male 16.45 110.4 13.5 3   ×   3  ×  3
5 year female 16.45 110.4 13.5 3   ×   3  ×  3
10 year male 30.16 140.1 15.4 3   ×   3  ×  3
10 year female 30.16 140.1 15.4 3   ×   3  ×  3
15 year male 53.13 166.5 19.2 3   ×   3  ×  3
15 year female 52.24 161.7 20.0 3   ×   3  ×  3
Pregnant female patient models
3 month pregnant 61.9 163.2 23.2 3   ×   3  ×  3
6 month pregnant 66.6 163.5 24.9 3   ×   3  ×  3
9 month pregnant 72.4 163.5 27.1 3   ×   3  ×  3
Average adult patient models
Average adult male 73 176 23.6 3   ×   3  ×  3
Average adult female 60.1 164 22.3 2.5   ×   2.5   ×   2.5
Obese patient models
Normal body-weight male 72.7 176 23.5 3.5   ×   3.5   ×   3.5
Normal body-weight female 63.5 163 23.9 3.5   ×   3.5   ×   3.5
Over-weight male 85.7 176 27.7 3.5   ×   3.5   ×   3.5
Over-weight female 75.3 163 28.3 3.5   ×   3.5   ×   3.5
Obese level-I male 103.1 176 33.3 3.5   ×   3.5   ×   3.5
Obese level-I female 90.6 163 34.1 3.5   ×   3.5   ×   3.5
Obese level-II male 117.0 176 37.8 3.5   ×   3.5   ×   3.5
Obese level-II female 102.4 163 38.5 3.5   ×   3.5   ×   3.5
Morbidly-Obese male 139.4 176 45.0 3.5   ×   3.5   ×   3.5
Morbidly-Obese female 123.3 163 46.4 3.5   ×   3.5   ×   3.5

These CFs were unique to each combination of beam energy (E) and beam collimation (NT).
A series of CFs were calculated using methods described in previous studies (DeMarco et al
2005, Gu et al 2009):
((CTDI100)in
Measured )
− air E,NT
((2)
CF)E,NT =
((CTDI100)Simulated
in − air ) E,NT

where ((CTDI100)in
Measured )
− air E,NT is the measured air kerma (CTDI100) in−air values in units of
mGy/100 mAs by using the ionization chamber in air at the CT scanner iso-center for a single
axial scan; ((CTDI100)Simulated
in − air )E,NT is the corresponding air kerma values in units of MeV
per gram per source parcel acquired by simulating the ionization chamber in the MCNPX
code under the same CT scan scenario. The units of (CF)E,NT are expressed as in units of
(mGy·gram·source particle)/ (MeV·100 mAs). The CTDIvol, which includes the effect of the

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Ionization chamber CTDI head phantom

Electrometer

CTDI body phantom

Figure 2. Typical equipment used in CTDI measurements including electrometer,

ionization chamber, and a CTDI phantom (CTDI head or body phantom). The measured
CTDI values were used to validate the CT scanner model in MCNPX code by comparing
with the simulated results (photo taken at Massachusetts General Hospital, Boston, MA).

bowtie filter at ‘off-center’ positions, was used to scale the organ doses for different scanners
as mentioned in section 2.4.
By using these CFs, the simulated results from the MCNPX code can be easily converted
to the absorbed dose according to the following conversion equation:
⎛ Total mAs ⎞
(Dabsolute )E,NT (in unit of mGy) = (DSimulated )E,NT × (CF)E,NT × ⎜ ⎟
⎝ 100 ⎠
(3)
where (Dabsolute )E,NT is the absorbed dose in unit of mGy, (DSimulated )E,NT is the MCNPX
simulation results in the units of MeV per gram per source particle, and (CF)E,NT is the con-
version factor for the beam energy E and beam collimation NT.
Effective dose (E) was first calculated as a weighted average of the equivalent doses to
selected body organs or tissues using the tissue weighting factors specified by the ICRP-60
(ICRP 1991) according to the equation (1). In addition, we adopted the latest ICRP-103 (ICRP
2007a) definition of E as being a sex-averaged value calculated from the averaged equivalent
doses of the male and female phantoms using the equation:
⎡ ∑ w FD F + ∑ w MD M ⎤
⎡ HTF + HTM ⎤ ⎢ R T,R R T,R ⎥
E = ∑ w T⎢ ⎥ = ∑ w T⎢ ⎥
R R
⎣ ⎦
(4)
2 ⎢ 2 ⎥
⎣ ⎦
T T

where HTF and HTM are the equivalent doses for organ or tissue T of the female and male
phantoms, respectively. w T is the updated tissue weighting factor for T provided in ICRP
F/M is the average absorbed dose in tissue T of the female or male phantoms
Publication 103. D T,R
from the radiation type R. w R is a radiation weighting factor.

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Head-to-toe MC organ dose simulations

Figure 3. Scheme of the contiguous axial MC organ dose simulations on the patient
phantom using a validated CT scanner model: a MC simulation mimics a series of
continuous axial scans covering a phantom from the head to toe.

2.4. Organ dose reporting algorithms in virtualdose

Once the axial slice-by-slice dose database has been established, organ doses from a contigu-
ous axial scan corresponding to a specific protocol can be obtained by directly summing the
corresponding single axial slices in the scan range. When no-integer number of slices appears
in the dose accumulation, a linear interpolation algorithm (based on the scan covered anatomy
length among one piece axial scan distance) was applied to interpolate the data at the starting
and ending places. In the helical scan mode, the dose calculation depends upon the ‘pitch’ of
the scan, which was the ratio of the patient shift (table movement) during one rotation to the
width of the beam. For a helical scan covering the same scan length and a pitch of 1, approxi-
mately the same radiation dose results as for a contiguous axial scan resulted in approximately
the same radiation dose with the same technique factor (McNitt-Gray et al 1999). For non-
contiguous (pitch  >  1) or overlapping (pitch  <  1) helical scans, radiation dose is inversely
proportionally to the pitch value if all other scan parameters remain unchanged.

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To correct for the use of CT scanners other than the scanners validated in this study, the
organ radiation dose DH can be estimated by:
((CTDIvol)E,NT )Scanner Total mAs
D H = Dc ×
(5) ×
((CTDIvol)E,NT )VirtualDose 100
where DC is the organ dose from CT scans as reported by the scanners in VirtualDose, in unit
of mGy, ((CTDIvol)E,NT )Scanner is the CTDIvol value of the scanner being used in practice for
a specific tube voltage (E) and beam collimation width (NT), ((CTDIvol)E,NT )VirtualDose is the
CTDIvol value used in VirtualDose for the same tube voltage and beam collimation width.
Because the organ dose in the final slice-by-slice dose database was given per 100 mAs tube
current time, the final dose result will be multiplied by the ratio of total mAs to 100 mAs.
In helical CT scans, additional rotations at the starting and ending points of the scan area of
interest along the Z-axis were always needed, called Z-over scanning, for the purpose of image
reconstruction of the first and last slices (Mahesh 2009, Seeram 2009, Tack and Gevenois
2007). The additional x-ray tube rotations must be included in the scan length and total inte-
grated dose. To account for the z-over scanning, the total radiation dose D H′ is calculated in
VirtualDose as:
D H′ = D H + (Dos )Z+ + (Dos )Z−
(6)
where (Dos )Z+ and (Dos )Z− represent the radiation dose from the over scan length as specified
by the user (due to the variability of over-scan length with different protocols, techniques, and
scanner features).
As a method to reduce the total applied radiation dose, automatic exposure control (AEC)
had become commonplace on modern MDCT scanners. AEC used tube current modulation
(TCM) to automatically adjust the tube current according to the size and attenuation charac-
teristics of the patient body region (McCollough et al 2006). To determine dose from CT scans
using AEC technologies, the average tube current per rotation is used, such that:
last slice

(7)
D H,AEC
′ = Di × wi ∑
i = first slice

where Di is the organ dose result (in units of mGy /100 mAs) calculated from the axial MC
simulations for the i-th slice in user specified scan region, wi is the tube current weighting
factor (the actual mAs in the i-th image divided by 100 mAs). The slice-averaged tube cur-
rent, along with CT output (e.g. CTDI, DLP), CT scanner setting parameters (e.g. kVp, mAs,
scan protocol) and patient information (weight, height, age, and gender) information may be
extracted from the CT digital imaging and communications in medicine (DICOM) files and
be imported automatically into VirtualDose to calculate the organ dose. If patient height and
weight information is not available, VirtualDose will automatically select an adult phantom as
default. Only the data necessary for the calculation need be extracted, so no protected patient
information is transmitted to the VirtualDose.

2.5. SaaS architecture and web services interface design

SaaS is a modern software distribution method that hosts all its associated data and up-to-date
resources centrally on a remote computer server (SaaS 2012). Different from the traditional
software distribution model that requires a user to install and configure the application first,
SaaS does not require any installation on user’s computers. Using a license pre-assigned by

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Figure 4. Schematic diagram of the SOA architecture for VirtualDose which includes 3
interface layers: the user, the service, and the data. Web-based interface uses javascript
object notation (JSON) to send user’s request and interpret the response messages from
the remote server.

an SaaS provider, users can remotely access the software application, typically through an
internet browser on demand at any time from any computer that is connected to the internet.
In this study, VirtualDose was designed as an SaaS application to allow multiple users to
simultaneously access the software functions via the Internet. To implement this, a ‘service-
orientated architecture (SOA)’ design was adopted (Erl 2005). As illustrated in figure 4, the
SOA architecture in VirtualDose includes 3 different interface layers: the user, the service, and
the data. Two main parts of the software design are needed: the client-side and the server-side.
The client-side provides an interactive graphical user interface (GUI) within which visitors
can provide the necessary scan parameters. The server-side hosts all the data and web service
functions. After a user input is specified, the organ dose and effective dose can be calculated
and tabulated instantly on the data grid panel embedded on the client-side GUI.
Using the SaaS platform, VirtualDose consists of many functional modules that were
developed using several programming languages or technologies, including C-sharp (C#),
JavaScript, hypertext markup language (HTML) specification, and cascading style sheets
(CSS). For the client-side scripting, the HTML specification was used to define the content
elements used in the web page; CSS was used to control the appearance and formatting of

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marked-up contents when presented to the front-end user. JavaScript was used to manipulate
the contents of HTML content elements and receive/respond to the user interaction, which can
be embedded directly into the HTML web page. For the server-side scripting, C# was used
as the primary programming language and all the service-side codes are implemented in C#.
Each data model or object on the server-side was mapped directly to an individual HTML tag
on the client-side and the entire web page was treated as a tree of HTML document object
model (DOM) objects. JavaScript and HTML DOM are both used in the programming to
better monitor and handle client-side events, such as when a user clicks a control, changes
the value in an input control, moves the mouse over or away from a control button. As all the
programming codes are stored and executed on a remote website host server but are invoked
by users in the client side, the active server pages (ASP).NET model-view-controller (MVC)
pattern was selected as the main development framework (Microsoft 2012b).
Another benefit of adopting the ASP.NET MVC is its high security for data protection.
When programming under the ASP.NET MVC framework, the client-side code is prevented
from directly reading a file or fetching data from a database hosted on the remote host server.
Instead, when executing a web service hosted on the remote server-side, the client-side code
sends a request message over the hypertext transfer protocol (HTTP) connection to the server.
The request is a unique uniform resource locator (URL) for a web service hosted on the
remote server-side which was essentially the endpoint of the user’s HTTP request connection.
This endpoint contains all information about the service function (Pathak 2011). A javascript
object notation (JSON) request-response interaction pattern was used as a shortcut method
for obtaining data from the remote server asynchronously (Richardson and Ruby 2008,
Richardson et al 2013). JSON provides a compact way to either serialize or de-serialize the
data from a remote host server to the client-side web page. In this way, the requested data can
be loaded quickly from the remote server-side asynchronously to the client-side web page and
rendered within the same browser without a visible page refresh.
In VirtualDose, all the detailed distributions of radiation doses to different organ/tissues are
derived from a large MC-simulated organ dose database. To efficiently handle this database
into VirtualDose, an ‘entity framework’ (EF) technology in the.NET development environ-
ment (Microsoft 2012a) was used to create various types of entity data models (e.g. patient
phantoms, dose for each different beam thickness).
In this study, Microsoft Visual Studio 2010 Professional was used as the development tool
for the designs of client- and server-side interfaces and functions developments. Microsoft
SQL Server 2008 was used to process and compile the organ dose data.

2.6. Testing of virtualdose for routine CT scans

A testing of the CT radiation dose reporting functions in VirtualDose was also performed.
Organ dose and effective dose reports were generated for four routine CT scan protocols of the
head, chest, abdomen–pelvis (AP), and chest–abdomen–pelvis (CAP). The technical parameter
settings for each of these sample scans were 120 kVp tube voltage, 100 mAs integrated tube
current, head (for head scan) and body (for chest, AP, and CAP scans) bowtie filters, 10 mm
collimation, and a pitch of 1. The scan ranges of these protocols were obtained from AAPM
CT scan protocols collections (www.aapm.org/pubs/CTProtocols) and summarized in table 2.

2.7. Comparison of organ dose data in virtualdose with other existing data

CT scans use low x-ray energies and the resultant CT scan doses are sensitive to small ana-
tomical details in the phantom. CT dose software packages such as the ImPACT CT patient

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Table 2. Definition of anatomical boundaries using AAPM CT protocols.

Name of the CT protocol Anatomic coverage

Head From top of C1 lamina through top of calvarium
Chest From top of lungs through the bottom of lungs
Abdomen–Pelvis From top of liver to the pubic symphysis
Chest–Abdomen–Pelvis From top of lungs to the pubic symphysis

dosimetry calculator (here inafter referred to as ‘ImPACT’) and CT-Expo (Stamm and Nagel
2002) are based on stylized patient phantoms with overly simplified anatomical informa-
tion. A previous study has found that these stylized models could present significant dose
­discrepancies, particularly for low-energy x-rays, when compared against anatomically real-
istic patient models (Liu et al 2010). To further demonstrate the CT radiation dose reporting
functions in VirtualDose, in this study we extended the comparison with the CT-Expo and
ImPACT software by considering pediatric, adult, and pregnant patients.

3. Results and discussion

3.1. Monte Carlo organ dose database

Table 3 summarizes the comprehensive organ dose database that was based on extensive MC
simulations of a total of 25 voxel phantoms covering pediatric, pregnant female, adult, and
obese patients. Each CT scan of the phantom required a separate MC simulation, leading to
more than 60 000 MC simulations to cover these phantoms involving different beam thick-
nesses and tube voltages in the MCNPX code. Results from each set of MC simulations were
processed to generate a datasheet showing organ names and corresponding dose results for the
axial continuous slice-by-slice scans. The datasheets were then integrated into a comprehen-
sive organ dose database which was compiled using Microsoft SQL server 2008, as illustrated
in figure 5.

3.2. VirtualDose

3.2.1. A Platform-independent CT dose reporting SaaS. VirtualDose was designed as an

SaaS for CT dose reporting and it involved a web-based dynamic GUI compatible with numer-
ous operating systems. The SaaS deliver mode can also be accessed from portable or mobile
devices to be useful to users away from the office environment.
The main interface consists of parameter selection panel, a patient model/scan range dis-
play, and a dose result display. The parameter selection panel provides the options for a user
to specify the operating conditions of a particular CT scan. Table 4 summarizes the available
input features in VirtualDose. When the patient model is selected from a drop-down list of 25
phantoms, an image of that phantom appears on the patient model/scan range display window,
with default coverage of the selected CT protocol superimposed on the phantom. The default
scan length/position can be accepted, or the boundaries can be adjusted with click-and-drag
controllers. To assist in the selection of the proper scan boundaries, transverse pseudo-CT
slices of the anatomy for the scan range are also displayed.
Based on the user-specified scan parameters, VirtualDose fetches and calculates the
patient-specific organ dose data from the remote server-side database. The results are then
displayed as a table and a figure, as illustrated in figure 6. In addition to the manual entry
of scan parameters, VirtualDose has the option to read the parameters from the DICOM

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Table 3. Summary of patient phantoms and CT scan parameters used in the slice-by-
slice MC simulations.
Beam
Bowtie Filter Collimation (mm) kVp CT scanner
Pediatric patient models
Newborn male
Newborn female
1 year male 24 80,100,120
Head
1 year female 10 80,100,120
Siemens
5 year male
SOMATOM
5 year female
Sensation 16
10 year male
10 year female 24 80,100,120,140
Body
15 year male 10 80,100,120,140
15 year female
Pregnant patient models
20 80,100,120,140
Head 10 80,100,120,140
5 80,100,120,140
3 month pregnant 1.25 80,100,120,140 GE LightSpeed
6 month pregnant Pro 16
9 month pregnant 20 80,100,120,140
Body 10 80,100,120,140
5 80,100,120,140
Average adult patient models
20 80,100,120,140
Head 10 80,100,120,140
5 80,100,120,140
Average adult male 1.25 80,100,120,140 GE LightSpeed
Average adult female Pro 16
20 80,100,120,140
Body 10 80,100,120,140
5 80,100,120,140
Obese patient models
Normal body-weight male
Normal body-weight 20 80,100,120,140
female 10 80,100,120,140
Head
Over-weight male 5 80,100,120,140
Over-weight female 1.25 80,100,120,140
GE LightSpeed
Obese level-I male Pro 16
Obese level-I female
Obese level-II male 20 80,100,120,140
Obese level-II female Body 10 80,100,120,140
Morbidly-Obese male 5 80,100,120,140
Morbidly-Obese female

file header, followed by the similar steps as the above to generate the dose report as above.
In cases when some parameters are not available from a DICOM file, some default param-
eters will be selected automatically and users are also allowed to change them later on the
interface.

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Organ names Scan-slice Organ dose results

Datasheets positions

Figure 5. An example of how the slice-by-slice organ dose datasheets retrieved from
MC simulations were incorporated into a comprehensive dose database compiled using
Microsoft SQL Server 2008. In each datasheet, each data column was for one of axial
continuous slice-by-slice scans that covered from head to toe for each phantom.

3.2.2. RESTful web service API available for third-party application integration. As a web-
based SaaS, VirtualDose offers the representational state transfer (REST) web service using
the JSON (Richardson and Ruby 2008, Richardson et al 2013) data exchange interface. This
RESTful feature allows VirtualDose to be integrated seamlessly in a third-party software
using an application programming interface (API). To retrieve the CT dosimetric metadata
from VirtualDose server, a user can send a HTTP POST request including the necessary input
parameters (e.g. patient gender, height, weight, kVp, pitch, mAs, TCM data, etc) to the target
RESTful link via Internet connection. The remote server can then fetch asynchronously the
parameters from user’s request message and then return the requested CT dose results through
the JSON data communication. In this way, the client software simply parses the contents of
the HTTP response and creates its own dosimetric object before continuing processing.

3.3. CT doses reporting for routine CT scans using virtualDose

To demonstrate the CT dose reporting capabilities for different individual populations (small,
average, and large patients), 3 pairs of male and female phantoms (1 year-old, median adult,
and morbidly-obese) in the phantom library of VirtualDose were selected for four routine
CT scan protocols of the head, chest, AP, and CAP. For each CT examination type, organ
dose results for the small (1 year-old), average (adult), and large (morbidly-obese) males and
females were reported by VirtualDose in tables 5–8. As CTDIvol was an effective parameter
for the comparison between different MDCT scanners (Turner et al 2010), all the reported CT
organ doses in tables 5–8 were normalized by the corresponding CTDIvol of the CT scanner
validated in this study.
For head scans, as shown in table 5, brain and salivary glands received considerably higher
radiation doses as compared to other organs. The brain was fully included in the head scan

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Table 4. Parameter selection features available in VirtualDose.

Features and functions defined in VirtualDose

1. Patient phantom library
2. CT scanner manufacturer and model
3. A list of pre-defined CT scan protocols
4. X-ray tube voltage (kVp)
5. Bowtie filter type
6. Beam collimation
7. 2D whole-body cross-section landmark
8. Scan mAs
9. CTDIw specification, with default value provided
10. Pitch specification
11. Z-over beaming length specification
12. DICOM file reader
13. ICRP organ weighting scheme

region and the CT radiation doses per tube current to the brain in the small, average, and
large patient phantoms were found to be very close. However, the doses to the salivary gland
increased slightly with increasing patient size. As the salivary gland was not fully covered
within the scan region, these increasing doses mostly resulted from the increasing covered
portion of the salivary gland in the CT scans of the larger patients. The organ dose results from
chest scans were tabulated in table 6 and it was found that, for the constant scan settings, the
CT radiation dose per tube current to most organs in the small patient phantoms, particularly
to those fully covered in the scan region (e.g. the breast, esophagus, lungs, etc) were signifi-
cantly higher than those in the average and large patient phantoms. For example, a 54–110%
decrease in the lung dose in the male phantoms and a 50–105% decrease in the lung dose in
the female phantoms were observed with increasing patient size. As for abdomen–pelvis scans
in table 7, these doses were found to decrease even more significantly as a function of size.
For the colon, the results showed a decrease of 74–291% in the male phantoms and 61–288%
in the female phantoms. For the stomach, these dose differences were even larger, ranging
from 158–431% in the male phantoms and 171–408% in the female phantoms, mostly due to
the fact that the stomach was highly shielded by adipose tissues abundant in the large patient
phantoms. It was also interesting to observe that the doses to the ovaries in the 1 year-old
female phantom were notably higher (up to six-fold) than observed for the larger phantoms.
This was most likely due to body size and shape of this organ in the 1 year-old female phan-
tom. Similar trends of dose per tube current versus patient size were found in most organs
(e.g. breast, colon, liver, lung, stomach, gonadal, and so on) for chest–abdomen–pelvis scan,
as shown in table 8. In summary, results showed that under the constant CT scan settings,
smaller patient phantoms received considerably higher radiation dose, particularly for those
organs within the CT scan region. This test illustrates how VirtualDose was used to evaluate
patient organ doses for a given CT protocol.

3.4. Comparison of organ dose data in virtualdose with CT-Expo and ImPACT

3.4.1. Adults and children patients. A series of CT scans with the same CT scan param-
eters—120 kVp, 100 mAs, head (children) and body (adult) scan mode, 10 mm collimation
and a pitch of 1—were performed using VirtualDose, CT-Expo (v2.3), and ImPACT (v1.0).
In V
­ irtualDose, 6 pairs of male and female phantoms (New-born, 1 year-old, 5 year-old,

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Figure 6. The results of organ doses were tabulated and plotted in the web-based GUI.

Table 5. Normalized organ doses in units of mGy per 100 mAs per CTDIvol reported by
VirtualDose for the small, average, and large males and females for head examinations.
Patient size Small patients Average patients Large patients
Patient phantom 1 year-M 1 year-F Adult-M Adult-F Morbidly-obese-M Morbidly-obese-F
Scan length (cm) 11.2 11.2 12.7 12.2 12.7 12.2
Bone Surface 0.34 0.34 0.07 0.13 0.11 0.15
Brain 0.96 0.96 0.83 0.87 0.83 0.85
Breast 0.01 0.01 0.01 0.01 0.01 0
Colon 0 0 0 0 0 0
Esophagus 0.05 0.05 0.01 0.02 0.02 0.02
Gonads 0 0 0 0 0 0
Liver 0.01 0.01 0 0 0 0
Lungs 0.02 0.02 0.01 0.01 0.01 0.01
Red Bone Marrow 0.25 0.26 0.05 0.09 0.08 0.11
Salivary Glands 0.18 0.17 0.15 0.39 0.47 0.48
Skin 0.17 0.18 0.05 0.06 0.04 0.04
Stomach 0.01 0.01 0 0 0 0
Thyroid 0.07 0.07 0.02 0.04 0.03 0.04
Urinary Bladder 0 0 0 0 0 0

10 year-old, normal weight and morbidly-obese) and 1 pregnant female phantom (3 month)
were selected to generate a comprehensive set of organ dose data for the comparison. In CT-
Expo, 3 pairs of male and female phantoms (baby, child, and adult) were used to generate the
organ dose data for pediatric and adult patients. In ImPACT, the only available hermaphroditic
stylized phantom was used. As previously illustrated by Lee et al (2012), it would be very

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Table 6. Normalized organ doses in units of mGy per 100 mAs per CTDIvol reported by
VirtualDose for the small, average, and large males and females for chest examinations.
Patient size Small patients Average patients Large patients
Patient phantom 1 year-M 1 year-F Adult-M Adult-F Morbidly-obese-M Morbidly-obese-F
Scan length (cm) 9.9 9.9 26.7 24.8 27 24.8
Bone Surface 0.52 0.52 0.45 0.46 0.38 0.38
Brain 0.04 0.04 0.04 0.04 0.05 0.05
Breast 1.83 1.88 1.16 1.12 0.94 0.8
Colon 0.07 0.08 0.08 0.1 0.05 0.05
Esophagus 1.33 1.34 0.81 0.94 0.47 0.57
Gonads 0.01 0.03 0.02 0.02 0.01 0.01
Liver 0.66 0.67 0.53 0.55 0.29 0.3
Lungs 2.04 2.05 1.32 1.36 0.97 1
Red Bone Marrow 0.53 0.54 0.37 0.37 0.29 0.29
Salivary Glands 0.18 0.18 0.13 0.1 0.09 0.09
Skin 0.36 0.36 0.3 0.31 0.26 0.28
Stomach 0.63 0.63 0.54 0.64 0.4 0.4
Thyroid 0.65 0.66 0.37 0.34 0.28 0.34
Urinary Bladder 0.02 0.02 0.02 0.02 0.01 0.01

Table 7. Normalized organ doses in units of mGy per 100 mAs per CTDIvol reported
by VirtualDose for the small, average, and large males and females for abdomen–pelvis
examinations.
Patient size Small patients Average patients Large patients
Patient phantom 1 year-M 1 year-F Adult-M Adult-F Morbidly-obese-M Morbidly-obese-F
Scan length (cm) 19.7 19.7 32.7 30.3 32.9 30.2
Bone Surface 0.48 0.49 0.47 0.54 0.25 0.28
Brain 0.01 0.01 0.01 0.02 0.01 0.02
Breast 0.13 0.14 0.08 0.09 0.14 0.19
Colon 2.23 2.25 1.28 1.4 0.57 0.58
Esophagus 0.25 0.25 0.04 0.05 0.03 0.05
Gonads 0.72 2.16 0.2 1.18 0.12 0.34
Liver 1.98 2 0.98 1.06 0.68 0.76
Lungs 0.45 0.46 0.15 0.16 0.14 0.17
Red Bone Marrow 0.52 0.52 0.41 0.47 0.2 0.22
Salivary Glands 0.04 0.04 0.03 0.02 0.02 0.02
Skin 0.73 0.74 0.37 0.38 0.31 0.32
Stomach 1.91 1.93 0.74 0.71 0.36 0.38
Thyroid 0.1 0.1 0.04 0.04 0.03 0.03
Urinary Bladder 2.11 2.14 0.96 1.16 0.37 0.36

difficult to define scan ranges in the pediatric phantoms of CT-Expo using anatomical land-
marks. Therefore, to eliminate the errors caused by the definition of scan ranges, a series of
whole-body scans were successively performed using CT-Expo, ImPACT, and VirtualDose on
the selected phantoms. All the reported CT organ doses were normalized by their correspond-
ing CTDIvol values of the CT scanner used in this study. Since only one hermaphroditic styl-
ized phantom is available in ImPACT, for the purpose of comparison, the organ doses to adult
phantoms reported by CT-Expo and VirtualDose were all averaged to obtain the sex-averaged

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Table 8. Normalized organ doses in units of mGy per 100 mAs per CTDIvol reported
by VirtualDose for the small, average, and large males and females for chest–abdomen–
pelvis examinations.
Patient size Small patients Average patients Large patients
Patient phantom 1 year-M 1 year-F Adult-M Adult-F Morbidly-obese-M Morbidly-obese-F
Scan length (cm) 28.4 28.4 57.6 53.4 57.4 53.4
Bone Surface 0.95 0.95 0.89 0.98 0.61 0.65
Brain 0.04 0.04 0.05 0.06 0.06 0.06
Breast 1.93 1.98 1.22 1.2 1.04 0.96
Colon 2.28 2.31 1.34 1.48 0.61 0.62
Esophagus 1.51 1.53 0.84 0.98 0.49 0.61
Gonads 0.72 2.18 0.21 1.2 0.12 0.35
Liver 2.35 2.37 1.36 1.44 0.89 0.98
Lungs 2.34 2.36 1.44 1.49 1.06 1.12
Red Bone Marrow 1 1.01 0.76 0.82 0.48 0.5
Salivary Glands 0.21 0.2 0.15 0.12 0.11 0.11
Skin 1.05 1.05 0.65 0.67 0.54 0.58
Stomach 2.29 2.32 1.18 1.26 0.69 0.72
Thyroid 0.73 0.74 0.4 0.37 0.3 0.36
Urinary Bladder 2.12 2.15 0.98 1.18 0.38 0.37

values (except for the case of the pregnant female phantoms, as there is no corresponding male
phantoms). Those sex-averaged organ doses from VirtualDose were then normalized to those
reported by the ImPACT and CT-Expo.
Figures 7 and 8 summarized the comparative organ dose values for a whole-body scan
involving each pair of pediatric (New-born, 1 year-old, 5 year-old, and 10 year-old) and adult
(normal weight and morbidly obese) phantoms from VirtualDose with the CT-Expo (baby,
child, and adult) and ImPACT (adult) stylized phantoms. Figures 7(a) and (b) showed that
most organ doses from CT-Expo in the whole body scan for the baby and child phantoms
agreed with the values for the pediatric phantoms from VirtualDose within 34%. However,
significant discrepancies were observed between the dose values for bone surface and breast
from CT-Expo and VirtualDose pediatric phantoms. For example, in figures 7(a) and (b),
doses for the bone surface in the baby and child phantoms in CT-Expo were 3-fold greater
than those for the pediatric phantoms in VirtualDose. Figure 7(a) also showed that the breasts
of the baby and child male phantoms receives 100% less dose than those for the pediatric male
phantoms in VirtualDose, which was the reason why CT-Expo did not provide breast dose
values for the male pediatric phantoms.
Figure 8 showed results for adult phantoms from CT-Expo, ImPACT, and VirtualDose.
When compared to those of the stylized phantom in CT-Expo and ImPACT, most organ doses
from VirtualDose were found to differ by  −45 to 58% for the normal weight adult phantom.
The differences were found to be significantly in the morbidly obese phantom for the same
scan settings. For example, VirtualDose reported a reduction of 91 and 96% in the colon dose,
104 and 105% in the stomach dose, and 128 and 145% in the urinary bladder dose, when com-
pared with those reported by CT-Expo and ImPACT, due to the shielding effect of the extra
adipose tissues in morbidly obese phantoms used in the VirtualDose.
As three separate series of whole-body scans were independently performed on the patient
phantoms in CT-Expo, ImPACT, and VirtualDose using the same CT scan settings, organs

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Figure 7. Plots of the organ dose differences reported by CT-Expo and VirtualDose for the
whole-body CT scan on the pediatric (a) male and (b) female phantoms. The organ dose
results for ‘Baby’ and ‘Child’ phantoms reported by CT-Expo were compared with those
for newborn, 1 year-old, 5 year-old, and 10 year-old phantoms reported by VirtualDose by
using the formula of (DoseCT-Expo  −  DoseVirtualDose)/ DoseVirtualDose * 100%.

in both the stylized phantom and voxel-based phantoms were entirely covered in the scan
region. Thus, these dose discrepancies can be attributed mostly to the anatomical variations.
These results confirm those were reported previously by Liu et al (2010) and Lee et al (2011,

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Figure 8. Plot of the sex-averaged organ dose differences reported by CT-Expo,

ImPACT, and VirtualDose for the whole-body scan on the stylized and voxel-based
adult normal weight (NW) and morbidly obese (MO) phantoms by using the formula of
(DoseCT-Expo/ImPACT  −  DoseVirtualDose)/ DoseVirtualDose * 100%.

Table 9. Normalized fetal organ (mGy per 100 mAs per CTDIvol) reported by ImPACT
and VirtualDose for pregnant patients from abdomen–pelvis examinations.
Organs ImPACT VirtualDose-P3
a
Fetal_Brain NA 1.09
Fetal_Skeleton NAa NAb
Fetal_Soft_Tissue NAa 1.14
Fetus_Total 1.3 1.13
a
ImPACT does not report fetal organ dose.
b
VirtualDose-P3 does not contain fetal skeleton.

2012) who concluded that the lack of realism offered by stylized phantoms caused significant
discrepancies in reported CT dose results.

3.4.2. Pregnant patients. For pregnant patients, the primary focus of the comparison for
pregnant patients was on CT radiation dose to fetus which was either partially or fully covered
in the scan region. As no fetal organs were available in the ImPACT software, ImPACT used
the uterus as a surrogate to estimate the fetal dose, as is done in similar situations (Angel et al
2008, Gu et al 2013). In VirtualDose, the CT radiation doses to the fetal brain, fetal skeleton,
fetal soft tissues, and fetus total can be reported. The CT dose results from 2 routine CT scan
protocols of the chest, and abdomen–pelvis from ImPACT and VirtualDose were tabulated in
tables 9 and 10, respectively. As shown in table 9 for abdomen–pelvis scans, when the fetus
is fully covered (for medical reasons) in the scan range, the CT radiation dose to the fetus
reported by ImPACT was found to be 15% larger than that reported by VirtualDose for the
voxel-based pregnant female at three-month gestational stage. However, for chest CT scans

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Table 10. Normalized fetal organ (mGy per 100 mAs per CTDIvol) reported by ImPACT
and VirtualDose for pregnant patients from chest examinations.
Organs ImPACT VirtualDose-P3
a
Fetal_Brain NA 0.02
Fetal_Skeleton NAa NAb
Fetal_Soft_Tissue NAa 0.03
Fetus_Total 0.002 0.03
a
ImPACT does not report fetal dose.
b
VirtualDose-P3 does not contain fetal skeleton.

when the fetus was only partially covered, the results in table 10 show that the dose to the
fetus reported by ImPACT can be even smaller (~15 times) compared to the value reported
by VirtualDose. These dose differences were mostly due to the fact that the stylized phantom
in ImPACT does not contain a representation of the fetus, using only a surrogate organ. The
size and position of the uterus in the stylized phantom introduce significant overestimating or
underestimating of the fetal radiation dose. Furthermore, the CT radiation doses to other fetal
organs (e.g. brain, skeleton, and soft tissues) were not available in ImPACT. The developing
fetus is very sensitive to radiation and the risk of developing leukemia varies with the ges-
tational age (Chatterson et al 2011). For this reason, the fetal dose information provided by
VirtualDose can be helpful to the physicians and pregnant patients.
In summary, for relatively low x-ray energies, CT doses depend on organ shape, size and
position. Therefore, VirtualDose, which is based on the latest patient phantoms, can be used to
significantly improve data for organ doses to patients undergoing CT examinations.

3.5. Limitations of this work

Although the VirtualDose software represents a significant improvement on realism and

accuracy of patient modeling and Monte Carlo dose calculations, there are several remaining
technological limitations that may introduce uncertainty in the calculation organ dose for a
specific patient undergoing CT scans. First, the MC dose calculations performed were based
on a limited number of validated CT source term models, namely, the GE LightSpeed Pro 16
and Siemens SOMATOM Sensation 16. Applications of the correction factor techniques to
extend to other scanners, while yielded reasonably good agreements with those reported in
the literature, may introduce an uncertainty in the estimated organ doses (Turner et al 2010,
Li et al 2011, Lee et al 2012, Sahbaee et al 2014). Second, the software does not currently
support tube current modulation employed by a modern CT scanner, but an interface is being
developed that will address the limitation in the near future. When projecting through different
body part of the patient, the tube current value can vary in the x–y axis (angular modulation),
z-axis (longitudinal modulation), or both. However, the angle-specific tube current informa-
tion is not currently captured in the scan record, and only the slice-averaged tube current
data are available in the DICOM file. When such slice-averaged information is used to com-
pute organ dose, some uncertainties can be introduced, particularly for organs with highly
asymmetric placement in the body, although the effect was found to be small in most cases
(Khatonabadi et al 2012). Third, the contiguous axial scans with a specific pitch value were
used to approximate the radiation dose for a helical scan covering the same scan length. This
axial scan approximation method may introduce an uncertainty due to the surface dose varia-
tion effect when a low pitch value is used (Zhang et al 2009a). An ideal solution is to simulate
real-time helical scans in a Monte Carlo code instead of using the pre-calculated axial scan

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data. A fast Monte Carlo code for CT dose calculation is being developed to address this issue
(Xu et al 2014). Finally, the software assumes the patient’s arms are in the overhead position
for scans of the body which may introduce an uncertainty in usual CT scans where the arms
are inside the scan range (such as for patients in the emergency situations that are sedated, or
that are unable to hold their arms above the head). The effects of arm positioning have been
discussed else (Liu et al 2015).

4. Conclusions

Based on an extensive and latest library of 25 patient phantoms of both genders and various
ages, VirtualDose has been shown in this study to be fully functional in reporting organ doses
for a variety of patient types. When compared against the CT-Expo and ImPACT software that
are based on anatomically simplified models, VirtualDose is found to be more accurate owing
to anatomically realistic geometries. These results confirm those were reported previously by
Liu et al (2010) and Lee et al (2011, 2012) who concluded that the lack of realism offered by
stylized phantoms caused significant discrepancies in CT dose estimations. The development
of VirtualDose as an SaaS platform allows multiple users to access the software simultane-
ously via Internet without having to install the software locally. The web-based GUI design
and reporting features of VirtualDose are designed to cover a large list of CT manufacturers
and scanner types and current ICRP recommendations. The SaaS framework and object-ori-
ented programming methods can provide the necessary flexibility to generate accurate dose
estimates for arbitrary scan protocols defined by a user. Furthermore, with innovative software
engineering features such as the RESTful web service API, VirtualDose permits seamless
integration with a third-party picture archiving and communication system (PACS) software
package. Effort is on-going to continue to improve both the accuracy and usability in reporting
CT doses for more than 50 current users worldwide. More information about VirtualDose is
available from www.virtual-dose.com.

Acknowledgments

The development of VirtualDose (www.virtul-dose.com) as a commercial software was sup-

ported by an STTR grant to Virtual Phantoms, Inc. (www.virtualphantoms.com) from the
national institute of biomedical imaging and bioengineering (NIBIB) (1R42EB010404).
Patient phantoms used in VirtualDose were developed previously by grants to Rensselaer
Polytechnic Institute from the national cancer institute (NCI) (R01CA116743) and the
national library of medicine (NLM) (R01LM009362; R01LM009362-03S1) and a grant to
the University of Florida from NIBIB (R01EB00267).

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AAPM 2011 American Association of Physicists in Medicine AAPM report No.204: Size-Specific Dose
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