Editorial

www.nuclmed.gr Hellenic J ournal of Nuclear Medicine May - August 2010 106

Medical radiation exposure and accidents. Dosimetry and
radiation protection. Do we only benefit the patient?
clear Medicine, 51 Hermou Str. PS 54623 Thessaloniki, Macedonia, Greece
2. Associate Professor of Medical Physics, Polynikous 3, Alimos P.C.17455, Athens, Greece.
l Med 2010; 13(2):106-110

on
he p
Mil
eve
the
tion
al r
ves and
e recently delt w
and we have suggested before a
mic Energy Agency now proposes: a
on
ed
pub
m
h
ex
he
n,
from earth, the cosmic rays and specifically from rad
proportion has r
pu
ay
sed MRE and MRA have tri
rot
d
ctio
per
98
myo
pu
tomography (CT) of abdomen, pelvis and chest for 38%,
of the total effective dose from medical imaging
procedures administered to the population studied [7]. The
fact that the CT scan is not covered by many insurance
companies does not deter patients from paying 750-1500
US dollars for it [8]. More than 62 millions of CT scans per
year were performed in the USA in 2007 as compared to 3
millions in 1980 [9].
Today we realize that medical procedures using
internal or external radiation are adding, sometimes
unnecessarily, an increased radiation burden to the public
and that no legislation exists to prevent accidents or
n emitting diagnostic or
uipment!
dents and
ve been described
ical diagnostic and
e performed annually
d, some of them late
y to manage, do not
e small part of all
ssing them is a way
e last 60 years there
e to various reasons
000 individuals and a
nalytical review out of
RA. All these MRA
eatment and occurred
l describe in this text
d nuclear medicine

sting that they do not
evelopment and that
stic and treatment
pparent weak links in
can lead to severe
weak links include among others,
surance procedures,
MRE has focused on
day are questionable
ation. The average
increase a patients
scans are repeated
,500 CT scans are
each patient to the
hs [14].
y in 2008 was well
zed. The boy underwent a CT scan at his cervical
spine because he had fallen out of bed and had difficulty
moving his head. A lady technologist R. K. administered to
the boy a radiation overdose that caused an immediate
local bright erythema and substantial chromosome
damage. It was estimated that the boy received at his
head and neck area between 1.5-7.3Gy and was
expected to develop cataracts within 3-8 years. The
technologist was fired, her license was suspended and the
hospital was fined with 25,000$. The technologist claimed
that the CT scanner displayed a failed code. The boys
family has reached a settlement with the hospital where
the incident occurred.
Philip Grammaticos
1
MD, PhD, Maria Lyr a
2
MD, PhD
1. Professor emeritus of Nu
Hell J Nuc
Abstract
This article presents and discusses new information
Hippocratic moto of not to harm but to benefit t
Some radiation accidents are due to medical errors.
medical tests exposing radiation are performed
worldwide increasing and sometimes exceeding
permissible dose administered to the general popula
authorities are now seriously concerned about medic
overused. In U.S.A. both the House of Representati
Food and Drug Administration hav
the old
atient.
lions of
ry day
annual
. Public
adiation

Medical radiation acci
rules to avoid them
Accidents and risks from MRE ha
before. Several millions of med
the
ith this
nd the
Smart
. In this
will be
lic from
therapeutic radiation procedures ar
worldwide, so MRA may be expecte
to recognize. Most of MRA are eas
usually causes casualties and ar
radiation accidents worldwide. Discu
to try to avoid them [10].
One may suppose that during th
were at least 600 radiation events du
and causing significant exposure to 6
total of 200 lethal issues [11]. In an a
problem. Others
International Ato
Card for every individual who receives medical radiati
card the amount of medical radiation administer
recorded. It is time to issue rules for protection of the
medical radiation overdose.

Introduction
Many years ago, Hippocrates the father of
suggested to medical practitioners: to benefit not
patients [1]. Sometime ago, medical radiation
(MRE) constituted only about 15%-20% of t
average dose we received from natural radiatio
edicine
arm the
posure
overall
derived
44 radiation accidents, 14 where M
were due to errors in radiotherapy tr
after 1974 [10]. Furthermore we shal
some MRA due to radiology an
procedures. Radiation accidents of all causes are
on,
isen to
terized
cause
diation
ggered
ect
increasing with time and it is intere
relate to economic and technical d
most of them are recognized late.
Although MRE from diagno
procedures is usually safe, several a
the diagnostic and treatment chain
overdose injuries. These
food, water, etc. [2, 3]. Now this
about 50% [4]. Radiotherapy, fluoroscopy, com
tomography and nuclear medicine procedures m
increased MRE and sometimes medical ra
accidents (MRA). Increa
state officials asking for regulations to better p
public. We shall try to describe the above an
suggestions for radiation protection in medicine.

Medical radiation exposure
The National Council on Radiation Prote
Measurements in the USA has reported that the
d
the
present
n and
capita
0-2009
cardial
terized
faulty computer software, quality-as
and also insufficient staffing.
Much of the recent concern over
CT scans. Many of the scans done to
on the grounds of medical justific
radiation dose of one CT scan may
lifetime risk of cancer, especially if CT
[12,13]. Every day, more than 19
performed in the US that subject
equivalent of 30-442 chest radiograp
A MRA on a 2 years old bo
publici
ose from medical imaging increased during 1
by a factor of nearly six [5, 6].
Fazel et al (2009) have reported that
perfusion accounted for 22%, and com
regulate the correct use of radiatio
therapeutic eq
Editorial
www.nuclmed.gr Hellenic J ournal of Nuclear Medicine May - August 2010 107
The U.S. Food and Drug Administrati
reported that has found cases of radiation ove
re
on
rex
ho
].
com
cen
pe
ose
ons
a d
t al
d fr
tive
0 ch
nt
m
Tc
st
) indica
ted
can
en
the
com
dergon
spe
(C
t as compa
nar
,
ch as
t p
ecei
e.
allo
u ne
iqu
no
rea
e i
c scan
phy
d
d [2
n R
hat
ion
ing
ve w
A, show d
do
the
(2D-NLAF) [25].
Fluoroscopy is another imaging procedure that can
pack a radiation wallop. In some cases patients are
leaving the fluoroscopy table unaware that theyve
received enough radiation to cause skin injury. Skin
injuries up to necrosis may appear due to multiple
coronary angiography and angioplasty procedures [26].
For handling beta-emitters like yttrium-90-
90
Y-
DOTATOC or
90
Y-Zevalin and for calculating their
Bremsstrahlung radiation it is advised to use shielding by
Perspex (10mm) or aluminum (5mm) and add lead [1mm]
on the outside. It is also advised to divide handling among
several individuals [27-29].
eleven fatalities were
st of them caused by
radiopharmaceuticals.
er scan was injected
Au) and died [30].
aging, Sheehy et al
y of reducing the total
activity in paediatric
o, without sacrificing
tandard reconstruction
) with the ordered
ith three-dimensional
method, in
99m
Tc-
renal single photon
The published
reconstruction and
ctivity by half, image
quent radiation dose
ndividuals, physician
nt claims for radiation
hcare agencies or in
garding the use and
Early this year the US Government dealt with the
any legislation, well
get answers to our
Pallone Jr. chairman
s subcommittee on
r several hours of
rance requirements,
olutely and urgently
e every day
ists, radiotherapists,
ine physicians. One
above mentioned
ay later be a cancer
sed or treated with
and safety assurance
by Medical Imaging
presented in the US
bruary 2010 involves
scanners to alert
or red (dont scan at
Manufacturers are
ds and will be able to
offer them to their
f 2010. The institution
ve to make a decision
hey want to prevent
scanning, if the dose reaches that level. Threshold levels
for new scans will establish diagnostic reference dose
necessary radiation are:
physicians decision-making,
b) to have also, a national dose registry, c) electronic
records d), accreditation for advanced imaging facilities, e)
training and education standards for the personnel, f) to
report medical errors, g) to have, radiation dose reference
values, h) quality control procedures, i) to check the CT
scanner display panels before and after every study and j)
to individualize the dose injected to every patient [12, 31-
33].

Medical radiation and dosimetry.
Some previous and recent views
(FDA)
posure
spitals
In the past during 1960-1980,
reported due to internal exposure mo
errors in medical administration of lated to CT brain perfusion scans in various
which involved more than one manufacturer [15
Others have mentioned that a CT scan
gives 25mSv to the subject examined [16]. A re
reported that a routine multiphase abdomen and
scan administers an overall median effective d
patient of 31mSv [17]. Multiple CT examinati
administered to some patients with renal colic,
19.5-153.7mSv [18]. According to Mettler Jr. e
the adult effective dose from a head CT an
abdomen CT are equivalent to the adult effec
from roughly 100 and 40 est X-rays, respective
N
monly
t study
lvis CT
to the
have
ose of
(2008)
om an
dose
ly [19].
to 10-
In 1968 a patient scheduled for a liv
with mCi and not Ci of gold-198 (
198
In Paediatric Nuclear Medicine im
(2009) have established the feasibilit
administered radiopharmaceutical
patients by at least a factor of tw
image quality. They compared the s
method filtered back projection (FBP
subset expectation maximization w
resolution recovery (OSEM-3D)
dimercaptosuccinic acid (DMSA)
emission tomography (SPET) in children. uclear medicine procedures may be equivale
2050 chest X-rays referring to lung ventilation
99
as the lowest and a stress
201
TlCl cardiac te
highest, respectively [19].
The National Academy of Science on Biol
Effects of Ionizing Radiation of USA (BEIR VI
that a 10mSv single population dose is associa
lif
DTPA
as the
ogical
results showed that by OSEM-3D
reducing the radiopharmaceutical a
quality was the same with a conse
reduction [31-33].
ted
with a
cer or
tly, that
age of
pared
Severe penalties are issued to i
groups, or hospitals for reimburseme
oncology treatments to federal healt
order to settle alleged violations re
handling of radioactive materials.
etime attributed risk for developing a solid
leukemia in 1:1000 [20]. It has been reported rec
1 in 270 women who underwent angiography at
40 years will develop cancer from that CT scan
to an estimate that 1:8100 women who had un
routine head CT scan will develop cancer [17].
It was recently shown that the new pro
gated 16-sliced coronary CT angiography
lowering the radiation dose to the patien
e a
ctively
TA) is
red to
y CTA,
taking
matter of MRE. Before we move on
need to have more hearings to
questions. Thats what Rep. Frank
of the US House of Representative
Health, told invited witnesses afte
hearings.
It is obvious that quality assu
accreditation and licensing are abs
the standard retrospectively gated 64-slice coro
from 10-25mSv to about 1mSv [21].
While scanning times today are much shorter
little more than a minute compared to as mu
minutes a few years ago, this does not mean tha
are receiving lower doses of radiation. They r
same amount of radiation as before, or even mor
However, significant image noise reduction
15
atients
ve the
ws for
clinical
es a
ise is
s with
n low
s with
dose
required for the equipment used and for th
practice of technologists, radiolog
radiophysicists and nuclear medic
never knows if someone of the
personnel or a relative or a friend, m
patient and needs to be diagno
procedures that do not meet quality
requirements.
A protective program suggested
and Technology Alliance (MITA) and
House of Representatives on 26 Fe
p to 60% radiation dose reduction in CT routi
use. Using iterative reconstruction techn
decoupling of spatial resolution and image
obtained; enhancement of spatial resolution in a
higher contrast and reduction of image nois
ontrast areas, enable the user to perform CT
lower radiation dose. Computerized tomogra
index reductions of 32%-65% can be obtaine
ad
when
2, 23].
ehani,
some
when
adult-
arned
software that can be installed on CT
operators with a yellow (warning)
this dose level) pop-up screen.
working on the new patient safeguar
include them in new scanners and
existing customers before the end o
that purchases the equipment will ha
during installation as to whether t
aptive statistical iterative reconstruction is use
An international study, coordinated by Mada
IAEA Radiation Safety specialist, has shown t
countries are over-exposing children to radiat
performing CT scans. These children are receiv
sized radiation doses, although experts ha
against this practice for over a decade [24].
A hopeful study though, presented at RSN
a reduction of 25 to 30 percent in radiation
paediatric chest and abdominal CT scans with
2D non-linear adaptive filters
e
se for
use of
values.
Key principles for reducing un
a) to have specific criteria for
Editorial
www.nuclmed.gr Hellenic J ournal of Nuclear Medicine May - August 2010 108
The World Health Organization (WHO) in
categorize all nuclear medicine and radiology pr
has long ago (1987) suggested the effec
equivalent (EDE). Effective dose equivalent is d
a weighted sum of the dose equivalents admin
individual tissues. It is a single figure sp
hypothetical uniform whole body dose equival
would involve the same risk as the actual dose d
[2]. It was suggested that the limit of 30mSv
approached but not exceeded, except if the
benefit to the individual and if the dose adminis
difficult to reduce or prevent [34, 35]. As nuclea
tests that could give a considerable MRE to pa
WHO categorized the following: a) Static brai
with technetium-99m (
99m
Tc)-pertechnetate for a
dose of 500MBq. b) Gated cardiac imaging with
blood cells for an injected dose of 800MBq.
imaging with
99m
Tc- methyldiphosphonate (MD
injected dose of 550MBq; today the usual dos
700MBq. d) Quantitative haemodynamics w
pertechnetate for a dose of 600MBq. e) M
imaging with thallium-201 (
201
TI) chloride for
75MBq. f) Abscess imaging with gallium-67 ci
dose of 80MBq. The first of these procedures (a
an EDE of 5.5mSv and the last one (f) an EDE o
[2,,34]. Others consider that above 3-5
examination the possible harm to the patient
th
or
oc
tive
efi
iste
ecify
ent
istr
co
re
tere
r m
tien
n im
n inj
99m
c)
P)
e is
ith
yo
a d
trate
) in
f
mSv
an
d a
e, in
ioth
he
any
r in
n o
e a
gh
ra
trav
ks a
ess
s i
rtmen
after day for their acting personnel) the radiologica
thus the low
and
biol
urv
diati
ow
ia
protection in nuclear medicine
Specific protective agents to the MRE effects in nuclear
medicine are not really available today. After treatment of
differentiated thyroid cancer, amifistine [Ethylor] has not
moved effective in xerostomia and colchicine and maleic
acid being toxic to the kidneys may not be used in peptide
receptor radionuclide treatment (PRRT) cases where
amino-acids are used to protect kidneys from the toxic
effects of PRRT [26].
A lead collar is partially protecting the environment of
patients who have received high
131
I doses for the
treatment of differentiated thyroid cancer [41].
nt of the American
) (2010) describes in
ropriate indicators for
ging [42]. The ASNC
ctual MRE to these
properly select the
d dose according to
cteristics of imaging
) use the stress test
can lower MRE up to
[42].
not a death sentence
patients examined by
s or treated by
ve an unacceptable radiation
manifest until 5-20
gest that this is an
important issue and interesting field of research.
and airport
etected in individuals
ndergone nuclear
The airport radiation
be triggered and the
ort for a few days.
diagnostic nuclear
ation detector alarms
99m
Tc and iodine-123
e when and how
elease patients who
oactive material or
e material [45, 46].
to patients or to their
to other individuals
Achievable. Many
facilities provide patients with adequate safety
nal materials, and verifiable
to law enforcement
ver, the educational
receiving therapeutic
patients undergoing
about the possibility
procedure, they may
ch radiation a person
e is among the latest
nergy Agency (IAEA)
protection of patients
y later induce a risk of
repeated [21]. Data
ical records and on
the electronic health cards, already carried by people in
many developed countries. The Medical Imaging and
Technology Alliance has agreed to begin reporting dose
information in a consistent fashion, for all new CT
scanners by the end of 2010 [48].
In this Journal, van Isselt et al (2004) suggested that it
would be diagnostically helpful for patients who are re-
examined in a foreign country to present to physicians of
this country a record of the radioactive tests and doses
they had received before in their own country [49].
Others have previously suggested that a reference
dosimetric card would be useful to the patient. This card
der to
edures
dose
ned as
red to
ing a
which
ibution
uld
A recent information stateme
Society of Nuclear Cardiology (ASNC
detail the appropriate and the inapp
performing myocardial perfusion ima
considers important to lower the a
patients and recommends: a) to
patients, b) adjust the administere
patients weight and to the chara
99m
be
was a
d was
edicine
ts, the
aging
ected
system, c) prefer Tc than
201
Tl, d
only, e) use new technologies that
50%, f) use image reconstruction etc.
Because in our days cancer is
we should not consider that cancer
nuclear medicines or radiologist
radiotherapy may well recei
Tc red
Bone
for an
burden [43]. Radiation effects may not
years after the scan [12]. One may sug
about
99m
Tc-
cardial
ose of
for a
duces
9mSv


Radionuclide tests
security
A false MRA if we may call it so is d
who are travelling by air and had u
medicine diagno
per
d/or to
gainst
every
erapy,
limit of
agree
ducing
rder to
nd low
doses,
diation
stic tests before.
detector alarms in these cases may
individuals may be detained at the airp
The number of days that after a
medicine test may trigger false radi
varies from 1-3 days for fluorine-18,
to about 30 to 67 days for
131
I [44].
Federal U.S. regulations describ
licensed health care facilities can r
have been treated with unsealed radi
with implants containing radioactiv
Safety instructions must be provided
guardians, to ensure that doses
remain As Low As Reasonably
eir relatives should be explained and balance
the benefit of the examination [36, 37]. Of cours
day practice, by performing angiography, rad
treatment with radio nuclides or CT imaging, t
30mSv is often or may be exceeded [34, 35]. M
that there is no low radiation dose threshold fo
cancer [38, 39].
According to Wakeford and Tawn (2010) i
better describe the biological effects of low dos
dose rate and differentiate these doses from hi
we should consider the elapsing time between
exposures, the number of tracks of ionization
cell nucleus, the ionization density of these trac
rate of traversal [39]. Due to DNA repair proc
time interval between successive brief exposure
than 6h (as happens in nuclear medicine depa
ersing
nd the
, when
documentation, educatio
s more
ts day
l effect
]. This
odified
dose
, high
ogical
e. The
ons, a
letters or cards for presentation
personnel. In other facilities, howe
emphasis appears to be on patients
treatments and it is less likely,
diagnostic procedures be informed
that, for a period of time after their
trigger radiation alarms [47].

The Smart Card issue
is directly proportional to the total dose [39, 40
operationally linear response can be sufficiently m
if the same dose is received acutely,
rate is equally important [39]. On the other h
dose and high dose rates do not have a linear
response but have a much higher response c
authors consider that for sparsely ionizing ra
low dose delivered acutely is <100mGy and a l
rate is <5mGy per hour [39].

dose-
tio
A Smart Card project to log how mu
receives in the course of a lifetim
efforts by the International Atomic E
[13] and its partners to ensure better
from any unnecessary MRE t
Drugs and rules for rad n

hat ma
cancer, especially, if CT scans are
about MRE could be included in med
Editorial
www.nuclmed.gr Hellenic J ournal of Nuclear Medicine May - August 2010 109
was called: dosage card by Grammaticos [50
problem was also postulated by Sinzinger et
[51]. Palumbo et al (2009) published in this
detailed record of radiation alarm incidents that co
b
] a
al
Jou
ul
e ra
is in
ly a
eff
in
nt
to
dos
aid also that: Physician is worth of
hysician who likes wisdom is a sem
nly
not h
t. Nu
view
ot 20
-6.
Get
.
asu
nited
the National Council on Radiation Pr
RP
al.
ults
02-7.
w E
ure fr
(1)
als/ijra
inc
00
rs. J
du
ire
g r
50-2
osur
ure t
9: 20
T r
eute
Preventive
tection. IAEA Bulletin 2005; 47: 56-8.
17. Smith-Bindman R, Lipson J, Marcus R et al. Radiation dose
associated with common computed tomography examinations
and the associated lifetime attributable risk of cancer. Arch Intern
Med 2009; 169: 2078-86.
18. Katz SI, Saluja S, Brink JA, Forman HP. Radiation dose
associated with unenhanced CT for suspected renal colic: impact
of repetitive studies. Am J Roentgenol 2006; 186: 1120-4.
19. Mettler Jr. FA, Huda W, Yoshizumi TT, Mahesh M. Effective
doses in radiology and diagnostic nuclear medicine: A catalog.
Radiology 2008; 248: 254-63.
20. Committee to assess the health risks from exposure to low
levels of ionizing radiation. BEIR VII: Health risks from exposure
to low levels of ionizing radiation. 2005: http://www.nap.edu/
reportbrief/11340/13 40rb
. Step-and-shoot data
ardiac X-ray computed
.
nd the
21. Hsieh J, Landt J, Vass M et al
acquisition and reco
(2005)
rnal a
d have
nstruction for c
tomography. Med Phys 2006; 33: 4236-48
een avoided if patients had a certificate of th
dose they had previously received [52].
A Smart Card project according to the IAEA
ways useful [13]. If the Smart Card is general
m
diation
many
pplied,
ort not edical radiation physicians will be doing every
to report and inform the public that they have adm
an unnecessarily high radiation dose to their patie
It is time to suggest that all papers related
when published should include MRE
Hippocrates s
istered
.
MRE,
imetry.
many
i-God. men and P
We need hard work and modesty in order to o
the patient.
benefit

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