IAEA Training Material on Radiation Protection in Diagnostic and Interventional Radiology Adapted for Regional Training Course on RP of Patients

for Radiographers Accra, Ghana, 11-15 July 2011

RADIATION PROTECTION IN DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY L 01. Overview of Radiation Protection in Diagnostic & Interventional Radiology Motivation for the Course

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International Atomic Energy Agency

Introduction
An overview of medical uses of radiation Radiation protection issues in diagnostic &
interventional radiology

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Introduction to Radiation Protection in Diagnostic Radiology

Current use of radiation in medicine

Every year, throughout the world, ionizing radiation is used in*:
4.000.000.000 diagnostic procedures 35.000.000 nuclear medicine procedures 8.000.000 radiotherapy treatment courses

These bring huge benefit to healthcare

- An expanding activity worldwide - Impacts on large portion of global population

Diagnostic procedure

Nuclear medicine procedure

Radiotherapy procedure *UNSCEAR 2010

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Introduction to Radiation Protection in Diagnostic Radiology

Increasing use of radiation in medical applications worldwide More machines, etc New technologies and techniques
Single slice CT Multi-Detector CT Film Computed & Digital Radiography Hybrid imaging, PET-CT

Image-guided interventional procedures Virtual procedures

New roles

E.g. Changes in the role of imaging: First port of call A move towards screening, in all its guises

Increasing complexity in the planning &

delivery of the radiation
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E.g. IMRT, IGRT, etc.

Introduction to Radiation Protection in Diagnostic Radiology

Increasing medical exposure

UNSCEAR 1993 Global annual per caput effective dose

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Increasing medical exposure

UNSCEAR 2000 Global annual per caput effective dose

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Increasing medical exposure

UNSCEAR 2008 Global annual per caput effective dose

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Increasing medical exposure

NCRP160 2009 U.S. annual per caput effective dose

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Collective dose from medical exposures

Relative contribution Level I versus USA
Relative contribution to collective dose
60%

50%

40%

Percentage

30%

USA Level I

20%

10%

0% CT Nuclear Medicine Interventional Conventional Rad/fluoro

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Introduction to Radiation Protection in Diagnostic Radiology

Context another reality

However, reports continue to appear on:
Accidental and unintended exposures Unnecessary exposures

Newspaper report on recent radiotherapy accident

Advertisement for radiological screening gift certificates

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Is this increasing use of radiation in medicine cause for concern? How do patient doses compare with other sources of exposure?

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Radiation from Natural Sources

Normally 1-3 mSv/year Global average is estimated to be 2.4 mSv
per year (UNSCEAR) In areas of high background, > 10 mSv/year

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Patient effective doses

Depends on the radiological procedure E.g.
Whole body dose LD50 3000 - 5000 mSv

Radiography A few Sv to a few mSv CT A few mSv to tens of mSv X ray exams Image-guided interventional procedures A few mSv to tens of mSv Skin doses up to several 1000 mSv

NBR, 2.4 mSv

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What are some of the RP issues in diagnostic and interventional radiology?

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What are the issues - radiography?

Staff doses are typically very low < 1 mSv per year Doses to the patient are typically low Effective dose a few Sv to a few mSv But variation by a factor of 20 more Many exams lack proper justification and/or optimization

Hospital A Dose = X
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Hospital B Dose = 2X

Hospital C Dose = 10X

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Introduction to Radiation Protection in Diagnostic Radiology

Radiography
Diagnostic reference levels (DRLs)
Very effective tool in optimization Concept introduced in the 1990s Implementation in Member States is very uneven
How many African countries have Established DRLs; and Use them in practice?

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In radiographic practice, does it happen?

Unjustified exposures - Yes Wrong patient - Yes Wrong body part - Yes Lack of optimization - Yes Lack of calibration Yes Lack of QA Yes DRLs not used - Yes

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Fluoroscopic examinations - diagnostic

Staff doses are typically low Doses to the patient are
typically a few mSv But variation through lack of optimization

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Image-Guided Interventional Procedures

Increase in use continues, in some countries
doubling every 2 - 4 years

Who are the patients?

Mostly adults, > 40 years old But also children, ~ 5 %

Doses can be high

Effective doses
Can exceed 20 mSv

Peak skin doses

Can exceed several Gy IAEA
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Repeat procedures not insignificant

Udine, Italy Cardiac Interventions Analysis of > 3000 patients
Number of procedures per patient Number of patients

>7

1967

940

194

138

41

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Nearly 6% of patients had 3 or more interventions

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Image-Guided Interventional Procedures

Staff issues
Induced lens opacities

Reference: Va E et al, BJR 1998; 71, 728-733

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Image-Guided Interventional Procedures

Increasing frequency High doses Paediatric patients Repeat rate not insignificant Radiation protection issues for staff

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CT
Usage increasing
More scanners Quicker to use Can do more with them
47%

Level I - UNSCEAR 2008

43%

CT Nuclear Medicine Interventional Conventional Rad/fluoro

Staff doses low at console,

but hand doses of concern in CT fluoroscopy

4%

6%

Patient doses
Effective doses 1 10 mSv But can exceed 20 mSv

Many patient dose reduction tools now available

But optimization often not happening IAEA
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CT
But issues with:
Justification
Unnecessary exams Self-referral Pressure through media for
screening

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CT
Issues with:
Multiple follow-up examinations

Hospital in Boston - 22 years of CT

Number of CT exams: 33% of patients - 5 or more CT exams 5% - between 22 & 132 CT exams Cumulative doses: 15 % - greater than 100 mSv 4 % - between 250 & 1375 mSv

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CT
Issues with children
Increasing number of children
undergoing CT examinations
E.g. in USA (Mettler, 2000) 1989 ~ 4 % of all CT scans 1993 ~ 6 % 2000 ~ 11 %

Optimization not always

implemented

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Deterministic Effects in CT?

Stroke protocol plus angiography caused temporary hair loss in this study

CT dose 2-3 Gy; angiography dose?

Yoshimasa Imanishi et al Eur Radiol (2005) 15:4146

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Principles of radiation protection

Justification Optimization Dose limitation (not for patients)
In Practice: Unjustified examinations are 20-50% Optimization can bring down patient doses by about 50%

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Radiographers make a difference

Radiographers reduce radiation exposure in Finland 2011 ECR
April 18, 2011 Radiographers have an important role to play in monitoring patient radiation exposure and adjusting x-ray equipment settings when rates rise, according to Finnish researchers.

The radiographer's attention to imaging details, such as chamber positioning, mAs and kVp settings, have helped reduce radiation exposure during lumbar x-ray studies at the Haukipudas Health Center in northwest Finland.

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Summary
1. Medical uses of radiation are increasing,
bringing great benefit 2. But there is a need to reduce unnecessary exposures 3. Radiographers have a key role to play

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