Escolar Documentos
Profissional Documentos
Cultura Documentos
1093/jicru/ndi016
PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING
Report Committee
J. Zoetelief (chairman), Faculty of Applied Sciences, Delft University of Technology,
Delft, Netherlands
D. R. Dance, The Royal Marsden NHS Foundation Trust, London, United Kingdom
G. Drexler, GSF-National Research Center for Environment and Health, Neuherberg, Germany and
State University of Rio de Janeiro, Rio de Janeiro, Brazil
H. Ja rvinen, Radiation and Nuclear Safety Authority (STUK), Helsinki, Finland
M. Rosenstein, Clarksburg, Maryland, USA
Commission Sponsors
H. G. Paretzke, GSF-National Research Center for Environment and Health, Neuherberg, Germany
K. Doi, The University of Chicago, Chicago, Illinois, USA
A. Wambersie, Universite Catholique de Louvain, Brussels, Belgium
Consultants to the Report Committee
P. Allisy-Roberts, Bureau International des Poids et Mesures, Sevres, France
H. Bosmans, University Hospital Gasthuisberg, Leuven, Belgium
C. J. Moretti, National Physical Laboratory, Teddington, UK
J. Van Dam, University Hospital Gasthuisberg, Leuven, Belgium
E. Va~nnoo, Complutense University, Madrid, Spain
B. F. Wall, Radiation Protection Division, Health Protection Agency, Chilton, UK
The Commission wishes to express its appreciation to the individuals involved in the preparation of this report,
for the time and efforts which they devoted to this task and to express its appreciation to the organizations with
which they are affiliated.
All rights reserved. No part of this book may be reproduced, stored in retrieval systems or transmitted in any
form by any means, electronic, electrostatic, magnetic, mechanical photocopying, recording or otherwise,
without the permission in writing from the publishers.
British Library Cataloguing in Publication Data. A Catalogue record of this book is available at the British
Library.
ISBN 0199203208
Journal of the ICRU Vol 5 No 2 (2005) Report 74 doi:10.1093/jicru/ndi017
Oxford University Press
THE INTERNATIONAL COMMISSION ON RADIATION UNITS
AND MEASUREMENTS
INTRODUCTION
The International Commission on Radiation Units
and Measurements (ICRU), since its inception in
1925, has had as its principal objective the develop-
ment of internationally acceptable recommenda-
tions regarding:
(1) quantities and units of radiation and radio-
activity,
(2) procedures suitable for the measurement and
application of these quantities in clinical radio-
logy and radiobiology, and
(3) physical data needed in the application of these
procedures, the use of which tends to assure
uniformity in reporting.
The Commission also considers and makes similar
types of recommendations for the radiation protec-
tion field. In this connection, its work is carried out
in close cooperation with the International Commis-
sion on Radiological Protection (ICRP).
POLICY
The ICRU endeavors to collect and evaluate the
latest data and information pertinent to the pro-
blems of radiation measurement and dosimetry and
to recommend the most acceptable values and tech-
niques for current use.
The Commissions recommendations are kept
under continual review in order to keep abreast of
the rapidly expanding uses of radiation.
The ICRU feels that it is the responsibility of
national organizations to introduce their own
detailed technical procedures for the development
and maintenance of standards. However, it urges
that all countries adhere as closely as possible to
the internationally recommended basic concepts of
radiation quantities and units.
The Commission feels that its responsibility lies in
developing a system of quantities and units having
the widest possible range of applicability. Situations
may arise from time to time when an expedient
solution of a current problem may seem advis-
able. Generally speaking, however, the Commission
feels that action based on expediency is inadvisable
from a long-term viewpoint; it endeavors to base
its decisions on the long-range advantages to be
expected.
The ICRU invites and welcomes constructive com-
ments and suggestions regarding its recommenda-
tions and reports. These may be transmitted to the
Chairman.
CURRENT PROGRAM
The Commission recognizes its obligation to pro-
vide guidance and recommendations in the areas of
radiation therapy, radiation protection, and the com-
pilation of data important to these fields, and to
scientific research and industrial applications of
radiation. Increasingly, the Commission is focusing
on the problems of protection of the patient and
evaluation of image quality in diagnostic radiology.
These activities do not diminish the ICRUs commit-
ment to the provision of a rigorously defined set of
quantities and units useful in a very broad range of
scientific endeavors.
The Commission is currently engaged in the
formulation of ICRU reports treating the following
subjects:
Approaches to the Dosimetry of Low-Dose Exposures to
Ionizing Radiation
Assessment of Image Quality in Nuclear Medicine
Bone Densitometry
Doses for Cosmic Ray Exposure for Aircrew
Dose and Volume Specifications for Reporting Intracavi-
tary Therapy in Gynecology
Dosimetry Systems for Radiation Protection
Elastic Scattering of Electrons and Positrons
Image Quality and Patient Exposure in CT
Mammography------Assessment of Image Quality
Measurement Quality Assurance for Ionizing
Radiation
Prescribing, Recording, and Reporting Conformal Photon
Beam Therapy
Prescribing, Recording, and Reporting Proton Beam
Therapy
Requirements for Radiological Sampling
ROC Analysis
International Commission on Radiation Units and Measurements 2005
In addition, the ICRU is evaluating the possibi-
lity of expanding its program to encompass non-
ionizing radiation, particularly the quantities and
units aspects.
The Commission continually reviews radiation
science with the aim of identifying areas where the
development of guidance and recommendations can
make an important contribution.
THE ICRUS RELATIONSHIP WITH OTHER
ORGANIZATIONS
In addition to its close relationship with the ICRP,
the ICRU has developed relationships with other
organizations interested in the problems of radiation
quantities, units, and measurements. Since 1955,
the ICRU has had an official relationship with the
World Health Organization (WHO), whereby the
ICRU is looked to for primary guidance in matters
of radiation units and measurements and, in turn,
the WHO assists in the worldwide dissemination of
the Commissions recommendations. In 1960, the
ICRU entered into consultative status with the
International Atomic Energy Agency (IAEA). The
Commission has a formal relationship with the Uni-
ted Nations Scientific Committee on the Effects of
Atomic Radiation (UNSCEAR), whereby ICRU
observers are invited to attend annual UNSCEAR
meetings. The Commission and the International
Organization for Standardization (ISO) informally
exchange notifications of meetings, and the ICRU
is formally designated for liaison with two of the
ISO technical committees. The ICRU also corres-
ponds and exchanges final reports with the following
organizations:
Bureau International de Metrologie Legale
Bureau International des Poids et Mesures
European Commission
Council for International Organizations of Medical
Sciences
Food and Agriculture Organization of the United Nations
International Committee of Photobiology
International Council of Scientific Unions
International Electrotechnical Commission
International Labor Office
International Organization for Medical Physics
International Radiation Protection Association
International Union of Pure and Applied Physics
United Nations Educational, Scientific and Cultural
Organization
The Commission has found its relationship with
all of these organizations fruitful and of substantial
benefit to the ICRU program. Relations with these
other international bodies do not affect the basic
affiliation of the ICRU with the International
Society of Radiology.
OPERATING FUNDS
In recent years, principal financial support has
been provided by the European Commission, the
National Cancer Institute of the U.S. Department
of Health and Human Services and the International
Atomic Energy Agency. In addition, during the last
10 years, financial support has been received from
the following organizations:
Belgian Nuclear Research Centre
Canadian Nuclear Safety Commission
Eastman Kodak Company
Electricite de France
Fuji Medical Systems
Hitachi, Ltd.
International Radiation Protection Association
International Society of Radiology
Ion Beam Applications
Italian Radiological Association
Japan Industries Association of Radiological Systems
Japanese Society of Radiological Technology
MDS Nordion
National Institute of Standards and Technology
Nederlandse Vereniging voor Radiologie
Philips Medical Systems, Incorporated
Radiation Research Society
Siemens
Varian
In addition to the direct monetary support pro-
vided by these organizations, many organizations
provide indirect support for the Commissions pro-
gram. This support is provided in many forms,
including, among others, subsidies for (1) the time
of individuals participating in ICRU activities,
(2) travel costs involved in ICRU meetings, and (3)
meeting facilities and services.
In recognition of the fact that its work is made
possible by the generous support provided by all of
the organizations supporting its program, the Com-
mission expresses its deep appreciation.
Andre Wambersie
Chairman, ICRU
Brussels, Belgium
PATIENT DOSIMETRY FOR X-RAYS USED IN MEDICAL IMAGING
Journal of the ICRU Vol 5 No 2 (2005) Report 74 doi:10.1093/jicru/ndi018
Oxford University Press
PATIENT DOSIMETRY FOR X RAYS USED IN
MEDICAL IMAGING
CONTENTS
PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.1 Evolution of radiation dosimetry in medical x-ray imaging . . . . . . . . . . . . . . . 9
1.2 Risks for the patient in radiological imaging and relevant
dosimetric quantities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.2.1 Acute deterministic effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.2.2 Late effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.2.2.1 Cancer induction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.2.2.2 Late effects in normal tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.2.2.3 Impairment of mental development . . . . . . . . . . . . . . . . . . . . . . . 12
1.2.2.4 Genetic risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.2.3 Relevant dosimetric quantities and dosimetric procedures . . . . . . . . . . . . . . . 12
1.2.4 Required accuracy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.3 Dosimetry in radiology: relevant quantities . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.3.1 Calibration at the Standards Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.3.2 From air kerma free-in-air to absorbed dose in water in patient or phantom . . . . 13
1.3.3 Air kerma-area product (KAP) and dose----area product (DAP) . . . . . . . . . . . . . 14
1.3.4 Reporting patient irradiation in radiological imaging . . . . . . . . . . . . . . . . . 14
1.3.4.1 Radiological parameters of the exposure . . . . . . . . . . . . . . . . . . . . 14
1.3.4.2 Air kerma----area product (KAP) or dose----area product (DAP) . . . . . . . . 15
1.3.4.3 Monte Carlo computation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.3.4.4 Phantoms and in vivo measurements. . . . . . . . . . . . . . . . . . . . . . . 15
1.3.5 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.4 Need for harmonization of quantities and terminology . . . . . . . . . . . . . . . . . 17
1.5 The two purposes of patient dosimetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.5.1 To set and check standards of good practice . . . . . . . . . . . . . . . . . . . . . . . 18
1.5.2 To assist in assessing detriment or harm . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.6 Relationship between patient dose and image quality . . . . . . . . . . . . . . . . . . 18
1.7 Scope of the report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2 SPECIFICATION OF X-RAY BEAMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.1 Photon spectrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.2 Half-value layer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.3 X-ray tube voltage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.4 Total filtration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2.5 X-ray tube output . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
3 QUANTITIES AND UNITS FOR MEASUREMENT AND CALCULATION IN MEDICAL
X-RAY IMAGING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.1 Basic dosimetric quantities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.2 Application-specific quantities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.2.1 Incident air kerma and incident air kerma rate . . . . . . . . . . . . . . . . . . . . . 28
3.2.2 Entrance-surface air kerma and entrance-surface air kerma rate . . . . . . . . . . . 29
3.2.3 Air kerma----area product and air kerma----area product rate . . . . . . . . . . . . . . 29
3.2.4 Air kerma----length product . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.2.5 CT air-kerma index free-in-air . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.2.6 CT air-kerma index in the standard CT dosimetry phantoms . . . . . . . . . . . . . 30
3.2.7 Weighted CT air-kerma index and normalized weighted CT air-kerma index . . . 30
3.2.8 CT air kerma-length product . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.3 Risk-related quantities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.3.1 Absorbed dose in relation to deterministic effects . . . . . . . . . . . . . . . . . . . . 31
3.3.2 Absorbed dose for assessment of stochastic effects (organ dose) . . . . . . . . . . . . 31
3.3.3 Equivalent dose and effective dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4 Dose-conversion coefficients for assessment of organ and tissue doses . . . . . . . 32
3.5 Quantities recommended for establishment and use of diagnostic
reference levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.5.1 Incident air kerma and entrance-surface air kerma . . . . . . . . . . . . . . . . . . . 34
3.5.1.1 Mean mammary glandular dose . . . . . . . . . . . . . . . . . . . . . . . . . 34
3.5.2 Incident air kerma rate and entrance-surface air kerma rate . . . . . . . . . . . . . 34
3.5.3 Air kerma----area product . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3.5.4 CT Air kerma----length product, P
DL,CT
. . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4 MEASUREMENT METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.1 Quality assurance of dosimeters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.1.1 Calibration of dosimeters in terms of air kerma free-in-air . . . . . . . . . . . . . . . 36
4.1.2 Calibration of air kerma----area product meters . . . . . . . . . . . . . . . . . . . . . . 37
4.1.3 Calibration of thermoluminescent dosimeters . . . . . . . . . . . . . . . . . . . . . . 38
4.2 Measurement methods for specific dosimetric quantities . . . . . . . . . . . . . . . . 39
4.2.1 Dosimeters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
4.2.1.1 Ionization chamber dosimeters . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.2.1.2 Thermoluminescent dosimeters . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.2.1.3 Scintillation dosimeters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.2.1.4 Film dosimeters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.2.2 Incident air kerma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.2.3 Entrance-surface air kerma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
4.2.4 Air kerma----area product . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
4.2.5 CT air-kerma index and CT air-kerma index in the standard CT head
and body dosimetry phantoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.2.5.1 Pencil ionization chamber dosimeter . . . . . . . . . . . . . . . . . . . . . . 44
4.2.5.2 Thermoluminescent dosimeters . . . . . . . . . . . . . . . . . . . . . . . . . 47
4.3 Features of measurements on patients and measurements with
physical phantoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING
4.4 Skin dose determination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
4.4.1 Direct measurement of the maximum skin dose . . . . . . . . . . . . . . . . . . . . . 48
4.4.1.1 Skin dose measurements on patients with thermoluminescent
dosimeters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
4.4.1.2 Skin dose measurements on patients with scinillation dosimeters . . . . . 50
4.4.1.3 Skin dose measurements on patients with film dosimeters . . . . . . . . . 50
4.4.2 Derivation of the skin dose from the air kerma----area product P
KA
. . . . . . . . . . 50
4.4.3 Derivation of the skin dose directly from the radiological parameters
of the exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5 METHODS FOR DETERMINING ORGAN AND TISSUE DOSES . . . . . . . . . . . . . . . . . . . . . . . 55
5.1 Dose measurements in physical phantoms . . . . . . . . . . . . . . . . . . . . . . . . . . 55
5.2 Monte Carlo radiation transport calculations . . . . . . . . . . . . . . . . . . . . . . . 56
5.2.1 Main features of the Monte Carlo technique . . . . . . . . . . . . . . . . . . . . . . . 56
5.2.2 Main features of the computational models of the human body . . . . . . . . . . . . 56
5.2.2.1 Mathematical phantoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
5.2.2.2 Special features of the active bone marrow . . . . . . . . . . . . . . . . . . . 57
5.2.2.3 Voxel phantoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
5.2.3 Uncertainties in Monte Carlo organ-dose calculations . . . . . . . . . . . . . . . . . 58
5.2.4 Comparison of conversion coefficients calculated at different institutes . . . . . . . 59
5.2.5 Comparison of measured and calculated organ doses . . . . . . . . . . . . . . . . . . 59
5.2.5.1 Adult phantoms: organs in the x-ray field . . . . . . . . . . . . . . . . . . . 59
5.2.5.2 Adult phantoms: organs outside the x-ray field . . . . . . . . . . . . . . . . 60
5.2.5.3 Adult phantoms: active bone marrow . . . . . . . . . . . . . . . . . . . . . . 60
5.2.5.4 Paediatric phantoms: head and neck . . . . . . . . . . . . . . . . . . . . . . 60
5.2.5.5 Paediatric phantoms: whole body . . . . . . . . . . . . . . . . . . . . . . . . 60
5.2.5.6 Adult phantoms: CT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.2.6 Sources of data on dose-conversion coefficients . . . . . . . . . . . . . . . . . . . . . . 61
6 CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
APPENDIX A BACKSCATTER FACTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
APPENDIX B HANDBOOKS PRODUCED BY THE CENTER FOR DEVICES
AND RADIOLOGICAL HEALTH (CDRH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
APPENDIX C REPORTS PRODUCED BY THE GERMAN NATIONAL RESEARCH
CENTER FOR ENVIRONMENT AND HEALTH (GSF) . . . . . . . . . . . . . . . . . . . . . 79
APPENDIX D REPORTS PRODUCED BY THE HEALTH PROTECTION AGENCY (HPA) (FORMERLY
NATIONAL RADIOLOGICAL PROTECTION BOARD) (NRPB) . . . . . . . . . . . . . . . . 87
APPENDIX E REVIEW OF MONTE CARLO CALCULATIONS FOR ASSESSMENT OF MEAN
GLANDULAR DOSE IN MAMMOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
APPENDIX F PCXMC ------ A PC-BASED MONTE CARLO PROGRAM FOR CALCULATING
PATIENT DOSES IN MEDICAL X-RAY EXAMINATIONS . . . . . . . . . . . . . . . . . . . 99
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
CONTENTS
Journal of the ICRU Vol 5 No 2 (2005) Report 74 doi:10.1093/jicru/ndi019
Oxford University Press
PREFACE
The mission and main objective of the Interna-
tional Commission on Radiation Units and Measure-
ments (ICRU) are to develop a coherent system of
radiological quantities and units that is accepted
worldwide and applied in all fields where ionizing
radiation is used. The ICRU also develops recom-
mendations on how to measure radiation-related
quantities to ensure a reliable exchange of results.
In addition, within the framework of this mission,
there is often a need for the definition of new terms
and concepts that could be adopted universally. The
ultimate goal of the ICRU is to improve harmoniza-
tion in the concepts and the methods used to describe
and to report radiation applications, and thereby
facilitate the exchange of information between cen-
tres using radiation in medicine, science, and indus-
try. The foundation of the ICRU by the First
Congress of Radiology in 1925 was to solve exactly
this harmonization problem.
The present Report is the first report published
by the ICRU that deals with patient dosimetry for
x rays used in diagnostic medical imaging. The
impetus for this report derives from the broad and
systemic application of x rays for diagnostic and
interventional imaging. The increasing number of
patients that benefits from radiology and the
increasing number and types of procedures that are
applied to these patients have resulted in a dramatic
increase of the population dose, which, in developed
countries, often exceeds the natural radiation levels.
The situation in developing countries will sooner or
later exhibit the same trend (UNSCEAR, 2000).
The relation between image quality and patient
dose has always been a matter of concern for the
radiology community. To initiate the production of
objective information, the European Commission
conducted several trials for various types of exam-
ination currently performed in diagnostic radiology.
As an example, a first trial, involving 24 radiology
departments from 10 European countries
(1987/1988) compared entrance doses for PA chest
radiography. The entrance surface doses ranged
from0.03 to 12 mGy, i.e., a ratio of about 400 (Maccia
et al., 1989). A second larger study (1991) involved
83 radiology departments from 16 countries. As
an example, in the second study, for PA chest radio-
graphs, the mean entrance doses measured in
the participating departments ranged from 0.1 to
0.5 mGy, i.e., a ratio of 5 between the maximum
and the minimum mean doses (EC, 1996a). This
ratio was worse in the first study. Most interesting
is the fact that there was no correlation between the
quality of the image and the dose to the patient. The
quality of the images was evaluated by the informa-
tion content of the film as assessed by a team of
experienced radiologists. Several other studies of
this kind were initiated (e.g., for breast, lumbar
spine), and quality criteria were established (CEC,
1990; EC, 1996b; ICRU, 2003).
A particular source of concern is that among the
different examinations some modern CT procedures
that are remarkably powerful in their diagnostic
capabilities deliver significant doses to large regions
of the body. The diagnostic power of the radiological
procedures to solve medical issues is of course the
first priority. Because of the increasing doses
delivered to an increasing number of patients, how-
ever, it becomes important and timely to optimize
the technical conditions, i.e., to reduce the patient
exposure for the same quality of diagnostic informa-
tion. This is simply common sense and is in agree-
ment with the recommendations of the radiation
protection commissions and agencies, and also of
national and international authorities.
An additional issue is the recent development and
rapid growth of interventional radiology, especially
in cardiology. The exposures are high for the patient
(and possibly also for the radiologists), and the num-
ber of reported cases of acute tissue reactions
1
with
different severity is increasing. The need for accur-
ate dosimetry becomes critical especially for the
skin, which is one of the tissues at highest risk.
For patient dosimetry in radiology, the required
accuracy depends on the clinical situation and the
dose range involved. It is, in general, much lower
than the accuracy required in radiation therapy. In
any case the quantities measured should always be
1
The ICRP has recently proposed (2005) to replace the
term deterministic effects by tissue reactions.
International Commission on Radiation Units and Measurements 2005
clearly identified. The relevant quantities to be
determined are those most closely related to the bio-
logical effects or risks of such effects. Presently, the
available data establish correlation between the bio-
logical effects and absorbed dose at the point or in
the volume of interest.
For the low doses delivered by most of the current
procedures in diagnostic radiology, cancer induction
(stochastic effect) is considered to be the main risk.
In contrast to diagnostic radiology, at the high doses
delivered, for example, during interventional radi-
ology, acute effects become the major source of con-
cern (deterministic effect). Late effects resulting
from acute effects constitute particularly dangerous
pre-cancerous lesions. This is well established for
the skin and is nowbeing investigated for the rectum
after radiotherapy of prostate and cervix tumors.
Previous ICRU Reports have dealt with patient
dosimetry for external beam therapy with photons
(ICRU Report 42 1987; ICRU Report 50, 1993; ICRU
Report 62, 1999; ICRU Report 64, 2001), with elec-
trons (ICRU Report 71, 2004a), protons (ICRU
Report 59, 1998b), and neutrons (ICRU Report 45,
1989a), for brachytherapy, and for b-ray applica-
tions (ICRU 38, 1985a; ICRU Report 58, 1997;
ICRU Report 72, 2004b). ICRU Reports 32 (1979)
and 67 (2002) dealt with patient dosimetry in
diagnostic nuclear medicine procedures.
Some aspects of the dosimetry of x rays generated
at tube voltages ranging from 5 to 150 kV were dis-
cussed in ICRU Report 17 (1970) but were not direc-
ted specifically at patient dosimetry in diagnostic or
interventional radiology.
In the field of radiation protection, the ICRU has
also provided advice on the determination of dose
equivalents from sources of radiation external to
the body (ICRU Report 39, 1985b; ICRU Report 43,
1988; ICRU Report 47, 1992a; ICRU Report 57,
1998a). The advice involved the use of operational
quantities suitable for practical measurements for
the evaluation of occupational exposures. In particu-
lar, these operational quantities introduced by the
ICRU facilitate an adequate and conservative estim-
ate of effective dose, that is, the protection quantity
defined by the International Commission on Radio-
logical Protection (ICRP) for use in its system of
radiological protection (ICRP Publication 60, 1991a).
Exposure to ionizing radiation due to medical
x-ray imaging entails the well-defined irradiation
of localized parts of the body. Diverging beams of
x rays, emitted from a point source and character-
ized by half-value layers of 0.310 mm of Al, are
collimated to penetrate the volume of interest. The
use of different irradiation conditions, in terms of
incident radiation quality and beam geometry in
relation to the patients body, has led to the develop-
ment of specific dosimetric methods and the defini-
tion of appropriate quantities quantities different
from those used for occupational and environmental
exposures.
Not surprisingly, the exposure conditions
assumed in deriving the relationships between the
effective dose and the operational quantities for
occupational and environmental exposures are not
appropriate for patient dosimetry in medical
imaging. In the first case one is dealing with whole
body irradiation by broad beams of photons or neut-
rons while, in the second case, strictly collimated
beams are used resulting in partial-body patient
irradiations.
Whereas some of the dosimetric concepts and tech-
niques used in radiotherapy have been successfully
employed in medical x-ray imaging, additional dosi-
metric quantities and measurement methods are
required for patient dosimetry for procedures such
as fluoroscopy, CT, and mammography. Conversion
coefficients are often used in practice to relate dir-
ectly measurable quantities to doses to different
critical organs or at specific reference points. When
deterministic effects are considered a possibility,
doses to the more heavily irradiated sites of the
body need to be critically evaluated.
The present Report provides a detailed framework
of recommendations for assessing patient dose in
radiological imaging. Moreover, this framework is
suitable for the accurate, harmonized exchange of
information as well as to provide an assessment to
avoid or reduce the severity of tissue reactions. This
report will be soon followed by a second one, exclus-
ively focused upon CT dosimetry and its image qual-
ity. The recent development and rapid growth of CT
applications, and the specific issues that are raised,
deserve a special ICRU Report.
Andre Wambersie
Paul M. DeLuca
Johannes Zoetelief
September 2005
PATIENT DOSIMETRY FOR X RAYS USED IN MEDIUM IMAGING
2
Journal of the ICRU Vol 5 No 2 (2005) Report 74 doi:10.1093/jicru/ndi020
Oxford University Press
GLOSSARY
AEC automatic exposure control
AP anteroposterior view: x rays enter from the front of a patient
BM bone marrow
CC cranio-caudal view: x rays enter on the top of the head of a patient
CT computed tomography
CTDI computed tomography dose index
DICOM digital imaging and communications in medicine
DRL diagnostic reference level
FID focal spot-to-image receptor distance
FOV field of view
FSD focal spot-to-surface distance
GI gastro-intestinal
GSD genetically significant dose
HVL half-value layer
LAT lateral incidence of radiation
LAO left anterior oblique view: x rays enter right rear side of patient and form an image on the left front
side
L LAT left lateral view: x rays enter from the right side of patient and form an image on the left side
LPO left posterior oblique view: x rays enter right front side of patient and form an image on the left rear
side (All oblique views lie in a transverse plane and form a 45
; HVL
1
:
2.98 mm Al. Bottom tube voltage: 28 kV constant potential,
molybdenum anode; filtration: 0.03 mm Mo, anode angle 12
,
behind 2 mm thick PMMA compression plate; HVL
1
: 0.32 mm
Al. Reproduced with permission from Dr. J. Th. M. Jansen.
International Commission on Radiation Units and Measurements 2005
tungsten K-edge, but the spectrum is dominated by
the bremsstrahlung contribution.
In x-ray mammography, a spectrum of much
lower energy, for example, from a molybdenum
target, is used to obtain good soft-tissue contrast.
This spectrum is modified by a K-edge filter (gener-
ally molybdenum although rhodium is used in some
situations) and shows strong peaks corresponding to
the K
a
and K
b
characteristic radiation, which for the
molybdenum target have average energies of 17.4
and 19.6 keV, respectively (Figure 2.1). The K-edge
filter reduces the low-energy end of the bremsstrahl-
ung spectrum and much of the bremsstrahlung
spectrum at energies above the K-edge, which for
molybdenum is at 20 keV.
A combination of calculations and measurements
has been used to produce catalogues of x-ray spectra
for specified values of tube voltage, filtration, target
material, target angle, and waveform (Birch et al.,
1979; Seelentag et al., 1979; Iles, 1987). More
recently, the Institute of Physics and Engineering
in Medicine (IPEM) prepared a catalogue of dia-
gnostic x-ray spectra and other data available on
CD-ROM (IPEM, 1997). This allows calculation of
x-ray spectra based upon the method of Birch et al.
(1979) in cases where an appropriate spectrum can-
not be found in one of the available catalogues. Such
information on the spectral distribution of the
photon fluence is required when calculating the
response of detectors or the air kerma or absorbed
dose in different materials when exposed to the
relatively broad photon spectra typical of x rays
used in medical x-ray imaging. It is important to
check calculated values for first and second HVL
against measurements.
2.2 HVL
Routinely, the practical determination of x-ray
beam quality relies on simple attenuation measure-
ments, usually in aluminium, to determine the HVL.
The first, HVL
1
, is the thickness of a specified mater-
ial, which attenuates the beam of radiation to an
extent such that the radiation quantity is reduced
to half its initial value (ICRU, 1970). The use of
different radiation quantities such as exposure or
absorbed dose will lead to different HVL
1
values.
For the characterization of x-ray beams used for
medical imaging, the air kerma, K
a
, or the air
kerma rate,
_
KK
a
, is recommended for the determina-
tion of the HVL. In the definition of HVL the con-
tribution of all scattered radiation, other than any
that might be present initially in the beam con-
cerned (see Section 2.4), is to be excluded. The HVL
alone is often not an adequate specification of the
x-ray beam quality because markedly different
spectra can sometimes result in the same value of
HVL
1
, as illustrated by Figure 2.2. It should be noted
that two of the spectra shown have very low filtra-
tion and would not be legal for use in medical x-ray
imaging in many countries. In the figure, photon
spectra are shown for four x-ray beams having sim-
ilar values of HVL
1
, but generated at different tube
voltages and having different filtration. The x-ray
spectra are rather different and may cause different
dosimeter responses and different dose distributions
in an irradiated medium, for example, phantom or
patient.
For measurement of the HVL the recommenda-
tions of the ICRU (1964) should be followed. It has
been shown that a narrow beam and a sufficiently
large distance between the absorber and measuring
device should be used to obtain the correct HVL.
The instrument used for attenuation measurements
should have weak energy dependence over the
range concerned. The use of a monitor is advisable
to facilitate a correction for variations in the output
of the x-ray tube. The monitor should be positioned
so that its readings are independent of the thickness
of the absorber. By limiting the field diameter, the
amount of scattered radiation recorded will be
reduced, but the field dimensions must be larger
than the sensitive volume of the measuring device.
The collimator must be of sufficient thickness to
absorb the primary beam. A radiographic method
may be used to check the alignment.
The variation of the measured HVL with field
diameter and with detectorabsorber distance is
presented elsewhere (ICRU, 1964). As a general
rule the absorbing material should be placed approx-
imately midway between the source and the
detector, the minimum sourcedetector distance is
50 cm at a maximum field diameter of 5 cm. If
greater accuracy is required, the method described
by Trout et al. (1960) should be used for which a
unique value can be determined by measuring the
HVL for three collimator sizes. A linear extrapola-
tion of a plot of HVL against the field diameter will
yield the zero-field-area value.
2.3 X-RAY TUBE VOLTAGE
The x-ray tube voltage may be measured using
either invasive or non-invasive equipment. Both
approaches have advantages and disadvantages.
Invasive measurements can be made, for example,
by means of a frequency-compensated high-voltage
divider combined with a storage oscilloscope. The
calibration of the high-voltage divider should ideally
be traceable to a primary or secondary voltage
standard. For connection to the oscilloscope, high-
impedance probes and low-impedance cables have
PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING
22
to be used. The oscilloscope probes should preferably
be calibrated in conjunction with the oscilloscope,
for the range of voltages to be measured.
In the past, the x-ray peak tube voltage has been
checked with an uncertainty of 12 kV using a modi-
fied Ardran and Crookes test cassette (Jacobson
et al., 1976). Although the test film produced with
this cassette can be evaluated visually, reliable res-
ults can only be obtained by using a densitometer
to read the patches on the film.
Non-invasive electronic devices for measurement
of the x-ray tube voltage are generally based on
attenuation measurements (Gard, 1996) but spectro-
metric methods may also be used. Methods differ as
to which value is indicated, for example, peak volt-
age or average voltage. Different instruments are
usually required for general radiology and mammo-
graphy. They need careful calibration against a
primary or secondary standard. The measured
value of the x-ray tube voltage will be influenced by
the degree of beam filtration and may be dependent
on the air kerma rate. Devices that rely on the
integrated or the peak signal cannot measure or
indicate the waveform, and it is desirable to addi-
tionally use an oscilloscope or similar device.
For both invasive and non-invasive devices
calibration facilities are essential, but primary or
secondary standard devices are not available in all
countries. While the quality of the calibration inev-
itably plays an important role, it must be appreci-
ated that the vagueness of the term peak voltage is
also a contributory factor (Kramer et al., 1998).
Therefore, a new quantity termed the practical
peak voltage has been proposed (IEC, 1996; Kramer
et al., 1998). This quantity is based on the concept
that the radiation generated by a high voltage of
any waveform produces the same contrast as radi-
ation generated by an equivalent constant potential
generator. The constant potential producing the
same contrast for a specified contrast configuration
and specified x-ray tube properties as the waveform
under test is the practical peak voltage. This quant-
ity is derived from the contrast produced by a
reference x-ray tube irradiating a 10 cm thick
0 20 40 60 80 100 120
PHOTON ENERGY; E/keV
R
E
L
A
T
I
V
E
N
U
M
B
E
R
O
F
P
H
O
T
O
N
S
0 20 40 60 80 100 120
PHOTON ENERGY; E/keV
R
E
L
A
T
I
V
E
N
U
M
B
E
R
O
F
P
H
O
T
O
N
S
0 20 40 60 80 100 120
PHOTON ENERGY; E/keV
R
E
L
A
T
I
V
E
N
U
M
B
E
R
O
F
P
H
O
T
O
N
S
0 20 40 60 80 100 120
PHOTON ENERGY; E/keV
R
E
L
A
T
I
V
E
N
U
M
B
E
R
O
F
P
H
O
T
O
N
S
Figure 2.2. Calculated spectra (IPEM, 1997) of filtered x-ray beams with almost the same HVL
1
but generated at different tube voltages
in a tungsten anode (constant potential, anode angle 16
) and with different filtration. Top left tube voltage, 60 kV; filtration, 4.3 mm
Al; HVL
1
, 2.74 mm Al; HVL
2
, 3.5 mm Al. Top right tube voltage, 75 kV; filtration, 2.9 mm Al; HVL
1
, 2.74 mm Al; HVL
2
, 3.9 mm Al;
Bottom left tube voltage, 90 kV; filtration, 2.0 mm Al; HVL
1
, 2.72 mm Al; HVL
2
, 4.3 mm Al. Bottom right tube voltage, 110 kV;
filtration, 1.2 mm Al; HVL
1
, 2.68 mm Al; HVL
2
, 4.8 mm Al. Reproduced with permission from Dr. J. Th. M. Jansen.
SPECIFICATION OF X-RAY BEAMS
23
PMMA phantom covered partially with a piece of
1 mm Al as a contrast medium (Kramer et al., 1998).
The result of the contrast-equivalent peak voltage
is insensitive to small differences in the contrast
geometry.
The experimental results of Baorong et al. (2000)
demonstrated that a contrast-equivalent x-ray tube
voltage can be determined with an accuracy ranging
from 200 V to 3 kV, depending on the magnitude
of the tube voltage in the range of 40150 kV. The
reference contrast geometry of 1 mm Al on 10 cm
PMMA selected on the basis of calculations (Kramer
et al., 1998) also appears suitable from experimental
evidence.
2.4 TOTAL FILTRATION
The materials of the x-ray tube window and any
permanent filters will attenuate the x rays produced
in the target (focal spot) of the x-ray tube. The thick-
ness of these materials is called the inherent filtra-
tion and often expressed in an equivalent thickness
of aluminium. There may be additional filtration
fromthe radiolucent mirror of the light-beamsystem
and from other parts of the collimator system.
Often additional (aluminium) filtration is applied
to remove the lower-energy photons, which will con-
tribute only to patient dose and not to the image. The
total filtration is the sum of the inherent and the
additional filtration.
The HVL can be used to estimate the total
filtration of x-ray tubes used in medical imaging.
The uncertainty of the total filtration will be within
10 % (Gilmore and Cranley, 1990) provided that the
HVL
1
can be measured within 0.06 mm Al, the tube
voltage within 1.9 kV, the tube voltage ripple within
5 %, and the effective target angle is known within
1.8
angle indicates radiation incident perpendicular to the largest surface of the detector. For the 28 kV x rays data are presented for
irradiation free-in-air and for irradiation at a depth of 5 mm in a PMMA phantom. The statistical (type A) standard uncertainties are less
than 1, 2.5, 1, and 1 % for Mo/Mo free-in-air, Mo/Mo in-phantom, C60, and C80, respectively. C60 and C80 are beam qualifications of
Seelentag et al. (1979) (Zoetelief et al., 2000).
MEASUREMENT METHODS
39
4.2 MEASUREMENT METHODS FOR
SPECIFIC DOSIMETRIC QUANTITIES
4.2.1 Dosimeters
For dosimetry in medical x-ray imaging, ioniza-
tion chamber systems and TLD systems are most
commonly used. Suitable ionization chamber dosi-
meters have advantages over TLD systems in that
their accuracy, precision, and energy independence
are better. In addition, ionization chambers can be
read out directly, contrary to TLDs, which have to be
transported to a reading system after irradiation.
Advantages of TLDs are their small size, which
make them suitable for dose measurements on
patients, and their capacity of storing dose informa-
tion over longer periods of time. This makes them
suitable for dosimetry at a distance, for example, at a
central laboratory, TLDs being transported by mail.
Scintillation as well as film dosimeters have also
been used for measurements on patients (Section
4.4), their main characteristics are presented in
this section.
4.2.1.1 Ionization chamber dosimeters
General information on dosimetry using ioniza-
tion chambers can be found elsewhere (ICRU, 1970,
1973; Boag, 1987; IAEA, 1996b). More detailed
information relevant to medical imaging has been
published by Dutreix and Bridier (1985), for
example. Some aspects, specific to medical x-ray
imaging are presented below. Free-in-air air kerma
measurements are best made with suitably designed
ionization chambers of typically between 0.6 and
180 cm
3
volume. The chambers should have air-
equivalent walls so that their energy response in
terms of air kerma is substantially uniform for all
relevant x-ray spectra. The leakage current should
be very small compared with the ionization current
produced by the minimum dose rate to be measured
and the response should not be affected appreciably
by ion recombination at high dose rates. Dosimeters
should be calibrated in a manner traceable to a
national primary standard of air kerma as described
in Section 4.1.
There are special requirements for ionization
chambers used for air-kerma measurements in
mammography: these are a thin entrance wall to
reduce attenuation at low photon energies, and ide-
ally a structure that does not appreciably disturb the
primary radiation field. Thin entrance window
chambers with small volumes generally have a
rather massive construction on the exit side, which
implies that the charge produced in the cavity con-
tains a significant contribution from scattered radi-
ation. Calibration at appropriate mammographic
radiation qualities will, however, overcome the lat-
ter problem. Ionization chambers and their energy
response for mammography beams have been pub-
lished by DeWerd et al. (2002).
4.2.1.2 TLDs
Discussion of general aspects of thermolumines-
cent dosimetry can be found elsewhere (McKinlay,
1981; Oberhofer and Scharmann, 1981; McKeever
et al., 1995; Zoetelief et al., 2000, 2003b). TLDs
have to be read out and annealed carefully to obtain
reliable results. TLDs can be stuck directly and
unobtrusively to the patients skin with very little
interference in patient mobility or comfort. They will
adequately measure the radiation backscattered
from the patient, and they are unlikely to obscure
useful diagnostic information on images made. TLDs
are available in a variety of physical forms and in
different materials. Solid chips are the most conveni-
ent form for application to dosimetry in medical
x-ray imaging.
Lithium fluoride and lithium borate are the most
commonly used phosphors for dosimetry in medical
imaging, combining the desirable features of a relat-
ively flat energy response, low fading characterist-
ics, and reasonable sensitivity. With careful use and
proper calibration they should be capable of measur-
ing doses down to 500 mGy with an expanded uncer-
tainty of <10 % (with a coverage factor of 2). At
100 mGy, the expanded uncertainty is increased to
<25 %. Smaller uncertainties at low doses can be
achieved with the considerably more sensitive cal-
cium fluoride phosphor, but this material is less air-
equivalent and exhibits a marked variationinenergy
response that requires careful calibration at appro-
priate x-ray qualities to achieve accurate measure-
ments. The sensitivity and the accuracy of lithium
fluoride TLDs at doses <50 mGy can be considerably
improved by using deconvolution techniques to sep-
arate out the individual peaks in the glow curve (Bos
et al., 1993, 1994). Alternatively, high-sensitivity
material doped with magnesium, copper, and phos-
phorus (Wu et al., 1984; Fill and Regulla, 1998; Sa ez
et al., 1999) can be used. The main characteristics
(see, e.g., Vij, 1993; McKeever et al., 1995) of four
TLD phosphors are shown in Table 4.5. The energy
dependence of six commonly used chips is shown in
Figure 4.2 (Zoetelief et al., 2000).
4.2.1.3 Scintillation dosimeters
General characteristics of scintillation dosimeters
can be found in Knoll (2000), for example. The
energy dependence of plastic scintillation dosimet-
ers in the energy range used in radiology has been
studied by several authors. Wagner and Pollock
PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING
40
(1999) found for this type of dosimeter a sensitivity
variation as a function of energy within 5 %
between peak tube voltages of 60 and 125 kV. This
value is confirmed by De Sousa et al. (2000), who
found a sensitivity variation of 10% between tube
voltages of 60 and 140 kV and 25 % between 50 and
140 kV. According to Waite and Fitzgerald (2001) the
variation of the sensitivity of scintillation dosimeters
above tube voltages of 90 kV was similar to that of a
calibrated ionization chamber but deviated at lower
tube voltages values.
The sensitivity of a scintillation dosimeter as a
function of absorbed dose has also been investigated.
Linear dependence of the signal as a function of dose
was observed for absorbed dose up to 60 mGy (De
Sousa et al., 2000) and up to 20 Gy (Wagner and
Pollock, 1999). For doses <0.3 mGy the accuracy
markedly decreases (De Sousa et al., 2000).
4.2.1.4 Film dosimeters
General characteristics of film dosimeters can be
found in Knoll (2000), for example. Two types of film
have been explored for patient dosemetry in inter-
ventional radiology, i.e., radiological film, with a
year-long tradition in this field, and radiochromic
film, which has been introduced more recently.
The radiological film dosimeter is known to have a
very poor tissue-equivalence, because of the high
atomic number of the film emulsion. Two types of
slow KODAK films have been investigated with
respect to their use in interventional radiology. The
X-OMAT-V film, with a long tradition as a radiother-
apy portal dose verification film, shows an increase
in sensitivity by a factor of 20 at peak tube voltage of
70 kV compared with
60
Co gamma rays (1.17 and
1.33 MeV) (Van o et al., 1997). The more recent
EDR2 film does not show a significant variation in
sensitivity between peak tube voltages of 60 and
110 kV (Guibelalde et al., 2003).
Using X-OMAT-V films doses of up to 500 mGy can
be explored and the corresponding linear dose range
is from20 to 200 mGy. For the EDR2 film, doses up to
1000 mGy can be measured and the linear dose range
is from 50 to 500 mGy (Guibelalde et al., 2003). The
EDR2 film is, thus, more suitable for higher-dose
radiological procedures than the X-OMAT-V film.
The tissue-equivalence of the radiochromic film is
considerably better than that of the radiological film,
consequently less variation of its response as a func-
tion of energy is expected. Nevertheless, a sensitivity
variation of up to 5 % between peak tube voltages of
60 and 100 kV has been observed by Giles and
Murphy (2002). For the radiochromic film dosimeter
the dose dependence has been found to be linear up
to an absorbed dose of 10 Gy (Giles and Murphy,
2002). This type of film is thus particularly suited
to evaluate the high doses delivered to the most
heavily irradiated regions, for example, the skin
during some interventional radiological procedures.
4.2.2 Incident air kerma
There are usually several steps required to deter-
mine incident air kerma. The most commonly used
method of determining K
a,i
relies on the measure-
ment of the x-ray tube output, Y(d) (Sections 2.5 and
3.2.1). To derive K
a,i
, Y(d) has to be corrected for the
focal spot-to-surface distance, d
FSD
, and combined
with the recording of the post-exposure P
It
after
examination of a patient or a phantom. The method
is usually suitable only for x-ray machines with a
post-exposure display of P
It
or units with manual
exposure only. Alternatively, K
a,i
can be derived
from a measurement of K
a,e
by applying an appro-
priate backscatter factor [Eq. (3.15); Appendix A].
The incident air kerma, K
a,i
, can be derived from
the air kerma free-in-air at a distance, d, from the
x-ray tube focal spot, K
a
(d)
K
a;i
K
a
d
d
2
d
2
FSD
, 4:2
0.1
1
10
100
10 100 1000
Photon energy (keV)
R
e
l
a
t
i
v
e
T
L
r
e
s
p
o
n
s
e
,
n
o
r
m
a
l
i
s
e
d
t
o
1
M
e
V
p
h
o
t
o
n
s
CaF
2
:Dy
CaSO
4
:Dy
Al
2
O
3
:C
Li
2
B
4
O
7
:Mn,Si
LiF:Mg,Ti
BeO
Figure 4.2. Calculated energy responses relative to air of some
commonly used TL chips. Calculations were performed, assuming
a thickness of 0.9 mm for all detectors (Zoetelief et al., 2000).
MEASUREMENT METHODS
41
where d
FSD
is the focal spot-to-surface distance.
Employing Eq. (2.1) the following relation is
obtained
K
a;i
Y d P
It
d
2
d
2
FSD
: 4:3
The output can be measured free-in-air in the
centre of the x-ray beam at a distance, d, from the
focal spot (d is usually 1 m). Measurements of K
a
(d)
should preferably be made in the manual exposure
mode for the range of exposure conditions met in
clinical practice and the corresponding values of P
It
recorded. In mammography, measurements are
often not made in the centre of the field but closer
to the chest wall edge (EC, 1996b). Because the air
kerma rates can differ appreciably for the same
exposure conditions from one x-ray tube to another,
it is necessary that output measurements are made
on the x-ray tube under study.
For a specific type of radiograph of a patient, for
example, for a posteroanterior (PA) view of the
chest and the exposure conditions (tube voltage,
anode material and angle, filtration) used in practice
for the type of radiograph in question, the post-
exposure P
It
is obtained. The relevant value of Y(d)
is derived from a series of output measurements at
various x-ray tube voltages and filtrations, if neces-
sary by interpolation. The value of K
a,i
for a particu-
lar radiograph of a patient can then be derived
according to Eq. (4.3).
If automatic exposure control (AEC) is used and
the post-exposure P
It
is not indicated, K
a,i
can only
be determined by using a phantom (Section 4.3)
representing the patient. The phantom should pro-
vide the same amount of attenuation as an average
patient and, ideally, should result in the same
x-ray spectrum incident on the AEC device detector.
The air kerma measurement should be made at some
distance from the phantom surface so as to exclude
the contribution from backscattered radiation
and the chamber should not shield the AEC detector.
The incident air kerma K
a,i
can then be calculated
using Eq. (4.2).
4.2.3 Entrance surface air kerma
Measurements of K
a,e
can be made directly on the
patient or a phantom with TLDs. The practical and
theoretical problems related to the use of ionization
chambers for the measurement of K
a,e
are consider-
able. When using phantoms, it may be necessary to
recess a larger dosimeter, for example, an ionization
chamber, in the surface of a phantom so that its
effective centre lies in the plane of the surface and
provides good results (Harrison, 1982; Petoussi-
Henss et al., 1998).
The recommendation in specific radiotherapy
dosimetry protocols for low-energy x rays (e.g.,
IAEA, 1987; IPSM, 1991; Ma et al., 2001) is to derive
K
a,e
from measurement of K
a,i
and application of an
appropriate backscatter factor through Eq. (3.15).
The same approach can be used here. Backscatter
factors for radiology range from 1.25 to 1.60 for
typical x-ray spectra and field sizes used for adults
(Petoussi-Henss et al., 1998). An important excep-
tion is for mammography where the lower energy
spectrum and smaller field size result in backscatter
factors of 1.10. The derivation of appropriate val-
ues for the backscatter factor is discussed in more
detail in Appendix A.
The entrance surface air kerma K
a,e
for a patient
or a phantom for a specific type of radiograph, for
example, for a PA view of the chest or for a medio-
lateral oblique view of the breast, can be obtained as
follows. TLDs should be encapsulatedto protect them
from dirt and exposure to visible light and to facilit-
ate fixing to the surface of a patient or phantom. The
encapsulationmaterial should be thinand should not
contain elements of high atomic numbers, which are
often used in dyes, to avoid significant absorption of
the low-energy x rays sometimes encountered in
radiology, for example, in mammography. For the
relevant radiation quality, the TLDs should be cal-
ibrated inside the encapsulation and at the same
orientation with respect to the x-ray beam as during
medical exposure. The encapsulated TLDs should be
positioned on the patients skin or on top of the
phantom as close as possible to where the centre of
the x-ray beam enters the patient or phantom. Then
the examination should be made in the normal way.
For mammography it has been proposed (EC, 1996b)
that the TLDs be positioned on the upper inner
quadrant of the breast, where the risk of obscuring
clinically important details is less than in the centre
of the beam. When too low a read-out is expected, for
example, for chest radiography, repeated exposures
of the TLDs should be made. Repeated exposures of
the same TLDs should be ideally made for a sample
of sufficient size to represent average patients. The
read-out of the TLDs corrected for background and if
necessary fading and multiplied by the calibration
coefficient results in the value of K
a,e
.
4.2.4 Air kermaarea product
Quantities P
KA
and
_
PP
KA
are most easily measured
using a specially designed ionization chamber,
which is mounted on the collimator housing, where
it affords minimum interference with the medical
imaging task. The chambers are of parallel-plate
design, set perpendicular to the beam axis and are
of sufficient area to encompass the largest beamsize.
PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING
42
The plates are often made to be transparent to vis-
ible light to allow use of a light beam collimator. The
electrometer and display unit are connected to the
chamber by a long cable so that the display can be
positioned for easy access to read and reset. The
response of the P
KA
meter will depend on whether
the chamber is installed on an overtable or under-
table x-ray tube (Section 4.1.2).
The requirements for air kermaarea product
(P
KA
) meters are similar to dosimeters in general,
as described in Section 4.1. This means that
re-calibration should be made at intervals not exceed-
ing 2 years, and whenever the instrument has been
repaired or its performance is suspect (AAPM, 1992).
Re-calibration at one radiation quality, the reference
quality, is often sufficient, as it is unlikely that
the dependence of the response on radiation energy
would change significantly. However, sometimes it
will be important to check comprehensively the
dependence of the response on the dose rate, particu-
larly if the dosimeter is used at widely varying dose
rates. Corrections for ion recombination are usually
insignificant but must be considered when using
very high instantaneous dose rates. Simple constancy
checks and checks of the various functions are recom-
mended before each use of the instrument.
Estimates of the uncertainty in the (in situ) calib-
ration coefficient of a P
KA
meter are 6 %at the 95 %
confidence level (Shrimpton and Wall, 1982; Larsson
et al., 1996) for overtable geometry. For undertable
geometry, the table may reduce the calibration coef-
ficient by 1520 % compared with the overtable
situation (Carlsson and Alm Carlsson, 1990).
Commonly, P
KA
meters consist of PMMA coated
with a conducting material. Carbon is often used for
this purpose as it is approximately air-equivalent,
however, to achieve light transparency other con-
ducting materials are used. These materials con-
tain high atomic number elements resulting in a
relatively strong energy dependence compared with
ionization chambers coated with graphite (Larsson
et al., 1996; BednarekandRudin, 2000). For example,
the addition of additional copper filtration may
affect the calibration coefficient by several per cent.
Experience with ageing of air kermaarea product
meters, for example, when installed at interven-
tional radiology systems and submitted to very
large doses during several years is still limited. Sim-
ple constancy checks of the instrument should be
able to reveal ageing.
Some P
KA
meters are capable of distinguishing
between values accumulated during radiography
and fluoroscopy. If this distinction is made purely
on the basis of a threshold in
_
PP
KA
(difference in
tube current exposure time product rate between
fluoroscopy and radiography), errors can occur. For
example, when large beam areas are used during
fluoroscopy of thick or dense areas of the patient,
_
PP
KA
approaches values seen during radiography.
Developments are in progress where the field size,
d
FSD
and K
a,i
are also registered. Modern x-ray
equipment may have built-in P
KA
meters or will dis-
play the value of P
KA
after an exposure by internal
calculation using the exposure factors (tube voltage
and filtration, P
It
) and the position of the beam lim-
iting collimators. The value of P
KA
does not contain
information on the projection.
The assessment of organ doses from P
KA
measure-
ments for procedures, involving both fluoroscopy
and radiography, is quite complex. This is illustrated
for colon examinations where the value of P
KA
has to
be related to individual radiographs and to interme-
diate fluoroscopy. Values of
_
PP
KA
and cumulative P
KA
are shown in Figure 4.3. The standard colon exam-
ination was biphasic (Geleijns et al., 1997). First,
Figure 4.3. Air kermaarea product rate,
_
PP
KA
(top panel) and
cumulative air kermaarea product, P
KA
(bottom panel) as a
function of examination time (sample rate 0.1 s) measured during
a colon examination of one patient (Reproduced from Geleijns
et al., 1997, with permission from Radiological Society of North
America). The P
KA
values have to be related to images as presen-
ted in Table 4.4 and to fluoroscopy. The data in the present figure
correspond to Patient 4 in Figure 4.4.
MEASUREMENT METHODS
43
after insertion of a rectal cannula, a barium suspen-
sion of low density and high viscosity was admin-
istered and a single contrast study was performed.
Second, after partial evacuation, air was insufflated
for the double contrast study of the rectum and the
colon. From this information it has to be determined
whether the increase in
_
PP
KA
belonged to a continu-
ous, prolonged signal, which is indicative of fluoro-
scopy, or to a short pulse, which is indicative of
radiography (imaging). If radiography was recog-
nized, the P
KA
value for the radiograph was calcu-
lated from all P
KA
samples in the pulse, which
included the P
KA
sample acquired at the start of
the pulse (for which the value might be low).
Although a standard protocol for colon examination
was implemented (Table 4.6), deviations from the
protocol were common and had to be taken into
account during analysis. The P
KA
for each radio-
graphic projection (image) and each fluoroscopy
interval can be estimated only after careful assign-
ment of the corresponding projection (Table 4.6.) to
each peak in the
_
PP
KA
signal (i.e., to each radiograph).
The distribution of P
KA
over the various projections
is shown in Table 4.6. For fluoroscopy, it is assumed
that the exposure conditions can be mimicked by the
subsequent radiograph, except for differences in
radiation quality (i.e., tube voltage). Consecutive
P
KA
for fluoroscopy and radiographs (images) during
colon examination of 13 patients are shown in
Figure 4.4. The figure illustrates the differences
occurring in practice even when a standard protocol
is implemented.
4.2.5 CT air-kerma index and CT air-kerma
index in the standard CT head and
body dosimetry phantoms
Following the convention established in Section
3.2, C
K
refers to measurements free-in-air and C
K,p
to measurements in-phantom.
4.2.5.1 Pencil ionization chamber dosimeter
For dosimetry in CT, pencil ionization chambers
are available with a diameter of 10 mm, a sensitive
length of 100 mm, and an active volume of 3 cm
3
.
An essential feature of these dosimeters is that their
response is designed to be uniform along the entire
length of the sensitive volume. They are usually cal-
ibrated in terms of air kerma by exposing the entire
sensitive volume to a uniform x-ray field. Thus they
indicate P
KL
/L when exposed to a CT slice or mul-
tiple slices free-in-air. Because the C
K
of Eq. (3.22)
rapidly falls to zero away from the position of the CT
slice, the pencil ionization chamber will also meas-
ure C
K
to a very good approximation. The relation-
ship between C
K
, and P
KL
/L, the single slice CT axial
air kerma profile K
a
(z), the chamber length L and
the nominal slice thickness T is shown in Figure 4.5.
By definition, the area under the single slice dose
profile (the dotted line) equals the areas of either
rectangle. For measurement inside a phantom, C
K,p
is obtained in a similar way.
For a measurement of C
K
, the pencil ionization
chamber should be fixed so that it extends beyond
the table end. The chamber should be mounted in
0
5
10
15
20
25
30
1 2 3 4 5 6 7 8 9 10 11 12 13
A
i
r
k
e
r
m
a
a
r
e
a
p
r
o
d
u
c
t
;
P
K
A
/
G
y
.
c
m
2
Patient number
Figure 4.4. Air kermaarea products, P
KA
values for fluoroscopy (white) and images (black) during colon examination of 13 patients
(Geleijns, 2000, private communication). The data for the 13 patients have been ordered in accordance with the total P
KA
for the
examination. Reproduced with permission from Dr. J. Geleijns.
PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING
44
such a way that its length axis corresponds to the
axis of rotation of the gantry and that its centre
corresponds to the centre of the slice, or the centre
of the slices for a multi-slice scanner (Figure 4.6).
The measurement with the ionization chamber
should be made for a single rotation. When the rota-
tion differs from360
this
should be noted. Special attention should be given to
the orientation of the peripheral measurement posi-
tions. Thus the C
K,PMMA,100,c
can be obtained from
the measurement at the central position and
C
K,PMMA,100,p
as the average of measurements at
four peripheral positions. By using Eqs (3.263.28),
the CT air kermalength product, P
KL,CT
for a com-
plete conventional (serial CT) examination can be
derived from C
K,PMMA,100,c
and C
K,PMMA,100,p
. In the
case of helical scanning, P
KL,CT
can be derived from
C
K,PMMA,100,c
and C
K,PMMA,100,p
by using Eqs (3.26),
(3.27), and (3.29).
4.2.5.2 TLDs
TLDs placed in a row within a suitable plastic
holder can be used to measure the CT axial air
kerma profile free-in-air. The TLDs should be con-
tiguous in the region of the primary beam, but away
from this region, they can be separated by spacers. It
is noted that TLDs can be arranged in a stack or
placed side by side. The latter arrangement is applic-
able for measurement of C
K
but does not give a good
measurement of the air kerma profile. In principle
TLDs can also be used for measurements in phan-
toms, but if several measurement positions are used
then this will require a large number of dosimeters.
Therefore, ionization chambers are preferred for in-
phantom measurements. A typical free-in-air single
slice dose profile measured with lithium fluoride or
lithium borate TLD chips, 0.8 mm thick and stacked
contiguously in a hollow cylindrical plastic capsule,
is shown in Figure 4.10A. For such a stack of n TLDs,
the C
K
is approximated by
C
K
1
T
Z
1
1
K
a
z dz
1
T
S
n
K
aj
h, 4:6
where K
aj
is the air kerma to the jth TLDfroma total
of n TLDs and h is the extension (0.8 mm in this
example) of each TLD in the axial direction, and T is
the nominal slice thickness.
The value of C
K
, thus derived, is shown in
Figure 4.10B; for this particular scanner and slice
thickness, is 8 % higher than the peak of the dose
profile.
For the measurement of C
K
, the stack of TLDs
should be fixed so that it extends beyond the table
end (similar to the fixation of the pencil ionization
chamber shown in Figure 4.6). The stack of TLDs
should be mounted so that its length axis coincides
with the axis of rotation of the gantry and that its
centre corresponds to the centre of the slice, or the
centre of the slices for a multi-slice scanner. The
measurement with the stack of TLDs should be
Figure 4.10. Typical free-in-air CT axial air kerma profile K
a
(z) for a nominal slice thickness of 4 mm measured by TLDs (A) and the
resulting C
K
(B) (after Shrimpton et al., 1991; Survey of CT Practices in the UK, Part 2: Dosimetric Aspects, NRPB-R249; HMSO, London,
UK).
MEASUREMENT METHODS
47
made for a single rotation. When the rotation differs
from 360
(left) Cranial 20
(right)
RAO 30
(right) LAO 45
Cranial 25
(left)
LAO 30
(right) LAO 45
(left)
LLAT (left) RAO 10
Cranial 40
(left)
RAO 15
Caudal 25
(left)
Anterior (left)
RAO 15
Cranial 25
(left)
Nominal conversion
coefficients
Entrance skin in primary field
Brain Pancreas
Thyroid Stomach
Thymus Liver
Active BM Kidneys
Oesophagus Colon
Lungs Small intestine
Female breasts Ovaries
Heart Uterus (surrogate for the embryo)
Adrenals Urinary bladder
Spleen Testes
PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING
76
The coefficients are presented for three beam
qualities for each reference patient (i.e., ADAM,
HVL
1
of 2.5, 4.0, and 5.5 mm Al; EVA, HVL
1
of 2.0,
3.5, and 5.0 mm Al). The ranges of beam qualities
correspond to the those observed in the study con-
ducted at the Institut de Cardiologie de Montreal
(Haddadi and Renaud, 1993) and that observed in a
nationwide survey of fluoroscopy practice in the Uni-
ted States (Conway, 1994). The beam qualities are
without the presence of a supporting tabletop. For
the usual ranges of tube voltage (kV) and aluminum
filtration combinations used in fluoroscopy and cine-
angiography of the coronary arteries, the results
should have uncertainties of <10 % when HVL
1
alone is used to describe beam quality. In preparing
the tabulations, the following diagnostic x-ray spec-
tra were applied, as shown below.
When the actual diameter of the FOV at the image
receptor plane differs fromthat used in the reference
simulation by >20 %, the dose-conversion factor in
Table B.5 should be corrected by multiplication with
[FOV(actual)/FOV(tabulated)]
2
. The basis for the
correction is given in the Handbook (Stern et al.,
1995b).
The correction is not applicable to the entrance
skin in the primary field, because the absorbed dose
does not depend on the size of the area of the skin
irradiated.
A tabulation for the conversion coefficients is
given in Table B.5.
B.6.3 Application of the handbook
The Handbook can be used to perform a view-
by-view or a nominal analysis of an examination.
To use the nominal approach, the coronary-artery
examination is characterized in an overall sense.
This permits a quick, but somewhat less accurate
way to estimate nominal tissue doses for a complete
examination without detailed specifications for the
particular views applied clinically.
The complete examination is characterized with
nominal values for four parameters.
(a) The HVL
1
;
(b) The total K
a,i
for all the fluoroscopic plus cine-
angiographic segments (i.e., summed for all
skin-entrance planes, wherever these planes
are located);
(c) The FOV diameter at the image receptor plane;
and
(d) The highest cumulative K
a,i
(i.e., fluoroscopic
plus cineangiographic) for any single skin
location. Such a skin region may be irradiated
in only one view or possibly in multiple views
that share a common locus of irradiation.
B.6.4 Illustrative calculation
The illustration below is for a left-heart study of
an adult male entailing a left ventriculogram in
biplanar mode followed by left and right coronary
Peak tube
voltage/kV
Total filtration/
mm Al
HVL
1
/mm Al
ADAM
60 3.5 2.5
90 4.0 4.0
120 4.3 5.5
EVA
50 3.3 2.0
80 3.9 3.5
110 4.2 5.0
Table B.5. Sample tabulation: Handbook of Tissue Doses
for Fluoroscopic and Cineangiographic Examinations of
the Coronary Arteries (Stern et al., 1995b).
(D
T
/mGy)/(K
a,i
/Gy)
Male Female
HVL
1
/mm Al 2.5 4.0 5.5 2.0 3.5 5.0
Entrance skin
in primary field
1000 1120 1180 950 1090 1170
Brain 0.003 0.020 0.041 0.001 0.018 0.045
Thyroid 0.12 0.50 0.85 0.075 0.53 1.1
Thymus 2.2 6.5 9.9 1.6 6.7 12
Active BM 6.1 12 16 5.2 12 17
Oesophagus 14 33 47 11 32 51
Lung 34 53 65 31 55 71
Breast 3.0 9.4 15
Heart 30 62 86 23 63 95
Adrenal 36 62 78 32 64 87
Spleen 4.9 11 15 3.8 11 17
Pancreas 5.4 14 20 3.8 13 22
Stomach 2.4 6.3 9.3 1.7 6.3 10
Liver 4.4 9.7 14 3.5 9.9 15
Kidney 3.2 6.8 9.3 2.7 7.1 11
Colon 0.071 0.31 0.56 0.043 0.32 0.67
Small intestine 0.091 0.40 0.72 0.050 0.39 0.82
Ovary 0.007 0.076 0.19
Uterus 0.005 0.071 0.17
Urinary bladder 0.003 0.021 0.044 0.001 0.023 0.054
Testis
a
0.002 0.004
Nominal conversion coefficients:
d
FSD
: 60 cm
d
FID
: 90 cm
FOV diameter at image receptor: 14 cm.
a
(D
T
/mGy)/(K
a,i
/Gy) < 0.001.
APPENDIX B
77
angiography. In a typical application of the nominal
approach, the user will rely on estimated values of
the parameters for the entire examination that may
be truly nominal. In any case the estimates will be
developed at the level of detail and with the degree
of accuracy available to the user.
The left-heart study is performed with an HVL
1
of 3.6 mm Al, a d
FSD
of 60 cm, a d
FID
of 90 cm, and a
FOV of 20 cm at image receptor plane.
The dose to the skin in primary field due to the
examination is
D
Skin;local
0:80 Gy 1090 mGy=Gy 870 mGy,
B:6
where 0.80 Gy is the highest K
a,i
for any single skin
location and 1090 the organ dose-conversion coeffi-
cient for the local skin derived by linear interpola-
tion between the reference values for HVL
1
from
Table B.5.
The dose to the active BM due to the examination is
D
BM
1:6 Gy 10 mGy=Gy 2:0 32 mGy,
B:7
where 1.6 Gy is the K
a,i
for all skin entrances planes,
10 the organ dose-conversion coefficient for the act-
ive BM derived by linear interpolation between the
reference values for HVL
1
from Table B.5, and 2.0 is
a correction factor needed for the actual FOV (20 cm
rather than the 14 cm in the reference tabulation in
Table B.5).
The dose to the lung due to the examination is
D
BM
1:6 Gy 48 mGy=Gy 2:0 150 mGy,B:8
where 1.6 Gy is the K
a,i
for all skin entrances planes,
48 the organ dose-conversion coefficient for the lung
derived by linear interpolation between the refer-
ence values for HVL
1
from Table B.5, and 2.0 is a
correction factor needed for the actual FOV.
PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING
78
Journal of the ICRU Vol 5 No 2 (2005) Report 74 doi:10.1093/jicru/ndi031
Oxford University Press
APPENDIX C: REPORTS PRODUCED BY THE
GERMAN NATIONAL RESEARCH CENTER FOR
ENVIRONMENT AND HEALTH (GSF)
C.1 GENERAL DESCRIPTION
The GSF, Institute for Radiation Protection,
Medical Physics Department has produced several
reports containing tabulations of organ dose-
conversion coefficients for reference adult and pae-
diatric patients for common radiographic and CT
examinations. The reports permit the calculation of
organ doses from measurable normalization quant-
ities for specified technical parameters relating to
the examinations, using the general relation:
Organ dose organ dose-conversion coefficient
normalization quantity: C:1
For standardized technical parameters, as given
in the European Guidelines on Quality Criteria for
Diagnostic Radiographic Images (EC, 1996a), the
organ doses are given.
The following material is available.
For the calculations on adult patients, gender-
specific mathematical human phantoms have been
used, whereas the calculations in paediatric radi-
ology have used voxel phantoms. The adaptation
of the data to individual patients is discussed.
Details are described in the GSF Report Series:
The Calculation of Dose from External Exposures
Using Reference Human Phantoms and Monte
Carlo Methods (Kramer et al., 1982; Drexler et al.,
1990; 1993; Zankl et al., 1991; 1993; 1997).
C.2 PROJECTIONS COMMON IN
DIAGNOSTIC RADIOLOGY (ADULTS)
GSF-BERICHT 11/90 (DREXLER
ET AL., 1990)
C.2.1 Main features of calculations
The organ dose-conversion coefficients are
obtained by applying a Monte Carlo calculation
method (Kramer et al., 1982; Veit et al., 1989) to
the modified MIRD-5 type mathematical male
ADAM and female EVA models (Kramer et al.,
1982). The main differences of the gender-specific
ADAM and EVA phantoms in comparison to the
MIRD-5 type phantoms are:
(i) the EVA phantom is representative of a refer-
ence adult female and contains the female
organs,
(ii) the ADAM phantom is representative of a
reference adult male and contains the male
organs,
(iii) the EVA phantom is significantly smaller than
the ADAM phantom.
(iv) the arms of both phantoms are removable,
(v) the phantoms have a chin so that less tissue
exists in front of the thyroid,
(vi) the skull of ADAM and EVA is improved with
regard to shape and size, and
(vii) an esophagus has been added (Zankl et al.,
1992).
In the Monte Carlo calculations the beam quality
is described by the spectral distributions of the
photons, which is a function of the tube voltage, the
total filtration, the target material, and the target
angle as determined by a computer program based
on semi-empirical methods (Birch and Marshall,
1979). In the tabulations of organ dose-conversion
coefficients, the beam quality is expressed in terms
of the constant tube voltage and the total filtration.
1. Projections Common
in Diagnostic Radiology
(Adults)
(GSF-Bericht 11/90,
Drexler et al., 1990).
2. Projections Common
in Diagnostic Radiology
(Paediatric)
(Zankl et al., 1988;
1989).
3. Organ Doses for
CT Examinations
of Adults
(GSF-Bericht 30/91,
Zankl et al., 1991).
4. Organ Doses for
CT Examinations in
Pediatric Radiology
(GSF-Bericht 30/93,
Zankl et al., 1993).
International Commission on Radiation Units and Measurements 2005
The beam geometry is given by the focus-to-
surface distance d
FSD
, the focus-to-image receptor
distance d
FID
, the field size at the image receptor
plane, and the direction of incidence on the human
body. The organ dose-conversion coefficients for each
projection are calculated by simulating 2 10
6
incid-
ent photons for the exposure under consideration.
The exposure conditions have been selected to be in
close accordance with routine exposure conditions
common in Europe.
Details are described in the GSF Report Series:
The Calculation of Dose from External Exposures
Using Reference Human Phantoms and Monte Carlo
Methods (Kramer et al., 1982; Drexler et al., 1990;
1993).
C.2.2 Scope of the report
The Report of Drexler et al. (1990) presents a ser-
ies of tabulations of organ dose-conversion coeffi-
cients for 40 common radiographic examinations
including techniques for pregnant women
(Table C.1). Additional organ dose tabulations are
provided for 28 projections with technical paramet-
ers as published in the EC Quality Criteria Docu-
ment (1996a). The organs and tissues for which
organ dose-conversion coefficients are presented is
listed in Table C.2.
A sample tabulation for the lung PA projection is
given in Table C.3. Organ dose-conversion coeffi-
cients are provided for the ADAM and the EVA
phantoms. Each x-ray examination is investigated
for three tube voltages. Atotal filtration of 2.5 mmAl
is used for all the radiographic projections. The last
column in the table presents the coefficient of vari-
ation of the organ dose-conversion coefficients estim-
ated from the Monte Carlo calculation.
C.2.3 Application of the report
Organ doses D
T
are determined from incident
air kerma K
a,i
using the organ dose-conversion
coefficients c
T,K
a,i
given in the Report as,
D
T
c
T,K
a,i
K
a,i
: C:2
The value of K
a,i
for the relevant radiographic pro-
jection and the applied tube voltage, field size, and
filtration are required to estimate the D
T
. For cases
where K
a,i
is not known, the report presents a graph
to estimate K
a,i
from tube voltage, filtration, tube-
current exposure-time product, P
It
, and the focal
Table C.1. Radiographic examination of adults included
in Drexler et al. (1990).
Skull
a
AP, PA, LAT Sacrum AP, LAT
Sinuses PA Pelvis AP
Shoulder joint AP Abdomen AP
Cervical spine
a
AP, PA, LAT Kidneys AP
Thoracic spine AP, LAT Gall bladder PA
Ribs AP Bladder AP
Lung
a
AP, PA, left LAT,
right LAT
Colon contrast enema
PA, LAT
Stomach PA Right hip joint AP
Duodenum PA Left femur AP
Lumbar spine sacrum AP, LAT
a
At various d
FSD
.
Table C.2. Tissues or organs for which organ dose-
conversion coefficients are given for radiographic
examinations of adults.
Brain Colon upper
Eye lenses Colon lower
Thyroid Ovaries
Breast Uterus
Lungs Testes
Spleen Active bone marrow
Pancreas Skeleton
Stomach wall Skin entrance
Small intestine Skin exit
The German edition (Drexler et al., 1993) contains in addition
data for the following.
Oesophagus Bladder wall
Adrenals Muscle
Liver Skin
Kidneys
Table C.3. Sample table from Drexler et al. (1990) showing
mean organ dose-conversion coefficients, i.e., mean organ
dose per unit K
a,i
for the lung PA projection for adult
females (f ) and males (m).
Field size (f ) 35 cm 35 cm d
FID
180 cm
Field size (m) 35 cm 40 cm d
FSD
150 cm
Patient thickness (f ) 19 cm Total filtration 2.5 mm Al
Patient thickness (m) 20 cm
Tube voltage/kV 90 125 140 c.v
a
Organ m f m f m f
Thyroid 0.06 0.06 0.10 0.10 0.12 0.12 0.035
Breast 0.13 0.19 0.22 0.006
Lungs 0.54 0.57 0.68 0.72 0.73 0.76 0.002
Spleen 0.25 0.18 0.33 0.24 0.35 0.26 0.009
Pancreas 0.17 0.12 0.25 0.17 0.27 0.19 0.012
Stomach wall 0.07 0.06 0.11 0.10 0.12 0.11 0.013
Small intestine d d d d 0.01 0.01 0.02
Colon (upper)
b
d d 0.01 0.01 0.01 0.01 0.035
Colon (lower)
c
d d d d d d
Active bone marrow 0.11 0.12 0.16 0.17 0.17 0.18 0.001
Skeleton 0.30 0.32 0.35 0.38 0.36 0.39 0.001
Surface (entrance) 1.24 1.24 1.27 1.32 1.35 1.34 0.001
Surface (exit) 0.04 0.05 0.07 0.08 0.09 0.10 0.04
a
Coefficient of variation.
b
Caecum Ascending Transverse.
c
Descending Sigmoid Rectum.
d
Less than 0.01.
PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING
80
spot-to-surface distance, d
FSD
. In addition, recom-
mendation is given in the Report on how to proceed,
when physical exposure parameters in a special
case considered differ from those assumed in the
tabulations.
C.2.4 Illustrative calculation
Breast dose from a PA chest examination per-
formed with a tube voltage of 125 kV, 2.5 mm Al
filtration, a P
It
of 4 mAs, a d
FSD
of 150 cm, corres-
ponding to a d
FID
of 180 cm and a field size of 35 cm
35 cm at d
FID
for the female phantom
D
Breast
0:19 0:4 mGy 0:076 mGy, C:3
where 0.19 is the organ dose-conversion coefficient
for breast fromTable C.3 and 0.4 mGy the K
a,i
, either
known from measurement or derived from the graph
in GSF-Bericht 11/90 (Drexler et al., 1990).
C.3 COMMON PROJECTIONS IN
DIAGNOSTIC RADIOLOGY (PEDIATRIC)
(ZANKL ET AL., 1988; 1989)
C.3.1 Main features of calculations
The features of the Monte Carlo program
employed are the same as that used for the adults.
The phantoms used are tomographic models of two
real patients, i.e., an 8-week-old girl BABY and a 7-
year-old girl CHILD. Details of these phantoms are
presented by Zankl et al. (1988) and Veit et al.
(1989).
To construct the GSF paediatric phantoms, whole-
body CT data were used. For each phantom, scans of
a single patient were used, performed as contiguous
slices of 4 and 8 mm thickness for the BABY and
CHILD, respectively. The baby was 8 weeks old
when it was scanned and thus represents babies
from newborn up to several months. The child was
7 years old; it was, however, slightly small for its
age and can be regarded as representative for the
ages between 5 and 7 years. The CT-based voxel
phantoms are more realistic for dose calculations
than any other type of phantom available thus far.
They do not represent an average over all persons of
a certain age and gender, as the shape of the body
and the shape and locations of the organs vary for
people of the same age and gender, and even for
different attitudes (standing, sitting, lying).
However, because the shape and location of the
organs is accurate for a particular person in a certain
attitude, the phantoms constructed from these data
give the best approach to reality. For organ dose
calculations, the body is modelled using seven
types of tissue. The distribution of active BM in
bone is derived from the CT-numbers belonging to
each voxel, thus providing realistic modelling of
this tissue.
C.3.2 Scope of the publications
Organ doses for BABY and organ dose-conversion
coefficients for CHILD for the most common types of
examination in paediatric radiology have been pub-
lished (Zankl et al., 1988; 1989) and are listed in
Tables C.5 (BABY) and C.7 (CHILD). The physical
exposure conditions for which they were determined
are shown in Tables C.4 (BABY) and C.6 (CHILD).
For BABY the tube voltage, the field sizes, and the
projections were chosen to be representative of
patients between the ages of 4 and 10 weeks who
had been x-rayed in the last 10 years in Munichs
University Children Hospital (Zankl et al., 1988).
For the thorax and pelvis examinations no grid was
used and the film was assumed to be in contact with
the body. For the other examinations grids were
used and the film was at 3.0 cm behind the surface.
Organ dose scaling factors enable the derivation of
organ doses for children deviating in size from the
original phantoms (Veit and Zankl, 1992, 1993).
The exposure conditions shown in Table C.6 for
CHILD are typical for the practice in Germany for
examinations of 57-year-old children with respect
to field size, tube voltage, filtration, focus-to-film
distance, and patient-to-film distance (Zankl et al.,
1989).
Table C.4. Exposure parameters used as input data for the dose calculation of the BABY phantom.
Type of examination Voltage/kV Height of field/cm Width of field/cm d
FID
a
/cm P
KA
a
/mGy cm
2
K
a,i
a
/mGy
Thorax AP 65 13.8 14.5 150 6.93 39.7
Abdomen AP 70 20.0 16.3 100 19.4 76.2
Pelvis AP 70 11.6 13.9 100 7.9 56.5
Skull AP 70 22.9 15.1 100 69.8 275
Skull LAT 65 19.8 20.1 100 51.3 179
a
d
FID
, focus-to-image receptor distance; P
KA
, dose-area product; K
a,i
, incident air kerma.
APPENDIX C
81
C.3.3 Application of the publications
For BABY, organ doses are presented for specific
exposure conditions and can be directly taken from
Table C.5. Organ doses for values of K
a,i
different
from that listed in Table C.4 can be easily
derived by normalizing them to the values given in
the table.
For CHILD, the quantity required to apply the
organ dose-conversion coefficients c
T,K
a,i
from
Table C.5. Organ doses D
T
/mGy for an 8-week-old BABY phantom for different x-ray procedures (as listed in Table C.4).
Type of examination Thorax AP Abdomen AP Pelvis AP Skull AP Skull LAT
Body organs and tissues D
T
/mGy D
T
/mGy D
T
/mGy D
T
/mGy D
T
/mGy
Bladder wall 0.02 60.9 47.6 0.02 0.00
Brain 0.28 0.04 0.00 88.9 60.2
Eye lenses 0.86 0.00 0.00 295 125
Heart 23.3 37.1 0.14 6.99 1.66
Lungs 18.6 23.8 0.11 16.6 2.68
Ovaries 0.02 52.1 42.1 0.03 0.00
Small intestine wall 0.13 69.0 25.8 0.26 0.07
Stomach wall 0.88 70.0 0.99 0.78 0.29
Testes 0.00 10.1 67.3 0.01 0.03
Thymus 27.4 4.38 0.06 51.7 6.04
Thyroid 34.2 1.12 0.02 212 90.3
Total skeleton 22.1 39.1 15.7 304 186
Active BM pelvis 0.01 29.2 22.1 0.07 0.04
Active BM ribs 7.53 13.3 0.10 11.7 1.46
Active BM skull 1.43 0.07 0.00 86.9 52.1
Total active BM 3.02 5.83 2.81 43.9 22.8
Table C.6. Exposure parameters used as input data for the dose calculation of the CHILD phantom, relevant for 57-year-
old patients in Germany.
Type of examination Voltage/kV Field width/cm Field height/cm d
FID
a
/cm d
PID
a
/cm
Skull AP 70 26.5 31.0 110 10
Skull LAT 70 26.5 30.5 110 10
Thorax AP 60 25.7 19.0 100 0
Thorax PA 60 26.7 19.7 150 10
Abdomen AP 70 25.6 39.4 110 10
Pelvis AP 70 26.2 22.7 110 10
a
d
FID
focus-to-image receptor distance; d
PID
: patient-to-image receptor distance.
Table C.7. Organ dose-conversion coefficients, i.e., D
T
/K
a,i
for different types of examination (Table C.6) for the CHILD
phantom.
Type of examination Skull AP Skull LAT Thorax AP Thorax PA Abdomen AP Pelvis AP
Body organs and tissues
Brain 0.285 0.351 0.003 0.003
a a
Eye lenses 1.30 0.563 0.006 0.002 0.002
a
Lungs 0.047 0.020 0.466 0.479 0.200 0.001
Ovaries
a a
0.003 0.001 0.569 0.505
Testes
a a a a
0.124 0.184
Thymus 0.173 0.060 0.616 0.238 0.036
a
Thyroid 0.417 0.585 0.799 0.163 0.012
a
Uterus
a a
0.001
a
0.627 0.636
Skeleton (hard bone) 0.694 0.691 0.351 0.502 0.449 0.309/0.303
b
Active BM 0.078 0.066 0.042 0.061 0.075 0.057
Total body 0.123 0.122 0.126 0.136 0.235 0.137/0.131
b
a
Less than 0.01.
b
The pelvic AP examination results for skeleton and total body in slightly higher doses for girls (first value) than for boys because of field
reduction due to shielding of testes.
PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING
82
Table C.7 is K
a,i
D
T
c
T,K
a,i
K
a,i
: C:4
C.3.4 Illustrative calculations
Total active BM dose D
BM,tot
for BABY from an
abdomen AP examination performed with the same
physical exposure parameters as given in
Table C.4, but a K
a,i
(exposure at skin entrance)
value of only 43.0 mGy (5 mR)
D
BM;tot
5:83 mGy 43:0/76:2 3:3 mGy, C:5
where 5.83 mGy is the total active BM dose from
Table C.5, 43.0 mGy (5.0 mR) the actual K
a,i
(expos-
ure at skin entrance) value and 76.2 mGy (8.684 mR)
the K
a,i
(exposure at skin entrance) value from
Table C.4.
Total active BM dose D
BM
for CHILD from an
abdomen AP examination performed with the same
physical exposure parameters as listed in
Table C.6 and a K
a,i
value of 0.7 mGy is given by
D
BM
0:061 0:7 mGy 0:043 mGy, C:6
where 0.061 is the organ dose-conversion coefficient
for active BM from Table C.7.
C.4 REPORT ON ORGAN DOSES FROM CT
EXAMINATIONS (ADULTS) GSF-BERICHT
30/91 (ZANKL ET AL., 1991)
C.4.1 Main features of the calculations
The Monte Carlo calculations and the phantoms
used (ADAM and EVA) are the same as those for
radiographic examinations of adults (Section C.2).
The irradiation conditions for the calculation of
organ dose-conversion coefficients were derived
from a field study in Germany (Panzer et al., 1989).
Most of the CT scanners at that time were of the
following type.
Rotate only systems
Tube rotation 360
or 180
rotation, anterior
radiation incidence was modelled.
The use of beam-shaping devices between focus
and patient was rare at that time in Germany and
was, therefore, not modelled. Scans were, however,
often performed using an asymmetric beam, which
means that the beam width is reduced to 10 cm on
one side. Consequently, only a circle with a radius
of 10 cm around the axis of rotation is fully irradi-
ated, the area outside is not. Because of their
small body size, this makes no difference for babies.
For heavier children, such beams lead to markedly
lower doses in the parts of their body outside the
10 cm field. For these tissues, additional tables for
scans using asymmetric beams are given in the
catalogue.
The radiation qualities considered in the Report
are shown in Table C.11. They cover a wide energy
range and allow interpolation or, to some extent,
extrapolation for beam qualities deviating from
those given.
C.5.2 Scope of the report
The organs and tissues for which organ dose-
conversion coefficients were calculated are listed in
Table C.12. The doses to the active BM are
given both as dose to the active BM in the single
bones listed in Table C.12 and as the mean dose to
the total active BM distributed in the body. The dose
to the skeleton is given as the mean dose to the
entire skeleton, including both mineral bone
and BM.
C.5.3 Application of the data
The determination of organ doses follows the same
procedure as described in Section C.4.3 for adults
according to Eqs. (C.7) and (C.8). Also anatomical
landmarks within the phantoms and orientation val-
ues for C
K
normalized to a P
It
value of 100 mAs per
slice or tube rotation are presented.
For each of the organs considered, separate tables
of organ dose-conversion coefficients are given for
the BABY and for the CHILD phantom. A sample
tabulation of the data for the brain in the BABY
phantom resulting from 1 cm slices with a symmet-
rical beam is given in Table C.13. The first column
describes the single slices with respect to their z-co-
ordinate within the phantom. The next column
shows the percentage of the organ volume included
in the single slice, i.e., the ratio of the organ
being directly irradiated during scanning with a
1-cm-thick slice.
Two pairs of columns of conversion coefficients
follow, one pair for each of the two radiation qualit-
ies considered. Within each of these pairs, the first
column presents conversion coefficients for full 360
tube rota-
tion and symmetrical beam:
D
Brain
14:4 mGy 0:902 13 mGy, C:10
where C
K
is 14.4 mGy from measurement or
from literature values given in the Report and
0.902 the sum of the 12 c(organ, z) values listed in
Table C.13 from slice 0 cm to 1 cm until slice 11 cm to
12 cm.
Table C.13. Sample table from Zankl et al. (1993) showing mean brain dose coefficients (D
T
/C
K
for a series of transverse CT
slices of the BABY phantom and average coefficients of variation per single 1-cm-thick slice. The volume ratio of the organ
located within each single slice is also shown.
Slice (cm) Volume ratio (%) Conversion coefficients Coefficient of variation
80 kV 125 kV
360
180
360
180
x-ray tube anode angle). The uncertainty bars shown correspond to two standard deviations of
the data.
APPENDIX F
101
energy. The final estimate of the absorption at each
energy is obtained as the average of these batches,
and the statistical uncertainty is estimated from
their standard deviation. The doses and their stat-
istical uncertainties for a practical x-ray spectrum of
interest are calculated afterwards by another mod-
ule included in the program. The same Monte Carlo
data can, therefore, be used for calculating doses for
any spectrum of interest. The calculation is fast
because it does not involve any further Monte Carlo
simulation.
The x-ray spectra are calculated according to the
theory of Birch and Marshall (1979) and specified in
terms of the x-ray tube voltage (kV), the angle of the
tungsten target of the x-ray tube, and filtration. In
the present version of the program, the user can
simultaneously define two filters of arbitrary atomic
numbers and thickness. The filter data are from the
compiled x-ray interaction data of McMaster et al.
(1969). Air kerma is calculated from photon fluence
data using the conversion coefficients in ICRU
Report 46 (1992c).
F.5 COMPARISON WITH OTHER DATA
The data calculated by PCXMC are most directly
comparable with the organ dose-conversion coeffi-
cients calculated at the NRPB by Jones and Wall
(1985) and Hart et al. (1994b, 1996b), because they
are based on the same phantom models (Cristy,
1980). In general, the agreement between the results
of PCXMC and the NRPB data is good (e.g.,
Figure F.1). The differences typically fall within
the statistical uncertainty and are generally <10
%. The remaining deviations can be explained by
the differences in the phantoms. An exception to
the good agreement is the calculations for esopha-
gus, where differences in the phantom model lead to
larger deviations (by up to a factor of 2, Tapiovaara
et al., 1997).
PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING
102
Journal of the ICRU Vol 5 No 2 (2005) Report 74 doi:10.1093/jicru/ndi035
Oxford University Press
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