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MINISTRY OF HEALTH MALAYSIA
REPORT
MEDICAL RADIATION EXPOSURE STUDY IN MALAYSIA
REPORT MEDICAL RADIATION EXPOSURE STUDY IN MALAYSIA
TABLE OF CONTENTS
1. Executive Summary i
2. Organization of the Report iii
3. Acknowledgements iv
4. List of Tables vi
5. List of Figures xi
6. List of Abbreviations xv
7. Chapter 1: Introduction
1.1 Background of the Study 1
1.2 Importance of the Study 3
1.3 Objectives 4
1.4 Analysis 5
8. Chapter 2: Diagnostic, Interventional and Dental Radiology
2.1 Literature Review 12
2.2 Methodology 18
2.3 Data Analysis 32
2.4 Result and Discussion 36
9. Chapter 3: Nuclear Medicine
3.1 Literature Review 69
3.2 Methodology 76
3.3 Data Analysis 96
3.4 Result and Discussion 103
10. Chapter 4: Summary, Conclusions and Recommendations 133
11. References 135
12. Appendixes
Appendix A A1
REPORT MEDICAL RADIATION EXPOSURE STUDY IN MALAYSIA
TABLE OF CONTENTS
1. Executive Summary i
2. Organization of the Report iii
3. Acknowledgements iv
4. List of Tables vi
5. List of Figures xi
6. List of Abbreviations xv
7. Chapter 1: Introduction
1.1 Background of the Study 1
1.2 Importance of the Study 3
1.3 Objectives 4
1.4 Analysis 5
8. Chapter 2: Diagnostic, Interventional and Dental Radiology
2.1 Literature Review 12
2.2 Methodology 18
2.3 Data Analysis 32
2.4 Result and Discussion 36
9. Chapter 3: Nuclear Medicine
3.1 Literature Review 69
3.2 Methodology 76
3.3 Data Analysis 96
3.4 Result and Discussion 103
10. Chapter 4: Summary, Conclusions and Recommendations 133
11. References 135
12. Appendixes
Appendix A A1
REPORT MEDICAL RADIATION EXPOSURE STUDY IN MALAYSIA
TABLE OF CONTENTS
1. Executive Summary i
2. Organization of the Report iii
3. Acknowledgements iv
4. List of Tables vi
5. List of Figures xi
6. List of Abbreviations xv
7. Chapter 1: Introduction
1.1 Background of the Study 1
1.2 Importance of the Study 3
1.3 Objectives 4
1.4 Analysis 5
8. Chapter 2: Diagnostic, Interventional and Dental Radiology
2.1 Literature Review 12
2.2 Methodology 18
2.3 Data Analysis 32
2.4 Result and Discussion 36
9. Chapter 3: Nuclear Medicine
3.1 Literature Review 69
3.2 Methodology 76
3.3 Data Analysis 96
3.4 Result and Discussion 103
10. Chapter 4: Summary, Conclusions and Recommendations 133
11. References 135
12. Appendixes
Appendix A A1
Appendix B A5
Appendix C A11
Appendix D A23
Appendix E A25
Appendix F A30
Appendix G A32
Appendix H A35
Appendix I A38
i
EXECUTIVE SUMMARY
The United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR)
was mandated with the task to assess and report levels of exposure to ionizing radiation and their
effects. This committee reports annually to the general assembly of the United Nations.
UNSCEAR collects and analyses data on the global and regional levels and trends of human
exposure to ionizing radiation. The Global Survey of Medical Radiation Usage and Exposures
was carried out since 1970 and the results published in various UNSCEAR Reports. UNSCEAR
2000 report states that radiation is carcinogenic. About 4% of all deaths from cancer can be
ascribed to ionizing radiation and the majority of these results from the natural radiation sources
outside human control [UNSCEAR, 2000]. In this regard, UNSCEAR collects and analyses data
on the global and regional use of radiation in medical diagnosis and treatment. The ICRP had
just presented the latest data from “UNSCEAR 2008 Report: Sources of ionizing radiation (2000
– 2005)” on Dec 2009.
The first national dose survey in Malaysia was initiated by the University of Malaya in
collaboration with the Ministry of Health (MOH). The survey was conducted from 1993 to 1995
to establish baseline patient dose data for seven routine types of x-ray examinations. For the first
time in history Malaysian data made it to the UNSCEAR 2000 report.
The second national medical radiation exposure study was commissioned by the MOH as a
follow up to the first study. The survey was conducted from 2005 to 2009. The scope covers
diagnostic and interventional radiology, nuclear medicine, radiotherapy and dental radiology. In
preparation for the study, four training courses for the MOH officers and research officers had
been conducted.
This report describes the objective, methodology developed for the dose survey, internal
dosimetry quantities and calculation, data analysis, results and discussion for the diagnostic,
interventional and dental radiology, nuclear medicine and also radiotherapy in Malaysia.
In the UNSCEAR 2000 report on the annual global practice and doses from medical uses
of radiation (1991-1996), it was estimated that 2,500 million procedures (medical, dental and
ii
nuclear medicine) were performed annually resulting in a collective dose of 2.5 million manSv.
The average effective dose per caput was 0.4 mSv.
Four levels of health-care in the world have been defined based on the population per
physician in the UNSCEAR 1988 report. At the highest level of health-care (Level I), there are
one or more physicians for each 1,000 population. In less developed countries with lower levels
of health-care, there is one physician each for 1,000 to 3,000 population (Level II), 3000 to
10,000 population (Level III) or greater than 10,000 population (Level IV). Malaysia with 1,429
persons per physician in 2009 belongs to health-care level II.
This survey, basically following the guidelines established by the UNSCEAR, was
conducted in 437 public and private hospitals, medical centres or general practitioners’ clinics;
and 329 public and private dental clinics in Malaysia. These hospitals / medical centres / clinics
(hereafter referred as “sites”) were selected nationwide by population and site-weighted to
represent 30% of the total number of sites in the country. The sites were grouped into five (5)
categories in this survey: public hospital, private hospital, general practitioners’ (GP) clinic,
public dental clinic and private dental clinic. Six (6) different diagnostic modalities were
included: general x-ray, mammography, fluoroscopy/angiography, computed tomography (CT),
bone mineral densitometry (BMD) and dental radiology.
The survey was conducted on the basis of statistics from all the common examinations
performed in diagnostic radiology and dental radiology from 2007 until 2009. The survey was
completed with demographic data covering different information including the equipment,
personnel and patient’s information, as well as the dosimetry data which some were measured
using TLD (i.e. general x-ray, BMD and dental) and Gafchromic films (i.e. fluoroscopy and
interventional radiology) while others were calculated using mathematical formula (i.e.
mammography) or computer software (i.e. computed tomography).
iii
ORGANIZATION OF THE REPORT
This report is a summary of overall design of the survey and analysis outcomes for
diagnostic, interventional and dental radiology, nuclear medicine and radiotherapy. It is divided
into four chapters:
• Chapter 1 for Introduction
• Chapter 2 for Diagnostic, Interventional and Dental Radiology
• Chapter 3 for Nuclear Medicine
• Chapter 4 for Summary, Conclusions and Recommendations
Chapter 2 and Chapter 3 are divided into four sub-chapters. First sub-chapter is Literature
Review which summarizes the literature review of this study. Second sub-chapter is
Methodology which describes the methodology of conducting the survey and the specific survey
protocol for different modality. Third sub-chapter is Data Analysis which explains the methods
of data analysis. Finally, sub-chapter Result and Discussion describe the summary of the analysis
result and discussion.
iv
ACKNOWLEDGEMENTS
This study was funded by Ministry of Health through its research grant, No. MRG-2006-
34. The Committee’s appreciation goes to all who had patiently responded to the questionnaire,
both staff and also clients of the healthcare system.
The Committee also wishes to express our heartfelt thanks to all those who had contributed
at any stage of the research process, from the formulation of the research proposal to the
production of this report.
Members of the committee list:
1. Dr. Gerard Lim Chin Chye Ketua Penyelaras Radioterapi dan Onkologi Kebangsaan
2. Y. Bhg. Datin Dr. Zaharah binti Musa Ketua Penyelaras Radiologi Kebangsaan 3. Y. Bhg. Dato’ Dr. Mohamed Ali bin
Abd Kader Ketua Penyelaras Perubatan Nuklear Kebangsaan
4. Y. Bhg. Dato’ Dr. Omar bin Ismail Ketua Penyelaras Kardiologi Kebangsaan 5. Y. Bhg. Dato’ Dr. Ibrahim bin A.
WahidMalaysian Oncological Society
6. Prof. Madya Dato’ Dr. Fuad bin Ismail Pakar Perunding Radioterapi Pusat Perubatan Universiti Kebangsaan Malaysia
7. Prof. Dr. Ng Kwan Hoong Ahli Fizik Perubatan Pusat Perubatan Universiti Malaya
8. Prof. Dr. Phrabhakaran a/l N Nambiar Fakulti Pergigian Universiti Malaya 9. Y. Bhg. Datuk Dr. Subramani a/l
Venugopal Pakar Perunding Kanan dan Ketua Jabatan Pengimejan Diagnostik Hospital Tuanku Jaafar
10. Dr. Noraini binti Ab. Rahim Pakar Perunding Kanan dan Ketua Jabatan Pengimejan Diagnostik Hospital Serdang
iv
ACKNOWLEDGEMENTS
This study was funded by Ministry of Health through its research grant, No. MRG-2006-
34. The Committee’s appreciation goes to all who had patiently responded to the questionnaire,
both staff and also clients of the healthcare system.
The Committee also wishes to express our heartfelt thanks to all those who had contributed
at any stage of the research process, from the formulation of the research proposal to the
production of this report.
Members of the committee list:
1. Dr. Gerard Lim Chin Chye Ketua Penyelaras Radioterapi dan Onkologi Kebangsaan
2. Y. Bhg. Datin Dr. Zaharah binti Musa Ketua Penyelaras Radiologi Kebangsaan 3. Y. Bhg. Dato’ Dr. Mohamed Ali bin
Abd Kader Ketua Penyelaras Perubatan Nuklear Kebangsaan
4. Y. Bhg. Dato’ Dr. Omar bin Ismail Ketua Penyelaras Kardiologi Kebangsaan 5. Y. Bhg. Dato’ Dr. Ibrahim bin A.
WahidMalaysian Oncological Society
6. Prof. Madya Dato’ Dr. Fuad bin Ismail Pakar Perunding Radioterapi Pusat Perubatan Universiti Kebangsaan Malaysia
7. Prof. Dr. Ng Kwan Hoong Ahli Fizik Perubatan Pusat Perubatan Universiti Malaya
8. Prof. Dr. Phrabhakaran a/l N Nambiar Fakulti Pergigian Universiti Malaya 9. Y. Bhg. Datuk Dr. Subramani a/l
Venugopal Pakar Perunding Kanan dan Ketua Jabatan Pengimejan Diagnostik Hospital Tuanku Jaafar
10. Dr. Noraini binti Ab. Rahim Pakar Perunding Kanan dan Ketua Jabatan Pengimejan Diagnostik Hospital Serdang
v
11. Dr. Lee Boon Nang Pakar Perunding Kanan dan Ketua Jabatan Perubatan Nuklear Hospital Kuala Lumpur
12. Dr. Mohd Rashid bin Baharon Timbalan Pengarah Bahagian Kesihatan Pergigian KKM
13. En. Nik Mohd Hazmi bin Nik Husain Timbalan Pengarah Kanan Bahagian Sains Kesihatan Bersekutu KKM
14. En. Mohd Azhar bin Musa Ahli Fizik Perubatan Hospital Kuala Lumpur 15. En. Mohd Hizwan bin Yahya Ahli Fizik Perubatan Hospital Pulau Pinang
URUSETIA 16. En. Zunaide bin Kayun @ Farni Timbalan Pengarah (Keselamatan Sinaran) 17. Dr. Pirunthavany a/p Muthuvelu Ketua Penolong Pengarah Kanan 18. En. Bazli bin Sapiin Ketua Penolong Pengarah Kanan 19. Dr. Bidi bin Ab. Hamid Ketua Penolong Pengarah Kanan 20. En. Mohd Khairudin bin Mohamed
Samsi Ketua Penolong Pengarah Kanan
21. Pn. Nurmazaina binti Md Ariffin Ketua Penolong Pengarah 22. Pn. Siti Nor binti Mohd Amin Ketua Penolong Pengarah 23. En. Yusri bin Yusuf Penolong Pengarah Kanan 24. Pn. Maznah binti Mohamad Penolong Pengarah Kanan 25. En. Syarul Iman bin Saufi Penolong Pengarah 26. Pn. Fazilatul Liza binti Idris Penolong Pengarah 27. En. Ng Aik Hao Penolong Pengarah 28. Pn. Soh Hwee Shin Penolong Pengarah 29. Cik Tan Hun Yee Penolong Pengarah 30. Pn. Nur Hafizah binti Zakaria Penolong Pengarah 31. En. Abdullah bin Mat Hussin Juru X-Ray Kanan 32. Pn. Rosnita binti Ibrahim Juru X-Ray Terapi Kanan
RESEARCH ASSISTANTS TEAM MEMBERS33. Zuridah binti Bodong 34. Nordiana binti Md Din
vi
35. Nur Syafura binti Ariffin 36. Saidatul Julia binti Jaafar 37. Farizan binti Abdul Mokti 38. Syarul Iman bin Saufi 39. Norzalina binti Zulkifli 40. Puteri Afini binti Abdul Razak 41. Muhammad Zaimie bin Zahari 42. Roslan bin Husin 43. Norshuhada ninti Mohamad Amir 44. Hirnani binti Ghazali 45. Nurhazwani binti Abdul Samad 46. Mohamad Shahir bin Abdul Kharim 47. Siti Fatimah binti Mat Husin 48. Norsuhaida binti Mohd Noor 49. Azalina binti Yahya
OTHERS
50. En. Taiman bin Kadni Agensi Nuklear Malaysia 51. En. Hasan bin Sham Agensi Nuklear Malaysia 52. Cik Yeong Chai Hong Universiti Malaya
vii
LIST OF TABLES
Table 1.1 Overall summary from UNSCEAR year 2000-2005 survey.
Table 2.1 Dosimetric quantities and units for different modalities in diagnostic, interventional and dental radiology.
Table 2.2 Types of examinations and radiographic projections for general x-ray.
Table 2.3 Types of procedures for fluoroscopy and interventional radiology.
Table 2.4 Types of CT examinations.
Table 2.5 Types of BMD examinations.
Table 2.6 Types of dental radiology examinations.
Table 2.7 Total number of personnel in diagnostic, interventional and dental radiology from all the sample sites in this survey (2007-2009).
Table 2.8 Total number of equipment in diagnostic, interventional and dental radiology from all the sample sites in this survey (2007-2009).
Table 2.9 Total number of cases collected by modality.
Table 2.10 Number of cases collected for general x-ray from all the sample sites in this survey.
Table 2.11 Entrance Surface Dose (mGy) by examination.
Table 2.12 Comparison of Entrance Surface Dose (mGy) for general x-ray collected from this survey with DRLs recommended by different international organizations.
Table 2.13 Number of cases collected for fluoroscopy and interventional radiology.
Table 2.14 Air Kerma-Area Product (mGy.m2) for different fluoroscopy examination types in conventional and interventional studies.
Table 2.15 Peak Skin Dose (mGy) for different fluoroscopy examination types in conventional and interventional studies.
Table 2.16 Mean Skin Dose (mGy) for different fluoroscopy/angiography examination types in conventional and interventional studies.
vii
LIST OF TABLES
Table 1.1 Overall summary from UNSCEAR year 2000-2005 survey.
Table 2.1 Dosimetric quantities and units for different modalities in diagnostic, interventional and dental radiology.
Table 2.2 Types of examinations and radiographic projections for general x-ray.
Table 2.3 Types of procedures for fluoroscopy and interventional radiology.
Table 2.4 Types of CT examinations.
Table 2.5 Types of BMD examinations.
Table 2.6 Types of dental radiology examinations.
Table 2.7 Total number of personnel in diagnostic, interventional and dental radiology from all the sample sites in this survey (2007-2009).
Table 2.8 Total number of equipment in diagnostic, interventional and dental radiology from all the sample sites in this survey (2007-2009).
Table 2.9 Total number of cases collected by modality.
Table 2.10 Number of cases collected for general x-ray from all the sample sites in this survey.
Table 2.11 Entrance Surface Dose (mGy) by examination.
Table 2.12 Comparison of Entrance Surface Dose (mGy) for general x-ray collected from this survey with DRLs recommended by different international organizations.
Table 2.13 Number of cases collected for fluoroscopy and interventional radiology.
Table 2.14 Air Kerma-Area Product (mGy.m2) for different fluoroscopy examination types in conventional and interventional studies.
Table 2.15 Peak Skin Dose (mGy) for different fluoroscopy examination types in conventional and interventional studies.
Table 2.16 Mean Skin Dose (mGy) for different fluoroscopy/angiography examination types in conventional and interventional studies.
viii
Table 2.17 Comparison of Air Kerma-Area Product (AKAP) from this survey with other published literature.
Table 2.18 Number of cases collected for computed tomography.
Table 2.19 CTDIw (mGy) for different examination types in CT.
Table 2.20 DLP (mGy.cm) for different examination types in CT.
Table 2.21 Effective dose (mSv) for different examination types in CT.
Table 2.22 Comparison of CTDIw (mGy) from this survey with other published surveys.
Table 2.23 Comparison of DLP (mGy.cm) from this survey with other published surveys.
Table 2.24 Comparison of effective dose (mSv) from this survey with other published surveys.
Table 2.25 Number of cases for mammography.
Table 2.26 Mean Glandular Dose (mGy) for different breast thickness in mammography.
Table 2.27 Number of cases collected for bone mineral densitometry.
Table 2.28 Entrance Surface Dose (mGy) for different examination types in bone mineral densitometry.
Table 2.29 Number of cases collected for dental radiology.
Table 2.30 Entrance Surface Dose (mGy) for intraoral examinations in dental radiology.
Table 2.31 Air Kerma-Area Product (mGy.m2) for panoramic examinations in dental radiology.
Table 2.32 Comparison of Entrance Surface Dose (mGy) for intraoral dental examinations collected from this survey with DRLs recommended by different international organizations.
Table 2.33 Comparison of Air Kerma-Area Product (mGy.m2) for panoramic dental examinations collected from this survey with other published literature.
ix
Table 3.1 Reference levels for diagnostic nuclear medicine procedures.
Table 3.2 Total number of personnel in nuclear medicine sites in Malaysia from 2005-2007.
Table 3.3 Total number of nuclear medicine equipment in Malaysia from 2005-2007.
Table 3.4 (a) Annual number of nuclear medicine diagnostic examinations in Malaysia from 2005-2007 according to examination types.
Table 3.4 (b) Annual number of nuclear medicine therapeutic procedures in Malaysia from 2005-2007 according to treatment types.
Table 3.4 (c) Annual number of PET/CT examinations in Malaysia from 2005-2007.
Table 3.5 (a)
Percentage contributions by types of examinations to total number of diagnostic examinations (2005-2007).
Table 3.5 (b) Percentage contributions by types of treatments to total number of therapeutic procedures (2005-2007).
Table 3.5 (c) Percentage contributions to total number of PET/CT examination (2005-2007).
Table 3.6 (a) Gender and age distribution of patients undergoing diagnostic examinations in nuclear medicine (2005-2007).
Table 3.6 (b) Gender and age distribution of patients undergoing therapeutic procedures in nuclear medicine (2005-2007).
Table 3.6 (c) Gender and age distribution of patients undergoing PET/CT examination in nuclear medicine (2005-2007).
Table 3.7(a) Administered activities (MBq) in different types of diagnostic examinations for paediatrics <16 years (2005-2007).
Table 3.7 (b) Administered activities (MBq) in different types of diagnostic examinations for adults ≥16 years (2005-2007).
Table 3.7 (c) Administered activities (MBq) in different types of therapeutic procedures for paediatrics <16 years (2005-2007).
Table 3.7 (d) Administered activities (MBq) in different types of therapeutic procedures for adults ≥16 years (2005-2007).
Table 3.7 (e) Administered activities (MBq) in PET/CT (2005-2007).
Table 3.8 (a) Mean effective dose (mSv) calculated for different types of diagnostic examinations for paediatrics <16 years (2005-2007).
x
Table 3.8 (b) Mean effective dose (mSv) calculated for different types of diagnostic examinations for adults ≥16 years (2005-2007).
Table 3.9 Comparison of mean administered activity and mean effective dose for paediatrics (age <16) and adults (age ≥16) for different diagnostic examinations.
Table 3.10 Comparison of number of nuclear medicine diagnostic imaging equipment per million population with UNSCEAR 2000 report.
Table 3.11 Comparison of number of procedures per 1000 population with UNSCEAR 2000 report (Table 46).
Table 3.12 Comparison of effective dose per procedure with UNSCEAR 2000 report (Table 46).
Table 3.13 Comparison of annual collective dose per procedure with UNSCEAR 2000 report (Table 46).
Table 3.14 Comparison of percentage contribution to total annual frequency with UNSCEAR 2000 report (Table 47).
Table 3.15 Comparison of percentage contribution to total annual collective dose with UNSCEAR 2000 report (Table 47).
Table 3.16 Summary of the data comparison between this survey and UNSCEAR 2000 report (Table 50).
Table 3.17 (a) Comparison of average administered activity (MBq) of different types of diagnostic examinations with difference recommended DRLs (Adults ≥ 16 years old).
Table 3.17 (b) Comparison of average administered activity (MBq) of different types of diagnostic examinations with difference recommended DRLs (Paediatrics < 16 years old).
Table 3.18 Comparison of average administered activity (MBq) of different types of diagnostic examinations with other national surveys (Adults ≥ 16 years old).
Table 3.19 Comparison of average administered activity (MBq) of different types of radionuclide therapy with other national surveys (Adults ≥ 16 years old).
xi
LIST OF FIGURES
Figure 1.1 Explanation of mean, median and mode.
Figure 1.2 An example of pie chart used in this survey.
Figure 1.3 An example of bar chart used in this survey.
Figure 1.4 An example of histogram used in this survey.
Figure 1.5 Interpretation of a typical box-plot.
Figure 2.1 Radiation dosimetric quantities.
Figure 2.2 The breakdown of data collection methodology.
Figure 2.3 Patient measurement set up.
Figure 2.4 Orientation markings on the reversed side of the Gafchromic® film.
Figure 2.5 AKAP reading displayed on fluoroscopy console.
Figure 2.6 Example of the calibration strips during the calibration of Gafchromic® film.
Figure 2.7 Scanned Gafchromic® film and the skin dose distribution map.
Figure 2.8 Medical Radiation Exposure Survey database management system.
Figure 2.9 Histogram showing the number of personnel in diagnostic, interventional and dental radiology from all the sample sites in this survey from 2007 to 2009.
Figure 2.10 Histogram showing the number of personnel in diagnostic, interventional and dental radiology from all the sample sites in this survey from 2007 to 2009.
Figure 2.11 Number of cases collected for general x-ray.
Figure 2.12 Entrance surface dose (mGy) by examination.
xii
Figure 2.13 Number of cases collected for angiography, conventional and interventional studies using fluoroscopy/angiography.
Figure 2.14 Number of cases collected for angiography (cardiac and non-cardiac).
Figure 2.15 Number of cases collected for fluoroscopy (conventional studies).
Figure 2.16 Number of cases collected for fluoroscopy (interventional studies).
Figure 2.17 Air Kerma-Area Product (mGy.m2) for different examination types in angiography and conventional fluoroscopy studies.
Figure 2.18 Air Kerma-Area Product (mGy.m2) for different procedures in interventional studies.
Figure 2.19 Peak Skin Dose (mGy) for different examination types in angiography and conventional fluoroscopy.
Figure 2.20 Peak Skin Dose (mGy) for different procedures in interventional studies.
Figure 2.21 Mean Skin Dose (mGy) for different examination types in angiography and conventional fluoroscopy.
Figure 2.22 Mean Skin Dose (mGy) for different procedures in interventional studies.
Figure 2.23 Number of cases collected for computed tomography.
Figure 2.24 CTDIw (mGy) for different examination types in CT.
Figure 2.25 DLP (mGy.cm) for different examination types in CT.
Figure 2.26 Effective dose (mSv) for different examination types in CT.
Figure 2.27 Mean Glandular Dose (mGy) for different breast thickness in mammography.
Figure 2.28 Number of cases collected for bone mineral densitometry.
Figure 2.29 Entrance Surface Dose (mGy) for different examination types in bone mineral densitometry.
Figure 2.30 Number of cases collected for dental radiology.
xiii
Figure 2.31 Entrance Surface Dose (mGy) for intraoral examinations in dental radiology.
Figure 2.32 Air Kerma-Area Product (mGy.m2) for panoramic examinations in dental radiology.
Figure 3.1 The flow chart of operation of study.
Figure 3.2 Types of diagnostic examinations and therapeutic procedures in nuclear medicine.
Figure 3.3 The structure of data collection methodology.
Figure 3.4 Screen shot of the login page of the database.
Figure 3.5 Screen shot of the database main page showing the organization of the database main and sub-menu.
Figure 3.6 Screen shot of the database “System Parameter” menu.
Figure 3.7 Screen shot of the database “Hospital Maintenance” menu.
Figure 3.8 Screen shot of the database “Case” menu for diagnostic examination entry.
Figure 3.9 Screen shot of the database “Case” menu for PET/CT data entry.
Figure 3.10 Screen shot of the database “Inquiry” menu.
Figure 3.11 Parameter tables relationship of the database.
Figure 3.12 Hospital tables relationship of the database.
Figure 3.13 Overall relationship of the database.
Figure 3.14 Radiation dose survey protocol for Nuclear Medicine procedures.
Figure 3.15 Medical Radiation Exposure Survey Database Management System.
Figure 3.16 Statistics of Malaysian population from 2005 to 2009.
xiv
Figure 3.17 (a) Bar chart showing the frequency of nuclear medicine diagnostic examinations in Malaysia from 2005 to 2007 according to different examination types.
Figure 3. 17 (b) Bar chart showing the frequency of nuclear medicine therapeutic procedures in Malaysia from 2005 to 2007 according to different treatment types.
Figure 3. 17 (c) Bar chart showing the frequency of PET/CT in Malaysia from 2005 to 2007.
Figure 3.18 (a) Pie chart showing the frequency distribution of different examination types in diagnostic nuclear medicine (2005-2007).
Figure 3.18 (b) Pie chart showing the frequency distribution of different treatment types in therapeutic nuclear medicine (2005-2007).
Figure 3.19 (a) Bar chart showing the frequency of nuclear medicine diagnostic examinations in Malaysia according to age groups (2005-2007).
Figure 3.19 (b) Bar chart showing the frequency of nuclear medicine therapeutic procedures in Malaysia according to age groups (2005-2007).
Figure 3.20 (a) Box plot showing the administered activities for different examination types in diagnostic nuclear medicine (2005-2007).
Figure 3.20 (b) Box plot showing the administered activities for different treatment types in therapeutic nuclear medicine (2005-2007).
Figure 3.21 Box plot showing the effective dose for different examination types in diagnostic nuclear medicine (2005-2007).
Figure 3.22 Comparison of number of procedure per 1,000 population with different healthcare levels.
Figure 3.23 Comparison of effective dose per procedure with different healthcare levels.
Figure 3.24 Comparison of annual collective effective dose with different healthcare levels.
Figure 3.25 Comparison of annual per caput effective dose with different healthcare levels.
xv
LIST OF ABBREVIATIONS
AAPM American Association of Physicists in Medicine
ACR American College of Radiology
AEC Automatic Exposure Control
AK Air Kerma
AKAP Air Kerma-Area Product
AP Anterior Posterior
ARSAC Administration of Radioactive Substances Advisory Committee
BMD Bone Mineral Densitometry
BSS Basic Safety Standards
CC Cranial-Caudal View
CRCPD Conference of Radiation Control Program Directors
CT Computed Tomography
CTDI Computed Tomography Dose Index
DLP Dose Length Product
DMSA Dimercaptosuccinic Acid
DRL Diagnostic Reference Level
xvi
DSA Digital Subtraction Angiography
DTPA Diethyl Triamine Penta-Acetic, Dithiophosphoric Acid, Diethylene Triamine Pentacetate, Diethylenetriamine Pentaacetic Acid
DXA Dual X-Ray Absorptiometry
EANM European Association of Nuclear Medicine
EC European Commission
ED Effective Dose
ERCP Endoscopic Retrograde Cholangiopancreatography
ESAK Entrance Surface Air Kerma
ESD Entrance Surface Dose
ESWL Extracorporeal Shock Wave Lithotripsy
FDG Fluoro-Deoxy-Glucose
FFD Focus-to-Film Distance
FOV Field of View
GP General Practitioners’
HDP Hydroxymethylene Diphosphonate
HIDA Hepatobiliary Iminodiacetic Acid
HMPAO Hexamethylpropyleneamine Oxime
HPA Health Protection Agency
xvii
HVL Half Value Layer
HQ Headquarters
IAEA International Atomic Energy Agency
ICRP International Commission on Radiological Protection
ICRU International Commission on Radiation Units
IPSM Institute of Physical Sciences in Medicine
KAP Kerma Area Product
KUB Kidney, Ureter and Bladder
LAT Lateral
MAA Methyl Acetoacetate
MAG 3 Mercaptoacetyltriglycine
MCU Micturating Cystourography
MCU Micturating Cysto-Urethrogram
MDP Methylene Diphosphonate
MGD Mean Glandular Dose
MIBG Meta-iodobenzylguanidine
MIBI Methoxy-Isobutyl-Isonitrile
MIRD Medical Internal Radiation Dosimetry
xviii
MLO Mediolateral Oblique
MNA Malaysian Nuclear Agency
MOH Ministry of Health
MRI Magnetic Resonance Imaging
MSAD Multiple Scan Average Dose
MSD Mean Skin Dose
MSCT Multi-Slice Computed Tomography
NRPB National Radiological Protection Board
OPG Orthopantomogram
PA Posterior Anterior
PACS Picture Archive and Communications Systems
PET Positron Emission Tomography
PSD Peak Skin Dose
PTBD Percutaneous Transhepatic Biliary Drainage
PTCA Percutaneous Transluminal Coronary Angioplasty
QA Quality Assurance
RADAR Radiation Dose Assessment Resource
RSNA Radiological Society of North America
xix
SPECT Single Positron Emission Computed Tomography
SPSS Statistical Package for the Social Sciences
SSDL Secondary Standard Dosimetry Laboratory
TAT Targeted Alpha Therapy
TLD Thermoluminescent Dosimeters
UNSCEAR United Nations Scientific Committee on the Effects of Atomic Radiation
Medical Radiation Exposure Study in Malaysia
__________________________________________________________________________________________________ Chapter 1: Introduction
1
CHAPTER 1: INTRODUCTION
1.1 BACKGROUND OF THE STUDY
Medical radiation is by far the largest man-made source of public exposure to
ionizing radiation. Such examinations are performed in all kinds of health care
establishments, including hospitals and clinics. Although the doses from diagnostic
radiology examinations are generally low, the magnitude of the practice makes for a
significant radiation impact but this is outweighed by the direct benefits in health
improvement. Nevertheless, there is a continuing need to analyze the frequencies,
doses and trends of radiological procedures [Ng et al., 1999].
Worldwide interest in patient dose measurement was stimulated by the
publication of Patient Dose Reduction in Diagnostic Radiology by the UK National
Radiological Protection Board (NRPB) [NRPB, 1990]. Several major dose surveys
have been reported, especially from advanced countries. However, in developing
countries, such basic information is still lacking [Ng et al., 1998].
The Global Survey of Medical Radiation Usage and Exposures has been
carried out since 1970’s over a period of five year interval, i.e., 1970-1979, 1980-
1984, and 1985-1989. The results were published in the UNSCEAR 1993 Report. In
the UNSCEAR 2000 Report, data were added covering the years 1990 to 1994 and
compared with the three preceding 5-years interval among countries from all regions
of the world. UNSCEAR has released the publication of the UNSCEAR 2008
Report. This report constitutes two volumes publishing the ionizing radiation survey
data from year 2000 to 2005. Table 1.1 summarizes the overall results from this
latest survey (2000 – 2005) which is published in the UNSCEAR 2008 report
[UNSCEAR, 2008]. This survey aims to establish national data and supplement to
UNSCEAR database.
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CHAPTER 1: INTRODUCTION
1.1 BACKGROUND OF THE STUDY
Medical radiation is by far the largest man-made source of public exposure to
ionizing radiation. Such examinations are performed in all kinds of health care
establishments, including hospitals and clinics. Although the doses from diagnostic
radiology examinations are generally low, the magnitude of the practice makes for a
significant radiation impact but this is outweighed by the direct benefits in health
improvement. Nevertheless, there is a continuing need to analyze the frequencies,
doses and trends of radiological procedures [Ng et al., 1999].
Worldwide interest in patient dose measurement was stimulated by the
publication of Patient Dose Reduction in Diagnostic Radiology by the UK National
Radiological Protection Board (NRPB) [NRPB, 1990]. Several major dose surveys
have been reported, especially from advanced countries. However, in developing
countries, such basic information is still lacking [Ng et al., 1998].
The Global Survey of Medical Radiation Usage and Exposures has been
carried out since 1970’s over a period of five year interval, i.e., 1970-1979, 1980-
1984, and 1985-1989. The results were published in the UNSCEAR 1993 Report. In
the UNSCEAR 2000 Report, data were added covering the years 1990 to 1994 and
compared with the three preceding 5-years interval among countries from all regions
of the world. UNSCEAR has released the publication of the UNSCEAR 2008
Report. This report constitutes two volumes publishing the ionizing radiation survey
data from year 2000 to 2005. Table 1.1 summarizes the overall results from this
latest survey (2000 – 2005) which is published in the UNSCEAR 2008 report
[UNSCEAR, 2008]. This survey aims to establish national data and supplement to
UNSCEAR database.
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Table 1.1: Overall summary from UNSCEAR year 2000-2005 survey (UNSCEAR, 2008).
UNSCEAR 2008 – Overall Summary
Source CollectiveDose(manSievert)
Worldwide averagedose (mSv)
Typical range of individual doses (mSv)
Comments
Total natural 15,000,000 2.4 1-10 Sizeable population at 10-20 mSv
Medicaldiagnosis
4,200,000 0.6 0-several tens Average is 1.9mSv in countries with high level healthcare
Atmospheric nuclear testing
32,000 0.005 Mainly from residual activity in soils
Peak 0.11mSv in 1963
Occupationalexposure
29,000 0.005 0-20 Highest collective doses to exposures from natural radiation (e.g. radon in mines)
Nuclearpowerpublicexposure
1,300 0.0002 Up to 0.3 near nuclearinstallations
Total man-made
4,260,000 0.6 From essentially zero up to several tens
Individual doses depend primarily on medical treatment and occupational exposure
Malaysia is a healthcare level II country according to the United Nations
Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) definition
based on physician densities, i.e., 1000-3000 population per physician. In 2004,
Malaysia was classified as a level II country where the population to physician ratio
was 1402:1. In level I countries there are fewer than 1000 population per physician.
Level I countries, with 25% of the world population, account for some 70% of the
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Table 1.1: Overall summary from UNSCEAR year 2000-2005 survey (UNSCEAR, 2008).
UNSCEAR 2008 – Overall Summary
Source CollectiveDose(manSievert)
Worldwide averagedose (mSv)
Typical range of individual doses (mSv)
Comments
Total natural 15,000,000 2.4 1-10 Sizeable population at 10-20 mSv
Medicaldiagnosis
4,200,000 0.6 0-several tens Average is 1.9mSv in countries with high level healthcare
Atmospheric nuclear testing
32,000 0.005 Mainly from residual activity in soils
Peak 0.11mSv in 1963
Occupationalexposure
29,000 0.005 0-20 Highest collective doses to exposures from natural radiation (e.g. radon in mines)
Nuclearpowerpublicexposure
1,300 0.0002 Up to 0.3 near nuclearinstallations
Total man-made
4,260,000 0.6 From essentially zero up to several tens
Individual doses depend primarily on medical treatment and occupational exposure
Malaysia is a healthcare level II country according to the United Nations
Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) definition
based on physician densities, i.e., 1000-3000 population per physician. In 2004,
Malaysia was classified as a level II country where the population to physician ratio
was 1402:1. In level I countries there are fewer than 1000 population per physician.
Level I countries, with 25% of the world population, account for some 70% of the
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3
diagnostic x-ray examinations [UNSCEAR, 1993]. The distribution of medical
radiation services in the world is far from equitable [Ng et al., 1998]. The statistics in
Malaysia showed that there were 1429 population per physician in 2009 [Department
of Statistics, Malaysia], which indicated that Malaysia was still classified as a
healthcare level II country.
1.2 IMPORTANCE OF THE STUDY
The measurement of patient dose will provide information for optimization of
radiation dose by obtaining radiological images with lowest amount of radiation.
This report would be able to assess radiation exposure as a factor of patient-outcome
efficacy, develop national reference levels as well as being an indicator of radiology
quality assurance (QA). The result of the first local dose survey provide valuable
baseline data for Malaysian patient doses. Ng et al. [Ng et al., 1998] reported a wide
variation in patient dose for the same type of x-ray examination carried out on
similar-sized patients in different hospitals. This suggested that significant reductions
in the dose from these exposures would be possible without adversely affecting
image quality. The spread is mainly due to the choice of exposure factors, technique,
focus-to-film distance, collimation, film-screen speed and the output of the x-ray
machine used.
This survey presents the results of an updated, broad review of medical
radiation exposures in Malaysia. Its purpose is to provide new qualitative and
quantitative information on the frequencies and doses for diagnostic and therapeutic
procedures to assess medical radiation exposures in Malaysia. Comparisons were
made with data from a previous survey and international published studies. This
survey also aims to explore temporal and regional trends in the usage of radiation in
medicine in Malaysia. Although the survey is not intended as a means to optimize
procedures or as a national guideline for radiation protection, it will nevertheless
provide the background for such work.
The Ministry of Health (MOH) Malaysia has designed and developed a
national medical radiation exposure database as a result of this project. The database
consists of the hospital data including equipment and personnel information, as well
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as the patients’ data associated with the medical radiation exposure. It is
recommended that the database be maintained and reviewed periodically and reports
to be published. The ultimate aim is to set up a long term, sustainable, national
medical radiation exposure database that can be reviewed periodically by the MOH
and relevant authorities and organizations. This database will be useful in providing
advice to the professional and regulatory bodies on national reference dose levels for
various examinations and procedures involving ionising radiation.
1.3 OBJECTIVES
The primary objectives were:
(i) to review the status of the medical radiation exposure in Malaysia as compared
to other countries.
(ii) to establish the national Diagnostic Reference Levels (DRLs) in promoting the
basis of optimization procedures in diagnostic radiology and nuclear medicine.
Secondary objectives were:
(i) to evaluate the trends in number of cases medical radiation exposure in
Malaysia in the period of 2005 to 2009.
(ii) to determine corresponding the number of personnel in selected site involved in
diagnostic radiology, nuclear medicine and radiotherapy department.
(iii) to determine the annual collective effective dose to the Malaysian population
from different disciplines and the relative contributions from various diagnostic
procedures.
(iv) to compare the local diagnostic dosimetry status with the DRLs recommended
by the international organizations such as International Atomic Energy Agency
(IAEA) and Health Protection Agency (HPA) (formerly known as NRPB).
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as the patients’ data associated with the medical radiation exposure. It is
recommended that the database be maintained and reviewed periodically and reports
to be published. The ultimate aim is to set up a long term, sustainable, national
medical radiation exposure database that can be reviewed periodically by the MOH
and relevant authorities and organizations. This database will be useful in providing
advice to the professional and regulatory bodies on national reference dose levels for
various examinations and procedures involving ionising radiation.
1.3 OBJECTIVES
The primary objectives were:
(i) to review the status of the medical radiation exposure in Malaysia as compared
to other countries.
(ii) to establish the national Diagnostic Reference Levels (DRLs) in promoting the
basis of optimization procedures in diagnostic radiology and nuclear medicine.
Secondary objectives were:
(i) to evaluate the trends in number of cases medical radiation exposure in
Malaysia in the period of 2005 to 2009.
(ii) to determine corresponding the number of personnel in selected site involved in
diagnostic radiology, nuclear medicine and radiotherapy department.
(iii) to determine the annual collective effective dose to the Malaysian population
from different disciplines and the relative contributions from various diagnostic
procedures.
(iv) to compare the local diagnostic dosimetry status with the DRLs recommended
by the international organizations such as International Atomic Energy Agency
(IAEA) and Health Protection Agency (HPA) (formerly known as NRPB).
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1.4 ANALYSIS
1.4.1 Statistic Methods
Descriptive statistics were used in this survey to describe the main features of a
collection of data in quantitative terms. The statistics were divided into univariate
(one variable) and bivariate (two variables). The descriptive terms used in this survey
are as follows:
(a) Univariate statistics:
• Frequency or counts (expressed in numbers or percentages)
(b) Bivariate statistics:
• Mean and standard deviation
• Median
• Mode
• Minimum (min) and maximum (max)
• 25th percentile (1st quartile) and 75th percentile (3rd quartile)
Mean or arithmetic mean of a list of numbers is the sum of all list divided by
the number of items in the list. If the list is a statistical population (i.e. number of
cases performed per year), the mean of that population is called a population mean; if
the list is a statistical sample (i.e. average administered activity per patient), the
resulting statistics is called a sample mean. To simplify, we used “mean” in both
conditions in this report. Mean is sometimes called the average which carries the
same meaning. The mean is often quoted along with the standard deviation: the mean
described the central location of the data, and the standard deviation describes the
spread. The value is written as mean ± standard deviation.
Median is the numeric value separating the higher half of the sample from the
lower half. The median of a finite list of numbers can be found by arranging all the
observations from lowest value to highest value and picking the middle one. If there
is an even number of observations, then there is no single middle value; the median is
then defined to be the mean of the two middle values. Median is generally a good
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6
descriptive measure of the location which works well for skewed data, or data with
outliers.
Mode is the most frequently occurring value in a set of discrete data. There can
be more than one mode if two or more values are equally common. The mode values
were not listed in the analysis tables in this report, however they were shown in the
histogram of some of the statistics. Figure 1.1 demonstrates the difference between
mean, median and mode. For an ideal symmetrical distribution, the mean, median and
mode are the same, however asymmetrical distribution is more likely in practice.
Minimum and maximum are the smallest (or lowest) and largest (or highest)
numerical value in the data set.
A percentile is the value of a variable below which a certain percent of
observations fall. So the 25th percentile is the value below which 25% of the
observations may be found; and 75th percentile is the value below which 75% of the
observations may be found. The 25th percentile is also known as the first quartile
(Q1); the 50% percentile as the median or second quartile (Q2); the 75th percentile as
the third quartile (Q3).
Figure 1.1: Explanation of mean, median and mode. (www.syque.com/quality_tools/toolbook/Variation/measuring_centering.htm)
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descriptive measure of the location which works well for skewed data, or data with
outliers.
Mode is the most frequently occurring value in a set of discrete data. There can
be more than one mode if two or more values are equally common. The mode values
were not listed in the analysis tables in this report, however they were shown in the
histogram of some of the statistics. Figure 1.1 demonstrates the difference between
mean, median and mode. For an ideal symmetrical distribution, the mean, median and
mode are the same, however asymmetrical distribution is more likely in practice.
Minimum and maximum are the smallest (or lowest) and largest (or highest)
numerical value in the data set.
A percentile is the value of a variable below which a certain percent of
observations fall. So the 25th percentile is the value below which 25% of the
observations may be found; and 75th percentile is the value below which 75% of the
observations may be found. The 25th percentile is also known as the first quartile
(Q1); the 50% percentile as the median or second quartile (Q2); the 75th percentile as
the third quartile (Q3).
Figure 1.1: Explanation of mean, median and mode. (www.syque.com/quality_tools/toolbook/Variation/measuring_centering.htm)
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1.4.2 Graphical Display of Statistics Data
(a) Pie Chart
A pie chart is a way of summarizing a set of categorical data. It is a circle
which is divided into different segments. Each segment represents a particular
category. The area of each segment is proportional to the number or percentage of
cases in that category. It was used to show the distribution and frequency of different
cases for a particular discipline, modality or parameter in this survey. Figure 1.2
demonstrates an example of pie chart plotted in this survey.
Figure 1.2: An example of pie chart used in this survey.
The Use of AEC mode in General X‐Ray Examinations
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(b) Bar Chart
Bar chart is one of the most commonly used graphical statistics in this survey.
It shows the numerical values of different variables represented by the height or
length of the rectangle bars with equal width. The bars can be drawn vertically or
horizontally depending on individual preference. In this study, we often use vertical
bar charts for those variables with long characters or names. The bar charts are
usually used for the comparison of numerical data for different variables, i.e. the
mean administered activity for different examinations types in diagnostic nuclear
medicine. The clustered bar charts were used in some circumstances when there was
a comparison of different groups of variables, as shown in Figure 1.3.
Figure 1.3: An example of bar chart used in this survey.
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(b) Bar Chart
Bar chart is one of the most commonly used graphical statistics in this survey.
It shows the numerical values of different variables represented by the height or
length of the rectangle bars with equal width. The bars can be drawn vertically or
horizontally depending on individual preference. In this study, we often use vertical
bar charts for those variables with long characters or names. The bar charts are
usually used for the comparison of numerical data for different variables, i.e. the
mean administered activity for different examinations types in diagnostic nuclear
medicine. The clustered bar charts were used in some circumstances when there was
a comparison of different groups of variables, as shown in Figure 1.3.
Figure 1.3: An example of bar chart used in this survey.
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(c) Histogram
Histogram was used to present the tabular frequencies of the specific
parameters or variables, shown as adjacent rectangles. Each rectangle is erected over
an interval, with an area equal to the frequency of the interval. The height of a
rectangle is also equal to the frequency density of the interval, i.e. the frequency
divided by the width of the interval. The total area of the histogram is equal to the
total number of data. A histogram may also be based on the relative frequencies
instead. It then shows what proportion of cases fall into each of several categories (a
form of data binning), and the total area then equals 1.
We used histogram to demonstrate the tabulation of the frequency for some
important parameters in this survey. For example, the histogram for the administered
activity for the specific cases is shown in Figure 1.4. The histogram shows the
number of cases fall in different intervals of administered activity. There was a total
number of 15,472 cases of bone scan performed in 2005 to 2007; the most frequent
used administered activity was between 700 – 800 MBq; and the mean administered
activity was 832.24 ± 141.01 MBq.
Figure 1.4: An example of histogram used in this survey.
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(d) Box Plot
In general, most of the dosimetric analysis outputs were demonstrated in box-
plot, which is an useful graphical display to depict groups of numerical data through
their five (5) number summaries: lowest value (sample minimum), 25 percentile (1st
quartile), 50 percentile (median), 75 percentile (3rd quartile) and highest value
(sample maximum). A box-plot may also indicate which observations, if any, might
be considered as outliers. Box-plot is also useful to display differences between
populations without making any assumptions of the underlying statistical distribution
because they are non-parametric. The spacing between the different parts of the box
helps indicate the degree of dispersion (spread) and skewness in the data, and identify
outliers. Figure 1.5 illustrates the interpretation of a typical box-plot using SPSS.
Figure 1.5: Interpretation of a typical box-plot (Source: SPSS version 16 user’s manual).
Outliers
75th percentile (3rd
quartile)
50th percentile (median)
25th percentile (1st
quartile)
Highest value(Sample maximum excluded outliers)
Lowest value(Sample minimum excluded outliers)
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Interpretation of Box-Plot:
1. Box and Whiskers:
The box plot shows a box encased by two outer lines known as whiskers. The box
represents the middle 50% of the data sample - half of all cases are contained within
it. The remaining 50% of the sample is contained within the areas between the box
and the whiskers, with some exceptions (outliers).
2. Median Line:
Inside the box, there is a single line. This line represents the median, which is the
middle value of the entire sample. Trace this line back to the axis to derive its value.
The location of the median line can also suggest skewness in the distribution if it is
noticeably shifted away from the center.
3. Box Position:
The location of the box within the whiskers can provide insight on the normality of
the sample's distribution. When the box is not centered between the whiskers, the
sample may be positively or negatively skewed. If the box is shifted significantly to
the low end, it is positively skewed; if the box is shifted significantly to the high end,
it is negatively skewed.
4. Box Size:
The size of the box can provide an estimate of the kurtosis - the peakedness of the
distribution. A very thin box relative to the whiskers indicates that a very high
number of cases are contained within a very small segment of the sample. This
signifies a distribution with a thinner peak. A wider box relative to the whiskers
indicates a wider peak. The wider the box, the more U-shaped the distribution
becomes.
5. Outliers:
Outliers are not present in every box plot. When they are present, they are found in
the form of points, circles, or asterisks outside of the boundaries of the whiskers.
These are extreme values that deviate significantly from the rest of the sample and
they can exist above or below the whiskers of the box plot.
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2.1 LITERATURE REVIEW
2.1.1 History of Medical X-Ray Development
Diagnostic examinations with x-rays have been used in medicine for over a
century. It represents the largest portion of medical radiation source according to the
UNSCEAR 2000 report. During the last two decades in particular, medical imaging
has experienced a technological revolution, and it now allows the improved imaging
of anatomy, physiology and metabolism. Steady advances in the quality of x-ray
images and in patient protection have ensured a continuing role for diagnostic x-rays
in healthcare, although alternative modalities for diagnosis are becoming
increasingly available, such as ultrasound, endoscopy and MRI. Nevertheless, since
x-ray examinations remain the most frequent use of ionizing radiation in medicine,
they are the most significant source of medical exposure for the world population.
An increasingly wide range of equipment and techniques is employed to meet a wide
range of diagnostic clinical purposes.
Digital methods for the processing and display of x-ray images were first
introduced into clinical practice with the advent of computed tomography (CT) in
1972. This revolutionary technology was able to provide high-quality images of
isolated slices of the patient using a thin rotating beam of x-rays, albeit with
relatively high patient doses. The subsequent development of helical CT has lead to
further scanning techniques such as CT endoscopy and CT fluoroscopy. Continuing
advances in computer technology have also promoted the general development of
digital radiography, where images are acquired in digital form. The technique of
digital subtraction angiography (DSA) is based on digital image processing with
logarithmic subtraction and edge enhancement. It is used increasingly for the
visualization of blood vessels throughout the body. Such improvements in imaging
and innovations in other equipment, such as needles, catheters, stents and contrast
media, have facilitated the development of interventional radiological techniques, in
CHAPTER 2: DIAGNOSTIC, INTERVENTIONAL AND DENTAL RADIOLOGY
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2.1 LITERATURE REVIEW
2.1.1 History of Medical X-Ray Development
Diagnostic examinations with x-rays have been used in medicine for over a
century. It represents the largest portion of medical radiation source according to the
UNSCEAR 2000 report. During the last two decades in particular, medical imaging
has experienced a technological revolution, and it now allows the improved imaging
of anatomy, physiology and metabolism. Steady advances in the quality of x-ray
images and in patient protection have ensured a continuing role for diagnostic x-rays
in healthcare, although alternative modalities for diagnosis are becoming
increasingly available, such as ultrasound, endoscopy and MRI. Nevertheless, since
x-ray examinations remain the most frequent use of ionizing radiation in medicine,
they are the most significant source of medical exposure for the world population.
An increasingly wide range of equipment and techniques is employed to meet a wide
range of diagnostic clinical purposes.
Digital methods for the processing and display of x-ray images were first
introduced into clinical practice with the advent of computed tomography (CT) in
1972. This revolutionary technology was able to provide high-quality images of
isolated slices of the patient using a thin rotating beam of x-rays, albeit with
relatively high patient doses. The subsequent development of helical CT has lead to
further scanning techniques such as CT endoscopy and CT fluoroscopy. Continuing
advances in computer technology have also promoted the general development of
digital radiography, where images are acquired in digital form. The technique of
digital subtraction angiography (DSA) is based on digital image processing with
logarithmic subtraction and edge enhancement. It is used increasingly for the
visualization of blood vessels throughout the body. Such improvements in imaging
and innovations in other equipment, such as needles, catheters, stents and contrast
media, have facilitated the development of interventional radiological techniques, in
CHAPTER 2: DIAGNOSTIC, INTERVENTIONAL AND DENTAL RADIOLOGY
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which imaging helps to guide therapeutic procedures and to deliver therapeutic
agents. Digital technology also provides for the storage and transfer of images within
and between hospitals and their transmission for remote consultation (teleradiology)
using digital networks known as picture archive and communications systems
(PACS).
2.1.2 Definition of Diagnostic and Interventional Radiology
Diagnostic radiology is the use of various imaging modalities to aid in the
diagnosis of disease. Diagnostic radiology can be further divided into multiple sub-
specialty areas. Interventional radiology uses the imaging modalities of diagnostic
radiology to perform minimally invasive procedures.
Imaging modalities include general radiography, mammography, fluoroscopy,
angiography, bone mineral densitometry (BMD), dental radiology, CT, magnetic
resonance imaging (MRI) and ultrasound.
2.1.3 Dosimetry in Diagnostic, Interventional and Dental Radiology
Although there are many articles and surveys in the literature concerning
dosimetry for a specific examination or procedure, there are few places in which the
recent literature has been reviewed and summarized in a concise form. There are a
number of ways in which radiation exposure and dose in medicine are quantified.
Measured quantities include Air Kerma (AK), Entrance Surface Dose (ESD), Air
Kerma-Area Product (AKAP), Peak Skin Dose (PSD), Dose-Length Product (DLP)
and Computed Tomography Dose Index (CTDI). Organ absorbed doses can be
estimated by using the radiation weighting factor and tissue weighting factor
recommended by International Commission on Radiological Protection (ICRP).
The levels of dose to patients undergoing diagnostic examinations with x-rays
are in principle determined by the quality of images required and the extent of
investigation necessary to meet the specific clinical objectives. In practice, numerous
factors relating to both the radiological equipment and the procedures in use have an
influence on the imaging process. UNSCEAR 2000 report Annex D summarised the
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important aspects of practice that have a broad impact on patient dose. X-ray
procedures characteristically involved exposures to the patients. They produce
complex patterns of energy deposition within the patient and various dose
measurement strategies are necessarily employed. Organ doses are in general
difficult to assess. In practice routine patient monitoring is usually based on directly
measurable dose quantities, such as ESD (with backscatter) per radiograph and,
particularly for complex procedures involving fluoroscopy, AKAP per examination.
AKAP meters are increasingly being fitted to x-ray equipment. Their development
allow the display in real-time of dose rate and cumulative dose.
Organ dose and effective dose are generally estimated from routine dose
measurements using conversion factors appropriate to the conditions of exposure;
coefficients that have been used in various dose studies are reviewed elsewhere.
These coefficients may be derived experimentally on the basis of physical
anthropomorphic phantoms. Theoretical normalised organ dose data are available in
relation to routine examinations of adults, paediatric patients, cardiac and
angiographic examinations, although care is needed when applying such coefficients
to clinical practice. The comparison of organ and effective doses derived from
measurements and calculations under similar conditions of exposure indicates
reasonable agreement between the methods and highlights the limitations and
uncertainties in both approaches. Computational methods of dosimetry in particular
are advancing steadily, with the development of more realistic (voxel) phantoms
based on digital images of humans.
Special dosimetric techniques are often employed in the case of mammography
and CT in view of the peculiar conditions of irradiation for these examinations.
Practice in mammography is generally assessed in terms of the mean dose to
glandular tissue, derived in relation to a standard breast thickness using coefficients
normalised to measurements of AK made free-in-air, although direct measurements
of ESD on patients have also been employed.
CT generally involves the irradiation of thin slices of the patient in rotational
geometry by a fan beam of x-rays. The principal dosimetric quantity in CT is the
CTDI, in which the dose profile along the axis of rotation for a single slice is
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averaged over the nominal slice thickness. The CTDI can be measured free-in-air or
in homogeneous CT dosimetry phantoms for the head and body, although such
reported values can reflect subtle differences in the definition of CTDI. A related
quantity, the multiple scan average dose (MSAD), provides an indication of the dose
in a phantom for a series of multiple scans with a constant separation. Organ dose
and effective dose to patients for particular scanning protocols can be estimated
using dose coefficients provided by mathematical modeling, which are normalized to
a free-in air axial dose, or by dose measurements with thermoluminescence
dosimeter (TLD) in phantoms. Other dosimetric quantities for CT practice include
DLP in relation to CTDI measurements in standard phantoms; these quantities in turn
allow the broad estimation of effective dose to patients.
2.1.4 Diagnostic Reference Levels (DRLs)
Diagnostic Reference Levels (DRLs) is defined by IAEA Basic Safety
Standards (BSS) as a value of dose, dose rate or activity selected by professional
bodies in consultation with the regulatory authority to indicate a level above which
there should be a review by medical practitioners in order to determine whether or
not the value is excessive. ICRP Publication 73 [ICRP, 1996] introduced the term
“diagnostic reference levels” (DRLs) and explained its place in the broader ICRP
concept of reference levels. The main points are summarised below:
(a) The term used is diagnostic reference levels (DRLs).
(b) The purpose is advisory. It is a form of investigation level to identify
unusually high levels, which calls for local review if consistently exceeded.
In principle, there could be a lower level also (i.e. below which there is
insufficient radiation dose to achieve a suitable medical image). DRLs are not
for regulatory or commercial purposes, not a dose constraint, and not linked
to limits or constraints.
(c) The examination types include diagnostic radiology and nuclear medicine.
(d) Their selection is by professional medical bodies, using a percentile point on
the observed distribution for patients, and specific to a country or region.
(e) The quantities should be easily measured, such as absorbed dose in air or
tissue-equivalent material at the surface of a simple standard phantom or
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representative patient for diagnostic radiology and administered activity for
diagnostic nuclear medicine.
The objective of DRLs is to optimize the use of radiation in medicine and help
avoid excessive radiation exposure. This is accomplished by comparison between
the numerical value of the DRL (derived from relevant regional, national or local
data) and the mean or other appropriate value observed in practice from a suitable
reference group of patients. A suitable reference group of patients is defined within a
certain range of physical parameters (e.g. height, weight). Corrective action should
be taken as necessary if exposures do not provide useful diagnostic information and
do not yield the expected medical benefit to patients.
There have been a number of different quantities used for DRLs. The quantity
selected is dependent on the type of clinical procedure, for example, whether it is an
individual radiographic projection, a procedure or examination consisting of multiple
projections or field locations, or a diagnostic nuclear medicine procedure. The
quantity used is also dependent on the authority setting the reference level, and is
related to the desired aim, local preference and the unique irradiation conditions. The
concept of a DRL permits flexibility in the choice of quantities, numerical values and
technical or clinical specifications, in order to allow authorized bodies to meet the
objective relevant to their circumstances.
DRLs for diagnostic radiology should be based on doses measured in various
types of hospitals, clinics and practices and not only in well-equipped hospitals.
These levels should be higher than the median or mean value of the measured patient
doses or doses in a phantom. Given that the curve representing the number of
examinations and their doses is usually skewed with a long tail, the level of the 75th
percentile seems appropriate. The use of this percentile is a pragmatic first approach
to identifying those situations in most urgent need of investigation [European
Commission, 1999].
DRLs can be assessed using ESD, measured with a TLD fixed on the patient’s
body, or the AKAP. For CT, the weighted CTDI (CTDIw) and the DLP are suitable
quantities to be used as DRLs. For mammography, there is a specific DRL called
Mean Glandular Dose (MGD) which indicate the absorbed dose to the breast tissues.
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For guided interventional procedures (especially fluoroscopy-guided
procedures), DRLs would provide useful guidance in the endeavour to avoid
deterministic effect (non-stochastic). However, the observed distribution of patient
doses is very wide, even for a specified protocol, because the duration and
complexity of the fluoroscopic exposure for each conduct of a procedure is strongly
dependent on the individual clinical circumstances. A potential approach is to take
into consideration not only the usual clinical and technical factors, but also the
relative “complexity” of the procedure.
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2.2 METHODOLOGY
2.2.1 Introduction
This survey, basically following the guidelines established by UNSCEAR, was
conducted in 437 public and private hospitals, medical centres or general
practitioner’s clinics; and 329 public and private dental clinics in Malaysia. These
hospitals/medical centres/clinics (hereafter referred as “sites”) were selected
randomly nationwide to represent 30 percent of the total number of sites in the
country. The sites are generally categorized into five (5) categories: public hospitals,
private hospitals, general practitioners’ (GP) clinics, public dental clinics and private
dental clinics. The 30 percent sampling size will serve as the minimum number of
sites for this survey. The selection of the sites should also represent the reasonable
good geographical spread of the population.
This survey was conducted on the basis of statistics from all the common
examinations performed in diagnostic radiology and dental radiology in 2007, 2008
and 2009. The survey was completed with demographic data covering different
information including the equipment, personnel and patients information, as well as
the dosimetric data which some were measured using TLD (i.e. general x-ray, BMD
and dental) and Gafchromic® films (i.e. fluoroscopy and interventional radiology)
while others were calculated using mathematical formula (i.e. mammography) or
computer software (i.e. CT). On the basis of above mentioned data, estimations were
carried out based on the frequency of examinations and the relative contribution (%)
of each procedure.
Six (6) different diagnostic modalities were included in this survey: general
x-ray, mammography, fluoroscopy/angiography, CT, BMD and dental radiology.
To estimate the typical dose delivered to an average Malaysian adult patient,
measurements were made on a sample of patients within a range of 40 – 80 kg. Both
genders were included in this survey.
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2.2.2 Dosimetric Quantities
Radiation quantities that are involved in patient dosimetry are basically divided
into three categories, namely, source quantities, field quantities and patient dose
quantities, as shown in Figure 2.1. In this survey, we only measured or calculated the
patient dose quantities based on the exposure parameters.
Figure 2.1: Radiation dosimetric quantities [Wall et al., 1998].
In patient dosimetry, several specialized dosimetric quantities can be used for
different radiation assessment purposes. Therefore, the recommended dosimetric
quantities to be used in this survey were explained clearly before the data collection
and analysis to meet the following objectives which are to:
(a) enable unambiguous definition so that everyone can clearly understand
what is to be measured;
(b) enable simple, direct measurement with readily available dosimeters of
sufficient precision and accuracy;
Energyimparted
SOURCE QUANTITIES Tube current Exposure time Applied potential Filtration
FIELD QUANTITIES Photon fluence Energy fluence Exposure Absorbed dose in air Air Kerma
Air Kerma-Area Product
PATIENT DOSE QUANTITIESEntrance Surface Dose (with backscatter)
Depth Dose
Exit Surface Dose
Organ Dose
Image Receptor
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(c) provide a measurement of the typical dose received by patients examined
in a particular centre.
Table 2.1 summarizes different quantities and units used in different modality
of diagnostic, interventional and dental radiology in this survey.
Table 2.1: Dosimetric quantities and units for different modalities in diagnostic, interventional and dental radiology.
Modality Measured Quantity
(Unit)
Derived Quantity
(Unit)
General X-ray Entrance Surface Dose (mGy) Effective Dose (mSv)
Mammography Incident Air Kerma (mGy) Mean Glandular Dose
(mGy)
Fluoroscopy / Angiography Kerma-Area Product
(mGy.m2) or
Peak Skin Dose (mGy)
Effective Dose (mSv)
Computed Tomography CT Dose Index (mGy) or
Dose Length Product
(mGy.cm)
Effective Dose (mSv)
Bone Mineral Densitometry Entrance Surface Dose (mGy) Effective Dose (mSv)
Dental - Intraoral
Dental - Panoramic
Entrance Surface Dose (mGy)
Air Kerma-Area Product
(mGy.m2)
Effective Dose (mSv)
Effective Dose (mSv)
2.2.3 Selection of Cases and Sample Size
A sample of diagnostic radiological examinations or procedures were taken for
dose measurement. Minimum 30 cases per examination were taken for measurement
in order to be statistically representative of the actual scenario of the exposure of
medical radiation in the country.
2.2.4 Data Collection Protocols
The data collection was basically divided into three (3) surveys: Background
information survey (Appendix A), radiation dose survey (Appendix B) and
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questionnaire survey (Appendix C). Figure 2.2 shows the breakdown of the overall
data collection methodology. The following section elaborate the specific objectives
and protocols for different survey.
Figure 2.2: The breakdown of data collection methodology.
2.2.5 Background Information Survey
The background information provides general information of the hospitals or
centres: The number of physicians in the hospital may be interpreted as the number
of medically qualified doctors. This survey aimed to obtain the total number of
personnel serving at diagnostic radiology and dental radiology departments from
2007 to 2009 according to different categories, i.e. radiologists, medical physicists
and radiographers.
Other than personnel information, the background information also includes
the modality or equipment information. For each centre, general information and
equipment specific data such as room or location of the equipment, model,
manufacturer, serial number and year of purchase were recorded. There are different
equipment used for different diagnostic modalities, for example, the general x-ray
Diagnostic & Dental Radiology Dose Survey
Part A Background Information
Survey
Part B Radiation Dose Survey
• General X-ray • CT • Mammography • BMD • Dental • Fluoroscopy/Angiography
Equipment Information
Part C Questionnaire Survey
Personnel Information
• Demographic
• Frequency
• Dosimetric
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unit used at diagnostic radiology is very much different from the x-ray unit used in
dental radiology.
A background information survey form was prepared and distributed to all the
research assistants for data collection as explained in the following sections.
(a) Diagnostic and Interventional Radiology Background Information
Information was recorded in the form as in Appendix A. Background
information was needed for the number of personnel; these include radiologists,
interventional radiologists, interventional cardiologists, medical physicists and
radiographers. Any operator who performs x-ray examinations should be included in
the number of radiographers. Information was required concerning the numbers of
individual machine used in diagnostic radiology. For x-ray equipment, this is broadly
taken to be the number of mobile or static generators (rather than x-ray tubes) that
were used for radiography or fluoroscopy, CT, mammography, BMD and dental
radiology. This information was recorded in form as in Appendix D. Detail
information such as the room location of the machine, model, manufacturer, serial
number and year of purchase also recorded. Additional information such as the
number of slices for each CT unit, half value layer (HVL) and incident air kerma
value for mammography unit would be useful for the dose measurement exercise.
(b) Dental Radiology Background Information
Information was recorded in the form as in Appendix A. Background information
was needed for the number of personnel; these included dentist, medical physicists
and radiographers. Information regarding dental x-ray and dental CT were recorded
in the same form as in Appendix D.
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2.2.6 Questionnaire Survey
The questionnaire survey forms recorded the number of cases performed
annually as well as the estimated patient dose. The dosimetric data should represent
typical or average values per examination or treatment. Data were also requested for
each type of procedure concerning the distributions of patients by age (0-15 years,
16-40 years, and >40 years) and by gender. It is important to know how many
examinations were undertaken on male and female patients separately. Consequently,
the data in the six boxes (3 age bands by 2 genderes) should add up to 100%. The
survey forms were designed based on the original UNSCEAR form with some minor
modifications to suit local conditions. The questionnaire survey forms are attached in
the Appendix C.
2.2.7 Dose Measurement Protocols
(a) General X-ray
General x-ray is by far the most common form of radiography technique all
over the world. The different types of radiographic techniques require knowledge of
the frequency of each type of examination and the associated levels of patient dose.
The general x-ray examinations and projections that were studied in this survey are
as listed in Table 2.2. The positioning of the TLDs for each examination type was
explained in detail in the document “Research Methodology”.
Table 2.2: Types of examinations and radiographic projections for general x-ray.
Examination Projections Chest Chest PA
Chest LAT Limbs & Joints Upper Extremities: Hand, Wrist, Radius, Ulna, Elbow,
Humerus, Shoulder Lower Extremities: Foot, Ankle, Tibia, Fibula, Femur, Knee
Spine Lumbo-sacral AP Lumbo-sacral LAT Thoracic AP Thoracic LAT Cervical AP Cervical LAT
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Pelvis/Hip Skull AP
LateralOthers (Towne, Caldwell, etc)
Abdomen/KUB
TLDs were used for measurement of ESD. The TLD that was used in this
survey was LiF(Tl) thermoluminescent dosimetry chips (TLD-100, Harshaw®). The
TLDs were calibrated at the Secondary Standard Dosimetry Laboratory of the
Malaysian Nuclear Agency (MNA). MNA did the annealing of the TLD chips to
erase the residual signal then packaged them into small sachets with two TLDs in
each sachet. Each TLD sachet was labeled with a unique code as agreed by both
MOH and MNA. Each TLD code consisted of two parts: a letter state code followed
by three numbers, e.g., A_001. The exposed TLDs were then sent back to MNA’s
Secondary Standard Dosimetry Laboratory (SSDL) for reading. Each TLD gave an
individual reading of ESD. Therefore, for each sachet, two ESD readings were
obtained. The average of the two TLD chips’ readings was calculated as the ESD for
that particular case.
2ESDESDESDDose,SurfaceEntrance 21
avg+
=
(b) Fluoroscopy and Interventional Radiology
For fluoroscopy and interventional radiology procedures, the Gafchromic® XR
type R film and KAP meter were used to measure the PSD and AKAP. The types of
fluoroscopy and interventional radiology procedures that were studied are as follows:
Table 2.3: Types of procedures for fluoroscopy and interventional radiology.
Procedures Types of procedures
Angiography
(Diagnostic)
Cardiac
Non-cardiac
Conventional Studies Endoscopic retrograde cholangiopancreatography (ERCP)
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Gastrointestinal Lower
Gastrointestinal Upper
Micturating Cystourography (MCU)
Interventional
Radiology
Cerebral
Extracorporeal Shock Wave Lithotripsy (ESWL)
Percutaneous Transluminal Coronary Angioplasty (PTCA)
Vascular
Others
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Figure 2.4: Orientation markings on the reversed side of the Gafchromic® film.
X-raytube
Couch
Typical patient-examination distance KAP meter
Patient
Image Intensifier/Flat Panel Detector
Collimator
Head
RDenoting the right side of the patient
Marker showing the orientation of the Gafchromic® film
Figure 2.3: Patient measurement set up.
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The AKAP value was obtained from the console of the fluoroscopy unit, as
shown in Figure 2.5. During the data collection, the unit of the AKAP reading was
converted into mGy.m2.
Figure 2.5: AKAP reading displayed on fluoroscopy console.
Prior to using the Gafchromic® film, the film was calibrated and the
characteristic calibration curve was established. This was done by cutting the sheets
of films into a 5 cm × 5 cm square. These pieces of films were then exposed to a
series of known amount radiation doses using the fluoroscopy unit. This created a
step-like calibration strip, as shown in Figure 2.6. The darkening of the film can be
cross-calibrated with an ion-chamber to determine the radiation dose.
Figure 2.6: Example of the calibration strips during the calibration of Gafchromic® film.
AKAPreading
0 mGy (Control)
3258 mGy
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The calibration strips were scanned by the computer using a reflective flat-bed
scanner (ScanMakerTM 9800XL, Microtek®) to obtain its pixel values related to the
known radiation dose. Therefore a calibration curve was obtained and the formula
was worked out from the relationship of pixel-radiation dose. This formula was used
later to analyze the exposed Gafchromic® film from the patient cases. The exposed
Gafchromic® films were scanned by the computer and the map of the skin dose
distribution was plotted. PSD as well as the mean and minimum dose were obtained
from the analysis of the intensity of the dose distribution map. Matlab® program
version R2007b was used for this analysis. An example of the skin dose distribution
map is shown in Figure 2.7.
Figure 2.7: Scanned Gafchromic® film and the skin dose distribution map.
(c) Computed Tomography (CT)
The introduction of CT into clinical practice was followed by a dramatic
increase in the number of CT examinations performed, hence the increase in
radiation dose delivered to the patients. Multi-slice CT (MSCT) increases the
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efficacy of CT procedures and offers new promising applications. The expanding use
of MSCT, however, has resulted in an increase in both frequency of procedures and
levels of patient exposure. The CT examinations that were studied in this survey
were as follow:
Table 2.4: Types of CT examinations.
Types of examinations
BrainSpine/Musculo-skeletal (including Cervical, Thorax, Lumbo-Sacral Spine) ChestAbdomen Pelvis Cardiac CT
The effective dose from CT examinations was calculated using the CT Expo
software version 1.6E developed by Georg Stamm and Hans Dieter Nagel. There
were three principal application modules in CT Expo: “Calculate”, “Standard” and
“Benchmarking”. The parameters required to calculate the effective dose include
patient age, patient gender, scan range, scanner model, select mode (helical or spiral),
scan parameters such as kV, mA, time, mAs, beam width, table feed per rotation,
reconstructed slice thickness, and number of scan series. The results of the dose
calculation were displayed as CTDIw, CTDIvol, DLP, ED and dose to the uterus (for
women). In addition, this version of CT Expo also provides the equivalent dose for
each different organ or tissue.
(d) Mammography
The risk and benefits of mammography screening programs are still being
widely debated. Although mammography may now be regarded as a ‘low-dose’
procedure, there remains a continuing need for periodic dose measurement. This
study recorded the mammography cases with cranial-caudal (CC), mediolateral
oblique (MLO) and lateral views. Finally the MGD were obtained by calculation
using the following formula:
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Kgcs=Dm
where K is the incident air kerma calculated (in the absence of scattered
radiation) at the upper surface of the breast. The factor g corresponds to a
glandularity of 50% adipose and 50% glandular breast tissue. c is factors for typical
breast compositions in the age ranges 40-49 and 50-64. The factor s corrects for any
difference due to the choice of x-ray spectrum.
(e) Bone Mineral Densitometry (BMD)
Dual x-ray absorptiometry (DXA) provides the gold standard for performing
bone mineral densitometry measurement. They provide a convenient, non-invasive
method of assessing skeletal bone mineral density which is widely used for clinical
studies. Just as any technique involving exposure of patient to ionizing radiation
requires an assessment of the risk of radiation injury. The quantity that is commonly
used to assess the radiation dose is the ESD, which is similar to the method used for
general x-ray dose measurements.
There were two types of bone mineral densitometry examination included in
this survey:
Table 2.5: Type of BMD examinations.
Types of examinations
AP Spine
Left Hip / Right Hip
(f) Dental Radiology
New therapeutic techniques in dental medicine require diagnostic procedures
that allow accurate planning of the dental implants and familiarization of the dental
anatomy. Conventional dental radiography is associated with low doses and risks for
the individual patient. However, while dental radiography is generally ‘low dose’, it
is a high volume procedure. Therefore, an assessment of the radiation dose incurred
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to patients from dental radiological procedures is needed. There were two types of
dental radiology examination studied in this survey:
Table 2.6: Type of dental radiology examinations.
Types of examinations
Intraoral
Panoramic
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2.3 DATA ANALYSIS
2.3.1 Introduction
This survey provides qualitative and quantitative information on the doses for
diagnostic, interventional and dental radiology, to assess medical radiation exposure
in Malaysia and to allow data comparison with other countries. The results of the
survey provide the basis for optimization procedures and guidelines for radiation
protection as well as the establishment of national DRLs for the country.
A centralized computer database was designed and developed for the data
management (Figure 2.8). The data from the background information survey and
dose survey were stored in the database. This database was also built in with the
radiation dose calculation formula for mammography; hence the MGD of patients
were calculated automatically and stored in the database as long as the
mammography x-ray unit and the exposure parameters were given.
Data analysis was done using the Statistical Package for the Social Sciences
(SPSS) version 16. SPSS is an established statistical analysis software used for
descriptive statistics, bivariate statistics, prediction for numerical outcomes and
prediction for identifying groups. Generally, the data analysis in this survey could be
divided into two (2) main categories, which are descriptive statistics and dosimetric
analysis. Descriptive statistics include the analysis of number of personnel, number
of equipment and frequency of cases performed; whereas the dosimetric analysis
include the numerical calculation for the radiation exposure such as mean, minimum,
maximum, standard deviation, median, 1st quartile and 3rd quartile. The analysis
outputs are displayed in pie charts and tables for descriptive statistics and box plots
for the dosimetric analysis. Histograms were also included in the analysis to
demonstrate the distribution or proportion of cases that fall into each of several
categories.
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Figure 2.8: Medical Radiation Exposure Survey database management system.
2.3.2 Data Screening
Prior to data analysis, the data was screened several times to identify errors and
outliers. The errors could be from human mistakes such as typographical errors, error
in calculation, unit conversion errors, misplaced variables, etc. These data were
either corrected or rejected from analysis depending on the validity of the data.
Incomplete or invalid data were rejected from the analysis.
During screening of the dosimetric data, values less than 2% and more than
98% from the mean were excluded (the first step of data screening to avoid being
affected by extreme values), and a new mean was calculated. The values which were
smaller, or larger than 2 standard deviations from the new mean were considered as
outliers and were excluded from the analysis.
MedicalRadiationExposureSurveyCentral
Database
DoseCalculation
Program
BackgroundInformation
Survey
Radiation Dose Survey
Statistical Analysis
Output / Result
InputDose
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2.3.3 Descriptive Statistics
The United Nations defines four levels of health care in the world based on
population per physician [UNSCEAR, 1988]. At the highest level of health care
(Level I), there are one or more physicians for each 1,000 population; Level II has
one physician for each 1,000 to 3,000 population; Level III has one physician for
3,000 to 10,000 population, and for Level IV has one physician for more than 10,000
population. The Background Information Survey allows the analysis of the number
of personnel, including physicians, medical physicists and
technologists/radiographers per 1,000 population. In this survey, the trend of
personnel growth in diagnostic, interventional and dental radiology was monitored
from 2007-2009. Malaysia with 27.17 million population in 2007, and an average of
1,429 population per physician is classified as health care Level II country.
The number of equipment or facilities provides useful information on the unit
to population ratio of the country. The results would be compared to the survey in
other countries worldwide to estimate the trend of growth of human assets in
Malaysia. The equipment in diagnostic and dental radiology include general x-ray,
mammography, fluoroscopy/angiography, CT scanner, BMD and dental x-ray.
For each procedure, basic patient demographics such as age, gender, ethnic
group, height and weight data were acquired from the respective hospital’s database.
Descriptive statistics such as mean, median, range, 1st quartile and 3rd quartile
histogram were tabulated.
2.3.4 Dosimetric Analysis
Patient dose for common types of diagnostic examinations were summarized as
follows:
(a) Entrance Surface Dose (mGy) for general x-ray, bone mineral
densitometry and dental radiology (intraoral);
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(b) Air Kerma-Area Product (mGy.m2) and Peak Skin Dose (mGy) for
fluoroscopy/angiography;
(c) Computed Tomography Dose Index (mGy), Dose Length Product
(mGy.m2) and Effective Dose (mSv) for computed tomography;
(d) Mean Glandular Dose (mGy) for mammography;
(e) Air Kerma-Area Product (mGy.m2) for dental radiology (panoramic)
Finally, the dosimetric data collected for all modalities were compared with the
data published from other surveys.
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2.4 RESULT AND DISCUSSION
2.4.1 Descriptive and Numerical Analysis
This section includes the analysis for number of personnel (radiation workers),
number of equipment or facilities, total number of cases and patient dosimetry in
30% of healthcare facilities of diagnostic and interventional radiology services in
Malaysia from 2007 to 2009.
(a) Number of Personnel
The radiation workers at above mentioned centres are radiographers, dental
practitioners, general medical practitioners, dental surgery assistants, trained
operators, radiologists, medical physicists, interventional cardiologists and
interventional radiologists. Table 2.7 summarizes the number of radiation workers in
all the sample sites from 2007 to 2009.
Among all the personnel, radiographers remained the highest number for all
three years. This was followed by dental practitioners, general medical practitioners,
dental surgery assistants and trained operators. A radiologist is defined as a physician
specialized in diagnostic radiology, the branch of medicine that uses ionizing and
non-ionizing radiation for the diagnosis and treatment of disease. An interventional
radiologist is a radiologist subspecialized in advanced interventional radiology
procedures. Both use imaging modalities such as fluoroscopy/angiography,
angiography, CT, MRI and ultrasound. An interventional cardiologist is a
cardiologist subspecialized in invasive cardiology who uses fluoroscopy/
angiography guidance to treat coronary and cardiovascular diseases.
In general, the number of personnel in diagnostic and interventional radiology
services in Malaysia are increasing over the years as shown in Table 2.7 and Figure
2.9.
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Table 2.7: Total number of personnel in diagnostic, interventional and dental radiology from all the sample sites (2007-2009).
Personnel 2007 2008 2009
Radiographers 656 690 1110
Dental Practitioners 300 322 528
General Medical Practitioners 170 195 312
Dental Surgery Assistants 76 103 237
Trained Operators 205 217 231
Radiologists 129 126 170
Medical Physicists 8 10 24
Interventional Cardiologists 14 15 20
Interventional Radiologists 3 4 4
Figure 2.9: Histogram showing the number of personnel in diagnostic, interventional and dental radiology from all the sample sites from 2007 to 2009.
200920082007
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(b) Number of Equipment
The equipments were grouped according to the modality, which are general x-
ray, mammography, fluoroscopy/angiography, CT, BMD and dental x-ray units
(intraoral and orthopantomogram (OPG)).
Table 2.8 and Figure 2.10 shows the total number of equipment in diagnostic,
interventional and dental radiology from all the sample sites. General x-ray made up
the highest number among all the equipment/modalities. This was followed by dental
x-ray, fluoroscopy/angiography, CT scanners, mammography and BMD.
Table 2.8: Total number of equipment in diagnostic, interventional and dental radiology from all the sample sites (2007-2009).
Equipment/Modality Total Number of Equipment
2007 2008 2009
General x-ray 424 467 530
Dental x-ray 348 384 419
Fluoroscopy / angiography 76 80 92
CT scanner 50 60 68
Mammography 36 43 50
Bone mineral densitometer 11 12 13
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Figure 2.10: Histogram showing the number of equipment in diagnostic, interventional and dental radiology from all the sample sites from 2007 to 2009.
(c) Total Number of Cases
The total number of cases collected is presented in Table 2.9. There was a total
of 19,885 cases collected from all the modalities. General x-ray examinations
constituted the highest number of cases, followed by CT, mammography, dental
radiology, fluoroscopy/angiography (includes interventional studies) and BMD.
Table 2.9: Total number of cases collected by modality.
Modality Number of Cases Collected
General X-ray 6533
Fluoroscopy/Angiography 410
Computed Tomography 6236
Mammography 5226
Bone Mineral Densitometry 154
Dental Radiology 1326
TOTAL 19885
200920082007
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2.4.2 General X-ray
(a) Number of Cases
The total number of cases collected is shown in Table 2.10 and Figure 2.11.
Table 2.10: Number of cases collected for general x-ray from all the sample sites.
Exam. Type Frequency Percentage (%)
Abdomen/KUB 402 6.2
Cervical AP, LAT 254 3.9
Chest LAT 32 0.5
Chest PA 2743 42.0
Lower and Upper Extremities 1963 30.0
Lumbo-Sacral AP, LAT 542 8.3
Pelvis/Hip 263 4.0
Skull 196 3.0
Thoracic AP, LAT 138 2.1
Total 6533 100.0
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Figure 2.11: Number of cases collected for general x-ray.
(b) Dosimetric Data
The dosimetric data for general x-ray was expressed in ESD using TLD. The
unit for ESD is mGy. The mean, median, minimum, maximum, standard deviation,
1st quartile (1st Q) and 3rd quartile (3rd Q) for ESD collected were summarized in
Table 2.11 by type of examination. Figure 2.12 shows the box-plot from the analysis.
Table 2.11: Entrance Surface Dose (mGy) by examination.
Exam. Type Entrance Surface Dose (mGy)
Mean Median Min Max Std. Dev. 1st Q 3rd Q
Abdomen / KUB 5.05 4.58 0.96 11.78 2.64 3.22 7.36
Cervical AP 1.58 1.10 0.27 6.40 1.25 0.69 2.10
Cervical LAT 1.57 1.44 0.28 5.66 1.03 0.76 2.05
Chest LAT 1.34 1.22 0.21 3.08 0.80 0.73 1.83
Chest PA 0.61 0.50 0.05 2.00 0.43 0.29 0.87
Extremities (Lower) 0.71 0.54 0.08 4.82 0.61 0.29 0.93
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Extremities (Upper) 0.67 0.52 0.08 3.08 0.53 0.29 0.85
Lumbo-Sacral AP 5.44 5.10 1.08 10.97 2.47 3.69 7.50
Lumbo-Sacral LAT 10.96 11.26 1.17 18.73 4.14 6.63 13.4
Pelvis 4.32 3.67 0.29 12.85 2.83 1.83 5.80
Skull AP 3.76 3.54 0.68 8.56 1.94 2.37 4.80
Skull LAT 1.77 1.60 0.50 3.46 0.79 0.98 2.40
Skull Others 3.85 3.16 1.10 7.53 2.37 1.85 5.51
Thoracic AP 4.78 4.36 1.29 9.61 2.28 3.24 6.80
Thoracic LAT 6.38 6.30 1.38 12.90 2.90 3.94 7.50
Figure 2.12: Entrance surface dose (mGy) by examination.
(c) Data Comparison with Recommended DRLs
The dosimetric data for general x-ray collected from this survey were
compared to the DRLs recommended by different international organizations, such
as NRPB, AAPM, EC, IAEA, IPSM and CRCPD. One of the main objectives of this
ESD (mGy) for Different Examination Types in General X-ray
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survey was to develop a local DRL in the relevant diagnostic imaging disciplines to
fit the local population and conditions. Table 2.12 presents the comparison between
the data collected from this survey with the DRLs recommended by the international
organizations for common general x-ray examinations.
Table 2.12: Comparison of Entrance Surface Dose (mGy) for general x-ray collected from this survey with DRLs recommended by different international organizations.
Exam.
Type
Projection Entrance Surface Dose (mGy)
*This
Survey
(2009)
UK1NRPB
(1999)
US2AAPM
(1999)
EC3EUR96
(1996)
IAEA4BSS
(1996)
UK5IPSM
(1992)
USA6CRCPD
(1988)
Abdomen AP 7.4 10 4.50 N/A 10.00 10.00 4.30
Cervical
Spine
AP 2.1 N/A 1.25 N/A N/A N/A 1.20
LAT 2.1 N/A N/A N/A N/A N/A N/A
Chest PA 0.9 0.30 0.25 0.30 0.40 0.30 0.10
LAT 1.8 1.50 N/A 1.50 1.50 1.50 N/A
Lumbar
Spine
AP 7.5 10.00 5.00 10.00 10.00 10.00 3.90
LAT 13.4 30.00 N/A 30.00 30.00 30.00 N/A
Pelvis/Hi
p
AP 5.8 10.00 N/A 10.00 10.00 10.00 N/A
Skull AP/PA 4.8 5.00 N/A 5.00 5.00 5.00 N/A
Lateral 2.4 3.00 N/A 3.00 3.00 3.00 1.30
Others 5.5 N/A N/A N/A N/A N/A N/A
Thoracic
Spine
AP 6.8 N/A N/A N/A 7.00 N/A 2.30
LAT 7.5 N/A N/A N/A 20.00 N/A N/A* The entrance surface doses presented in this table are the 3rd quartile values calculated from the
total cases collected in this survey in the period of 2007-2009. 1. National Radiological Protection Board. Guidance on patient dose to promote optimization of
protection for diagnostic medical exposures. Documents of the NRPB, Vol 10, No. 1. 1999.
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2. American Association of Physicists in Medicine Task Group. Reference values – Application and impact in radiology. AAPM. 1999.
3. European Commission. European guidelines of quality criteria for diagnostic radiographic images. Eur 16260 EN. EC. 1996.
4. International Atomic Energy Agency. International Basic Safety Standards protection against ionizing radiation and for the safety of radiation sources. Safety Series No. 115. IAEA. 1996.
5. Institute of Physical Sciences in Medicine. National protocol for patient dose measurements in diagnostic radiology. Dosimetry Working Party, IPEM. 1992.
6. Conference of Radiation Control Program Directors. Average patient exposure guides. CRCPD Publication 88-5. 1988.
2.4.3 Fluoroscopy and Interventional Radiology
(a) Number of Cases Collected
The total number of cases collected for fluoroscopy and interventional
radiology is shown in Table 2.13.
Table 2.13: Number of cases collected for fluoroscopy and interventional radiology.
Exam. Categories Exam. Type Frequency Percentage
(%)
Angiography Cardiac 88 21.5
Non-cardiac 36 8.8
Conventional Studies ERCP 25 6.0
Lower Gastrointestinal 82 20.0
MCU 4 1.0
Upper Gastrointestinal 29 7.0
Interventional Cardiac (PTCA) 31 7.6
Cerebral 32 7.8
ESWL 8 2.0
Vascular 57 13.9
Others 18 4.4
Total 410 100.0
Note: Others include Nephrostomy, Percutaneous Transhepatic Biliary Drainage (PTBD), Sinogram, Anal Fistulogram, Ascending Urethrogram, Lower Limb Angiography, Cystography and Renal Embolization
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Figure 2.13: Number of cases for angiography, conventional and interventional studies using fluoroscopy/angiography
Figure 2.14: Number of cases for angiography (cardiac and non-cardiac).
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Figure 2.15: Number of cases for fluoroscopy (conventional studies).
Figure 2.16: Number of cases collected for fluoroscopy (interventional studies).
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(b) Dosimetric Data
The dosimetric data for fluoroscopy and interventional radiology were
expressed in both AKAP using KAP meter and PSD using gafchromic film. The unit
used for AKAP is mGy.m2 whereby for PSD is mGy. PSD represents the maximum
point dose in a defined area or volume. In this survey, the Mean Skin Dose (MSD)
which represents the average skin dose in a defined exposure area was also presented.
The mean, median, minimum, maximum, standard deviation, 1st quartile (1st Q) and
3rd quartile (3rd Q) for AKAP, PSD and MSD collected were summarized in Table
2.14 to 2.16 according to different examination types. Figure 2.17 to 2.22 shows the
box-plot from the analysis.
Table 2.14: Air Kerma-Area Product (mGy.m2) for various fluoroscopy examination types in conventional and interventional studies.
Exam. Type Air Kerma-Area Product (mGy·m2)
Mean Median Min Max Std. Dev. 1st Q 3rd Q
Angiography
Cardiac 4.19 3.08 0.23 15.21 3.13 2.22 5.44
Non-Cardiac 3.06 1.35 0.01 13.26 3.77 0.05 5.22
Conventional Studies
ERCP 0.64 0.49 0.20 1.57 0.38 0.35 0.83
GI Lower 0.70 0.48 0.03 3.90 0.75 0.25 0.68
GI Upper 0.65 0.58 0.07 2.52 0.52 0.26 0.85
MCU 1.16 1.28 0.49 1.92 0.50 0.80 1.41
Interventional Studies
Cerebral 8.22 6.61 3.10 31.32 5.96 4.81 8.70
ESWL 0.62 0.58 0.15 1.18 0.43 0.39 0.81
PTCA 13.01 12.52 2.10 34.02 8.50 5.38 15.70
Vascular 4.76 1.94 0.01 36.58 7.07 0.62 5.87
Others 1.55 0.80 0.06 4.68 1.52 0.63 2.01
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Figure 2.17: Air Kerma-Area Product (mGy.m2) for various examination types in angiography and conventional fluoroscopy.
Figure 2.18: Air Kerma-Area Product (mGy.m2) for various procedures in interventional studies.
AKAP (mGy.m2) for Various Examination Types in Angiography & Conventional Fluoroscopy Studies
AKAP (mGy.m2) for Various Procedures in Interventional Studies
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Table 2.15: Peak Skin Dose (mGy) for various fluoroscopy examination types in conventional and interventional studies.
Exam. Type Peak Skin Dose (mGy)
Mean Median Min Max Std. Dev. 1st Q 3rd Q
Angiography
Cardiac 693.16 560.70 221.50 2186.40 466.50 346.9 825.63
Non-Cardiac 696.53 648.00 196.30 1403.10 310.27 515.3 753.80
Conventional Studies
ERCP 747.54 620.45 245.60 1894.10 477.87 351.98 961.50
GI Lower 621.95 503.50 210.63 1710.90 338.53 355.80 844.40
GI Upper 458.41 387.75 199.70 977.30 216.75 279.30 602.93
MCU 770.67 803.40 268.00 1383.20 428.70 434.95 991.25
Interventional Studies
Cerebral 891.77 609.10 330.10 2322.40 590.06 444.90 1108.80
ESWL 273.80 278.75 165.90 371.80 106.18 141.18 361.38
PTCA 1116.01 951.70 199.20 2675.90 650.78 30.00 1508.28
Vascular 576.31 422.90 207.70 1577.60 367.31 8.00 703.40
Others 657.35 511.80 270.00 1535.70 406.12 392.00 790.85
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Figure 2.19: Peak Skin Dose (mGy) for various examination types in angiography and conventional fluoroscopy.
Figure 2.20: Peak Skin Dose (mGy) for various procedures in interventional studies.
PSD (mGy) for Various Examination Types in Angiography & Conventional
Fluoroscopy Studies
PSD (mGy) for Various Procedures in Interventional Studies
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Table 2.16: Mean Skin Dose (mGy) for various fluoroscopy/angiography examination types in conventional and interventional studies.
Exam. Type Mean Skin Dose (mGy)
Mean Median Min Max Std. Dev. 1st Q 3rd Q
Angiography
Cardiac 111.76 113.20 79.60 163.50 18.00 97.05 122.13
Non-Cardiac 117.71 118.00 88.50 172.20 21.54 105.00 122.40
Conventional Studies
ERCP 103.53 97.05 79.10 181.20 27.39 82.95 115.18
GI Lower 100.68 97.20 73.90 152.40 19.87 82.20 115.40
GI Upper 106.93 113.75 76.30 141.90 20.51 81.85 118.03
MCU 95.22 93.55 79.70 114.60 15.72 81.25 107.95
Interventional Studies
Cerebral 128.12 132.70 98.90 183.90 18.24 117.00 135.80
ESWL 113.62 113.20 111.00 117.10 2.93 111.30 115.53
PTCA 145.58 141.05 84.80 251.40 37.09 119.25 168.10
Vascular 125.31 120.20 86.80 261.70 34.56 108.85 134.80
Others 103.54 109.40 80.90 129.10 16.74 86.33 115.83
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Figure 2.21: Mean Skin Dose (mGy) for various examination types in angiography and conventional fluoroscopy.
Figure 2.22: Mean Skin Dose (mGy) for various procedures in interventional studies.
MSD (mGy) for Various Examination Types in Angiography & Conventional
Fluoroscopy Studies
MSD (mGy) for Various Procedures in Interventional Studies
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(c) Data Comparison with Published Literature
The dosimetric data collected for fluoroscopy and interventional radiology
were compared with the data published from other national surveys. Table 2.17
presents the comparison between the data collected from this survey with the
published data from other studies.
Table 2.17: Comparison of Air Kerma-Area Product (AKAP) with other published literature.
Exam.
Type
Air Kerma-Area Product or Dose-Area Product (mGy.m2)1This
Survey
(2009)
2Efstathopoulous
et al.(2005)
3Sapiinet al.
(2004)
4Van de Putteet al.
(2000)
5Tsalafoutas
et al. (2003)
6Vanoet al.
(1998)
7Warren-Forward
et al. (1998)
Angiography
Cardiac 5.4 N/A 3.70 5.68 N/A 4.58 N/A
Non-
Cardiac
5.2 N/A 8.66 N/A N/A 6.66 N/A
Conventional Studies
ERCP 0.8 N/A N/A N/A 0.85 N/A N/A
GI Lower 0.7 N/A N/A N/A N/A N/A 0.22-0.77
GI Upper 0.9 N/A N/A N/A N/A N/A 0.11-0.44
MCU 1.4 N/A N/A N/A N/A N/A N/A
Interventional Studies
Cerebral 8.7 10.98 N/A N/A N/A N/A N/A
ESWL 0.8 N/A N/A N/A N/A N/A N/A
PTCA 15.7 7.89 11.06 10.88 N/A 6.68 N/A
Vascular 5.9 32.50 12.81 N/A N/A N/A N/A
Others 2.0 N/A N/A N/A N/A N/A N/A1. The AKAP presented in this table are the 3rd quartile values calculated from the total cases
collected (2007-2009). 2. Efstathopoulous EP, Brountzos EN, Alexopoulou E. Patient radiation exposure measurements
during interventional procedures: a prospective study. Health Physics; 91(1): 41-45.2006. 3. Sapiin B, Ng KH, Abdullah BJJ. Radiation dose to patients undergoing interventional
radiological procedures in selected hospitals in Malaysia: retrospective study. J HK Coll. Radiol. 7: 129-136. 2004.
4. Van de Putte S, Verhaegen F, Taeymans Y, Thierens H. Correlation of patient skin doses in cardiac interventional radiology with dose area product. Br. J Radiol. 73: 504-513. 2000.
5. Tsalafoutas IA, Paraskeva KD, Yakoumakis EN, Vassilaki AE et al. Radiation doses to patients from endoscopic retrograde cholangiopancreatography examinations and image quality considerations. RPD; 106(3): 241-246. 2003.
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6. Vano E, Arranz L, Sastre JM et al. Dosimetric and radiation protection considerations based on some cases of patient skin injuries in interventional cardiology. Br. J Radiol. 71: 510-516. 1998.
7. Warren-Forward HM, Haddaway MJ, Temperton DH, McCall IW. Dose-are product readings for fluoroscopic and plain film examinations, including an analysis of the source of variation for barium enema examinations. Br. J Radiol. 71:961-967. 1998.
2.4.4 Computed Tomography
(a) Number of Cases
The total number of cases collected for computed tomography is shown in
Table 2.18 and Figure 2.23.
Table 2.18: Number of cases for computed tomography.
Exam Type Frequency Percentage (%)
Abdomen 1137 18.2
Brain 2648 42.5
Cardiac 134 2.2
Chest 351 5.6
Pelvis 234 3.8
Spine/Musculo-skeletal 145 2.3
Thorax 371 5.9
Others 1216 19.5
Total 6236 100.0
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Figure 2.23: Number of cases for computed tomography.
(b) Dosimetric Data
The dosimetric data for computed tomography was expressed in CTDI, DLP
and ED. The mean, median, minimum, maximum, standard deviation, 1st quartile and
3rd quartile for CTDIw and DLP collected were summarized in Table 2.19 and Table
2.20 according to different examination types, respectively. Figure 2.24 and Figure
2.25 shows the box-plot from the analysis.
In addition, the mean, median, minimum, maximum, standard deviation, 1st
quartile and 3rd quartile for ED calculated were summarized in Table 2.21 according
to different examination types. Figure 2.26 shows the box-plot from the analysis. The
examination types are listed by region only and did not take into consideration the
type of scanner or type of study (contrast, non-contrast, single or multi-phase).
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Table 2.19: CTDIw (mGy) for various examination types in CT.
Exam. Types CTDIw (mGy)
Mean Median Min Max Std. Dev. 1st Q 3rd Q
Abdomen 11.1 10.2 6.2 18.5 2.6 9.8 12.8
Brain 42.3 43.8 12.8 61.2 7.9 36.1 46.8
Cardiac 9.2 8.2 1.2 28.5 6.7 2.9 11.8
Chest 15.1 13.4 4.8 31.4 6.8 10.4 19.9
Pelvis 23.3 11.6 5.1 72.2 18.5 10.2 39.1
Spine/Musculo-Skeletal 13.5 12.8 6.5 26.9 5.4 10.0 16.3
Thorax 18.8 18.3 3.1 46.9 11.4 10.2 21.3
Others 9.5 10.0 5.1 29.9 4.4 6.1 12.3
Table 2.20: DLP (mGy.cm) for various examination types in CT.
Exam. Types DLP (mGy.cm)
Mean Median Min Max Std. Dev. 1st Q 3rd Q
Abdomen 371.5 291.5 40.0 1030.0 269.1 148.2 454.7
Brain 665.2 588.0 39.0 1773.0 462.5 295.5 1050.0
Cardiac 646.2 447.5 44.0 3263.0 643.8 163.7 869.2
Chest 478.6 267.0 67.0 3994.0 551.4 143.0 606.5
Pelvis 521.7 324.0 63.0 2271.0 503.8 224.5 726.5
Spine/Musculo-Skeletal 399.4 279.0 64.0 1383.0 348.0 175.0 389.0
Thorax 337.2 303.0 45.0 1195.0 198.8 212.0 415.0
Others 326.0 244.5 55.0 1308.0 281.2 136.2 378.0
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Table 2.21: Effective dose (mSv) for various examination types in CT.
Exam. Types Effective Dose (mSv)
Mean Median Min Max Std. Dev. 1st Q 3rd Q
Abdomen 8.3 7.3 1.8 26.7 4.8 4.5 10.1
Brain 1.9 1.6 0.5 8.1 1.1 0.9 2.1
Cardiac 9.1 9.2 1.0 19.7 5.9 2.7 12.3
Chest 7.9 7.3 1.4 17.7 4.0 4.5 8.97
Pelvis 7.5 6.7 2.0 19.0 4.0 3.75 8.4
Spine/Musculo-Skeletal 4.9 3.8 1.0 15.8 3.3 2.3 6.15
Thorax 6.2 5.2 1.2 22.5 3.7 3.4 8.0
Others 7.0 5.0 0.6 23.6 5.6 2.73 10.3
Figure 2.24: CTDIw (mGy) for various examination types in CT.
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Figure 2.25: DLP (mGy.cm) for various examination types in CT.
Figure 2.26: Effective dose (mSv) for various examination types in CT.
Effective Dose (mSv) for Various Examination Types in Computed
Tomography
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(c) Data Comparison with Published Literature
The dosimetric data collected for CT in this survey were compared with the
data published from other studies. The DRLs recommended for CT are expressed in
MSAD (mGy), CTDIw (mGy) or DLP (mGy.cm2) by international organizations such
as IAEA, NRPB, EC and AAPM. The dosimetric data for CT in this survey were
compared with the recommended DRLs in other published surveys. Table 2.22 and
Table 2.23 presents the comparison of CTDIw and DLP between the data collected
from this survey with the published data from other studies. Table 2.24 presents the
comparison of effective dose between the data collected from this survey with the
published data from other studies.
Table 2.22: Comparison of CTDIw (mGy) from this survey with other published surveys.
Exam Types CTDIw (mGy) *This Survey
(2009)
1NRPB
(1999)
2EC
(1999)
3UK
(2003)
Abdomen 12.8 35 35 20 Brain 46.8 60 60 N/A Cardiac 11.8 N/A N/A N/A
Chest 19.9 30 30 N/A
Pelvis 39.1 35 35 N/A
Spine/Musculo-
Skeletal
16.3N/A 70 N/A
Thorax 21.3 N/A N/A N/A
Others 12.3 N/A N/A N/A
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Table 2.23: Comparison of DLP (mGy.cm) with other published surveys.
Exam Types DLP (mGy.cm) *This Survey
(2009)
1NRPB
(1999)
2EC
(1999)
3UK
(2003)
Abdomen 454.7 800 780 470
Brain 1050.0 1050 1050 930
Cardiac 869.2 N/A N/A N/A
Chest 606.5 650 650 N/A
Pelvis 726.5 600 570 N/A
Spine/Musculo-
Skeletal
389.0N/A 460 N/A
Thorax 415.0 N/A N/A N/A
Others 378.0 N/A N/A N/A
* Table 2.22 and Table 2.23 presenting CTDIw and DLP values of 3rd quartile values calculated from the total cases collected of 2007-2009.
1. National Radiological Protection Board. Guidance on patient dose to promote optimization of protection for diagnostic medical exposures. NRPB, Vol 10, No. 1. 1999.
2. European Commission. European Guidance on Quality Criteria for Computed Tomography. EUR16262. EC. 1999.
3. Shrimpton P.. Assessment of Patient Dose in CT in Bongart G.Z., Golding S.J, Jurik A.G., et. al., European Guidelines for Multislice Computed Tomography. 2004.
Table 2.24: Comparison of effective dose (mSv) from this survey with other published surveys.
Exam Types Effective Dose (mSv) *This
Survey
(2009)
1Yales
et al.
Survey
(2004)
2Brix
et al.
Survey
(2003)
3UK CT
Dose
Review
(2003)
4Mettler
et al.
Survey
(1999)
5NRPB
(1999)
Abdomen 10.1 7.0-9.2 14.4 4.3-5.5 3.1 10
Brain 2.1 1.7 2.8 0.3-1.7 1.5 2
Cardiac 12.3 N/A 6.7 2.2-7.1 N/A N/A
Chest 8.97 2.2-10.9 5.7 2.6-8.8 5.4 8
Pelvis 8.4 N/A 7.2 6.1-8.0 3.1 N/A
Spine/Musculo-
Skeletal
6.15 6.4 8.1 8.2-12 N/A N/A
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Thorax 8.0 N/A 6.7 2.4-7.1 N/A N/A
Others 10.3 N/A N/A N/A 3.0 N/A* The effective doses presented in this table are the 3rd quartile values calculated from the total cases
collected in this survey in the period of 2007-2009. 1. Yales SJ, Pike LC, Goldstone KE. Effect of multi-slice scanners on patient dose from routine CT
examinations in East Anglia. Br. J. Radiol. 77:472-478. 2004. 2. Brix G, Nagel HD, Stamm G, Veit R, Lechel U, Griebel J, Galanski M. Radiation exposure in
multi-slice versus single-slice spiral CT: results of a nationwide survey. Eur. Radiol. 13: 1973-1991. 2003.
3. Shrimpton PC, Hillier MC, Lewis MA, Dunn M. Doses from Computed Tomography (CT) examinations in the UK – 2003 Review. NRPB-W67. 2005.
4. Mettler FA, Wiest PW, Locken JA, Kelsey CA. CT scanning: patterns of use and dose. J Radiol. Prot. 20: 353-359. 2000.
5. National Radiological Protection Board. Guidelines on patient dose to promote the optimization of protection for diagnostic medical exposures. NRPB Vol 10, No. 1. 1999.
2.4.5 Mammography
(a) Number of Cases
The total number of cases for mammography is shown in Table 2.25.
Table 2.25: Number of cases for mammography.
Exam. Type Frequency Percentage (%)
Mammography 5226 100.0
(b) Dosimetric Data
The dosimetric data for mammography was expressed in MGD. The unit used
for MGD is mGy. The mean, median, minimum, maximum, standard deviation, 1st
quartile (1st Q) and 3rd quartile (3rd Q) for MGD collected in this survey were
summarized in Table 2.26 according to different breast thickness. Figure 2.27 shows
the box-plot from the analysis.
Table 2.26: Mean Glandular Dose (mGy) for various breast thickness in mammography.
Breast thickness Mean Glandular Dose (mGy)
Mean Median Min Max Std. Dev. 1st Q 3rd Q
2 – 3.9 cm 1.43 1.21 0.10 4.85 0.86 0.77 1.89
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Breast thickness Mean Glandular Dose (mGy)
Mean Median Min Max Std. Dev. 1st Q 3rd Q
2 – 3.9 cm 1.43 1.21 0.10 4.85 0.86 0.77 1.89
4 – 7.9 cm 1.56 1.36 0.09 4.97 0.87 0.93 1.99
8 - 10 cm 2.32 2.21 0.34 4.87 1.22 1.32 3.23
Figure 2.27: Mean Glandular Dose (mGy) for various breast thickness in mammography.
2.4.6 Bone Mineral Densitometry
(a) Number of Cases
The total number of cases for bone mineral densitometry is shown in Table
2.27 and Figure 2.28.
Table 2.27: Number of cases collected for bone mineral densitometry.
Exam. Type Frequency Percent (%)
AP Spine 83 53.9
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Left Hip / Right Hip 71 46.1
Total 154 100.0
Figure 2.28: Number of cases collected for bone mineral densitometry.
(b) Dosimetric Data
The dosimetric data for bone mineral densitometry was expressed in Entrance
Surface Dose (ESD). The unit used for ESD is mGy. The mean, median, minimum,
maximum, standard deviation, 1st quartile (1st Q) and 3rd quartile (3rd Q) for ESD
collected in this survey were summarized in Table 2.28 according to different
examination types. Figure 2.29 shows the box-plot from the analysis.
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Table 2.28: Entrance Surface Dose (mGy) for different examination types in bone mineral densitometry.
Exam. Type Entrance Surface Dose (mGy)
Mean Median Min Max Std. Dev. 1st Q 3rd Q
AP Spine 0.33 0.23 0.01 0.96 0.28 0.08 0.51
L/R Hip 0.37 0.26 0.00 1.16 0.33 0.07 0.61
Figure 2.29: Entrance Surface Dose (mGy) for different examination types in bone mineral densitometry.
2.4.7 Dental Radiology
(a) Number of Cases
The total number of cases for dental radiology is shown in Table 2.29 and
Figure 2.30.
ESD (mGy) for Different Examination Types in
Bone Mineral Densitometry
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Table 2.29: Number of cases collected for dental radiology.
Exam. Type Frequency Percent (%)
Intraoral 1205 90.9
Panoramic 121 9.1
Total 1326 100.0
Figure 2.30: Number of cases collected for dental radiology.
(b) Dosimetric Data
The dosimetric data for dental radiology was expressed in ESD for intraoral
examinations and AKAP for panoramic examinations. The unit used for ESD is mGy
whereby for AKAP is mGy.m2. The mean, median, minimum, maximum, standard
deviation, 1st quartile (1st Q) and 3rd quartile (3rd Q) for ESD and AKAP collected in
this survey were summarized in Table 2.30 and Table 2.31 according to different
examination types. Figure 2.31 and Figure 2.32 shows the box-plot from the analysis.
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Table 2.30: Entrance Surface Dose (mGy) for intraoral examinations in dental radiology.
Exam. Type Entrance Surface Dose (mGy)
Mean Median Min Max Std. Dev. 1st Q 3rd Q
Intraoral 2.39 2.45 0.10 4.12 0.99 1.42 3.18
Figure 2.31: Entrance Surface Dose (mGy) for intraoral examinations in dental radiology.
ESD (mGy) for Intraoral Examinations in Dental Radiology
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Table 2.31: Air Kerma-Area Product (mGy.m2) for panoramic examinations in dental radiology.
Exam. Type AKAP (mGy·m2)
Mean Median Min Max Std. Dev. 1st Q 3rd Q
Panoramic 0.011 0.011 0.005 0.018 0.003 0.007 0.016
Figure 2.32: Air Kerma-Area Product (mGy.m2) for panoramic examinations in dental radiology.
(c) Data Comparison with Recommended DRLs
The dosimetric data for dental radiology collected from this survey were
compared to the DRLs recommended by different international organizations such as
NRPB, AAPM and CRCPD. Table 2.32 presents the comparison between the data
collected from this survey with the DRLs recommended by the international
organizations for intraoral examinations. As for panoramic dental examination, there
is no DRL available recommended by the above mentioned organizations. However
the data for panoramic dental collected from this survey were compared with the
published data from other surveys/countries, as shown in Table 2.33.
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Table 2.32: Comparison of Entrance Surface Dose (mGy) for intraoral dental examinations collected from this survey with DRLs recommended by different international organizations.
Exam.
Type
Entrance Surface Dose (mGy)
* This
Survey
(2009)
UK1NRPB
(1999)
US2AAPM
(1999)
EC3EUR96
(1996)
IAEA4BSS
(1996)
UK5IPSM
(1992)
USA6CRCPD
(1988)
Intraoral 3.18 1.80 3.50 NA NA NA 2.10-3.10* The entrance surface doses presented in this table are the median values calculated from the total
cases collected in the period of 2007-2009. 1. National Radiological Protection Board. Guidance on patient dose to promote optimization of
protection for diagnostic medical exposures. Documents of the NRPB, Vol 10, No. 1. 1999. 2. American Association of Physicists in Medicine Task Group. Reference values – Application
and impact in radiology. AAPM. 1999. 3. European Commission. European guidelines of quality criteria for diagnostic radiographic
images. Eur 16260 EN. EC. 1996. 4. International Atomic Energy Agency. International Basic Safety Standards protection against
ionizing radiation and for the safety of radiation sources. Safety Series No. 115. IAEA. 1996. 5. Institute of Physical Sciences in Medicine. National protocol for patient dose measurements in
diagnostic radiology. Dosimetry Working Party, IPEM. 1992. 6. Conference of Radiation Control Program Directors. Average patient exposure guides. CRCPD
Publication 88-5. 1988.
Table 2.33: Comparison of Air Kerma-Area Product (mGy.m2) for panoramic dental examinations collected from this survey with other published literature.
Exam.
Type
Air Kerma-Area Product (mGy.m2)*This
Survey
(2009)
1Chu
et al.
(2007)
2Doyle
et al.
(2006)
3Helmrot
et al.
(2005)
4Perisinakis
et al.
(2004)
5Tierris
et al.
(2004)
6Williams
et al.
(2000)
Panoramic 0.0160 0.0071 0.0089 0.0073 0.0113 0.0101 0.0113* The entrance surface doses presented in this table are the median values calculated from the total
cases collected of 2007-2009. 1. Chu RYL, Lam T, Liang Y. GafChromic XR-QA film in testing panoramic dental radiography. J
Appl. Clin. Med. Phys. 8(2): 727-730. 2007. 2. Doyle P, Martin CJ, Robertson J. Techniques for measurement of dose width product in
panoramic dental radiography. Br. J Radiol. 79: 142-147. 2006. 3. Helmrot E, Carlsson GA. Measurement of radiation dose in dental radiology. RPD; 114(1-3):
168-171. 2005. 4. Perisinakis K, Damilakis J, Neratzoulakis J, Bourtsoiannis N. Determination of dose-area
product from panoramic radiography using a pencil ionization chamber: normalized data for the estimation of patient effective and organ doses. Med. Phys. 31-4. 2004.
5. Tierris CE, Yakoumakis EN, Bramis GN, Georgiou E. Dose area product reference levels in dental panoramic radiology. RPD; 111 (3): 283-287. 2004.
6. Williams JR, Montgomery A. Measurement of dose in panoramic dental radiology. Br. J. Radiol. 73: 1002-1006. 2000.
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CHAPTER 3: NUCLEAR MEDICINE
3.1 LITERATURE REVIEW
3.1.1 History of Nuclear Medicine Development
Nuclear Medicine is a branch of medicine that uses radionuclides to provide
information about the function of a person's specific organs (diagnosis) or to treat
disease (therapy). In most cases, the information is used by physicians to make a
quick, accurate diagnosis of the patient's illness. The thyroid, bones, heart, liver and
many other organs can be easily imaged, and disorders in their function revealed. In
some cases radiation can be used to treat diseased organs, or tumours. Five Nobel
Laureates have been intimately involved with the use of radioactive tracers in
medicine [World Nuclear Association, 2009].
Over 10,000 hospitals worldwide use radioisotopes in medicine, and about
90% of the procedures are for diagnosis. The most common radioisotope used in
diagnosis is Technetium-99m (Tc-99m), with some 30 million procedures per year,
accounting for 80% of all nuclear medicine procedures worldwide. In developed
countries (26% of world population) the frequency of diagnostic nuclear medicine is
1.9% per year, and the frequency of therapy with radioisotopes is about one tenth of
this. In the USA there are some 18 million nuclear medicine procedures per year
among 305 million people, and in Europe about 10 million among 500 million
people. In Australia there are about 560,000 per year among 21 million people,
470,000 of these using reactor isotopes. The use of radiopharmaceuticals in diagnosis
is growing at over 10% per year [World Nuclear Association, 2009].
Nuclear medicine was developed in the 1950s by physicians with an endocrine
emphasis, initially using Iodine-131 (I-131) to diagnose and then treat thyroid
disease. In recent years specialists have also come from radiology, as dual PET/CT
procedures have become established. According to the US National Council on
Radiation Protection & Measurements report in 2009, Computed Tomography (CT)
and nuclear medicine contribute 36% of the total radiation exposure and 75% of the
medical exposure to the US population. The report also showed that American’s
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average total yearly radiation exposure had increased from 3.6 mSv to 6.2 mSv per
year since the early 1980s, due to medical-related procedures.
3.1.2 Diagnostic Examination in Nuclear Medicine
Diagnostic techniques in nuclear medicine use radioactive tracers which emit
gamma rays from within the body. These tracers are generally short-lived isotopes
linked to chemical compounds which permit specific physiological processes to be
scrutinized. They can be given by injection, inhalation or orally. The first SPECT
prototype of diagnostic imaging in nuclear medicine is where single photons are
detected by a gamma camera which can view organs from many different angles.
The camera builds up an image from the points from which radiation is emitted; this
image is enhanced by a computer and viewed by a physician on a monitor for
indications of abnormal conditions.
A more recent development is Positron Emission Tomography (PET) which is
a more precise and sophisticated technique using isotopes produced in a cyclotron. A
positron-emitting radionuclide is introduced, usually by injection, and accumulates in
the target tissue. As it decays it emits a positron, which promptly combines with a
nearby electron with innihilates resulting in the simultaneous emission of identifiable
gamma rays in diametrically opposite directions. These are detected by a PET
camera and give very precise indication of their origin. The most important clinical
role in PET scanning is in oncology, with Fluorine-18-Fluorodeoxyglucose (F-18
FDG) as the tracer, since it has proven to be the most accurate non-invasive method
of detecting and evaluating most cancers. It is also well used in cardiac and brain
imaging.
New procedures combine PET with computed tomography (CT) scans to give
co-registration of the two images (PET/CT), enabling better diagnosis than with
traditional PET alone. It is a very powerful and significant tool which provides
unique information on a wide variety of diseases from dementia to cardiovascular
disease and cancer.
Positioning of the radiation source within the body makes the fundamental
difference between nuclear medicine imaging and other imaging techniques such as
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x-rays. Gamma imaging by either method described provides a view of the position
and concentration of the radioisotope within the body. Organ malfunction can be
indicated if the isotope is either partially taken up in the organ (cold spot), or taken
up in excess (hot spot). If a series of images is taken over a period of time, an
unusual pattern or rate of isotope movement could indicate malfunction in the organ.
A distinct advantage of nuclear imaging over x-ray techniques is that it provides
functional rather than structural information successfully. This has led to an
increasing number of nuclear medicine procedures in the country over the years.
3.1.3 Therapeutic Procedure in Nuclear Medicine
Rapidly dividing cells are particularly sensitive to damage by radiation. For
this reason, some cancerous growths can be controlled or eliminated by irradiating
the area containing the growth. The radioisotope that generates the radiation can be
localized in the required organ in the same way it is used for diagnosis, through a
radionuclide following its usual biological path, or through the radionuclide being
attached to a suitable biological compound. In most cases, it is beta radiation which
causes the destruction of the abnormal cells. Iodine-131 (I-131) which is commonly
used to treat thyroid cancer is probably the most successful example of therapeutic
radionuclide. It is also used to treat non-malignant thyroid disorders. Phosphorus-32
(P-32) is another commonly used radioisotope in treating the disease called
polycythemia vera, where an excess of red blood cells is produced in the bone
marrow.
Many therapeutic procedures are palliative, usually to relieve pain. For
instance, Strontium-89 (Sr-89) and Samarium-153 (Sm-153) are used for the relief of
cancer-induced bone pain. Rhenium-186 (Re-186) is a newer product for this.
Although therapeutic application is less common than diagnostic use of radioisotopes
in nuclear medicine, it is nevertheless widespread, important and growing. An ideal
therapeutic radioisotope is a strong beta emitter with just enough gamma to enable
imaging, eg. Yttrium-90 (Y-90) is used for treatment of cancer, particularly non-
Hodgkin's lymphoma and liver carcinoma, and its more widespread use is envisaged,
including for arthritis treatment. Considerable medical research is being conducted
worldwide into the use of radionuclides attached to highly specific biological
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chemicals such as immunoglobulin molecules (monoclonal antibodies). The eventual
tagging of these cells with a therapeutic dose of radiation may lead to the regression,
or even cure of some diseases.
3.1.4 Diagnostic Radiopharmaceuticals
Every organ in our bodies acts differently from a chemical point of view.
Doctors and chemists have identified a number of chemicals which are absorbed by
specific organs. The thyroid, for example, takes up iodine, the brain consumes
quantities of glucose, and so on. With this knowledge, radiopharmacists are able to
attach various radioisotopes to biologically active substances. Once a radioactive
form of one of these substances enters the body, it is incorporated into the normal
biological processes and excreted in the usual ways.
Diagnostic radiopharmaceuticals can be used to examine blood flow to the
brain, function of the liver, lungs, heart or kidneys, to assess bone growth, and to
confirm other diagnostic procedures. Another important use is to predict the effects
of surgery and assess changes after treatment. The amount of the
radiopharmaceutical given to a patient is just sufficient to obtain the required
information before its decay. The radiation dose received is medically insignificant.
The patient experiences no discomfort during the test and after a short time there is
no trace that the test was ever done. The non-invasive nature of this technology,
together with the ability to observe an organ functioning from outside the body,
makes this technique a powerful diagnostic tool.
A radioisotope used for diagnosis must emit gamma rays of sufficient energy
to escape from the body and it must have a half-life short enough for it to decay away
soon after imaging is completed. The radioisotope most widely used in medicine is
Tc-99m, employed in some 80% of all nuclear medicine procedures. It is an isotope
of the artificially-produced element Technetium and it has almost ideal
characteristics for a nuclear medicine scan. These are:
(a) It has a physical half-life of six hours which is long enough to examine
metabolic processes yet short enough to minimize the radiation dose to the
patient.
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(b) Tc-99m decays by a process called "isomeric"; which emits gamma rays
and low energy electrons. Since there is no high energy beta emission the
radiation dose to the patient is low.
(c) The low energy gamma rays easily escape the human body and are
accurately detected by a gamma camera. Hence the radiation dose to the
patient is minimized.
(d) The chemistry of Tc-99m is versatile. It can form tracers by being
incorporated into a range of biologically-active substances to ensure that it
concentrates in the tissue or organ of interest.
Its logistics also favour its use. Tc-99m generators, a lead pot enclosing a glass
tube containing the radioisotope, are supplied to hospitals from the nuclear reactor
where the isotopes are made. They contain Molybdenum-99 (Mo-99), with a half-life
of 66 hours, which progressively decays to Tc-99m. The Tc-99m is washed out of
the lead pot by saline solution when it is required. A similar generator system is used
to produce Rubidium-82 (Rb-82) for PET imaging from Strontium-82 (Sr-82) which
has a half-life of 25 days.
For PET imaging, the main radiopharmaceutical is Fluoro-Deoxy-Glucose
(FDG) incorporating F-18 with a half-life of less than two hours, as a tracer. The
FDG is readily incorporated into the cell without being broken down, and is a good
indicator of cell metabolism. In diagnostic medicine, there is a strong trend to using
more cyclotron-produced isotopes such as F-18 as PET and PET/CT become more
widely available. However, the procedure generally needs to be undertaken within
two hours reach of a cyclotron.
3.1.5 Therapeutic Radiopharmaceuticals
For some medical conditions, it is useful to destroy or weaken malfunctioning
cells using radiation. The radioisotope that generates the radiation can be localized in
the required organ in the same way it is used for diagnosis through a radioactive
element following its usual biological path, or through the element being attached to
a suitable biological compound. In most cases, it is beta radiation which causes the
destruction of the abnormal cells. This is a form of radionuclide therapy.
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I-131 and Phosphorus-32 (P-32) are also used for therapy. I-131 is used to treat
the thyroid for cancers and other abnormal conditions such as hyperthyroidism (over-
active thyroid). In a disease called polycythemia vera, an excess of red blood cells is
produced in the bone marrow. P-32 is used to control the disease.
Considerable medical research is being conducted worldwide into the use of
radionuclides attached to highly specific biological chemicals such as
immunoglobulin molecules (monoclonal antibodies). The eventual tagging of these
cells with a therapeutic dose of radiation may lead to the regression or cure of some
diseases.
3.1.6 Diagnostic Reference Levels (DRLs)
The objective of DRL is to optimize the use of radiation in medicine and help
avoid excessive radiation exposure. This is accomplished by comparison between the
numerical value of the DRL (derived from relevant regional, national or local data)
and the mean or other appropriate value observed in practice from a suitable
reference group of patients. A suitable reference group of patients defined within a
certain range of physical parameters (e.g. height and weight). Corrective actions
should be taken as necessary if exposures do not provide useful diagnostic
information and do not yield the expected medical benefit to patients.
In diagnostic nuclear medicine, DRLs are expressed in administered activity
(MBq) rather than as absorbed dose. This reference administered activity is based on
the administered activity necessary for a good image during a standard procedure. In
standard diagnostic nuclear medicine procedure, a poorly-functioning gamma camera
or other equipment are factors that can necessitate a higher activity. Another
important factor influencing the administered activity is the quality of the dose
calibration.
Apart from the quantity used, DRLs in nuclear medicine differ in two ways
from those in diagnostic radiology:
(a) The DRL in nuclear medicine is a guidance level for administered
activities. It is recommended that this level of activity be administered for a
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certain type of examination in standard situations. (In diagnostic radiology,
if the DRL is consistently exceeded there should be a review or
investigation).
(b) In nuclear medicine, for a recommended amount of administered activity
the outcome may be poor. This indicates that the efficacy of gamma
cameras, the dose calibration or the procedures used by the staff need to be
checked. (In diagnostic radiology, the criterion is normally a satisfactory
image. However, the dose needed for this image quality can be too high,
and in this case, the radiological equipment should be checked).
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3.2 METHODOLOGY
3.2.1 Introduction
Nuclear medicine is a branch or specialty of medicine that uses radioactive
isotopes (radioisotopes) and relies on the process of radioactive decay in the
diagnosis and treatment of disease. The procedures are primarily intended for
diagnostic purposes. Many of the diagnostic applications of radioisotopes are
conducted in vitro rather than in vivo. For example, about 100 million procedures
with such material were performed in the United States in 1989, although only 10%
of these involved the administration of radiopharmaceuticals directly to patients. The
remaining 90% of practice comprised radioimmunoassay procedures, which use
small amounts of radioactive material in the analysis of biological specimens such as
blood and urine and do not give rise to the exposure of patients [UNSCEAR, 2000].
It is important to clarify that the in vitro applications are not included in this survey.
The radioactivity is generally administered to the patient in the form of a
radiopharmaceutical - the term “radiotracer” is also commonly used. This follows
some physiological pathway to accumulate for a short period of time in some part of
the body. A good example is Tc-99m sulphur colloid which following intravenous
injection accumulates mainly in the patient's liver. The substance emits gamma rays
while it is in the patient's liver and we can produce an image of its distribution using
a nuclear medicine imaging system. This image can tell us whether the function of
the liver is normal or abnormal or if sections of it are damaged from some forms of
diseases. The “Tc-99m” is the radioisotope which emits gamma ray for imaging
purposes; whereas “sulphur colloid” is a chemical form which to deliver the
radioisotope to the targeting tissue or organ for uptake. Different
radiopharmaceuticals are used to produce images from almost every regions of the
body. Table 3.1 shows the examples of reference level for diagnostic nuclear
medicine procedures recommended by the International Atomic Energy Agency
(IAEA) associated with the commonly used radiopharmaceutical. Appendix E
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summarizes the procedures and types of radiopharmaceuticals with the relevant
diagnostic and therapeutic purposes in nuclear medicine.
Table 3.1: Reference levels for diagnostic nuclear medicine procedures (IAEA BSS, 2006).
Examination Radio-nuclide Chemical Form
MaxUsual
Activity(MBq)
Bone imaging Tc-99m Phosphonate & phosphate compound
600
Bone imaging (SPECT) Tc-99m Phosphonate & phosphate compound
800
Brain imaging Tc-99m TcO4-, DTPA 500
Brain imaging(SPECT) Tc-99m TcO4-, DTPA 800
Liver & spleen imaging Tc-99m Labelled colloid 80Liver & spleen imaging (SPECT)
Tc-99m Labelled colloid 200
Lung perfusion studies Tc-99m Isotonic solution 200Lung imaging (SPECT) Tc-99m MAA 200Myocardial imaging Tc-99m Phosphonate &
phosphate compound 600
Myocardial imaging (SPECT) Tc-99m Phosphonate & phosphate compound
800
Renal imaging Tc-99m DMSA 160Renal imaging/Renography Tc-99m DTPA gluconate &
glucoheptonate350
Thyroid imaging Tc-99m TcO4- 200
Thyroid imaging I-123 20Thyroid metastases (after ablation)
I-123 400
This survey was conducted on the basis of statistics from nuclear medicine
diagnostic examinations and therapeutic procedures carried out by twelve (12)
nuclear medicine centres in Malaysia from 2005 to 2007. The survey was completed
with demographic data covering different aspects including the equipment, personnel
and patients information, as well as the dosimetry data taking into account types and
activities of the radiopharmaceuticals used. In order to estimate the effective dose for
different procedures, internal dosimetry formalism recommended by the Medical
Internal Radiation Dosimetry (MIRD) Committee of the United States Society of
Nuclear Medicine was followed. On the basis of above mentioned data, estimations
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were carried out based on the frequency of examinations and the relative contribution
(%) of each procedure to the total effective collective dose. From this survey, we
could also estimate the total effective collective dose (man Sv) and per capita
effective dose (mSv).
3.2.2 Nuclear Medicine Techniques
Whereas the broad aim in diagnostic radiology is the imaging of anatomy, the
practice of nuclear medicine is more closely linked to the investigation of patho-
physiological processes. In essence, radioisotopes are used as a biological tracer by
incorporating them into a pharmaceutical appropriate to the nature of an investigation.
Following administration of the radiopharmaceutical to the patient, the resulting
biodistribution and localization is dictated by the pharmaceutical preparation used
with the radionuclide label providing the means of detection. Most procedures
involve some types of measurement concerning the retention or excretion of the
tracer so as to quantify organ or tissue function. Probe detectors can be used to
measure uptake in particular organs such as the thyroid whereas imaging is carried
out by using a single or double head gamma camera with the large field of view.
Diagnostic technique with radiopharmaceuticals are widely utilized in
medicine; clinical applications include oncology, cardiology, neurology, psychiatry,
endocrinology, as well as the investigation of infection and inflammation and various
biological systems (musculo-skeletal, respiratory, gastrointestinal and genitourinary).
In oncology, important roles for nuclear medicine include detecting unknown
primary sites of cancer, differentiating between benign and malignant disease,
staging the extent of disease (local, nodal and metastases), planning and assessing the
response to therapy and detecting recurrence. The activities administered are
determined by the diagnostic information required within the chosen period of the
procedure. International and national guidance levels are available concerning the
techniques and typical activities for common procedures.
In practice, a range of radioisotopes are used in diagnostic nuclear medicine
that meet the necessary requirements for effective and efficient imaging. All are
produced artificially, using four principal routes of manufacture: cyclotron
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bombardment [e.g. Gallium-67 (Ga-67), Indium-111 (In-111), Fluorin-18 (F-18)];
reactor irradiation [e.g. Chromium-51 (Cr-51), I-131]; fission products [e.g. I-131,
Strontium-90 (Sr-90)]; and generators that provide secondary decay products from
longer-lived parent radioisotopes (e.g. Mo-99 generator to generate Tc-99m). Among
all the available radioisotopes, Tc-99m is the most commonly used radionuclide in
diagnostic nuclear medicine because of its highly suitable physical characteristics for
a wide range of applications. It therefore forms the basis for over 80% of the
radiopharmaceuticals used in nuclear medicine.
In addition to conventional planar imaging, nuclear medicine applications
have also been developed to allow emission tomography. Two basic modalities have
evolved. The more common is Single Photon Emission Computed Tomography
(SPECT). This utilizes conventional gamma-emitting radiopharmaceuticals and is
often performed in combination with planar imaging. SPECT imaging requires a
scanning system incorporating a circular array of detectors or, more often, a rotating
gamma camera system. The second modality is the more specialized technique of
Positron Emission Tomography (PET). This is based on the simultaneous detection
of the pairs of photons (511 keV) arising from positron annihilation and mostly uses
the short-lived biologically active radioisotopes such as Oxygen-15 (O-15), Carbon
(C-11), F-18 and Nitrogen-13 (N-13). The more recent developments in nuclear
medicine include the hybrid PET/CT and SPECT/CT imaging. These innovations led
to fusion imaging of PET or SPECT with CT to provide information about the
anatomy and physiology without requiring a more invasive procedure or surgery.
Following the innovation of PET imaging, the radiopharmaceutical, F-18-FDG has
been widely used in PET or PET/CT imaging because of its similar structure to
glucose, which can be used for the assessment of glucose metabolism in various
organs in the body as well as for tumour imaging in oncology.
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3.2.3 Overall Study Design
A research team consisting of various assistant directors, scientific officers and
research assistants from the Engineering Services Division, MOH was established in
order to carry out this survey.
A complete volume of the research methodology along with six volumes of
literature compilations had been published in the beginning of the project. These
publications were referred to as the guidance protocols. Along with that, three
training courses had been organized by the MOH in collaboration with the University
of Malaya to provide training and guidance to the research assistants who would be
involved directly in the dose survey. Following these activities, five echo courses
were organized in five different zones in Malaysia (Northern Zone, Western Zone,
Eastern Zone, Central & Southern Zone and Sabah & Sarawak Zone) to the staff
members (mostly radiographers, technologists and physicists) representing the
participating hospitals. These courses aimed to explain the design and methodology
of the study as well as to introduce the research team members to the participating
hospitals.
A computer database with authorized access was developed to store and
manage the data. This database was completed with automatic edit checks to detect
the duplication of data and the abnormal variables input. Automatic backup system
was also utilized daily to prevent the loss of data.
Several meetings and three project reviews were held during the period of the
study. These meetings allowed the research assistants to discuss the difficulties and
limitations in running the survey as well as to find the best solution for all the parties
involved. Figure 3.1 presents the flow chart of the overall operation of the study.
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Figure 3.1: The flow chart of operation of study.
1. Project Design and Planning
4. Development of Survey Methodology
2. Determination of Sampling Sizes
3. Identification of Participating Sites &Sites Visit
10. Data De-duplication
8. Data Standardization, Data Review & Coding
5. Training Courses and Pilot Run
6. Data Collection
7. Visual Review
9. Data Entry / Verification & Update
11. Initial Data Analysis
12. Database Lock
13. Final Data Analysis
14. Draft Report
15. Dissemination
16. Final Report
End
StartR
eject Data /
Query G
eneration
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3.2.4 Data Collection
The data collected in the nuclear medicine discipline were divided into two
main categories: diagnostic nuclear medicine examinations (included PET/CT) and
nuclear medicine therapeutic procedures. Figure 3.2 shows the types of diagnostic
examinations and therapeutic procedures in nuclear medicine which were included in
this study. Positron Emission Tomography (PET) examination is not available in
Malaysia but all the examinations involved with PET scanner came from the PET/CT
examinations. Only four (4) centres were involved with PET/CT examinations,
namely Penang Hospital, Prince Court Medical Centre, Sime Darby Medical Centre
and Wijaya International Medical Centre (Beacon International Specialist Centre Sdn.
Bhd.). Penang Hospital is located in the Northern zone whereas the other three
centres are located in the Central Zone.
There were eleven (11) types of diagnostic examinations and five (5) types of
therapeutic procedures as listed in Figure 3.2. Other diagnostic examinations include
the tumour localization imaging using Ga-67 or I-131 MIBG, and white blood cell
leucocyte scintigraphy using Tc-99m. Other therapeutic procedures include the Y-90
liver metastasis and Y-90 synovitis.
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3.2.5 Data Collection Protocols
The data collection in nuclear medicine was divided into three (3) surveys:
Background information survey, radiation dose survey and questionnaire survey.
Figure 3.3 shows the structure of the overall data collection methodology. The
following sessions elaborate the specific objectives and protocols for the different
survey.
Diagnostic Examinations
1. Bone
2. Brain
3. Cardiac
4. Gastroenterology
5. Liver or Spleen
6. Lung perfusion
7. Lung ventilation
8. Renal
9. Thyroid
10. Others
11. PET/CT
Therapeutic Procedures
1. Bone metastases
2. Hyperthyroidism
3. Polycythaemia vera
4. Thyroid malignancy
5. Others
NUCLEAR MEDICINE
Figure 3.2: Types of diagnostic examinations and therapeutic procedures in nuclear medicine.
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Figure 3.3: The structure of data collection methodology.
(a) Background Information Survey
The background information provides general information of the hospitals or
centres, including the number of personnel and the equipment information. The staffs
at the nuclear medicine centre/department consist of nuclear medicine physicians,
medical physicists and nuclear medicine technologists. According to the current
practice in Malaysia, the nuclear medicine physicians are qualified after undergoing
specific Master in Medicine (Nuclear Medicine) training or other qualified specialist
who have undergone specific period of training in nuclear medicine, and the nuclear
medicine technologists may be a qualified radiographer, assistant medical officer or
medical laboratory technologist. All nuclear medicine centers in the MOH, have their
own nuclear medicine physicists but most of the nuclear medicine centers other than
in MOH in Malaysia are sharing the medical physicists with other department such
as radiotherapy or the radiology department. This background survey aim to provide
information of the total number of personnel at nuclear medicine centres or
departments from 2005 to 2007 according to different categories.
Nuclear Medicine Medical Radiation Dose Survey
Part A Background
Information Survey
Part B Radiation Dose Survey
Gamma Camera or SPECTImaging
PET/CTImaging
TherapeuticProcedures
Equipment Information
Part C Questionnaire
Survey
PersonnelInformation
• Demographic • Frequency • Dosimetry
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Other than personnel information, the background information also includes
the modality or equipment information. For each centre, general information and
equipment specific data such as room or location of the equipment, model,
manufacturer, serial number and year of purchase were recorded. Generally there are
two (2) major equipment or modality used for diagnostic imaging in nuclear
medicine, namely Gamma Camera (or SPECT), and PET/CT. There are also other
equipment available in nuclear medicine such as gamma counter, rectilinear scanner
and gamma probe but they are not included in this survey because they are not
mainly used for the diagnostic purposes. The SPECT camera is basically a gamma
camera which acquires multiple planar views to be processes mathematically to
create the 3D cross-sectional views of the organ. The basic design for SPECT camera
is similar to that of a planar camera but with two additional features. First the SPECT
camera is constructed so that the head can rotate either stepwise or continuously
about the patient to acquire multiple views. Second, it is equipped with a computer
that integrates the multiple images to produce the cross-sectional views of the organ.
The more advanced SPECT camera designs have more than one head or are
constructed with a ring of detectors. SPECT utilizes the single photon emitted by
gamma-emitting radioisotopes such as Tc-99m, Ga-67, In-111 and I-123. This is in
contrast to PET which utilizes the paired 511 keV photons arising from positron
annihilation. In Malaysia, PET scanner alone is unavailable but all the PET scanner
were came with the integration of CT scanner and they are called PET/CT scanner.
A background information survey form was prepared and distributed to all the
research assistants for data collection as in Appendix F.
(b) Radiation Dose Survey
For each procedure, basic patient demographics (age and gender) were
acquired from the respective hospital’s database. This was added to the pool of
information on national patient demographics. For each patient, the following
parameters were recorded: ethnic group, age, weight and height to demonstrate the
patient demographic. Other than the patient demographic data, the dosimetry
information was obtained through the type of radiopharmaceutical used, activity
administered to the patients and patient age group.
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The principle of the internal radiation dosimetry is rather complicated as it
involves a number of parameters such as the energy emitted per radioactive decay,
the fraction of the emitted energy that is absorbed in various target organs, the
masses of these organs, and both the physical decay and biologic clearance of the
injected radioactive material [Toohey et. al., 2000]. These radiation doses are
received from the radioactive materials within the body, so they are normally
referred to as internal doses. Unlike radiation doses received from external sources
such as medical x-ray, internal doses can never be directly measured; rather, they are
calculated from standardized assumptions and procedures [Stabin et. al., 1999].
Although several methodologies exist to calculate internal doses, the schema
developed by the Medical Internal Radiation Dose (MIRD) Committee of the Society
of Nuclear Medicine is normally used to calculate doses from radiopharmaceuticals.
The MIRD schema uses a unique set of symbols and quantities to calculate the
absorbed dose of radiation in any target organ per radioactive decay in any source
organ. A few of computer program such as MIRDose and OLINDA/EXM was
therefore developed by the MIRD Committee to calculate the dose per unit
administered activity of various radiopharmaceuticals. In this particular survey, we
were using the online dose calculator supplied by the Radiation Dose Assessment
Resource (RADAR) to calculate the internal radiation dose from nuclear medicine
patients. However, this program only allow the calculation of internal radiation dose
from nuclear medicine diagnostics procedures but not for the therapeutic procedures.
Therefore, no effective dose was calculated for nuclear medicine therapeutic
procedures but the dosage was compared in term of activity administered (MBq).
The dose survey forms are attached in the Appendix G.
(i) Radiation Dose Survey Protocols for Diagnostic Nuclear Medicine
1. Fill in the hospital name and date of survey.
2. Fill in the date of examination and examination name. The type of
examination and its abbreviation can be reffered to the legend at the bottom
of the form.
3. Record the scanning room number, patient identification, gender, age, ethnic
group, weight (kg) and height (cm).
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4. Record the radiopharmaceutical which is administered into the patient during
the examination.
5. Record the activity (in mCi) of the radiopharmaceutical administered to the
patient at the time of dosing.
6. Ignore the column of the Effective Dose (mSv) as this is the radiation dose
that will be calculated using the MIRD method. This column will be filled in
after the data collection and dose calculation.
7. Note down the remarks if there is any additional information / remarks
observed from the cases.
(ii) Radiation Dose Survey Protocols for Therapeutic Nuclear Medicine
1. Fill in the hospital name and date of survey.
2. Fill in the date of treatment and treatment name. The type of treatment and its
abbreviation can be referred to the legend at the bottom of the form.
3. Record the treatment room number, patient identification, gender, age, ethnic
group, weight (kg) and height (cm).
4. Record the radiopharmaceutical which is administered into the patient for
treatment purposes.
5. Record the activity (in mCi) of the radiopharmaceutical administered to the
patient at time of dosing.
6. Ignore the column of the Effective Dose (mSv) as this is the radiation dose
that will be calculated using the MIRD method. This column will be filled in
after the data collection and dose calculation.
7. Note down any additional information observed from the cases.
(iii) Radiation Dose Survey Protocols for PET-CT
1. Fill in the hospital name, room and date of survey.
2. Record the date of examination, patient identification, gender, age, ethnic
group, weight (kg) and height (cm).
3. Record the clinical indication as mentioned in the patient’s record or as
advised by the physician.
4. Record the activity (in mCi) of the radiopharmaceutical (only F-18 FDG is
used in this case) which is administered to the patient during the examination.
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5. Record the parameters for the CT scan, such as kV, mAs, rotation time (s),
nominal slice thickness, pitch, scan length (mm) and scan region. The groups
and abbreviation of the scan regions can be referred to the legend at the
bottom of the form. The formulas to obtain nominal slice thickness, pitch and
scan length are also listed in the legend.
6. Ignore the column of the Effective Dose (mSv) as this is the radiation dose
that will be calculated using the MIRD and CT Expo method. This column
will be filled in after the data collection and dose calculation.
(c) Questionnaire Survey
The questionnaire survey aimed to collect information on the annual average
level of practice in nuclear medicine from 2005 to 2007. The questionnaire survey
forms recorded the estimated number of procedures performed annually, the most
commonly used radiopharmaceutical for the specific examination or treatments and
the percentage, mean activity administered for different procedures and the
frequency of procedures performed according to the age and distribution. The
dosimetric data should represent typical or average values per examination or
treatment, giving the range in minimum and maximum activity (in MBq). The
distribution of ages was divided into three (3) groups: 0-15 years old, 16-40 years
old, >40 years old. It is also important to know how many examinations are
undertaken on male and female patients separately. The questionnaire survey forms
are designed based on the original UNSCEAR survey forms with some minor
modifications to suit the local conditions. The questionnaire survey forms are
attached in the Appendix H.
3.2.6 National Medical Radiation Exposure Database
A national medical radiation exposure database was designed and developed to
store all the raw data from this survey. This database was created using the Hypertext
Preprocessor (PHP) programming script. The design was kept to be simple,
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straightforward and unambiguous for the convenience of the users. Figure 3.4 shows
the screen shot of the login page of the database. For security purposes, the database
was protected by restricting the access to authorized users only, therefore username
and password were needed in order to login to the database. Different menu were
installed in the database by following the hierarchy of the data flow. The menu
includes the system parameters, user maintenance, hospital maintenance, case, data
upload and inquiry, as shown in Figure 3.5. In the “System Parameter” (Figure 3.6),
different parameters regarding the disciplines, modality, examination types,
multipurpose parameters, etc. were stored. Figure 3.7 shows the menu for “Hospital
Maintenance” where the information regarding the hospital, examination rooms,
equipment, personnel and specific machine parameters were stored. Figure 3.8 and
3.9 shows the “Case” menu where the data for every single case were stored. Finally,
the database was also designed with the “Inquiry” menu (Figure 3.10), where a quick
search on the total number of cases and the cases data can be obtained instantly. The
users can also easily download the data based on the cases selected and export them
into Excel or other file format for analysis. The flow and the relationships of the
database design are presented in Figure 3.11 to 3.13. The data collection flow chart is
presented in Figure 3.14.
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Figure 3.4: Screen shot of the login page of the database.
Figure 3.5: Screen shot of the database main page showing the organization of the database main and sub-menu.
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Figure 3.6: Screen shot of the database “System Parameter” menu.
Figure 3.7: Screen shot of the database “Hospital Maintenance” menu.
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Figure 3.8: Screen shot of the database “Case” menu for diagnostic examination entry.
Figure 3.9: Screen shot of the database “Case” menu for PET/CT data entry.
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Figure 3.10: Screen shot of the database “Inquiry” menu.
Parameter Tables Relationship
Figure 3.11: Parameter tables relationship of the database.
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Hospital Tables Relationship
Figure 3.12: Hospital tables relationship of the database.
Figure 3.13: Overall relationship of the database.
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Figure 3.14: Radiation dose survey protocol for Nuclear Medicine procedures.
Data Collection – identify cases and fill in the appropriate forms: UNSCEAR:Forms/Nuclear Medicine: Diagnostic/1.1
UNSCEAR : Forms/Nuclear Medicine : Therapeutics/1.1 UNSCEAR : Forms/Nuclear Medicine : PET-CT/1.1
Start
Make a copy of the forms, keep in file (JKN)
Send complete forms to MOH HQ
Calculate the effective dose (mSv) using the online MIRD software
Enter data into database
Data screening and analysis
End
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3.3 DATA ANALYSIS
3.3.1 Introduction
This survey provides qualitative and quantitative information on the doses for
diagnostic examinations and therapeutic procedures in nuclear medicine, to assess
medical radiation exposure in Malaysia and to allow comparison between data from
the countries worldwide and to explore temporal or regional trends in the usage of
radiation in medicine. The survey on the nuclear medicine facilities represents the
first attempt in Malaysia to assess the actual usage of the procedures in the country.
The results of the survey provide the basis for optimization procedures and
guidelines for radiation protection as well as the establishment of national diagnostic
reference levels (DRLs) of the country.
A centralized computer database was designed and developed for the data
management. Figure 3.15 shows the Medical Radiation Exposure Survey Database
Management System. The data from the background information survey and dose
survey were stored in the database in the study. This database was also built in with
the MIRD calculation formula based on the reference from the RADAR® online
software (http://www.doseinfo-radar.com), hence the effective dose would be
calculated automatically and stored in the database as long as the types of
radiopharmaceutical and the administered activity were given.
Data analysis was done using the Statistical Package for the Social Sciences
(SPSS) version 16. SPSS is an established statistical analysis software used for
descriptive statistics, bivariate statistics, prediction for numerical outcomes and
prediction for identifying groups. Generally, the data analysis in this survey could be
divided into two (2) main categories, which are descriptive statistics and dosimetric
analysis. Descriptive statistics including the analysis of number of personnel, number
of equipment, frequency of examinations performed and patient demographics
statistics; whereas the dosimetry analysis including the numerical calculation for the
radiation exposure such as mean, minimum, maximum, standard deviation, medium,
first quartile (1st quartile) and third quartile (3rd quartile). The analysis outputs are
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generally displayed in tables and pie charts for descriptive statistics, and tables as
well as box plots for the dosimetric analysis. Histograms were also included in the
analysis to demonstrate the distribution or proportion of cases that fall into each of
several categories.
Figure 3.15: Medical Radiation Exposure Survey Database Management System.
3.3.2 Data Screening
Prior to data analysis, the data was screened several times to identify errors and
outliers. The errors could be from human mistakes such as typographical error,
calculation mistakes, unit conversion errors, misplaced variables, etc. These data
were either corrected or excluded from analysis depending on the validity of the data,
i.e. year 20005 was reentered as year 2005; 500 kg was reentered as 50 kg. Suspected
errorneous data of which the cause could not be ascertained were excluded.
MedicalRadiationExposure
SurveyCentral
Database
DoseCalculation
Program
BackgroundInformation
Survey
Radiation Dose Survey
Statistical Analysis
Output / Result
InputDose
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Data screening will also figure out the missing values and outliers in the
numerical data. In cases where the data was suspect or missing (blank data) it was
not included in the data analysis. During screening of the dosimetric data, initially
values less than 2% and more than 98% from the mean were excluded (this is the
first step of data screening to avoid being affected by extreme values), and a new
mean was calculated. The values which were smaller, or larger than 2 standard
deviations from the new mean were considered as outliers and were excluded.
Overall the number of data that was excluded from the final analysis
represented less than 5% of the entire data collection.
3.3.3 Descriptive Statistics
(a) Number of Personnel
The United Nations defined four levels of health care in the world based on
population per physician [UNSCEAR, 1988]. At the highest level of health care
(Level 1), there are one or more physicians for each 1,000 population; Level II has
one physician for each 1,000 to 3,000 population; Level III has one physician for
3,000 to 10,000 population, and for Level IV has one physician for more than 10,000
population. The Background Information Survey allows the analysis of the number
of personnel, including physicians, medical physicists and nuclear medicine
technologists per 1,000 population. In this survey, the trend of personnel growth in
nuclear medicine was monitored from 2005 to 2007. Malaysia with 27.17 million
population in 2007, and an average of 1,429 population per physician is classified as
health care Level II country.
(b) Number of Equipment or Facilities
The number of equipment or facilities provides useful information on the
machine to population ratio of the country. The results were compared to the survey
in other countries worldwide to estimate the trend of growth of human resources in
Malaysia. The major equipment in nuclear medicine comprises gamma camera
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(SPECT) and PET/CT. This analysis establishes the major trends in the frequency of
different nuclear medicine facilities from 2005 to 2007, as well as the imaging
techniques used.
(c) Frequency of Examinations and Therapeutic Procedures
The frequency of diagnostic examinations and therapeutic procedures were
analyzed. Annual examination or therapeutic procedure, annual effective dose per
capita and collective effective dose of the population were analysed. The population
statistics in Malaysia from 2005 to 2009 is shown in Figure 3.16. The trend and
frequencies of examinations and therapeutic procedure were analyzed according to
the age group distribution. This information was used to compare the statistics of this
survey to the relevant international and regional published studies.
In addition, the combination statistics of examination frequency and number of
equipment enables the estimation of medical equipment utilization levels in the
nation.
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Figure 3.16: Statistics of Malaysian population from 2005 to 2009 (Department of Statistics
Malaysia, 2009).
(d) Patient Demographics Statistics
For each procedure, basic patient demographics such as age, gender, height and
weight data were acquired from the respective hospital database. This data will add
to the pool of knowledge on national nuclear medicine patient demographics.
Descriptive statistics such as mean, median, range, 1st quartile and 3rd quartile
histogram were tabulated. The study of age-distribution revealed the average
population that underwent different examinations and procedures whereas the study
of gender-distribution of patients demonstrated the prevalence of certain disease in a
certain gender. The analysis would provide insight into the frequency of
examinations and radiation dose distribution with respect to gender and ethnic group
distribution.
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3.3.4 Dosimetric Analysis
The radiation doses to patients resulting from administrations of
radiopharmaceuticals are determined by a range of physical and biological factors
which included the amount and form of the radioactive material administered, the
route of administration, the biokinetics and physiological fate of the
radiopharmaceutical, and the decay scheme of the radionuclide [UNSCEAR, 2000].
Absorbed doses to the various organs and tissues are generally estimated using the
dosimetric formalism developed by the Medical Internal Radiation Dose Committee
of the United States Society of Nuclear Medicine (MIRD). Broadly, this approach
involves knowledge of the cumulative activities in each source organ, together with
estimates and summation of the absorbed fractions of energy in every target organ
from each source organ. Cumulative activities were derived on the basis of
quantification of organ uptake in human studies using SPECT and PET imaging.
Specific absorbed fractions are estimated by Monte Carlo calculations using
anthropomorphic mathematical phantoms; values are available for standardized
phantoms representing typical adult, paediatric and pregnant patients. More realistic
voxel phantoms are also being developed for use in internal dosimetry [Stabin,
1996]. The MIRD formalism is shown in the following equation:
rkD - The mean dose (rads) for a target organ, rk
∑h
- The sum of all the source organs, rh, where the units are rads
hA~ - The accumulated activity (μCi·hr) for each source organ, rh
)( hk rrS ← - The absorbed dose (rads/μCi·hr) in the target organ, rk per unit of cumulated activity in each source organ (S factor is specific for each pair of source – target organs. Acquired from published tables).
( )∑ ←=h
hkhr rrSADk
~
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Coefficients derived using this methodology have been published that allow
the estimation of organ and effective doses to adults and children from administered
activities for a wide range of commonly used radiopharmaceuticals. Data are also
available for some new radiopharmaceuticals and for other computational
techniques. The administration of radiopharmaceuticals to patients also gives rise to
the exposure of other population groups, such as breast-feeding infants, although
these doses are not considered further in this survey. The average doses to specific
organs provided by conventional macroscopic dosimetry can grossly underestimate
radiation exposures to individual cells. New methods of cellular dosimetry are being
developed for assessing the risks associated with new pharmaceuticals that target
specific cells and cellular components with short-range radiations, such as Auger
electrons.
Patient doses for common types of procedure are summarized principally in
this survey in terms of the administered activities (MBq) for each
radiopharmaceutical, as well as the effective dose (mSv) for diagnostic examinations.
The collective effective dose to the Malaysian population and the relative
contributions of different procedures were also tabulated in this survey. Inter
comparison was made in national and international level.
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3.4 RESULT AND DISCUSSION
3.4.1 Descriptive Analysis
This session includes the analysis for number of personnel (number of staffs eg.
nuclear medicine physicians, medical physicists and nuclear medicine technologists),
number of equipment or facilities (eg. gamma cameras or SPECT and PET/CT
scanners), and the frequency of diagnostic examinations and therapeutic procedures
performed in nuclear medicine centre / department / unit / section (hereafter referred
as “sites”) in Malaysia from year 2005 to 2007.
(a) Number of Personnel
The staff at nuclear medicine sites are generally represented by the nuclear
medicine physicians, medical physicists and nuclear medicine technologists. Table
3.2 summarizes the total number of staff in nuclear medicine sites in Malaysia from
year 2005 to 2007. The total number of nuclear medicine physicians up to 2007 was
8. The number of medical physicists was the same in year 2005 and 2006 (total
number = 14) but in year 2007 there was a slight increase to 16. The number of
nuclear medicine technologists increased every year; there were 24 technologists in
year 2005, 28 in year 2006 and 39 in year 2007, respectively.
Table 3.2: Total number of personnel in nuclear medicine sites in Malaysia from year 2005-2007.
Personnel 2005 2006 2007
†Nuclear Medicine Physicians 7 8 8
Medical Physicists 14 14 16
‡Nuclear Medicine Technologists 24 28 39
†Nuclear medicine physicians in some centres are also qualified as specialist with sub specialization training in nuclear medicine. ‡Nuclear medicine technologists in some centres are also qualified as radiographers, medical assistants and medical laboratory technologist.
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(b) Number of Equipment
There are three (3) different types of equipment used for diagnostic imaging in
nuclear medicine, namely Gamma Camera, PET and PET/CT. However, the stand-
alone PET scanner was unavailable in Malaysia up to the date of this report, so they
were excluded from the survey. Therefore, there were only two (2) types of
equipment available for analysis in nuclear medicine: Gamma Camera, and PET/CT.
Table 3.3 shows the total number of Gamma Camera and PET/CT available in
Malaysia from 2005 to 2007. The gamma camera camera increased consistently with
one (1) unit each year from 2005 to 2007; whereas the PET/CT scanner increased
from three (3) units in 2005 to five (5) units in 2007.
Table 3.3: Total number of nuclear medicine equipment in Malaysia from 2005-2007.
Equipment/Modality 2005 2006 2007
Gamma Camera 14 15 16
PET/CT 3 4 5
(c) Frequency of Examinations or Therapeutic Procedures
The use of radiopharmaceuticals in medical diagnosis is less widespread than
the use of x-rays. There are large variations in practice from state to state, with
nuclear medicine examinations not being performed at all in some states in the
country. Annual number of diagnostic and therapeutic administration of
radiopharmaceuticals performed in Malaysia from 2005 to 2007 are summarized in
Table 3.4 (a) to (c) and Figure 3.17 (a) to (c) by types of examinations and
therapeutic procedures.
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Table 3.4 (a): Annual number of nuclear medicine diagnostic examinations in Malaysia from 2005-2007 according to examination types.
Diagnostic Examinations Year Total2005 2006 2007
Bone 5650 5790 6028 17468
Brain 21 18 15 54
Cardiac 2275 5020 4566 11861
Gastroenterology 67 86 67 220
Liver or Spleen 148 141 118 407
Lung Perfusion 83 58 42 183
Lung Ventilation 82 59 65 206
Renal 2790 3163 3193 9146
Thyroid 1691 2194 2006 5891
Others 2 9 2 13
Total 12809 16538 16102 45449
Table 3.4 (b): Annual number of nuclear medicine therapeutic procedures in Malaysia from 2005-2007 according to disease types.
Therapeutic Procedures Year Total
2005 2006 2007
Bone metastases 0 0 1 1
Hyperthyroidism 606 858 702 2166
Polycythaemia vera 2 1 1 4
Thyroid malignancy 268 382 404 1054
Others 0 5 8 13
Total 876 1246 1116 3238
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Table 3.4 (c): Annual number of PET/CT examinations in Malaysia from 2005-2007.
PET/CT Examination Year Total
2005 2006 2007
PET/CT 100 385 650 1135
Figure 3.17 (a): Bar chart showing the frequency of nuclear medicine diagnostic examinations in Malaysia from 2005 to 2007 according to different examination types.
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Figure 3.17 (b): Bar chart showing the frequency of nuclear medicine therapeutic procedures in Malaysia from 2005 to 2007 according to different disease types.
Figure 3.17 (c): Bar chart showing the frequency of PET/CT in Malaysia from 2005 to 2007.
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Generally, both diagnostic examinations and therapeutic procedures show
small, increasing trends from 2005 to 2007. The first PET/CT scanner was installed
at Penang Hospital in 2005. One (1) PET/CT scanner was installed at Sime Darby
Medical Centre and one (1) at Wijaya International Medical Centre in the same year,
making the total number of PET/CT scanners in Malaysia in 2005 to three (3). The
total number of cases performed in 2005 was 100, all done in Penang Hospital. The
total number of cases performed in 2006 was 385. In 2007, the total number of
PET/CT examinations increased to 650 cases after the Sime Darby Medical Centre
and Prince Court Medical Centre started their services. During the survey period of
2005 to 2007, a total of 1135 cases were performed. The percentage contributions of
each type of diagnostic examinations and therapeutic procedures to the total
frequency are given in Table 3.5 (a) and (b) and Figure 3.18 (a) to (b).
Table 3.5 (a): Percentage contributions by types of examinations to total number of diagnostic examinations (2005-2007).
Diagnostic Examinations Frequency Percentage to Total (%)
Bone 17468 38.4
Brain 54 0.1
Cardiac 11861 26.1
Gastroenterology 220 0.5
Liver or Spleen 407 0.9
Lung Perfusion 183 0.4
Lung Ventilation 206 0.5
Renal 9146 20.1
Thyroid 5891 13.0
Others 13 < 0.1
Total 45449 100.0
* PET/CT examination is not included
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Table 3.5 (b): Percentage contributions by types of diseases to total number of therapeutic procedures (2005-2007).
Therapeutic Procedures Frequency Percentage to Total (%)
Bone metastases 1 <0.1
Hyperthyroidism 2166 66.9
Polycythaemia vera 4 0.1
Thyroid malignancy 1054 32.6
Others 13 0.4
Total 3238 100.0
Figure 3.18 (a): Pie chart showing the frequency distribution of different disease in diagnostic nuclear medicine (2005-2007).
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Figure 3.18 (b): Pie chart showing the frequency distribution of different disease in therapeutic nuclear medicine (2005-2007).
(d) Exposed Populations
The distributions by age and gender of patients undergoing various types of
diagnostic and therapeutic nuclear medicine procedures from 2005 to 2007 are
presented in Table 3.6 (a) to (c) and Figure 3.19 (a) to (b). This analysis uses the
same three broad ranges of patient age that were used for x-ray examinations.
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Table 3.6 (a): Gender and age distribution of patients undergoing diagnostic examinations in nuclear medicine (2005-2007).
Diagnostic
Examinations
Gender and Age Distribution
Female Male
0-15 16-40 >40 Total
No.
0-15 16-40 >40 Total
No.
Bone 203 1670 9468 11341 287 868 4972 6127
Brain 1 3 20 24 2 8 20 30
Cardiac 45 159 3808 4012 54 315 7480 7849
Gastroenterology 4 35 59 98 9 39 74 122
Liver or Spleen 100 47 38 185 161 29 32 222
Lung Perfusion 6 56 58 120 6 25 32 63
Lung Ventilation 0 38 52 90 0 50 66 116
Renal 1571 633 1924 4128 1902 897 2219 5018
Thyroid 202 1503 1874 3579 151 792 1369 2312
Others 0 0 6 6 0 1 6 7
Total 2132 4144 17307 23583 2572 3024 16270 21866
Table 3.6 (b): Gender and age distribution of patients undergoing therapeutic procedures in nuclear medicine (2005-2007).
Therapeutic
Procedures
Gender and Age Distribution
Female Male
0-15 16-40 >40 Total
No.
0-15 16-40 >40 Total
No.
Bone metastases 0 0 1 1 0 0 0 0Hyperthyroidism 15 625 935 1575 4 199 388 591Polycythaemia vera 0 0 0 0 0 1 3 4Thyroid malignancy 11 333 449 793 6 83 172 261Others 0 2 0 2 0 2 9 11Total 26 960 1385 2371 10 285 572 867
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Table 3.6 (c): Gender and age distribution of patients undergoing PET/CT examination in nuclear medicine (2005-2007).
PET/CT
Examination
Gender and Age Distribution
Female Male
0-15 16-40 >40 Total
No.
0-15 16-40 >40 Total
No.
PET-CT 20 133 399 552 14 121 448 583
Figure 3.19 (a): Bar chart showing the frequency of nuclear medicine diagnostic examinations in Malaysia according to age groups (2005-2007).
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0.0
66.3
0.2
32.0
0.4
0
0.6
0
0.5
0
0.0 20.0 40.0 60.0 80.0
Bone metastasis
Hyperthytoidism
Polycythaemia vera
Thyroid malignancy
Others
Percentage
Ther
apeu
tic P
roce
dure
s
Frequency of Nuclear Medicine Therapeutic Procedures in Malaysia (2005-2007)
Paediatrics
Adult
Figure 3.19 (b): Bar chart showing the frequency of nuclear medicine therapeutic procedures in Malaysia according to age groups (2005-2007).
In the diagnostic nuclear medicine examinations, most of the cases were
dominated by the age group >40 years, particularly for bone, cardiac, renal and
thyroid examinations. Among all the diagnostic examinations, only renal, bone and
liver or spleen studies composed the highest percentage of paediatrics (0-15 years)
patients. There was no lung ventilation cases performed in paediatrics over the three
years. However, there were a few cases (12) of lung perfusion performed in
paediatrics, equally distributed between the male and female. Other uncommon cases
on in the paediatrics age group were in the gastroenterology group. In term of
gender-distribution, the numbers of male patients were more than the female patients
in all of the diagnostic examinations except in bone, lung perfusion, and thyroid. The
number of female patients underwent bone examination was almost double the
number of male patients in 2005 to 2007.
In therapeutic procedures, all of the cases are dominated by the age group >16
years. In the therapeutic procedures for paediatrics, there were a few cases of
hyperthyroidism (19) and thyroid malignancy (17) performed on patients <16 years
old. In term of gender-distribution, female patients far outnumbered the male
patients in hyperthyroidism (73%) and thyroid malignancy (75%). For bone
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114
metastases treatment, there was only one case performed in the period of 2005 to
2007. This case should probably be excluded from the survey, however, in order to
figure out the number of bone metastases treatment in Malaysia compared to other
countries, we decided to include this number in our data. Another uncommon
therapeutic procedure in nuclear medicine was polycythaemia vera (4).
In PET/CT examination, again, the cases were dominated by the age group >16
years. Male patients were slightly more than the female patients in receiving the
PET/CT examinations in 2005 to 2007. PET/CT for paediatrics was uncommon as
there were only 34 cases performed in three years.
3.4.2 Dosimetric Analysis
(a) Administered Activity (MBq)
The samples mean, median, minimum and maximum, 1st quartile and 3rd
quartile of administered activities in different types of diagnostic examinations and
therapeutic procedures from all the nuclear medicine sites in Malaysia from 2005 to
2007 are presented in Table 3.7 (a) to (e). The dosage for paediatrics (age <16) and
adults (age ≥16) were compared separately. Table 3.7 (a), Table 3.7 (b) and Figure
3.25 3.20 (a) show the administered activities according to different diagnostic
examination types for paediatrics and adults and Table 3.7 (c), Table 3.7 (d) and
Figure 3.20 (b) shows the administered activities according to different therapeutic
procedures for paediatrics and adults. Table 3.7 (e) shows the administered activities
for PET/CT examinations.
Table 3.7 (a): Administered activities (MBq) in different types of diagnostic examinations for paediatrics <16 years (2005-2007).
Diagnostic Examinations (Age <16)
Radio-pharmaceutical
Administered activity (MBq)
Mean Median Min Max Std. Dev.
Q1 Q3
Bone Tc-99m MDP/HDP 574 518 234 1110 206 407 732 Phosphate 292 356 151 370 122 254 363 Brain Tc-99m HMPAO 326 350 185 444 131 267 397 Cardiac Tc-99m MIBI, Rest 497 497 222 771 388 359 634
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Tc-99m Tetrofosmin,
Rest
509 444 333 925 150 370 592
Tc-99m Tetrofosmin,
Stress
359 370 167 518 104 315 407
Gastro-
enterology
Ga-67 Citrate 163 148 148 204 26 148 176
Tc-99m Sn Colloid 381 381 381 381 - 381 381
Liver or
Spleen
Tc-99m HIDA 69 60 37 289 33 46 84
Tc-99m Sn Colloid 197 204 93 296 102 148 250
Lung
Perfusion
Tc-99m MAA 307 333 130 333 60 324 333
Renal Tc-99m DMSA 177 126 20 970 129 75 244
Tc-99m MAG 3 74 59 37 265 52 37 78
Tc-99m DTPA 294 300 122 531 110 185 407
Thyroid I-131 NaI 183 185 74 370 102 81 204
Tc-99m TcO4 202 179 110 555 83 137 259
Table 3.7 (b): Administered activities (MBq) in different types of diagnostic examinations for adults ≥16 years (2005-2007).
Diagnostic Examinations (Age ≥16)
Radio-pharmaceutical
Administered activity (MBq)
Mean Median Min Max Std. Dev.
Q1 Q3
Bone Tc-99m MDP/HDP
832 798 370 1295 140 740 925
Phosphate 579 555 507 666 49 555 601 Brain Tc-99m
HMPAO 769 740 233 1369 310 555 962
Tc-99m TcO4 436 407 333 555 78 370 509 Cardiac Tc-99m MIBI,
Rest 832 925 380 1058 150 744 925
Tc-99m MIBI, Stress
638 555 264 1110 242 481 870
Tc-99m Tetrofosmin, Rest
850 925 370 1406 206 733 1036
Tc-99m Tetrofosmin, Stress
699 555 333 1432 238 503 925
Gastro-enterology
Ga-67 Citrate 238 185 148 444 94 178 370
In-111 230 224 218 248 16 221 236
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Pentetreotide
Tc-99m Sn Colloid
388 429 137 614 150 304 470
Liver or Spleen
Tc-99m HIDA 244 222 90 407 92 185 311
Tc-99m Sn Colloid
379 370 185 592 103 348 407
Lung Perfusion
Tc-99m MAA 308 333 148 444 70 259 333
Lung Ventilation
Tc-99m DTPA 1023 1036 740 1332 188 845 1192
Tc-99m Technegas 396 370 148 555 92 370 444
Renal Tc-99m DMSA 354 296 148 1110 173 189 485 Tc-99m MAG 3 219 210 148 259 35 185 259 Tc-99m DTPA 365 297 185 818 164 203 490 Thyroid I-131 MIBG 19 19 19 19 0 19 19 I-131 NaI 172 185 74 400 42 185 185 Tc-99m TcO4 349 278 185 740 165 212 555 Others 561 555 185 925 223 398 740
Table 3.7 (c): Administered activities (MBq) in different types of therapeutic procedure for paediatrics <16 years (2005-2007). Therapeutic
Procedures
(Age <16)
Radionuclide Administered activity (MBq)
Mean Median Min Max Std.
Dev. Q1 Q3
Hyperthyroidism I-131 448 444 111 740 166 370 555
Thyroid malignancy
I-131 3169 2960 1110 5550 1330 2220 3689
Table 3.7 (d): Administered activities (MBq) in different types of therapeutic procedures for adults ≥16 years (2005-2007). Therapeutic
Procedures
(Age ≥16)
Radionuclide Administered activity (MBq)
Mean Median Min Max Std.
Dev. Q1 Q3
Hyperthyroidism I-131 419 370 111 1295 146 296 555
Polycythaemia
vera
P-32 305 333 185 370 87 268 370
Thyroid
malignancy
I-131 4480 3700 1110 9620 1950 2960 5550
Others Y-90 860 888 555 1147 179 694 967
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Table 3.7 (e): Administered activities (MBq) in PET/CT (2005-2007).
Procedures Radio-pharmaceutical
Administered activity (MBq)
Mean Median Min Max Std.
Dev. Q1 Q3
PET/CT F-18-FDG 411 401 117 629 58 382 433
Figure 3.20 (a): Box plot showing the administered activities for different examination types in diagnostic nuclear medicine (2005-2007).
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118
Figure 3.20 (b): Box plot showing the administered activities for different disease types in therapeutic nuclear medicine (2005-2007).
For diagnostic examinations, the highest mean administered activity to the
nuclear medicine paediatrics patients was from the bone studies (Tc-99m MDP/HDP,
574 MBq). The highest mean administered activity to the nuclear medicine adult
patients was from the lung ventilation studies (Tc-99m DTPA, 1023 MBq). This was
followed by cardiac, gastroenterology, brain, lung perfusion, renal, thyroid and liver
or spleen, for paediatrics; cardiac, bone, renal, brain, others, gastroenterology, liver
or spleen, lung perfusion and thyroid for adults. There was no lung ventilation
performed on the paediatrics age group.
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For therapeutic procedures, the highest mean administered activity was for
treatment of thyroid malignancy for both the paediatric (3169 MBq) and the adult
group (4480 MBq). In both groups, the administered activity for treatment of thyroid
malignancy was 7 to 9 times the administered activity for treatment of
hyperthyroidism. For the adults group, the other disease types during 2005 to 2007
comprised of bone metastases, polycythaemia vera and others. Most of the “Others”
therapy were from the Y-90 therapy for liver metastases and synovitis. There was no
other disease type besides for thyroid malignancy and hyperthyroidism for the
paediatric group. Bone metastases treatment using radionuclide is not common in
Malaysia. There was only a case performed in 2007 by Sime Darby Medical Centre
with administered activity of 148 MBq. As such, no comparative analysis with other
centres were analysed.
(b) Effective Dose (mSv)
The mean effective doses calculated using MIRD method for different types of
diagnostic examination are shown in Table 3.8 (a), Table 3.8 (b) and Figure 3.21.
Table 3.8 (a): Mean effective dose (mSv) calculated for different types of diagnostic examination for paediatrics <16 years (2005-2007).
Diagnostic Examinations (Age <16)
Mean Effective Dose (mSv) Mean Median Min Max Std.Dev.
Bone 2.85 2.73 0.86 6.30 1.19Brain 3.03 3.25 1.72 4.13 1.22Cardiac 3.66 3.09 1.17 7.03 1.24Gastroenterology 1.85 1.48 1.48 3.57 0.63Liver or Spleen 1.19 1.02 0.63 4.91 0.57Lung Perfusion 3.37 3.66 1.42 3.66 0.66Renal 1.09 0.98 0.18 8.52 0.63Thyroid 2.92 2.41 1.43 13.54 1.73
Table 3.8 (b): Mean effective dose (mSv) calculated for different types of diagnostic examinations for adults ≥16 years (2005-2007).
Diagnostic Examinations (Age ≥16)
Mean Effective Dose (mSv) Mean Median Min Max Std.Dev.
Bone 3.91 4.00 1.25 7.35 1.23Brain 6.75 6.54 2.17 12.73 2.59Cardiac 5.69 5.90 2.08 10.68 1.80Gastroenterology 3.84 3.70 1.28 18.50 3.26Liver or Spleen 4.07 3.65 1.53 6.92 1.51Lung Perfusion 3.38 3.66 1.63 4.88 0.77Lung Ventilation 5.35 5.55 2.22 8.33 1.19
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Renal 1.87 1.63 0.91 7.77 0.93Thyroid* 7.62 7.22 2.41 15.80 3.75Others 6.11 6.11 1.72 10.18 2.55
Figure 3.21: Box plot showing the effective dose for different examination types in diagnostic nuclear medicine (2005-2007).
For the paediatric group, the highest mean effective dose was from the
examinations of cardiac (3.66 mSv) and the lowest was from the renal examinations
(1.09 mSv). Renal studies had the highest frequency of examinations, however, the
study had relatively low mean effective dose (1.09 mSv). The range for the effective
dose among the paediatric patients was from 0.18 to 13.54 mSv.
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For the adult group, the highest mean effective dose recorded was from the
examinations of thyroid (7.62 mSv) and the lowest was from the renal studies (1.87
mSv). The range for the effective dose among the adult patients was from 0.91 to
18.50 mSv.
The comparison of mean administered activity and mean effective dose for
paediatrics (age <16) and adults (age ≥16) for different diagnostic examination types
is presented in Table 3.9.
Table 3.9: Comparison of mean administered activity and mean effective dose for paediatrics (age <16) and adults (age ≥16) for different diagnostic examinations.
Diagnostic
Examinations
Paediatrics (Age <16) Adults (Age ≥16)
Mean
Activity
(MBq)
Mean
Eff. Dose
(mSv)
Mean
Activity
(MBq)
Mean
Eff. Dose
(mSv)
Bone 573 2.85 832 3.91
Brain 326 3.03 678 6.75
Cardiac 484 3.66 776 5.69
Gastroenterology 196 1.85 358 3.84
Liver or Spleen 71 1.19 262 4.07
Lung Perfusion 307 3.37 308 3.38
Lung Ventilation - - 795 5.35
Renal 177 1.09 354 1.87
Thyroid 190 2.92 256 7.62
Others - - 561 6.11
There is a general correlation between the average administered activity (MBq)
and the calculated mean effective dose (mSv) (with the exception of lung ventilation
and ‘other’ examination types), although the actual relationship is not immediately
clear as the mean effective dose takes into account different organ sensitivities
towards radiation and the amount of radiopharmaceutical uptake into the particular
organ, among other factors.
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122
In summary, for diagnostic examinations in nuclear medicine, examinations
which constantly had high effective dose were cardiac, lung perfusion and brain for
the paediatric group (all were above 3.00 mSv). The constantly high effective dose in
the adult age group were from the thyroid, brain and ‘others’ examinations (all were
above 6.00 mSv). In both groups, renal examinations typically recorded one of the
lowest mean effective dose. The average administered activity for adults is usually
1.5 to 2 times higher than the administered activity for paediatrics. The administered
activities are generally scaled according to body surface area or weight. When
calculated by weight, the resultant effective doses to the paediatrics in general will be
roughly the same as those to an adult. The average mean effective doses calculated
for the adults were found to be mostly slightly higher for each examination type
compared to the paediatrics. The analysis of patient exposures is also complicated by
the variety of different radiopharmaceuticals in use for each type of procedure.
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3.4.3 Data Comparisons with Published Literature
The results from this survey were compared with the previously published
papers. The main source for the comparison is from the UNSCEAR 2000 report
(refer UNSCEAR 2000 Annex D in Appendix I). The data comparisons were
presented in the following tables. The main parameters for comparison are the
number of equipment per population, frequency of procedure per population, mean
effective dose per procedure, annual collective effective dose and the annual per
caput effective dose.
The dosimetric data collected from this survey were compared to the
Diagnostic Reference Levels (DRLs) recommended by different international
organizations, eg. IAEA, NRPB, EC and ARSAC. One of the main objectives of this
survey was to develop a local DRL in the relevant diagnostic imaging disciplines to
outfit the local population and conditions. Furthermore, we also compared the data
from this survey to other national surveys carried out by different countries.
(a) Data Comparisons with UNSCEAR 2000 Report
Table 3.10 to Table 3.16 and Figure 3.22 to Figure 3.25 represent the
comparisons between the data collected from this survey with the published
UNSCEAR 2000 report.
Table 3.10: Comparison of number of nuclear medicine diagnostic imaging equipment per million population with UNSCEAR 2000 report.
Nuclear
Medicine
Equipment
Diagnostic Imaging Equipment per Million Population
Level
I
Level
II
Level
III
Level
IV
Malaysia
(2007)
Gamma Cameras 7.19 0.32 0.13 0.03 0.59
PET or PET/CT 0.2 0.002 0 0 0.18
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Table 3.11: Comparison of number of procedures per 1000 population with UNSCEAR 2000 report (Table 46).
Procedure
No. of Procedures per 1,000 Population
Level
I
Level
II
Level
III
Level
IV
World Malaysia
(2007)
Bone 4.5 0.24 0.053 0.001 1.3 0.21
Cardiovascular 2.7 0.17 0.018 0.00002 0.8 0.16
Lung Perfusion 1.8 0.023 0.007 0.0001 0.49 0.0012
Lung Ventilation 0.34 0.011 0.0003 0.00002 0.095 0.001
Thyroid Scan 4.1 0.3 0.16 0.003 1.3 0.0355
Renal 0.89 0.16 0.02 0.002 0.32 0.089
Liver/Spleen 2.1 0.09 0.005 0.0002 0.59 0.0043
Brain 1.3 0.05 0.01 0.003 0.37 0.0006
Total 19 1.1 0.28 0.02 5.6 0.5016
Table 3.12: Comparison of effective dose per procedure with UNSCEAR 2000 report (Table 46).
Procedure Effective Dose Per Procedure (mSv)
Level
I
Level
II
Level
III
Level
IV
World Malaysia
(2007)
Bone 4.5 4.5 4 4 4.5 3.91
Cardiovascular 8 8 12 12 8 5.69
Lung Perfusion 1.5 2 2 2 1.5 3.38
Lung Ventilation 1 1 1 1 1 5.35
Thyroid Scan 2 10 30 30 3.4 7.62
Renal 1.5 3 3 3 1.9 1.87
Liver/Spleen 1.7 2 2 2 1.7 4.07
Brain 6 6 6 6 6 6.75
Average Effective
Dose Per
Procedure (mSv)
4.3 6.7 20 20 4.6 4.83
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125
Table 3.13: Comparison of annual collective dose per procedure with UNSCEAR 2000 report (Table 46).
Procedure
Annual Collective Dose (man Sv)
Level
I
Level
II
Level
III
Level
IV
World Malaysia
(2007)
Bone 31000 3300 140 3 35000 22.314
Cardiovascular 33000 4150 140 0.1 37000 25.178
Lung Perfusion 4150 140 9 0.1 4300 0.115
Lung Ventilation 520 35 0.2 0.01 600 0.144
Thyroid Scan 12500 9300 3200 55 25000 7.353
Renal 2000 1500 40 4 3500 4.533
Liver/Spleen 5300 600 6 0.2 5900 0.480
Brain 12000 900 40 9 13000 0.101
Total 123000 23000 3500 200 150000 60.218
Average Effective
Dose Per Caput
(mSv)
0.081 0.008 0.006 0.0003 0.026 0.0022
Table 3.14: Comparison of percentage contribution to total annual frequency with UNSCEAR 2000 report (Table 47).
Procedure Contribution to total annual frequency (%)
Level
I
Level
II
Level
III
Level
IV
World Malaysia
(2007)
Bone 24 21 19 8 24 41.61
Cardiovascular 14 15 6 0.1 14 32.26
Lung Perfusion 10 2 2 0.4 9 0.25
Lung Ventilation 2 1 0.1 0.1 2 0.20
Thyroid Scan 22 27 59 19 22 7.04
Renal 5 14 7 13 6 17.67
Liver/Spleen 11 8 2 1 11 0.86
Brain 7 4 4 16 7 0.11
Total 100 100 100 100 100 100
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Table 3.15: Comparison of percentage contribution to total annual collective dose with UNSCEAR 2000 report (Table 47).
Procedure Contribution to total annual collective dose (%)
Level
I
Level
II
Level
III
Level
IV
World Malaysia
(2007)
Bone 25 14 4 2 23 37.04
Cardiovascular 27 18 4 0.1 25 41.80
Lung Perfusion 3 0.6 0.3 <0.1 3 0.19
Lung Ventilation 0.4 0.1 <0.1 <0.1 0.4 0.24
Thyroid Scan 10 40 89 28 17 12.24
Renal 2 6 1 2 2 7.52
Liver/Spleen 4 2 0.2 0.1 4 0.80
Brain 10 4 1 5 8 0.17
Total 100 100 100 100 100 100
Table 3.16: Summary of the data comparison between this survey and UNSCEAR 2000 report (Table 50).
Health-Care Level
Population (millions)
Annual per caput Effective Dose
(mSv)
Annual Collective Effective Dose
(man Sv)
I 1530 0.08 123000
II 3070 0.008 23000
III 640 0.006 3500
IV 565 0.0003 200
World 5800 0.03 150000
Malaysia (2007) 27.17 0.0022 60.218
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Effective Dose per Procedure (mSv)
0 5 10 15 20 25 30 35
Bone
Cardiovascular
Lung Perfusion
Lung Ventilation
Thyroid Scan
Renal
Liver/Spleen
BrainEx
amin
atio
n Ty
pes
Effective dose per procedure (mSv)
Malaysia (2007)Level IVLevel IIILevel IILevel I
Figure 3.23 3.22: Comparison of effective dose per procedure with different healthcare levels.
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128
Comparison of Annual Collective Effective Dose (manSv)
602003500
23000
123000
0
20000
40000
60000
80000
100000
120000
140000
Level I Level II Level III Level IV Malaysia (2007)
Ann
ual C
olle
ctiv
e Ef
fect
ive
Dos
e (m
anSv
)
Figure 3.23: Comparison of annual collective effective dose with different healthcare levels.
Comparison of Annual per Caput Effective Dose (mSv)
0.00030.0022
0.0060.008
0.08
0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
0.09
Level I Level II Level III Malaysia (2007) Level IV
Ann
ual p
er C
aput
Effe
ctiv
e D
ose
(mSv
)
Figure 3.24: Comparison of annual per caput effective dose with different healthcare levels.
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129
(b) Data Comparisons with Recommended DRLs
Table 3.17 (a) and Table 3.17 (b) present the comparisons between the data
collected from this survey with the recommended DRLs by international
organizations.
Table 3.17 (a): Comparison of average administered activity (MBq) of different types of diagnostic examination with difference recommended DRLs (Adults ≥ 16 years old).
Diagnostic Exam.
Radio-pharmaceutical
Average Administered Activity (MBq) This
survey
1IAEA 1996
2ARSAC 2006
3RSNA 2008
4EC 1999a
5SSK 2000
Bone Tc-99m MDP/HDP 832 800 800 1110 600 750Brain Tc-99m HMPAO 769 800 500 740 N/A N/ACardiac Tc-99m MIBI, Rest 832 800 800 1100 N/A N/A
Tc-99m MIBI, Stress 638 600 800 1100 N/A N/A
Tc-99m Tetrofosmin, Rest
850 800 800 1500 N/A N/A
Tc-99m Tetrofosmin, Stress
699 600 800 1500 N/A N/A
Gastro-enterology
Ga-67 Citrate 238 N/A 150 150 N/A N/A
In-111 Pentetreotide 230 N/A 220 222 N/A N/A
Tc-99m Sn Colloid 388 200 400 N/A N/A N/A
Liver or Spleen
Tc-99m HIDA 244 150 150 N/A 150 150Tc-99m Sn Colloid 379 200 200 222 80 N/A
LungPerfusion
Tc-99m MAA 308 200 200 185 100 200
LungVentilation
Tc-99m DTPA 1023 N/A 80 1300 N/A N/A
Tc-99m Aerosol 396 N/A 400 740 N/A N/A
Renal Tc-99m DMSA 354 160 80 370 80 70Tc-99m MAG3 219 100 100 370 100 200Tc-99m DTPA 365 350 300 370 300 150
Thyroid I-131 MIBG 19 20 20 25 N/A N/AI-131 NaI 172 400 N/A N/A N/A N/A
TcO4- 349 200 80 370 N/A N/A
1. International Atomic Energy Agency. International Basic Safety Standards protection against ionizing radiation and for the safety of radiation sources. Safety Series No. 115. IAEA. 1996.
2. Administration of Radioactive Substances Advisory Committee. Notes for guidance on the clinical administration of radiopharmaceuticals and use of sealed radioactive sources. Health Protection Agency, UK, 2006.
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130
3. Fred AM, Walter H, Terry TY, Mahadevappa M. Effective doses in radiology and diagnostic nuclear medicine: A catalog. Radiology. 2008, 246(1).
4. European Commission. Radiation Protection 109: Guidance on diagnostic reference levels (DRLs) for medical exposures. Directorate-General Environment, Nuclear Safety and Civil Protection. 1999.
5. Strahlenschutzkommission (SSK). Diagnostic Reference Levels in Nuclear Medicine. Recommendation of the Radiation Protection Commission (Session 167) (Germany). 2000.
Table 3.17 (b): Comparison of average administered activity (MBq) of different types of diagnostic examination with difference recommended DRLs (Paediatrics < 16 years old).
Diagnostic Exam.
Radio-pharmaceutical
Average Administered Activity (MBq) This
survey
1ARSAC 2006
2EANM 1990
3Iran 2005
4Ireland2008
Bone Tc-99m MDP/HDP 574 40 40 457 40-549Brain Tc-99m HMPAO 326 100 100 537 N/ACardiac Tc-99m Sestamibi,
Rest497 N/A N/A N/A N/A
Tc-99m Tetrofosmin, Rest
509 N/A N/A N/A N/A
Tc-99m Tetrofosmin, Stress
359 N/A N/A N/A N/A
Gastro-enterology
Ga-67 Citrate 163 10 10 103 N/A
Tc-99m Sn Colloid 381 10 10 119 N/A
Liver or Spleen
Tc-99m HIDA 69 N/A 20 117 N/A
Tc-99m Sn Colloid 197 15 15 119 N/A
LungPerfusion
Tc-99m MAA 307 N/A 10 106 N/A
Renal Tc-99m DMSA 177 15 15 79 15-91Tc-99m MAG3 74 15 15 N/A 15-91Tc-99m DTPA 294 20 20 256 20-201
Thyroid I-131 NaI 183 3 3 1.32 N/A
Tc-99m TcO4- 202 10 10 457 10-73
1. Administration of Radioactive Substances Advisory Committee. Notes for guidance on the clinical administration of radiopharmaceuticals and use of sealed radioactive sources. Health Protection Agency, UK, 2006.
2. European Association of Nuclear Medicine, 1990. 3. Neshandar Asli I., Tabeie F. Paediatric radiation exposure from diagnostic nuclear medicine
examinations in Tehran. Iran J. Radiol. 2005, 3(1). 4. Gray L, Torreggiani W, O’Reilly G. Paediatric diagnostic reference levels in nuclear medicine
imaging in Ireland. Br J Radiol. 2008, 81(971): 918-9.
Medical Radiation Exposure Study in Malaysia
__________________________________________________________________________________________________ Chapter 3: Nuclear Medicine, Result and Discussion
131
(c) Data Comparisons with Surveys From Other Countries
Table 3.18 and Table 3.19 present the comparisons between the data collected
from this survey with the data published by other national (countries) surveys.
Table 3.18: Comparison of average administered activity (MBq) of different types of diagnostic examinations with survey from other countries (Adults ≥ 16 years old).
Diagnostic Exam.
Radio-pharmaceutical
Average Administered Activity (MBq) This
Survey
1ARG 2BRA 3CUB 4NHS 5GRC 6TWN 7USA
Bone Tc-99m MDP/ HDP
832 860 1016 740 682 536.5 560 740
Brain Tc-99m HMPAO 769 640 1009 N/A N/A N/A 420 740Cardiac Tc-99m MIBI,
Rest832 600 589 N/A N/A N/A 540 N/A
Tc-99m MIBI, Stress
638 600 589 N/A N/A N/A 540 N/A
Tc-99m Tetrofosmin, Rest
850 700 N/A N/A N/A N/A 540 N/A
Tc-99m Tetrofosmin, Stress
699 700 N/A N/A N/A N/A 540 N/A
Gastro-enterology
Ga-67 Citrate 238 190 N/A N/A N/A 129.5 110 N/A
In-111Pentetreotide
230 N/A N/A N/A N/A N/A N/A N/A
Tc-99m Sn Colloid
388 720 N/A N/A N/A 18.5 150 N/A
Liver or Spleen
Tc-99m HIDA 244 N/A N/A 222 N/A 263 140 N/ATc-99m Sn Colloid
379 220 510 N/A N/A 114.7 150 185
LungPerfusion
Tc-99m MAA 308 280 421 N/A 100 172 120 185
LungVentilation
Tc-99m DTPA 1023 938 894 N/A N/A N/A N/A N/A
Tc-99m Aerosol 396 N/A N/A N/A N/A N/A N/A N/A
Renal Tc-99m DMSA 354 230 234 222 77 92.5 150 N/A
Tc-99m MAG3 219 400 N/A N/A 89 N/A N/A N/A
Tc-99m DTPA 365 220 N/A N/A 204 370 150 N/AThyroid I-131 MIBG 19 470 N/A 3.7 N/A 25.9 0.8 N/A
I-131 NaI 172 180 4.4 74 75 N/A 20 3.7
Medical Radiation Exposure Study in Malaysia
__________________________________________________________________________________________________ Chapter 3: Nuclear Medicine, Result and Discussion
132
TcO4- 349 210 426 222 N/A 114.7 80 185
1. Bomben AM, Chiliutti CA. Radiopharmaceutical activities administered for diagnostic and therapeutic procedures in nuclear medicine in Argentine: Results of a national survey. International Congress on the International Radiation Protection Association. 2004.
2. Khoury HJ, Pereira MA, Stabin MG, Hazin CA, Drexler G. Assessment of population dose from nuclear medicine procedures in Pernambuco (Brazil) during the period 1990-1994.
3. Flores OB, Caballero AB, Sanchez OL, Estrada AM, Garcia JH. Population effective collective dose from nuclear medicine examination in Cuba. Radiat Prot Dosimetry. 2006, 121(4): 438-444.
4. NHS: Procedure for Use of Diagnostic Reference Levels for Radiodiagnosis, Hull & East Yorkshire. Hospitals Radiation Protection Service.
5. Papadopoulos G, Okkalides D. Dose to patients through nuclear medicine procedures in a department in northern Greece. European Journal of Nuclear Medicine. 1990, 17: 212-215.
6. Lai SY, Sabol J, Weng PS. Assessment of the population effective doses from the diagnostic use of radiopharmaceuticals in Taiwan. Radiat Prot Dosimetry. 1995, 62(4): 255-261.
7. Mettler FA, Christie JH, Williams AG, Moseley RD. Population characteristics and Absorbed dose to the population from nuclear medicine: United States – 1982. Health Phys. 1986, 50(5): 619-628.
Table 3.19 : Comparison of average administered activity (MBq) of different types of radionuclide therapy with other survey from other countries (Adults ≥ 16 years old).
Countries Average Administered Activity (MBq) I-131 Y-90 P-32 Sr-89
Malaysia (This survey)
1741 860 305 148
Austria 3500 10 0.2 7.5Germany 41426 1025 23 13Hungry 951 9.3 N/A 1.5Israel 1000 740 N/A N/A
Norway 932 1.9 0.33 9.4Portugal 1194 0.74 1.66 3Slovakia 4000 55 15 15Slovenia 582 7.59 1.3 2Spain 10000 N/A N/A N/A
Switzerland 1690 31 11 8The Netherlands 2900 75 18 42Turkey 2080 N/A 0.45 2.22UK 16695 88 94.96 57.06Source: Hoefnagel, C. A., Clarke, S. E., Fischer, M., Chatal, J. F., Lewington, V. J., Nilsson, S., Troncone, L. and Vieira, M. R. 1999 'Radionuclide therapy practice and facilities in Europe. EANM Radionuclide Therapy Committee', Eur J Nucl Med 26(3): 277-82.
Medical Radiation Exposure Study in Malaysia
__________________________________________________________________________________________________Chapter 4: Summary, Conclusions and Recommendations
133
The main objective of this study was to develop a national database of patient
dose in diagnostic imaging in view of establishing the DRL in Malaysia. The study
was carried out under the actual clinical settings and did not consider the potential
factors that might affect the dose measured, namely exposure parameters and
performance of the machine. This study was limited to adult patients with age greater
than 16 years. However in nuclear medicine, the patients involves were categorised
from age 0-15, 16-40 and >40 years old.
The results of this study are comparable to the published studies from other
international surveys, except in the field of interventional cardiology. Nonetheless, it
should be noted that common practice for interventional cardiology in this country is
to perform both diagnostic and therapeutic interventional procedures at the same
sitting.
The proposed DRLs were based on the third quartile value of the dose
distribution collected in this study. These DRLs will be useful in providing guidance
to the professional and regulatory bodies on national reference dose levels for
various examinations and procedures involving ionising radiation.
To improve the management of patient’s doses involving ionising radiation,
radiation exposure data must be recorded and systematically compared to the DRLs.
For radiology and nuclear medicine, MOH recommends that the medical facilities in
the country to adopt these DRLs as a guidance in order to compare with their local
practices. If doses exceed the DRLs, a review is considered to ensure the optimized
protection of patients and maintaining appropriate level of good practice.
Nevertheless, if the DRLs are exceeded, this does not necessarily mean that the
examination has been improperly conducted. Exposures exceeding the DRLs may be
expedient in order, for example, to achieve image quality which is better than usual.
On the other hand, corrective action should be taken as necessary if exposures do not
CHAPTER 4: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
Medical Radiation Exposure Study in Malaysia
__________________________________________________________________________________________________Chapter 4: Summary, Conclusions and Recommendations
134
provide useful diagnostic information and do not yield the expected medical benefit
to patients.
This study presents the results of an updated and broad review of medical
radiation exposures in Malaysia. It involves both, public and private sectors that
covers diagnostic radiology, dental radiology and nuclear medicine. However, there
are some areas in which the study could be further improved or explored. This
includes the following:
i. General x-ray, dental x-ray and mammography examinations dose survey
carried out in this study involved conventional imaging modalities. Thus, it
would be of interest to carry out a study involving digital imaging modalities,
i.e., examinations using general x-ray machine, dental x-ray machine, and full
field digital mammography (FFDM).
ii. In this study, the dose survey for mammography carried out using real
patients and calculation to get the MGD values. In the future, a study using
phantom can be performed. Thus, the results would be comparable with other
published studies.
iii. PET/CT consists of two components: PET and CT. Each component will
contribute to the dose received by the patient. Thus, future studies would
include the total effective dose for PET/CT, i.e., the total dose received by the
patient due to administered activity and CT examination.
Medical Radiation Exposure Study in Malaysia
_______________________________________________________________________________________________________ References
135
REFERENCES
Department of Statistics Malaysia. 2009. Key Statistics: Population (Updated 31
July 2009). Available at http://www.statistics.gov.my. Accessed on 18 Nov
2009.
European Commission (EC). 1999. Radiation Protection 109: Guidance on
diagnostic reference levels (DRLs) for medical exposures. Environment,
Nuclear Safety and Civil Protection, European Commission.
International Atomic Energy Agency. 2005. Radiation oncology physics: A
handbook for teachers and students. Austria, Vienna: IAEA.
International Atomic Energy Agency (IAEA). 2006. Developing and using dose
guidance (reference) levels in radiology and nuclear medicine examinations.
Contributed papers, pages 403-487, in Radiological Protection of Patients in
Diagnostic and Interventional Radiology, Nuclear Medicine and Radiotherapy
International Commission on Radiological Protection (ICRP). 1996. Radiological
protection and safety in medicine. ICRP Publication 73. Annals of the ICRP
26, No. 2. Oxford: Pergamon Press.
National Radiological Protection Board/Royal College of Radiologists. 1990.
Patient dose reduction in diagnostic radiology. In: Documents of the NRPB.
London: HMSO; 1(3).
Ng KH, Abdullah BJ and Sivalingam S. 1999. Medical radiation exposures for
diagnostic radiology in Malaysia. Health Phys; 77(1): 33-6.
Ng KH, Rassiah P, Wang HB, Hambali AS, Muthuvellu P and Lee HP. 1998.
Doses to patients in routine X-ray examinations in Malaysia. Br J Radiol;
71(846): 654-60.
Medical Radiation Exposure Study in Malaysia
_______________________________________________________________________________________________________ References
136
Stabin MG. 1996. MIRDOSE: personal computer software for internal dose
assessment in nuclear medicine. J Nucl Med; (37): 538-46.
Stabin MG, Tagesson M, Thomas SR, Ljungberg M and Strand SE. 1999.
Radiation dosimetry in nuclear medicine. Appl Radiat Isot; (50): 73-87.
Toohey RE, Stabin MG and Watson EE. 2000. The AAPM/RSNA physics tutorial
for residents: internal radiation dosimetry: principles and applications.
Radiographics; 20: 533-46.
United Nations Scientific Committee on the Effects of Atomic Radiation: Sources,
Effects and Risks of Ionizing Radiation. 1993. UNSCEAR 1993 Report to
the General Assembly, with annexes. New York. United Nation.
United Nations Scientific Committee on the Effects of Atomic Radiation: Sources,
Effects and Risks of Ionizing Radiation. 2006. UNSCEAR 2006 Report to
the General Assembly, with annexes. New York. United Nation.
United Nations Scientific Committee on the Effects of Atomic Radiation: Sources,
effects and risks of ionizing radiation. UNSCEAR 1988 Report to the
General Assembly, with Scientific Annexes. New York. United Nation.
United Nations Scientific Committee on the Effects of Atomic Radiation
(UNSCEAR). 2000. UNSCEAR 2000 Report: Effects of ionizing radiation,
Vol II, Annex D. New York. United Nation.
US National Council on Radiation Protection & Measurements. 2009. Report No.
160 - Ionizing Radiation Exposure of the Population of the United States
(2009). NRPB, United States.
Wall, B., Harrison, R. and Spiers, F. W. 1988. Patient Dosimetry Techniques in
Diagnostic Radiology. UK: The Institute of Physical Science in Medicine.
World Nuclear Association. 2009. Radioisotopes in nuclear medicine. Available at
http://www.world-nuclear.org. Accessed on 15 Nov 2009.
Medical Radiation Exposure Study in Malaysia
_______________________________________________________________________________________________________ References
136
Stabin MG. 1996. MIRDOSE: personal computer software for internal dose
assessment in nuclear medicine. J Nucl Med; (37): 538-46.
Stabin MG, Tagesson M, Thomas SR, Ljungberg M and Strand SE. 1999.
Radiation dosimetry in nuclear medicine. Appl Radiat Isot; (50): 73-87.
Toohey RE, Stabin MG and Watson EE. 2000. The AAPM/RSNA physics tutorial
for residents: internal radiation dosimetry: principles and applications.
Radiographics; 20: 533-46.
United Nations Scientific Committee on the Effects of Atomic Radiation: Sources,
Effects and Risks of Ionizing Radiation. 1993. UNSCEAR 1993 Report to
the General Assembly, with annexes. New York. United Nation.
United Nations Scientific Committee on the Effects of Atomic Radiation: Sources,
Effects and Risks of Ionizing Radiation. 2006. UNSCEAR 2006 Report to
the General Assembly, with annexes. New York. United Nation.
United Nations Scientific Committee on the Effects of Atomic Radiation: Sources,
effects and risks of ionizing radiation. UNSCEAR 1988 Report to the
General Assembly, with Scientific Annexes. New York. United Nation.
United Nations Scientific Committee on the Effects of Atomic Radiation
(UNSCEAR). 2000. UNSCEAR 2000 Report: Effects of ionizing radiation,
Vol II, Annex D. New York. United Nation.
US National Council on Radiation Protection & Measurements. 2009. Report No.
160 - Ionizing Radiation Exposure of the Population of the United States
(2009). NRPB, United States.
Wall, B., Harrison, R. and Spiers, F. W. 1988. Patient Dosimetry Techniques in
Diagnostic Radiology. UK: The Institute of Physical Science in Medicine.
World Nuclear Association. 2009. Radioisotopes in nuclear medicine. Available at
http://www.world-nuclear.org. Accessed on 15 Nov 2009.
Medical Radiation Exposure Study in Malaysia
_______________________________________________________________________________________________________ References
137
http://www.doseinfo-radar.com
www.syque.com/quality_tools/toolbook/Variation/measuring_centering.htm
MINISTRY OF HEALTH UNSCEAR SURVEY PROJECT Diagnostic Radiology
Hospital:
Radiologist: Years Radiologist
2007 (a)(b)(c)(d)(e)
2008 (a)(b)(c)(d)(e)
2009 (a)(b)(c)(d)(e)
Personnel:
Number of Personnel
2007 2008 2009
Radiologist
Interventional Radiologists
Interventional Cardiologists
Medical Physicists
Radiographers/ Radiation Technologists
Modality:
X-Ray Unit
Model Manufacturer
Appendix A
UNSCEAR: Forms/Background/Diagnostic/1.0 1 of 2
MINISTRY OF HEALTH UNSCEAR SURVEY PROJECT Diagnostic Radiology
Hospital:
Radiologist: Years Radiologist
2007 (a)(b)(c)(d)(e)
2008 (a)(b)(c)(d)(e)
2009 (a)(b)(c)(d)(e)
Personnel:
Number of Personnel
2007 2008 2009
Radiologist
Interventional Radiologists
Interventional Cardiologists
Medical Physicists
Radiographers/ Radiation Technologists
Modality:
X-Ray Unit
Model Manufacturer
Appendix A
UNSCEAR: Forms/Background/Diagnostic/1.0 1 of 2
Computed Tomography (CT)
Model Manufacturer
Mammography Unit
Model Manufacturer
Fluoroscopy Unit
Model Manufacturer
Bone Mineral Density Unit
Model Manufacturer
Name of individual completing the form
e-mail address
UNSCEAR: Forms/Background/Diagnostic/1.0 2 of 2
MINISTRY OF HEALTH UNSCEAR SURVEY PROJECT Dental Examinations
Hospital:
Dentists: Years Radiologist
2007 (a)(b)(c)(d)(e)
2008 (a)(b)(c)(d)(e)
2009 (a)(b)(c)(d)(e)
Personnel:
Number of Personnel
2007 2008 2009
Dentists
Medical Physicists
Radiographers
Modality:
Dental X-Ray Unit
Model Manufacturer
Dental CT Unit
Model Manufacturer
UNSCEAR: Forms/Background/Dental/1.0 1 of 2
MINISTRY OF HEALTH UNSCEAR SURVEY PROJECT Dental Examinations
Hospital:
Dentists: Years Radiologist
2007 (a)(b)(c)(d)(e)
2008 (a)(b)(c)(d)(e)
2009 (a)(b)(c)(d)(e)
Personnel:
Number of Personnel
2007 2008 2009
Dentists
Medical Physicists
Radiographers
Modality:
Dental X-Ray Unit
Model Manufacturer
Dental CT Unit
Model Manufacturer
UNSCEAR: Forms/Background/Dental/1.0 1 of 2
Name of individual completing the form
e-mail address
UNSCEAR: Forms/Background/Dental/1.0 2 of 2
Gen
eral
X-r
ay
Mea
sure
men
t of e
ntra
nce
Surf
ace
Air
Ker
ma
per s
tudy
Hos
pita
l: …
……
……
……
……
……
……
.. R
oom
: ……
……
….
Dat
e
Type
of e
xam
inat
ion
Patie
nt D
ata:
Patie
nt ID
Ethn
ic G
roup
M
/ C/ I
/ O
Sex
Mal
e/F
emal
e
Age
Wei
ght
kg
Hei
ght
cm
Stud
y Pa
ram
eter
s:
Imag
e N
o.Pr
ojec
tion
(AP/
PA/L
AT/
Obl
ique
) FF
D(c
m)
kVp
mA
sA
EC used
(*Y
/N)
Cas
sette
size
(c
m x
cm
) TL
D ID
En
tranc
e Su
rfac
e A
ir K
erm
a (m
Gy)
R
emar
k
1 2 3 4 5
Y –
Yes
, N
– N
o
UN
SCEA
R: F
orm
s/D
iagn
ostic
/Gen
Xra
y/ 1
.0
Fluo
rosc
opy
Mea
sure
men
t of d
ose-
area
-pro
duct
and
ent
ranc
e sk
in d
ose
per s
tudy
H
ospi
tal:
……
……
……
……
……
……
…..
Roo
m: …
……
……
.
Dat
e
Type
of e
xam
inat
ion
Ang
iogr
aphy
(Dia
gnos
tic):
Car
diac
/ N
on-c
ardi
ac
Con
vent
iona
l:U
pper
Gas
troin
test
inal
/ Lo
wer
Gas
troin
test
inal
/ M
CU
/ ER
CP
Inte
rven
tiona
l: C
ardi
ac (P
TCA
) / C
ereb
ral /
Vas
cula
r / E
SWL
/ Oth
ers
Patie
nt D
ata:
Patie
nt ID
Ethn
ic G
roup
M
/ C/ I
/ O
Sex
Mal
e/F
emal
e
Age
Wei
ght
kg
Hei
ght
cm
Stud
y Pa
ram
eter
s:
Serie
sN
o.St
udy
kV(m
ean)
m
ATi
me
(s
)m
As
Fram
e R
ate
(fps
)
Tota
lTi
me
(s)
No.
of
Acq
uisi
tion
DA
P(m
Gy.
m2 )
Gaf
chro
mic
Fi
lm L
abel
R
emar
k
1 2 3 4 5Y
– Y
es,
N –
No
UN
SCEA
R: F
orm
s/D
iagn
ostic
/Flu
oro/
1.0
Com
pute
d T
omog
raph
y (C
T)
Mea
sure
men
t of C
TDI a
nd e
ffec
tive
dose
per
stud
y
Hos
pita
l:
Roo
m:
Dat
e
Type
of e
xam
inat
ion
Patie
nt D
ata:
Patie
nt ID
Ethn
ic G
roup
M
/ C
/ I /
O
Sex
Mal
e/F
emal
e
Age
Wei
ght
kg
Hei
ght
cm
Info
rmat
ion:
FOV
Fiel
d of
Vie
w (c
m x
cm
) M
atrix
Siz
e eg
. 512
x 5
12 ,
1024
x 1
024
TF (T
able
Fee
d)
dist
ance
/rota
tion
(mm
) P
Pitc
hC
ollim
atio
n/ D
etec
tor S
elec
tion
Eg. 1
6 x
0.62
5, 4
x 2
.5.
For s
ingl
e sl
iced
CT,
leav
e th
is em
pty.
N
o. o
f Pha
ses
Num
ber o
f sca
n w
ith sa
me
para
met
ers (
only
for
mul
tiple
pha
ses)
*Stu
dy P
aram
eter
s:
Serie
sN
o.Sc
an A
rea
kVm
Am
As
Tim
e
(s)
FOV
Mat
rix
size
TF (mm
) P
Col
limat
ion/
Det
ecto
r Se
lect
ion
Rec
onSl
ice
Thic
knes
s(m
m)
Scan
Leng
th(c
m)
Spira
lM
ode
(Y/N
)
Rem
ark
(e.g
. No.
of
Pha
ses)
1 2 3 4 5
*Do
not r
ecor
d sc
out s
can
UN
SCEA
R: F
orm
s/D
iagn
ostic
/CT/
1.0
Mam
mog
raph
y
Mea
sure
men
t of M
ean
Gla
ndul
ar D
ose
per s
tudy
Hos
pita
l: …
……
……
……
……
……
……
.. R
oom
: ……
……
….
Dat
e
Type
of e
xam
inat
ion
Scre
enin
g / C
linic
al D
iagn
osis
Patie
nt D
ata:
Patie
nt ID
Ethn
ic G
roup
M
/ C
/ I /
O
Age
Wei
ght
kg
Hei
ght
cm
Info
rmat
ion:
CC
Cra
nial
-cau
dal v
iew
M
LO
Med
iola
tera
l obl
ique
vie
w
FFD
Focu
s-to
-Film
Dis
tanc
eTa
rget
/Filt
er
eg.,
Mo/
Mo,
Mo/
Rh,
Rh/
Rh,
W/W
A
ECA
utom
atic
Exp
osur
e Co
ntro
l
Stud
y Pa
ram
eter
s:
Serie
sN
o.Pr
ojec
tion
(CC
/MLO
)FF
D(c
m)
Targ
et/ F
ilter
kV
pm
As (e
xp)
AEC
use
d (*
Y/N
)C
ompr
esse
d B
reas
tTh
ickn
ess
(mm
)
Mea
n G
land
ular
D
ose
(mG
y)
Rem
ark
1 2 3 4 5
Y –
Yes
, N –
No
UN
SCEA
R: F
orm
s/D
iagn
ostic
/Mam
mo/
1.0
Bon
e M
iner
al D
ensi
ty E
xam
inat
ions
Mea
sure
men
t of e
ntra
nce
surf
ace
dose
per
stud
y H
ospi
tal:
……
……
……
……
……
……
…..
Roo
m: …
……
……
.
Dat
e
Patie
nt D
ata:
Patie
nt ID
Ethn
ic G
roup
M
/ C
/ I /
O
Sex
Mal
e/F
emal
e
Age
Wei
ght
kg
Hei
ght
cm
Info
rmat
ion:
Proj
ectio
n A
P Sp
ine
/ Lef
t Hip
/ R
ight
Hip
Sc
an M
ode
Hi-R
es, F
ast /
Hi-R
es, M
ed /
Low
-Res
, Med
Stud
y Pa
ram
eter
s:
Imag
e N
o.Pr
ojec
tion
(AP
Spin
e / L
eft H
ip /
Rig
ht H
ip)
kVp
mA
Tim
e (s
)Sc
an M
ode
TLD
labe
l En
tranc
eSu
rfac
e D
ose
(mG
y)
Rem
ark
1 2 3 4 5
Y –
Yes
N
– N
o
UN
SCEA
R: F
orm
s/D
iagn
ostic
/BM
D/ 1
.0
Den
tal E
xam
inat
ions
Mea
sure
men
t of e
ntra
nce
surf
ace
dose
per
stud
y H
ospi
tal:
……
……
……
……
……
……
…..
Roo
m: …
……
……
.
Dat
e
Type
of e
xam
inat
ion
Intra
oral
/ Pa
nora
mic
/ D
enta
l CT
Patie
nt D
ata:
Patie
nt ID
Ethn
ic G
roup
M
/ C
/ I /
O
Sex
Mal
e/F
emal
e
Age
Wei
ght
kg
Hei
ght
cm
Stud
y Pa
ram
eter
s:
Imag
e N
o.FF
D(c
m)
kVp
mA
sA
EC used
(*Y
/N)
Film
size
(c
m x
cm
) TL
D la
bel
Entra
nce
Surf
ace
Dos
e (m
Gy)
Rem
ark
1 2 3 4 5
Y –
Yes
N
– N
o
UN
SCEA
R: F
orm
s/D
iagn
ostic
/Den
tal/
1.0
Dia
gnos
tic X
-ray
Exa
min
atio
ns (Y
ear 2
005)
UN
SCEA
R: F
orm
s/Su
rvey
/Dia
gnos
tic/2
005
1 of
3
Gen
eral
X-r
ayEs
timat
ed n
umbe
r of
exam
inat
ions
pe
rfor
med
ann
ually
(a)
Estim
ated
ave
rage
pa
tient
dos
e
Estim
ated
effe
ctiv
e do
se (m
Sv)(I
f av
aila
ble)
Ag
e an
d se
x di
stri
butio
n (%
)
0-15
yea
rs
16-4
0 ye
ars
>40
yea
rs
Exam
inat
ion
Con
ven-
tiona
l D
igita
l
Entr
ance
surf
ace
Dos
e (m
Gy)
±SD
M
ean
±SD
M
ale
Fem
ale
Mal
e Fe
mal
e M
ale
Fem
ale
Che
st R
adio
grap
hy
Che
st P
A
Che
st L
AT
Lim
bs &
Joi
nts
Upp
er E
xtre
miti
es:
Han
d, W
rist,
Radi
us,
Uln
a, E
lbow
, Hum
erus
, Sh
ould
erL
ower
Ext
rem
ities
: Fo
ot, A
nkle
, Tib
ia,
Fibu
la, F
emur
, Kne
eSp
ine
Lum
bo-s
acra
l AP
Lum
bo-s
acra
l LA
T Th
orac
ic A
P Th
orac
ic L
AT
Cer
vica
l AP
Cer
vica
l LA
T Pe
lvis
/Hip
Sk
ull
AP
Lat
Oth
ers (
Tow
ne,
Cal
dwel
l, et
c)
Abd
omen
/KU
B
Dia
gnos
tic X
-ray
Exa
min
atio
ns (Y
ear 2
005)
UN
SCEA
R: F
orm
s/Su
rvey
/Dia
gnos
tic/2
005
2 of
3
Mam
mog
raph
yEs
timat
ed n
umbe
r of
exam
inat
ions
per
form
ed
annu
ally
(a)
Estim
ated
ave
rage
pat
ient
do
se
Estim
ated
effe
ctiv
e do
se
(mSv
)(If a
vaila
ble)
Ag
e an
d se
x di
stri
butio
n (%
)
Exam
inat
ion
Con
vent
iona
l D
igita
l M
ean
glan
dula
r dos
e(m
Gy)
±S
DM
ean
±SD
16-4
0 ye
ars
>40
yea
rs
Scre
enin
g C
linic
al d
iagn
osis
Fluo
rosc
opy
Estim
ated
ave
rage
pat
ient
dos
e Es
timat
ed e
ffect
ive
dose
(mSv
)(If
avai
labl
e)
Age
and
sex
dist
ribu
tion
(%)
0-15
yea
rs
16-4
0 ye
ars
>40
yea
rs
Exam
inat
ion
Estim
ated
nu
mbe
r of
exam
inat
ions
pe
rfor
med
an
nual
ly (a
)Pe
ak S
kin
Dos
e (m
Gy)
±S
D
Ker
ma
Area
Prod
uct
(Gyc
m2 )
±SD
M
ean
±SD
M
ale
Fem
ale
Mal
e Fe
mal
e M
ale
Fem
ale
Ang
iogr
aphy
(Dia
gnos
tic)
Car
diac
Non
-car
diac
C
onve
ntio
nal S
tudi
es
Upp
er G
astro
inte
stin
al
Low
er G
astro
inte
stin
al
MC
UER
CP
Cho
lecy
stog
raph
y U
rogr
aphy
In
terv
entio
nal
Car
diac
(PTC
A)
Cer
ebra
lV
ascu
lar
ESW
L O
ther
s
Dia
gnos
tic X
-ray
Exa
min
atio
ns (Y
ear 2
005)
C
ompu
ted
Tom
ogra
phy
(CT
) Es
timat
ed a
vera
ge
patie
nt d
ose
Estim
ated
effe
ctiv
e do
se
(mSv
)(If a
vaila
ble)
Ag
e an
d se
x di
stri
butio
n (%
)
0-15
yea
rs
16-4
0 ye
ars
>40
yea
rs
Exam
inat
ion
Estim
ated
num
ber o
f ex
amin
atio
ns
perf
orm
ed a
nnua
lly
(a)
CTD
I (vol
)±S
D
Mea
n ±S
D
Mal
e Fe
mal
e M
ale
Fem
ale
Mal
e Fe
mal
e B
rain
Spin
e/M
uscu
lo-s
kele
tal
(Cer
vica
l, th
orax
, lum
bo-s
acra
l sp
ine)
C
hest
Abd
omen
Pe
lvis
Car
diac
CT
Oth
er:
……
……
……
……
……
T
OT
AL
of a
ll m
edic
al
exam
inat
ions
Bon
e M
iner
al D
ensi
ty (B
MD
)Es
timat
ed a
vera
ge
patie
nt d
ose
Estim
ated
effe
ctiv
e do
se (m
Sv)(I
f av
aila
ble)
Ag
e an
d se
x di
stri
butio
n (%
)
0-15
yea
rs
16-4
0 ye
ars
>40
yea
rs
Exam
inat
ion
Estim
ated
num
ber
of e
xam
inat
ions
pe
rfor
med
an
nual
ly (a
)
Entr
ance
surf
ace
Dos
e (m
Gy)
±SD
M
ean
±SD
M
ale
Fem
ale
Mal
e Fe
mal
e M
ale
Fem
ale
AP
Spin
e Le
ft H
ip /
Rig
ht H
ip
(a) I
f the
con
vent
iona
l/dig
ital m
ix is
not
kno
wn,
ple
ase
chec
k th
e bo
x an
d pu
t ent
ries i
n th
e Co
nven
tiona
l col
umn
UN
SCEA
R: F
orm
s/Su
rvey
/Dia
gnos
tic/2
005
3 of
3
Dia
gnos
tic X
-ray
Exa
min
atio
ns (Y
ear 2
006)
UN
SCEA
R: F
orm
s/Su
rvey
/Dia
gnos
tic/2
006
1 of
3
Gen
eral
X-r
ayEs
timat
ed n
umbe
r of
exam
inat
ions
pe
rfor
med
ann
ually
(a)
Estim
ated
ave
rage
pa
tient
dos
e
Estim
ated
effe
ctiv
e do
se (m
Sv)(I
f av
aila
ble)
Ag
e an
d se
x di
stri
butio
n (%
)
0-15
yea
rs
16-4
0 ye
ars
>40
yea
rs
Exam
inat
ion
Con
ven-
tiona
l D
igita
l
Entr
ance
surf
ace
Dos
e (m
Gy)
±SD
M
ean
±SD
M
ale
Fem
ale
Mal
e Fe
mal
e M
ale
Fem
ale
Che
st R
adio
grap
hy
Che
st P
A
Che
st L
AT
Lim
bs &
Joi
nts
Upp
er E
xtre
miti
es:
Han
d, W
rist,
Radi
us,
Uln
a, E
lbow
, Hum
erus
, Sh
ould
erL
ower
Ext
rem
ities
: Fo
ot, A
nkle
, Tib
ia,
Fibu
la, F
emur
, Kne
eSp
ine
Lum
bo-s
acra
l AP
Lum
bo-s
acra
l LA
T Th
orac
ic A
P Th
orac
ic L
AT
Cer
vica
l AP
Cer
vica
l LA
T Pe
lvis
/Hip
Sk
ull
AP
Lat
Oth
ers (
Tow
ne,
Cal
dwel
l, et
c)
Abd
omen
/KU
B
Dia
gnos
tic X
-ray
Exa
min
atio
ns (Y
ear 2
006)
UN
SCEA
R: F
orm
s/Su
rvey
/Dia
gnos
tic/2
006
2 of
3
Mam
mog
raph
yEs
timat
ed n
umbe
r of
exam
inat
ions
per
form
ed
annu
ally
(a)
Estim
ated
ave
rage
pat
ient
do
se
Estim
ated
effe
ctiv
e do
se
(mSv
)(If a
vaila
ble)
Ag
e an
d se
x di
stri
butio
n (%
)
Exam
inat
ion
Con
vent
iona
l D
igita
l M
ean
glan
dula
r dos
e(m
Gy)
±S
DM
ean
±SD
16-4
0 ye
ars
>40
yea
rs
Scre
enin
g C
linic
al d
iagn
osis
Fluo
rosc
opy
Estim
ated
ave
rage
pat
ient
dos
e Es
timat
ed e
ffect
ive
dose
(mSv
)(If
avai
labl
e)
Age
and
sex
dist
ribu
tion
(%)
0-15
yea
rs
16-4
0 ye
ars
>40
yea
rs
Exam
inat
ion
Estim
ated
nu
mbe
r of
exam
inat
ions
pe
rfor
med
an
nual
ly (a
)Pe
ak S
kin
Dos
e (m
Gy)
±S
D
Ker
ma
Area
Prod
uct
(Gyc
m2 )
±SD
M
ean
±SD
M
ale
Fem
ale
Mal
e Fe
mal
e M
ale
Fem
ale
Ang
iogr
aphy
(Dia
gnos
tic)
Car
diac
Non
-car
diac
C
onve
ntio
nal S
tudi
es
Upp
er G
astro
inte
stin
al
Low
er G
astro
inte
stin
al
MC
UER
CP
Cho
lecy
stog
raph
y U
rogr
aphy
In
terv
entio
nal
Car
diac
(PTC
A)
Cer
ebra
lV
ascu
lar
ESW
L O
ther
s
Dia
gnos
tic X
-ray
Exa
min
atio
ns (Y
ear 2
006)
C
ompu
ted
Tom
ogra
phy
(CT
) Es
timat
ed a
vera
ge
patie
nt d
ose
Estim
ated
effe
ctiv
e do
se
(mSv
)(If a
vaila
ble)
Ag
e an
d se
x di
stri
butio
n (%
)
0-15
yea
rs
16-4
0 ye
ars
>40
yea
rs
Exam
inat
ion
Estim
ated
num
ber o
f ex
amin
atio
ns
perf
orm
ed a
nnua
lly
(a)
CTD
I (vol
)±S
D
Mea
n ±S
D
Mal
e Fe
mal
e M
ale
Fem
ale
Mal
e Fe
mal
e B
rain
Spin
e/M
uscu
lo-s
kele
tal
(Cer
vica
l, th
orax
, lum
bo-s
acra
l sp
ine)
C
hest
Abd
omen
Pe
lvis
Car
diac
CT
Oth
er:
……
……
……
……
……
T
OT
AL
of a
ll m
edic
al
exam
inat
ions
Bon
e M
iner
al D
ensi
ty (B
MD
)Es
timat
ed a
vera
ge
patie
nt d
ose
Estim
ated
effe
ctiv
e do
se (m
Sv)(I
f av
aila
ble)
Ag
e an
d se
x di
stri
butio
n (%
)
0-15
yea
rs
16-4
0 ye
ars
>40
yea
rs
Exam
inat
ion
Estim
ated
num
ber
of e
xam
inat
ions
pe
rfor
med
an
nual
ly (a
)
Entr
ance
surf
ace
Dos
e (m
Gy)
±SD
M
ean
±SD
M
ale
Fem
ale
Mal
e Fe
mal
e M
ale
Fem
ale
AP
Spin
e Le
ft H
ip /
Rig
ht H
ip
(a) I
f the
con
vent
iona
l/dig
ital m
ix is
not
kno
wn,
ple
ase
chec
k th
e bo
x an
d pu
t ent
ries i
n th
e Co
nven
tiona
l col
umn
UN
SCEA
R: F
orm
s/Su
rvey
/Dia
gnos
tic/2
006
3 of
3
Dia
gnos
tic X
-ray
Exa
min
atio
ns (Y
ear 2
007)
UN
SCEA
R: F
orm
s/Su
rvey
/Dia
gnos
tic/2
007
1 of
3
Gen
eral
X-r
ayEs
timat
ed n
umbe
r of
exam
inat
ions
pe
rfor
med
ann
ually
(a)
Estim
ated
ave
rage
pa
tient
dos
e
Estim
ated
effe
ctiv
e do
se (m
Sv)(I
f av
aila
ble)
Ag
e an
d se
x di
stri
butio
n (%
)
0-15
yea
rs
16-4
0 ye
ars
>40
yea
rs
Exam
inat
ion
Con
ven-
tiona
l D
igita
l
Entr
ance
surf
ace
Dos
e (m
Gy)
±SD
M
ean
±SD
M
ale
Fem
ale
Mal
e Fe
mal
e M
ale
Fem
ale
Che
st R
adio
grap
hy
Che
st P
A
Che
st L
AT
Lim
bs &
Joi
nts
Upp
er E
xtre
miti
es:
Han
d, W
rist,
Radi
us,
Uln
a, E
lbow
, Hum
erus
, Sh
ould
erL
ower
Ext
rem
ities
: Fo
ot, A
nkle
, Tib
ia,
Fibu
la, F
emur
, Kne
eSp
ine
Lum
bo-s
acra
l AP
Lum
bo-s
acra
l LA
T Th
orac
ic A
P Th
orac
ic L
AT
Cer
vica
l AP
Cer
vica
l LA
T Pe
lvis
/Hip
Sk
ull
AP
Lat
Oth
ers (
Tow
ne,
Cal
dwel
l, et
c)
Abd
omen
/KU
B
Dia
gnos
tic X
-ray
Exa
min
atio
ns (Y
ear 2
007)
UN
SCEA
R: F
orm
s/Su
rvey
/Dia
gnos
tic/2
007
2 of
3
Mam
mog
raph
yEs
timat
ed n
umbe
r of
exam
inat
ions
per
form
ed
annu
ally
(a)
Estim
ated
ave
rage
pat
ient
do
se
Estim
ated
effe
ctiv
e do
se
(mSv
)(If a
vaila
ble)
Ag
e an
d se
x di
stri
butio
n (%
)
Exam
inat
ion
Con
vent
iona
l D
igita
l M
ean
glan
dula
r dos
e(m
Gy)
±S
DM
ean
±SD
16-4
0 ye
ars
>40
yea
rs
Scre
enin
g C
linic
al d
iagn
osis
Fluo
rosc
opy
Estim
ated
ave
rage
pat
ient
dos
e Es
timat
ed e
ffect
ive
dose
(mSv
)(If
avai
labl
e)
Age
and
sex
dist
ribu
tion
(%)
0-15
yea
rs
16-4
0 ye
ars
>40
yea
rs
Exam
inat
ion
Estim
ated
nu
mbe
r of
exam
inat
ions
pe
rfor
med
an
nual
ly (a
)Pe
ak S
kin
Dos
e (m
Gy)
±S
D
Ker
ma
Area
Prod
uct
(Gyc
m2 )
±SD
M
ean
±SD
M
ale
Fem
ale
Mal
e Fe
mal
e M
ale
Fem
ale
Ang
iogr
aphy
(Dia
gnos
tic)
Car
diac
Non
-car
diac
C
onve
ntio
nal S
tudi
es
Upp
er G
astro
inte
stin
al
Low
er G
astro
inte
stin
al
MC
UER
CP
Cho
lecy
stog
raph
y U
rogr
aphy
In
terv
entio
nal
Car
diac
(PTC
A)
Cer
ebra
lV
ascu
lar
ESW
L O
ther
s
Dia
gnos
tic X
-ray
Exa
min
atio
ns (Y
ear 2
007)
C
ompu
ted
Tom
ogra
phy
(CT
) Es
timat
ed a
vera
ge
patie
nt d
ose
Estim
ated
effe
ctiv
e do
se
(mSv
)(If a
vaila
ble)
Ag
e an
d se
x di
stri
butio
n (%
)
0-15
yea
rs
16-4
0 ye
ars
>40
yea
rs
Exam
inat
ion
Estim
ated
num
ber o
f ex
amin
atio
ns
perf
orm
ed a
nnua
lly
(a)
CTD
I (vol
)±S
D
Mea
n ±S
D
Mal
e Fe
mal
e M
ale
Fem
ale
Mal
e Fe
mal
e B
rain
Spin
e/M
uscu
lo-s
kele
tal
(Cer
vica
l, th
orax
, lum
bo-s
acra
l sp
ine)
C
hest
Abd
omen
Pe
lvis
Car
diac
CT
Oth
er:
……
……
……
……
……
T
OT
AL
of a
ll m
edic
al
exam
inat
ions
Bon
e M
iner
al D
ensi
ty (B
MD
)Es
timat
ed a
vera
ge
patie
nt d
ose
Estim
ated
effe
ctiv
e do
se (m
Sv)(I
f av
aila
ble)
Ag
e an
d se
x di
stri
butio
n (%
)
0-15
yea
rs
16-4
0 ye
ars
>40
yea
rs
Exam
inat
ion
Estim
ated
num
ber
of e
xam
inat
ions
pe
rfor
med
an
nual
ly (a
)
Entr
ance
surf
ace
Dos
e (m
Gy)
±SD
M
ean
±SD
M
ale
Fem
ale
Mal
e Fe
mal
e M
ale
Fem
ale
AP
Spin
e Le
ft H
ip /
Rig
ht H
ip
(a) I
f the
con
vent
iona
l/dig
ital m
ix is
not
kno
wn,
ple
ase
chec
k th
e bo
x an
d pu
t ent
ries i
n th
e Co
nven
tiona
l col
umn
UN
SCEA
R: F
orm
s/Su
rvey
/Dia
gnos
tic/2
007
3 of
3
Den
tal R
adio
logy
(Yea
r 200
5)
UN
SCEA
R: F
orm
s/ S
urve
y /D
enta
l/200
5
1
of 3
Den
tal R
adio
logy
Es
timat
ed a
vera
ge
patie
nt d
ose
Estim
ated
effe
ctiv
e do
se
(mSv
)(If a
vaila
ble)
Ag
e an
d se
x di
stri
butio
n (%
)
0-15
yea
rs
16-4
0 ye
ars
>40
yea
rs
Exam
inat
ion
Estim
ated
num
ber o
f ex
amin
atio
ns
perf
orm
ed a
nnua
lly
(a)
Entr
ance
surf
ace
Dos
e (m
Gy)
±S
D
Mea
n ±S
D
Mal
e Fe
mal
e M
ale
Fem
ale
Mal
e Fe
mal
e In
traor
al
Pano
ram
ic
Den
tal C
T
Den
tal R
adio
logy
(Yea
r 200
6)
UN
SCEA
R: F
orm
s/Su
rvey
/Den
tal/2
006
1 of
3
Den
tal R
adio
logy
Es
timat
ed a
vera
ge
patie
nt d
ose
Estim
ated
effe
ctiv
e do
se
(mSv
)(If a
vaila
ble)
Ag
e an
d se
x di
stri
butio
n (%
)
0-15
yea
rs
16-4
0 ye
ars
>40
yea
rs
Exam
inat
ion
Estim
ated
num
ber o
f ex
amin
atio
ns
perf
orm
ed a
nnua
lly
(a)
Entr
ance
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mal
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Mal
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mal
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traor
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Den
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Den
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7)
UN
SCEA
R: F
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007
1 of
3
Den
tal R
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Es
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Estim
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0-15
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Exam
inat
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Estim
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Entr
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Dos
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D
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D
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mal
e M
ale
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Mal
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mal
e In
traor
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ram
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tal C
T
UN
SCEA
R: F
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ISTR
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1
2
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5
6
7
8
9
Gen
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of S
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No.
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lice
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f Slic
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Com
pute
rT
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5
No.
of S
lice
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1
2
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5
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SCEA
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7
8
9
10
1
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2
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3
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K =
4
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5
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ESA
K =
1
2
3
4
Bon
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iner
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sity
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1
2
3
4
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tal
5
Rad
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ose
Equi
pmen
tSk
elet
alS
199
m-T
c M
DP
WB
Bon
e P
lana
r sci
ntig
raph
yTo
det
ect s
kele
tal l
esio
ns a
t the
ear
liest
pos
sibl
e S
PE
CT
Gam
ma
cam
era
with
time,
mon
itor t
he c
ours
e of
ske
leta
l dis
ease
and
plan
ar c
ollim
ator
.ev
alua
te m
etab
olic
act
ivity
of s
kele
tal l
esio
ns.
S2
99m
-Tc
MD
P L
ocal
ised
Bon
e P
lana
r sci
ntig
raph
ysa
me
as a
bove
sam
e as
abo
veS
399
m-T
c M
DP
Loc
alis
ed B
one
SP
EC
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me
as a
bove
sam
e as
abo
veS
499
m-T
c B
ilate
ral H
ip P
lana
r sci
ntig
raph
ysa
me
as a
bove
sam
e as
abo
veS
599
m-T
c M
DP
Bila
tera
l Hip
SP
EC
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me
as a
bove
sam
e as
abo
veS
699
m-T
c S
n co
lloid
WB
Bon
e M
arro
w s
tudy
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etec
t mar
row
spa
ce d
isea
se p
roce
sses
.sa
me
as a
bove
S7
99m
-Tc
Sn
collo
id L
ocal
ised
Bon
e M
arro
w s
tudy
sam
e as
abo
vesa
me
as a
bove
S8
99m
-Tc
MD
P B
one
Pin
hole
sci
ntig
raph
ysa
me
as it
em S
1G
amm
a ca
mer
a w
ithpi
nhol
e co
llim
ator
.S
999
m-T
c M
DP
Flo
w &
Equ
i. B
one
Pla
nar s
cint
igra
phy
sam
e as
item
S1
Gam
ma
cam
era
with
pla
nar
colli
mat
or.
Car
diov
ascu
lar
C1
99m
-Tc
MIB
I Exe
rcis
e M
yoca
rdia
l Per
fusi
on s
tudy
To a
sses
s re
gion
al a
nd g
loba
l myo
card
ial p
erfu
sion
SP
EC
T G
amm
a ca
mer
a w
ithfo
r dia
gnos
is a
nd m
anag
emen
t of c
oron
ary
arte
ry
plan
ar c
ollim
ator
.di
seas
e.C
299
m-T
c M
IBI D
P S
tress
Myo
card
ial P
erfu
sion
stu
dysa
me
as a
bove
sam
e as
abo
veC
399
m-T
c M
IBI R
est M
yoca
rdia
l Per
fusi
on s
tudy
sam
e as
abo
vesa
me
as a
bove
C4
99m
-Tc
RB
C R
est G
ated
Ven
tricu
logr
aphy
To e
xam
ine
the
func
tion
of th
e he
art's
cha
mbe
rs
SP
EC
T G
amm
a ca
mer
a w
ithin
clud
ing
vent
ricul
ar s
ize,
con
figur
atio
n an
d w
all
plan
ar c
ollim
ator
.m
otio
n.C
599
m-T
c R
BC
Exe
rcis
e G
ated
Ven
tricu
logr
aphy
sam
e as
abo
vesa
me
as a
bove
C6
99m
-Tc
RB
C R
est G
ated
SP
EC
T V
entri
culo
grap
hysa
me
as a
bove
sam
e as
abo
veC
799
m-T
c C
ardi
ac F
irst P
ass
stud
yTo
pro
vide
qua
ntita
tive,
sem
i-qua
ntita
tive
and
Gam
ma
cam
era
with
pla
nar
qual
itativ
e in
dice
s of
car
diac
func
tion
and
anat
omic
co
llim
ator
.in
form
atio
n.C
899
m-T
c C
ardi
ac G
ated
Firs
t Pas
s st
udy
sam
e as
abo
vesa
me
as a
bove
C9
99m
-Tc
PY
P M
yoca
rdia
l Inf
arct
Pla
nar s
cint
igra
phy
Loca
lizat
ion
of a
cute
myo
card
ial i
nfar
ctio
n.sa
me
as a
bove
C10
99m
-Tc
PY
P M
yoca
rdia
l Inf
arct
SP
EC
T sc
intig
raph
ysa
me
as it
em C
9S
PE
CT
Gam
ma
cam
era
with
plan
ar c
ollim
ator
.C
1120
1-Tl
Exe
rcis
e M
yoca
rdia
l Per
fusi
on s
tudy
sam
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item
C1
sam
e as
abo
veC
1220
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DP
Stre
ss M
yoca
rdia
l Per
fusi
on s
tudy
sam
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item
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sam
e as
abo
veC
1320
1-Tl
Red
istri
butio
n M
yoca
rdia
l Per
fusi
on s
tudy
sam
e as
item
C1
sam
e as
abo
veC
1420
1-Tl
24h
r Red
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butio
n M
yoca
rdia
l Per
fusi
on s
tudy
sam
e as
item
C1
sam
e as
abo
veC
1520
1-Tl
24h
r (R
e-in
j) R
edis
tr. M
yoca
rdia
l Per
fusi
on
sam
e as
item
C1
sam
e as
abo
ve
Cod
eSt
udy
Purp
ose
Equi
pmen
tst
udy
C16
99m
-Tc
TET
Exe
rcis
e M
yoca
rdia
l Per
fusi
on s
tudy
sam
e as
item
C1
sam
e as
abo
veC
1799
m-T
c TE
T D
P S
tress
Myo
card
ial P
erfu
sion
stu
dysa
me
as it
em C
1sa
me
as a
bove
C18
99m
-Tc
TET
Res
t Myo
card
ial P
erfu
sion
stu
dysa
me
as it
em C
1sa
me
as a
bove
Cen
tral
Ner
vous
Sys
tem
B1
99m
-Tc
HM
PA
O C
ereb
ral P
erfu
sion
SP
EC
TTo
dia
gnos
e ab
norm
aliti
es o
f reg
iona
l cer
ebra
l blo
odS
PE
CT
Gam
ma
cam
era
with
flow
. pl
anar
col
limat
or.
B2
99m
-Tc
Bra
in B
lood
Flo
w s
tudy
Ass
ess
cere
bral
func
tion.
Gam
ma
cam
era
with
pla
nar
colli
mat
or.
B3
99m
-Tc
WB
C C
ereb
ral S
PE
CT
Det
ectio
n of
site
s of
foca
l inf
ectio
n.S
PE
CT
Gam
ma
cam
era
with
plan
ar c
ollim
ator
.B
499
m-T
c D
TPA
Pla
nar C
iste
rnog
raph
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sses
s C
SF
hydr
odyn
amic
s, d
eter
min
atio
n of
Gam
ma
cam
era
with
pla
nar
pate
ncy
of s
hunt
s or
intra
vent
ricul
ar b
lock
s.co
llim
ator
.B
599
m-T
c D
TPA
SP
EC
T C
iste
rnog
raph
ysa
me
as a
bove
SP
EC
T G
amm
a ca
mer
a w
ithpl
anar
col
limat
or.
Gas
troi
ntes
tinal
& H
epat
obili
ary
G1
99m
-Tc
Sn
collo
id O
esop
hage
al T
rans
it st
udy
Qua
ntita
te th
e m
otor
func
tion
of o
esop
hagu
s.G
amm
a ca
mer
a w
ith p
lana
rco
llim
ator
.G
299
m-T
c D
TPA
Gas
tric
Em
ptyi
ng T
ime
stud
yQ
uant
itatin
g ga
stric
em
ptyi
ng.
sam
e as
abo
veG
399
m-T
c M
ecke
l's D
iver
ticul
um s
cint
igra
phy
Loca
lizat
ion
of b
leed
ing
site
in e
ctop
ic g
astri
c sa
me
as a
bove
muc
osa.
G4
99m
-Tc
Sn
collo
id A
cute
Gas
troin
test
inal
Ble
ed
Loca
lizat
ion
of b
leed
ing
site
.sa
me
as a
bove
scin
tigra
phy
G5
99m
-Tc
RB
C G
astro
inte
stin
al B
leed
sci
ntig
raph
ysa
me
as a
bove
sam
e as
abo
veG
699
m-T
c B
RID
A H
epat
obili
ary
scin
tigra
phy
Ass
ess
bilia
ry tr
ee fu
nctio
n.
sam
e as
abo
veG
799
m-T
c S
n co
lloid
Acc
esso
ry S
plee
n sc
intig
raph
yTo
det
ect p
rese
nce
of a
cces
sory
spl
een
follo
win
g sa
me
as a
bove
scin
tigra
phy
sple
nect
omy.
G8
99m
-Tc
Hea
t Dam
aged
RB
C A
cces
sory
Spl
een
sam
e as
abo
vesa
me
as a
bove
scin
tigra
phy
G9
99m
-Tc
Sn
collo
id G
astro
inte
stin
al R
eflu
x st
udy
Eva
luat
e re
flux
oeso
phag
itis.
sam
e as
abo
veG
1099
m-T
c S
n co
lloid
Liv
er/S
plee
n P
lana
r sci
ntig
raph
yTo
del
inea
te v
ario
us s
tate
s of
live
r/spl
een
dise
ase.
sam
e as
abo
veG
1199
m-T
c S
n co
lloid
Liv
er/S
plee
n S
PE
CT
scin
tigra
phy
sam
e as
abo
veS
PE
CT
Gam
ma
cam
era
with
plan
ar c
ollim
ator
.G
1299
m-T
c R
BC
Liv
er B
lood
Poo
l Pla
nar s
cint
igra
phy
Loca
lizat
ion
of h
eman
giom
as.
Gam
ma
cam
era
with
pla
nar
colli
mat
or.
G13
99m
-Tc
RB
C L
iver
Blo
od P
ool S
PE
CT
scin
tigra
phy
sam
e as
abo
veS
PE
CT
Gam
ma
cam
era
with
plan
ar c
ollim
ator
.G
1499
m-T
c S
n co
lloid
Per
itone
al S
hunt
stu
dyTo
det
ect o
bstru
ctio
n of
LeV
een
shun
t.G
amm
a ca
mer
a w
ith p
lana
r
Cod
eSt
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Purp
ose
Equi
pmen
tco
llim
ator
.
Infe
ctio
n &
Onc
olog
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99m
-Tc
HM
PA
O L
euco
cyte
Pla
nar s
cint
igra
phy
Det
ect s
ites
of a
bsce
ss a
nd in
flam
mat
ion.
Gam
ma
cam
era
with
pla
nar
colli
mat
or.
I299
m-T
c W
BC
Leu
cocy
te s
cint
igra
phy
sam
e as
abo
vesa
me
as a
bove
I367
-Ga
WB
Pla
nar s
cint
igra
phy
Det
ect s
ites
of in
fect
ion
and
tum
ours
. sa
me
as a
bove
I467
-Ga
Loca
lised
SP
EC
Tsa
me
as a
bove
SP
EC
T G
amm
a ca
mer
a w
ithpl
anar
col
limat
or.
I567
-Ga
Loca
lised
Pla
nar s
cint
igra
phy
sam
e as
abo
veG
amm
a ca
mer
a w
ith p
lana
rco
llim
ator
.I6
131-
I WB
Pla
nar s
cint
igra
phy
To d
etec
t met
asta
sis
from
thyr
oid
canc
ers.
sam
e as
abo
veI7
131-
I Loc
alis
ed P
lana
r sci
ntig
raph
ysa
me
as a
bove
sam
e as
abo
veI8
131-
I Loc
alis
ed S
PE
CT
sam
e as
abo
veS
PE
CT
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ma
cam
era
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plan
ar c
ollim
ator
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75-S
e S
elen
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orch
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teno
l Adr
enal
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caliz
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ympa
thom
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amm
a ca
mer
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ith p
lana
rsc
intig
raph
ydi
seas
e.co
llim
ator
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013
1-I M
IBG
WB
Pla
nar s
cint
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phy
Det
ect p
rese
nce
of a
dren
al p
heoc
hrom
ocyt
oma,
sam
e as
abo
veex
tra-a
dren
al m
etas
tatic
dep
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and
cate
chol
amin
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ting
tum
ours
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113
1-I M
IBG
Loc
alis
ed S
PE
CT
sam
e as
abo
veS
PE
CT
Gam
ma
cam
era
with
plan
ar c
ollim
ator
.I1
213
1-I M
IBG
Loc
alis
ed P
lana
r sci
ntig
raph
ysa
me
as a
bove
Gam
ma
cam
era
with
pla
nar
colli
mat
or.
I13
99m
-Tc
V-D
MS
A W
B P
lana
r sci
ntig
raph
yTo
det
ect m
edul
lary
car
cino
ma.
sam
e as
abo
veI1
413
1-I L
ocal
ised
Pin
hole
sci
ntig
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thyr
oid
glan
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amm
a ca
mer
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ith p
inho
leco
llim
ator
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567
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Loca
lised
Pin
hole
sci
ntig
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me
as it
em I5
sam
e as
abo
veI1
699
m-T
c H
MP
AO
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cocy
te S
PE
CT
sam
e as
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PE
CT
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ma
cam
era
with
plan
ar c
ollim
ator
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799
m-T
c H
MP
AO
Leu
cocy
te W
B P
lana
r sci
ntig
raph
ysa
me
as it
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Gam
ma
cam
era
with
pla
nar
colli
mat
or.
I18
99m
-Tc
HM
PA
O L
euco
cyte
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hole
sci
ntig
raph
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me
as it
em I1
Gam
ma
cam
era
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pin
hole
colli
mat
or.
I19
111-
In P
ente
treot
ide
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lised
SP
EC
TLo
caliz
atio
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prim
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and
met
asta
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euro
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PE
CT
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ma
cam
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endo
crin
e tu
mou
rs b
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mat
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tin re
cept
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plan
ar c
ollim
ator
.I2
011
1-In
Pen
tetre
otid
e W
B P
lana
r sci
ntig
raph
ysa
me
as a
bove
Gam
ma
cam
era
with
pla
nar
colli
mat
or.
I21
111-
In P
ente
treot
ide
Loca
lised
Pla
nar s
cint
igra
phy
sam
e as
abo
vesa
me
as a
bove
I22
99m
-Tc
Tetro
fosm
in O
steo
sarc
oma
scin
tigra
phy
To d
etec
t ost
eosa
rcom
asa
me
as a
bove
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eSt
udy
Purp
ose
Equi
pmen
tI2
320
1-Tl
Ost
eosa
rcom
a sc
intig
raph
ysa
me
as a
bove
sam
e as
abo
veI2
499
m-T
c TE
T Tu
mou
r WB
sci
ntig
raph
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caliz
atio
n of
mal
igna
nt tu
mou
rs.
sam
e as
abo
veI2
599
m-T
c TE
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mou
r SP
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me
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bove
SP
EC
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ithpl
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limat
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I26
99m
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Tum
our P
lana
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ntig
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ysa
me
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bove
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ma
cam
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pla
nar
colli
mat
or.
I28
99m
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t SP
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caliz
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sam
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999
m-T
c N
anoc
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ymph
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emon
stra
te h
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ular
tiss
ue o
f ret
rope
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eal,
sam
e as
abo
veax
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y, p
aras
tern
al a
nd c
ervi
cal l
ymph
nod
es.
I30
99m
-Tc
Sci
ntim
un G
ranu
locy
tesa
me
as it
em I1
sam
e as
abo
ve
Lacr
ymal
& S
aliv
ary
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m-T
c D
acry
o P
lana
r sci
ntig
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yD
efin
e pa
tenc
y of
lacr
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duc
t.G
amm
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mer
a w
ith p
lana
rco
llim
ator
.L2
99m
-Tc
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ivar
y G
land
sci
ntig
raph
yTo
est
ablis
h fu
nctio
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sal
ivar
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and.
sa
me
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bove
L399
m-T
c S
aliv
ary
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nd P
inho
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cint
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sam
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abo
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mer
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ith p
inho
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gas
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dis
tingu
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ted
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sion
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ects
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ma
cam
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pla
nar
thos
e se
cond
ary
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ulm
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boliz
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llim
ator
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299
m-T
c M
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valu
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mon
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lood
flow
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me
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bove
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99m
-Tc
DTP
A R
adio
aero
sol L
ung
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tilat
ion
stud
ysa
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em P
1sa
me
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bove
P4
99m
-Tc
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nega
s Lu
ng V
entil
atio
n S
PE
CT
sam
e as
item
P1
SP
EC
T G
amm
a ca
mer
a w
ithpl
anar
col
limat
or.
P5
99m
-Tc
MA
A P
erfu
sion
SP
EC
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me
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em P
2sa
me
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bove
Ren
al &
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ary
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199
m-T
c D
TPA
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retic
Ren
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tudy
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sitiv
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tive
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l blo
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ow,
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ma
cam
era
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pla
nar
glom
erul
ar fi
ltrat
ion,
tubu
lar f
unct
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urin
ary
colli
mat
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excr
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299
m-T
c D
TPA
Ren
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rans
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abo
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TPA
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il E
nhan
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Ren
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vesa
me
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bove
R4
99m
-Tc
DM
SA
Ren
al P
lana
r stu
dyE
valu
atio
n of
func
tioni
ng c
ortic
al re
nal p
aren
chym
asa
me
as a
bove
R5
99m
-Tc
DM
SA
Ren
al S
PE
CT
sam
e as
abo
veS
PE
CT
Gam
ma
cam
era
with
plan
ar c
ollim
ator
.R
699
m-T
c D
TPA
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tura
ting
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tosc
intig
raph
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anag
emen
t of v
esic
oure
tera
l ref
lux
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ma
cam
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pla
nar
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ct m
etho
d)co
llim
ator
.R
799
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c D
TPA
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tura
ting
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tosc
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y sa
me
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bove
sam
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abo
ve(In
dire
ct m
etho
d)R
899
m-T
c M
AG
3 R
enal
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dysa
me
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bove
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udy
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ose
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pmen
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999
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mer
ular
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ate
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imat
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lom
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ar fi
ltrat
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rate
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ma
wel
l cou
nter
R10
99m
-Tc/
51-C
r ED
TA G
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me
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bove
sam
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abo
ve
Thyr
oid
& P
arat
hyro
idT1
99m
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oid
scin
tigra
phy
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efin
e fu
nctio
ning
ben
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thyr
oid
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d to
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ma
cam
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pla
nar
dete
ct p
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nce
and
loca
tion
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etas
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m
colli
mat
or.
thyr
oid
canc
er.
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hyro
id s
cint
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phy
sam
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abo
veT3
131-
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stud
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valu
ate
thyr
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nctio
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131-
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chlo
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asG
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mer
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ith p
lana
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llim
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athy
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ntig
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abo
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oid
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ma
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plan
ar c
ollim
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athy
roid
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ntig
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em T
5G
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mer
a w
ith p
lana
rco
llim
ator
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ers
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illin
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st (V
itam
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12 m
alab
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tion)
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iffer
entia
te m
alab
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rom
e fro
m
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ma
wel
l cou
nter
pern
icio
us a
naem
ia.
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lood
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est
imat
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cell
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est
imat
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asm
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lum
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me
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bove
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r Red
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l Sur
viva
l & S
eque
stra
tion
stud
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det
erm
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func
tiona
l hal
f cle
aran
ce ti
me
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ma
wel
l cou
nter
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ptak
e la
belle
d is
olog
ous
red
cells
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life
spa
n of
red
cells
prob
e.in
hae
mol
ytic
ana
emia
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adio
nucl
ide
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apy
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py fo
r thy
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ide
dose
cal
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tor
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eta
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roph
ylac
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ost-o
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ntiu
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rapy
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ontro
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etas
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adio
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ide
dose
cal
ibra
tor
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m th
erap
ysa
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bove
sam
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abo
veZ6
131-
I Hig
h D
ose
abla
tion
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tmen
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hyro
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ance
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eval
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erap
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eatm
ent f
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r ref
ract
ory,
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gra
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r sa
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on H
odgk
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lym
phom
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mic
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erap
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elec
tive
inte
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atio
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erap
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r liv
er c
ance
r.sa
me
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bove
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8-R
e th
erap
yTr
eatm
ent f
or d
isse
min
ated
ske
leta
l met
asta
sis.
sam
e as
abo
ve
UNSCEAR: Forms/Background/Nuclear Medicine/1.0 1 of 2
MINISTRY OF HEALTH UNSCEAR SURVEY PROJECT
Nuclear Medicine
Hospital:
Nuclear Medicine Physicians: Years Nuclear Medicine Physicians
2005 (a)
(b)
(c)
(d)
(e)
2006 (a)
(b)
(c)
(d)
(e)
2007 (a)
(b)
(c)
(d)
(e)
Personnel:
Number of Personnel
2005 2006 2007
Nuclear Medicine Physicians:
Medical Physicists
Nuclear Medicine Technologist
Modality:
Gamma Camera
Model Manufacturer
PET
Model Manufacturer
UNSCEAR: Forms/Background/Nuclear Medicine/1.0 2 of 2
PET/CT
Model Manufacturer
Name of individual completing the form
E-mail address
NU
CLE
AR
MED
ICIN
E: D
IAG
NO
STIC
D
OSE
SU
RVE
Y FO
RM
Hos
pita
l:
Dat
e of
Sur
vey:
Pat
ient
Dat
a:
Dat
e of
ex
amin
atio
n(d
d/m
m/y
y)
Exa
m N
ame
Sca
nnin
g R
oom
No
Pat
ient
ID
Sex
/ A
ge
Eth
nic
grou
p W
eigh
t /
Hei
ght
( kg
/ cm
)
Rad
io-
phar
mac
eutic
al
Activ
ity
(mC
i) E
ffect
ive
Dos
e (m
Sv)
Rem
arks
//
//
//
//
//
//
//
//
//
//
Lege
nd:
Exa
m n
ame:
BO
- B
one,
BR
- B
rain
, C -
Car
diac
, G -
Gas
troen
tero
logy
, LP
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ng P
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sion
, LV
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entil
atio
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- R
enal
, T -
Thyr
oid,
oth
ers
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: M-m
ale,
F-fe
mal
e E
thni
c gr
oup:
M-M
alay
, C-C
hine
se, I
-Indi
an, O
-oth
ers
UN
SCEA
R: F
orm
s/N
ucle
ar M
edic
ine:
Dia
gnos
tic/1
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NU
CLE
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MED
ICIN
E: T
HER
APE
UTI
C
DO
SE S
UR
VEY
FOR
M
Hos
pita
l:
Dat
e of
Sur
vey:
Pat
ient
Dat
a:
Dat
e of
Tr
eatm
ent
(dd/
mm
/yy)
Trea
tmen
t Nam
e Tr
eatm
ent
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m N
o P
atie
nt ID
S
ex /
Age
E
thni
cgr
oup
Wei
ght /
H
eigh
t ( k
g / c
m)
Rad
io-
phar
mac
eutic
al
Activ
ity
(mC
i) E
ffect
ive
Dos
e (m
Sv)
Rem
arks
//
//
//
//
//
//
//
//
//
//
Lege
nd:
Trea
tmen
t nam
e: B
M -
Bon
e m
etas
tase
s, H
T - H
yper
thyr
oidi
sm,
PV
- P
olyc
ytha
emia
ver
a, S
Y - S
ynov
itis,
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d m
alig
nanc
y,
othe
rs
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: M-m
ale,
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mal
e E
thni
c gr
oup:
M-M
alay
, C-C
hine
se, I
-Indi
an, O
-oth
ers
UN
SCEA
R: F
orm
s/N
ucle
ar M
edic
ine:
The
rape
utic
/1.1
NU
CLE
AR
MED
ICIN
E: P
ET-C
T D
OSE
SU
RVE
Y FO
RM
Hos
pita
l:
Roo
m:
Dat
e of
sur
vey:
Pat
ient
Dat
a:
CT
prot
ocol
D
ate
of
exam
.(d
d/m
m/y
y)
Pat
ient
ID
Sex
/ A
geE
thni
cgr
oup
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ght /
H
eigh
t ( k
g / c
m)
Clin
ical
in
dica
tion
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ity
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8-FD
G(m
Ci)
kV
mAs
R
ot.
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)
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ick
Pitc
hSc
an
leng
th(m
m)
Sca
nre
gion
Effe
ctiv
e D
ose
(mS
v)
//
//
//
//
//
//
//
//
//
//
Lege
nd:
Sex
: M-m
ale,
F-fe
mal
e E
thni
c gr
oup:
M-M
alay
, C-C
hine
se, I
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-oth
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. S/th
ickn
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for S
SC
T =
slic
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ickn
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SC
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no. o
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e X
slic
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ickn
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h =
tabl
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vel d
ista
nce
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ickn
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n le
ngth
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nd s
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art s
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us s
ign
mus
t be
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clud
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can
regi
on: A
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bdom
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rain
pos
terio
r fos
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rain
, C -
Che
st, P
F - P
oste
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ossa
, N -
Nec
k, P
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elvi
s, o
ther
s
UN
SCEA
R: F
orm
s/N
ucle
ar M
edic
ine:
PET
-CT/
1.1
Nuc
lear
Med
icin
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oced
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r 200
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yea
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Exam
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Estim
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AT
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troen
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inat
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ER
APE
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IC T
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AT
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l
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TA
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f all
treat
men
ts
UN
SCEA
R: F
orm
s/Su
rvey
/Nuc
lear
Med
icin
e/20
05
1 of
1
Nuc
lear
Med
icin
e Pr
oced
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r 200
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and
sex
dist
ribu
tion
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yea
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Exam
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t com
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ean
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mal
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mal
e
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IC E
XA
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AT
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ardi
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oid
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al
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TA
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ions
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APE
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UN
SCEA
R: F
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edic
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2006
1 of
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lear
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oced
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r 200
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Exam
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mal
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AT
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APE
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RE
AT
ME
NT
S
Thyr
oid
mal
igna
ncy
Hyp
erth
yroi
dism
Poly
cyth
aem
ia v
era
Bon
em
etas
tase
s
Syno
vitis
Oth
er: e
.g. 90
YC
l
TO
TA
L o
f all
treat
men
ts
UN
SCEA
R: F
orm
s/ S
urve
y /N
ucle
ar M
edic
ine/
2007
1 of
1
Tabl
e15
Typi
cale
ffect
ive
dose
sto
patie
nts
unde
rgoi
ngso
me
com
mon
type
sof
diag
nost
icm
edic
ala
x-ra
ypr
oced
ures
(199
119
96)
Data
from
UNSC
EAR
Surv
eyof
Med
icalR
adia
tion
Usag
ean
dEx
posu
res
unle
ssot
herw
isein
dica
ted
PA
RT
A
Cou
ntry
Typi
cale
ffect
ive
dose
perp
roce
dure
b(m
Sv)
Che
stLi
mbs
and
join
ts
Spin
ePe
lvis
and
hips
Hea
dAb
dom
enG
Itra
ctC
hole
-cy
sto-
grap
hyRa
dio-
grap
hyPh
oto-
fluor
ogra
phy
Fluo
ro-
scop
yLu
mba
rTh
orac
icC
ervi
cal
Upp
erLo
wer
Heal
th-c
are
leve
lI
Aus
tralia
0.02
5(±
0.00
8)c
2 (±1)
0.6
1(±
0.7)
Bel
arus
0.25
(30
50%
)0.
5(3
050
%)
1.0
(30-
50%
)0.
2(3
0-50
%)
1.1
(30-
50%
)1.
6(±
30-5
0%)
1.1
(30-
50%
)1.
1(3
0-50
%)
0.12
(30-
50%
)1.
4(3
0-50
%)
0.6
(30-
50%
)1
(30-
50%
)0.
2(3
0-50
%)
Bul
garia
0.16
(0.0
4-0.
18)
0.91
(0.7
71.
05)
1.85
(1.6
2.1)
Chin
a,Ta
iwan
Prov
.0.
020.
480.
193.
84.
1
Cze
chR
epub
lic0.
050.
72
1.76
0.28
1.26
0.28
33
8.5
1.26
Finl
and
0.1
2.3
10.
21.
30.
12.
29
9.7
Ger
man
y0.
3(0
.01
5.5)
0.06
(0.0
01-0
.5)
20.
70.
20.
8(0
.1-4
.8)
0.03
(0.0
01-0
.7)
1.2
(0.1
-5.3
)8.
3(0
.1-3
8)17
.7(0
.2-8
5)7.
1(0
.7-3
6)
Japa
n0.
057
0.05
31.
141.
450.
650.
260.
580.
090.
243.
332.
680.
88
Net
herla
nds
0.06
(±0.
08)
21
11
0.1
16.
4(±
3.4)
4.7
(±2.
4)
New
Zeal
and
510
Nor
way
0.13
0.23
1.1
0.5
0.2
0.5
0.2
14
8
Pana
ma
0.02
1(±
0.01
3)0.
003
(±0.
003)
2.17
(±1.
0)1.
20(±
0.43
)0.
07(±
0.01
)0.
44(±
0.13
)0.
045
(±0.
02)
0.30
(±0.
12)
6.9
(±2.
9)3.
12(±
0.76
)0.
87(±
0.14
)
Pola
nd0.
110.
824.
10.
024.
333.
030.
610.
12.
214
22.7
Rom
ania
0.25
(±0.
11)
0.63
(±0.
3)0.
95(±
0.4)
0.08
(±0.
03)
3(±
1.4)
2.1
(±1.
2)0.
21(±
0.1)
2.6
0.17
(±0.
12)
1.9
(±1)
4.1
(±1.
9)9
(±3.
8)1.
6(±
0.9)
ANNEX D: MEDICAL RADIATION EXPOSURES374
Tabl
e15
(con
tinue
d)
Cou
ntry
Typi
cale
ffect
ive
dose
perp
roce
dure
b(m
Sv)
Che
stLi
mbs
and
join
ts
Spin
ePe
lvis
and
hips
Hea
dAb
dom
enG
Itra
ctC
hole
-cy
sto-
grap
hyRa
dio-
grap
hyPh
oto-
fluor
ogra
phy
Fluo
ro-
scop
yLu
mba
rTh
orac
icC
ervi
cal
Upp
erLo
wer
Rus
sian
Fede
ratio
n0.
40.
673.
3
Swed
en0.
150.
13
10.
21.
50.
12.
53
86
Switz
erla
nd0.
1(±
0.03
)0.
5(±
0.2)
0.2
(±0.
1)0.
05(±
0.05
)1.
5(±
0.5)
0.8
(±0.
5)0.
2(±
0.2)
1(±
0.5)
0.1
(±0.
1)0.
5(±
0.3)
5 (±4)
5 (±4)
8 (±4)
Uni
ted
Ara
bEm
irate
s0.
059
0.01
8(0
.011
-0.0
28)
0.47
0.35
0.28
0.35
(0.1
1-0.
67)
1.06
0.43
4.4
9.8
Uni
ted
Kin
gdom
0.02
1.3
0.7
0.7
0.04
0.7
2.6
7.2
Ave
rage
d0.
140.
651.
080.
061.
81.
40.
270.
830.
070.
533.
66.
42.
3
Heal
th-c
are
leve
lII
Bra
zil
0.05
30.
5(±
0.36
)
Mal
aysia
[N26
]0.
030.
041.
040.
460.
030.
740.
041.
056
1.5
Ave
rage
0.05
0.04
1.0
0.46
0.03
0.74
0.04
0.62
61.
5
PA
RT
B
Cou
ntry
Typi
cale
ffect
ive
dose
perp
roce
dure
(mSv
)
Uro
grap
hyM
amm
ogra
phy
Com
pute
dto
mog
raph
yAn
giog
raph
yPT
CA
Tota
lofa
llm
edic
alex
amin
atio
nsSc
reen
ing
Clin
ical
All
Hea
dBo
dyAl
lC
ereb
ral
Car
diac
All
Heal
thca
rele
velI
Aus
tralia
0.4
(±0.
16)
2.6
(±2.
0)10
.6(±
7.5)
6.9
1.33
Bel
arus
2(±
30-5
0%)
Bul
garia
1.28
Can
ada
1.05
ANNEX D: MEDICAL RADIATION EXPOSURES 375
Tabl
e15
(con
tinue
d)
Cou
ntry
Typi
cale
ffect
ive
dose
perp
roce
dure
b(m
Sv)
Che
stLi
mbs
and
join
ts
Spin
ePe
lvis
and
hips
Hea
dAb
dom
enG
Itra
ctC
hole
-cy
sto-
grap
hyRa
dio-
grap
hyPh
oto-
fluor
ogra
phy
Fluo
ro-
scop
yLu
mba
rTh
orac
icC
ervi
cal
Upp
erLo
wer
Rus
sian
Fede
ratio
n0.
40.
673.
3
Swed
en0.
150.
13
10.
21.
50.
12.
53
86
Switz
erla
nd0.
1(±
0.03
)0.
5(±
0.2)
0.2
(±0.
1)0.
05(±
0.05
)1.
5(±
0.5)
0.8
(±0.
5)0.
2(±
0.2)
1(±
0.5)
0.1
(±0.
1)0.
5(±
0.3)
5 (±4)
5 (±4)
8 (±4)
Uni
ted
Ara
bEm
irate
s0.
059
0.01
8(0
.011
-0.0
28)
0.47
0.35
0.28
0.35
(0.1
1-0.
67)
1.06
0.43
4.4
9.8
Uni
ted
Kin
gdom
0.02
1.3
0.7
0.7
0.04
0.7
2.6
7.2
Ave
rage
d0.
140.
651.
080.
061.
81.
40.
270.
830.
070.
533.
66.
42.
3
Heal
th-c
are
leve
lII
Bra
zil
0.05
30.
5(±
0.36
)
Mal
aysia
[N26
]0.
030.
041.
040.
460.
030.
740.
041.
056
1.5
Ave
rage
0.05
0.04
1.0
0.46
0.03
0.74
0.04
0.62
61.
5
PA
RT
B
Cou
ntry
Typi
cale
ffect
ive
dose
perp
roce
dure
(mSv
)
Uro
grap
hyM
amm
ogra
phy
Com
pute
dto
mog
raph
yAn
giog
raph
yPT
CA
Tota
lofa
llm
edic
alex
amin
atio
nsSc
reen
ing
Clin
ical
All
Hea
dBo
dyAl
lC
ereb
ral
Car
diac
All
Heal
thca
rele
velI
Aus
tralia
0.4
(±0.
16)
2.6
(±2.
0)10
.6(±
7.5)
6.9
1.33
Bel
arus
2(±
30-5
0%)
Bul
garia
1.28
Can
ada
1.05
ANNEX D: MEDICAL RADIATION EXPOSURES 375
ANNEX D: MEDICAL RADIATION EXPOSURES376
Tabl
e15
(con
tinue
d)
Cou
ntry
Typi
cale
ffect
ive
dose
perp
roce
dure
(mSv
)
Uro
grap
hyM
amm
ogra
phy
Com
pute
dto
mog
raph
yAn
giog
raph
yPT
CA
Tota
lofa
llm
edic
alex
amin
atio
nsSc
reen
ing
Clin
ical
All
Hea
dBo
dyAl
lC
ereb
ral
Car
diac
All
Chi
na,T
aiw
anPr
ov.
0.43
Cze
chR
epub
lic2.
040.
51.
19.
23.
82.
83.
67.
3
Den
mar
k0.
7
Finl
and
4.5
0.1
0.2
1.3
7.9
3.8
14.8
0.64
Ger
man
y4.
9(0
.219
)0.
5(0
.12)
2.6
(15)
15.4
(450
)11
.312
.3(1
190)
23(1
190)
1.5
(0.0
0119
0)
Japa
n2.
475.
56
Net
herla
nds
40.
1e
0.1
0.1
e1.
7e
10.2
e6.
7e
5e
5e
5e
1.0
e
New
Zeal
and
0.07
(±0.
02)
2.2
(±1.
1)7.
8(±
4)12
.3(±
5.4)
16.2
(±9.
2)
Nor
way
20.
122
106.
5
Pana
ma
2.07
(±0.
39)
0.24
(±0.
11)
1.06
(±0.
12)
3.8
(±0.
51)
2.1
3.7
(±1.
1)
Pola
nd3.
11
(±0.
3)3.
525
71.
2
Portu
gal
0.83
Rom
ania
5.8
(±2.
9)0.
62(±
0.3)
0.22
1.35
(±0.
63)
Rus
sian
Fede
ratio
n0.
560.
45.
80.
73
Swed
en5
0.1
0.2
210
5.8
112
9.2
221.
2
Switz
erla
nd4 (±2)
0.1
(±0.
1)2 (±1)
5 (±2)
3.9
2 (±1)
10 (±1)
6.7
100.
8(±
0.4)
Ukr
aine
0.83
Uni
ted
Ara
bEm
irate
s2.
660.
130.
11(0
.01
0.14
)2.
62(1
.75
3.3)
9.83
(6.8
11.8
)
Uni
ted
Kin
gdom
2.4
0.06
29
6
Tabl
e15
(con
tinue
d)
Cou
ntry
Typi
cale
ffect
ive
dose
perp
roce
dure
(mSv
)
Uro
grap
hyM
amm
ogra
phy
Com
pute
dto
mog
raph
yAn
giog
raph
yPT
CA
Tota
lofa
llm
edic
alex
amin
atio
nsSc
reen
ing
Clin
ical
All
Hea
dBo
dyAl
lC
ereb
ral
Car
diac
All
aEx
clud
ing
dent
alx-
ray
exam
inat
ions
.b
Var
iatio
nssh
own
inbr
acke
ts(s
tand
ard
devi
atio
n,co
effic
ient
ofva
riatio
nor
rang
e).
cN
oda
taav
aila
ble.
dFr
eque
ncy-
wei
ghte
dav
erag
eof
natio
nalv
alue
s.e
Thes
ere
vise
dda
taw
ere
rece
ived
byth
eC
omm
ittee
afte
rcom
plet
ion
ofth
egl
obal
anal
ysis.
Uni
ted
Kin
gdom
2.4
0.06
29
6
Uni
ted
Stat
es0.
52
Ave
rage
3.7
0.07
0.21
0.51
2.3
13.3
8.8
2.0
7.3
12.4
220.
83
Heal
th-c
are
leve
lII
Bra
zil
3.89
(±2.
8)0.
26
Chi
na[Z
10]
0.57
Mal
aysia
[N26
]2.
40.
10.
12.
87.
84.
96.
86.
80.
28
Ave
rage
3.9
0.1
0.1
2.8
7.8
4.9
6.8
6.8
0.56
The
entri
esin
this
Tabl
ear
equ
alifi
edas
follo
ws:
Braz
il:Su
rvey
data
forP
aran
áSt
ate
(with
apo
pula
tion
of9
mill
ion
and
aso
cial
and
econ
omic
prof
ileab
ove
the
aver
age
forB
razi
l).C
hina
(Tai
wan)
:Dat
afo
rlum
bars
pine
,GIt
ract
and
tota
lofa
llm
edic
alex
amin
atio
nsfro
mre
fere
nce
[L23
].G
erm
any:
Mea
nef
fect
ive
dose
forg
ener
alcl
assif
icat
ion
ofsp
ine
is1.
2m
Sv(r
ange
:0.1
20m
Sv).
Mal
aysi
a:D
ata
forc
hest,
spin
ean
dhe
adre
fert
oA
P/PA
proj
ectio
ns.D
ata
for‘
GIt
ract
’rel
ate
tobo
th‘U
pper
’and
‘Low
er’c
ateg
orie
s.N
orwa
y:D
ata
from
natio
nals
urve
yin
volv
ing
abou
t50
hosp
itals
and
5000
mea
sure
men
ts.Ro
man
ia:
Add
ition
alsu
rvey
data
inre
latio
nto
‘Che
stflu
oros
copy
’:m
ean
entra
nce
surfa
cedo
seof
13.4
mG
yan
dm
ean
dose
-are
apr
oduc
tof3
.6m
Gy
cm2
[I28
].Ru
ssia
:A
dditi
onal
surv
eyda
tain
rela
tion
toef
fect
ive
dose
sfro
m‘C
hest
fluor
osco
py’:
dose
rate
swith
outa
ndw
ithel
ectro
nic
imag
ein
tens
ifica
tion
of1.
4m
Svpe
rmin
ute
and
0.9
mSv
perm
inut
e,re
spec
tivel
y.D
ata
show
nfo
r‘G
Itra
ct’r
elat
eto
both
‘Upp
er’a
nd‘L
ower
’cat
egor
ies.
Effe
ctiv
edo
sera
tesf
rom
fluor
osco
pyw
ithou
tand
with
elec
troni
cim
age
inte
nsifi
catio
nof
4.2
mSv
perm
inut
ean
d2.
3m
Svpe
rmin
ute,
resp
ectiv
ely
durin
gup
perG
Iexa
min
atio
ns,a
nd3.
6m
Svpe
rmin
ute
and
2.2
mSv
perm
inut
e,re
spec
tivel
y,du
ring
low
erG
Iexa
min
atio
ns.D
ata
for‘
CT
-Bod
y’re
fert
oex
amin
atio
nsof
the
abdo
men
;mea
nef
fect
ive
dose
forC
Tch
esti
s2.8
mSv
.U
nite
dAr
abEm
irat
es:S
urve
yda
tafro
mon
eho
spita
l,ex
cept
thos
efo
rche
stra
diog
raph
yan
dpe
lvis/
hip
(from
seve
nho
spita
ls),a
ndch
estp
hoto
fluor
ogra
phy
(from
four
units
attw
oho
spita
ls).
ANNEX D: MEDICAL RADIATION EXPOSURES 377
Tabl
e15
(con
tinue
d)
Cou
ntry
Typi
cale
ffect
ive
dose
perp
roce
dure
(mSv
)
Uro
grap
hyM
amm
ogra
phy
Com
pute
dto
mog
raph
yAn
giog
raph
yPT
CA
Tota
lofa
llm
edic
alex
amin
atio
nsSc
reen
ing
Clin
ical
All
Hea
dBo
dyAl
lC
ereb
ral
Car
diac
All
aEx
clud
ing
dent
alx-
ray
exam
inat
ions
.b
Var
iatio
nssh
own
inbr
acke
ts(s
tand
ard
devi
atio
n,co
effic
ient
ofva
riatio
nor
rang
e).
cN
oda
taav
aila
ble.
dFr
eque
ncy-
wei
ghte
dav
erag
eof
natio
nalv
alue
s.e
Thes
ere
vise
dda
taw
ere
rece
ived
byth
eC
omm
ittee
afte
rcom
plet
ion
ofth
egl
obal
anal
ysis.
Uni
ted
Kin
gdom
2.4
0.06
29
6
Uni
ted
Stat
es0.
52
Ave
rage
3.7
0.07
0.21
0.51
2.3
13.3
8.8
2.0
7.3
12.4
220.
83
Heal
th-c
are
leve
lII
Bra
zil
3.89
(±2.
8)0.
26
Chi
na[Z
10]
0.57
Mal
aysia
[N26
]2.
40.
10.
12.
87.
84.
96.
86.
80.
28
Ave
rage
3.9
0.1
0.1
2.8
7.8
4.9
6.8
6.8
0.56
The
entri
esin
this
Tabl
ear
equ
alifi
edas
follo
ws:
Braz
il:Su
rvey
data
forP
aran
áSt
ate
(with
apo
pula
tion
of9
mill
ion
and
aso
cial
and
econ
omic
prof
ileab
ove
the
aver
age
forB
razi
l).C
hina
(Tai
wan)
:Dat
afo
rlum
bars
pine
,GIt
ract
and
tota
lofa
llm
edic
alex
amin
atio
nsfro
mre
fere
nce
[L23
].G
erm
any:
Mea
nef
fect
ive
dose
forg
ener
alcl
assif
icat
ion
ofsp
ine
is1.
2m
Sv(r
ange
:0.1
20m
Sv).
Mal
aysi
a:D
ata
forc
hest,
spin
ean
dhe
adre
fert
oA
P/PA
proj
ectio
ns.D
ata
for‘
GIt
ract
’rel
ate
tobo
th‘U
pper
’and
‘Low
er’c
ateg
orie
s.N
orwa
y:D
ata
from
natio
nals
urve
yin
volv
ing
abou
t50
hosp
itals
and
5000
mea
sure
men
ts.Ro
man
ia:
Add
ition
alsu
rvey
data
inre
latio
nto
‘Che
stflu
oros
copy
’:m
ean
entra
nce
surfa
cedo
seof
13.4
mG
yan
dm
ean
dose
-are
apr
oduc
tof3
.6m
Gy
cm2
[I28
].Ru
ssia
:A
dditi
onal
surv
eyda
tain
rela
tion
toef
fect
ive
dose
sfro
m‘C
hest
fluor
osco
py’:
dose
rate
swith
outa
ndw
ithel
ectro
nic
imag
ein
tens
ifica
tion
of1.
4m
Svpe
rmin
ute
and
0.9
mSv
perm
inut
e,re
spec
tivel
y.D
ata
show
nfo
r‘G
Itra
ct’r
elat
eto
both
‘Upp
er’a
nd‘L
ower
’cat
egor
ies.
Effe
ctiv
edo
sera
tesf
rom
fluor
osco
pyw
ithou
tand
with
elec
troni
cim
age
inte
nsifi
catio
nof
4.2
mSv
perm
inut
ean
d2.
3m
Svpe
rmin
ute,
resp
ectiv
ely
durin
gup
perG
Iexa
min
atio
ns,a
nd3.
6m
Svpe
rmin
ute
and
2.2
mSv
perm
inut
e,re
spec
tivel
y,du
ring
low
erG
Iexa
min
atio
ns.D
ata
for‘
CT
-Bod
y’re
fert
oex
amin
atio
nsof
the
abdo
men
;mea
nef
fect
ive
dose
forC
Tch
esti
s2.8
mSv
.U
nite
dAr
abEm
irat
es:S
urve
yda
tafro
mon
eho
spita
l,ex
cept
thos
efo
rche
stra
diog
raph
yan
dpe
lvis/
hip
(from
seve
nho
spita
ls),a
ndch
estp
hoto
fluor
ogra
phy
(from
four
units
attw
oho
spita
ls).
ANNEX D: MEDICAL RADIATION EXPOSURES 377
Tabl
e16
Patie
ntdo
sefr
omdi
agno
stic
x-ra
yex
amin
atio
nsDa
tafro
mUN
SCEA
RSu
rvey
ofM
edica
lRad
iatio
nUs
age
and
Expo
sure
sun
less
othe
rwise
indi
cate
d
PA
RT
A
Cou
ntry
/are
aSc
ope
ofda
taD
ose
quan
tity
a
Mea
nva
lue
ofdo
sequ
antit
ype
rrad
iogr
aph
b
Skul
lC
hest
Thor
acic
spin
eLu
mba
rspi
neAb
dom
enPe
lvis
AP/P
ALA
TPA
LAT
APLA
TAP
LAT
LSJ
APAP
Heal
th-c
are
leve
lI
Aus
tralia
[B29
]St
ate
ESD
1.9
(0.9
2.7)
1.2
(0.5
2.3)
0.12
(0.0
2-0.
21)
0.63
(0.2
2-1.
42)
c6.
1(2
.319
.7)
15.1
(3.7
32.5
)22
.4(5
.343
.3)
4.2
(1.4
7.3)
3.9
(1.5
7.0)
Arg
entin
a[I
4]3
hosp
itals
ESD
ESD
0.38
(pre
)(0
.24-
0.48
)0.
33(p
ost)
(0.3
1-0.
34)
5.10
(pre
)
3.31
(pos
t)
Can
ada
Reg
iona
lES
D
ESD
0.68
(man
.)(±
0.23
)0.
74(a
uto.
)(±
0.21
)
0.11
(man
.)(±
0.03
)0.
13(a
uto.
)(±
0.04
)
1.82
(man
.)(±
0.6)
1.50
(aut
o.)
(±0.
05)
3.34
(man
.)(±
1.0)
3.69
(aut
o.)
(±1.
3)
2.35
(man
.)(±
0.5)
1.64
(aut
o.)
(±0.
5)
Chi
na,T
aiw
anPr
ovin
ce[Y
9]N
atio
nal
E0.
040
(±0.
12)
0.21
(±0.
10)
Cze
chR
epub
lic[I
4]3
hosp
itals
ESD
ESD
0.41
(pre
.)(0
.08-
0.99
)0.
12(p
ost.)
(0.1
-0.1
3)
8.36
(pre
.)(5
.56-
10.8
)5.
64(p
ost.)
3.87
-8.3
9)
6.37
(pre
.)(5
.59-
6.99
)4.
12(p
ost.)
3.09
-6.9
9)
Esto
nia
[S29
]4
hosp
itals
ESD
15.1
(2.2
30.1
)8.
1(1
.114
.3)
0.30
(0.1
5-0.
49)
0.86
13.8
(0.8
4-31
.7)
30.3
(7.3
61.0
)14
.0(2
.226
.8)
15.8
(2.5
29.9
)
Finl
and
[R11
]N
atio
nal
ESD
DA
P
E
3.37
(1.0
6-8.
53)
1.63
(020
-5.8
2)0.
12(0
.03-
0.42
)
1.93
(0.5
7-8.
01)
0.24
(0.0
6-3.
28)
0.44
(0.0
8-3.
47)
0.10
(0.0
3-1.
10)
0.73
(0.1
5-4.
44)
4.89
(0.4
9-11
.3)
4.14
(1.1
0-22
.2)
1.02
(0.2
3-3.
92)
11.6
(2.1
0-26
.2)
8.80
(0.4
9-43
.5)
8.25
(0.8
8-68
.8)
2.27
(0.2
5-11
.4)
18.2
(2.1
0-11
1)7.
08(0
.76-
19.0
)6.
90(0
.86-
20.8
)2.
22(0
.60-
5.89
)
6.15
(2.0
2-22
.0)
3.80
(0.7
9-16
.0)
1.25
(0.3
1-4.
49)
Ger
man
y[B
9]N
atio
nal
DA
P1.
071.
373.
519.
323.
623.
62
Gre
ece
[O3]
1ho
spita
lES
D E
3.5
(±1.
95)
0.09
4
2.68
(±1.
49)
0.03
4
0.69
(±0.
4)0.
11
2.94
(±1.
57)
0.22
8.25
(±4.
63)
0.74
10.9
(±8.
1)0.
33
18.9
(±6.
76)
1.88
44.9
(±22
.9)
0.94
11.2
(±7.
3)1.
45
12.5
(±6.
85)
1.35
ANNEX D: MEDICAL RADIATION EXPOSURES378
Tabl
e16
(con
tinue
d)
Cou
ntry
/are
aSc
ope
ofda
taD
ose
quan
tity
a
Mea
nva
lue
ofdo
sequ
antit
ype
rrad
iogr
aph
b
Skul
lC
hest
Thor
acic
spin
eLu
mba
rspi
neAb
dom
enPe
lvis
AP/P
ALA
TPA
LAT
APLA
TAP
LAT
LSJ
APAP
Irel
and
[J10
]N
atio
nal
ESD
0.22
(0.0
2-0.
65)
6.47
(0.2
7-20
.3)
16.9
(1.8
67.1
)36
.9(1
.510
2)4.
75(0
.518
.3)
5.63
(1.2
26.5
)
Lith
uani
aN
atio
nal
ESD
2.11
2.73
0.81
1.39
22.8
35.5
37.4
20.4
321
.43
Nor
way
[O6]
Nat
iona
lD
AP
E0.
640.
127.
613.
48
Pana
ma
Nat
iona
lES
D0.
17(±
0.10
)2.
33(±
0.91
)3.
28(±
1.0)
Pola
ndN
atio
nal
ESD E
0.20
(0.1
6-2.
76)
0.06
(0.0
6-0.
49)
0.88
0.10
5.1
(0.7
-18.
5)0.
9(0
.63-
12.6
)
8.3
(1.2
-23.
2)2.
13(0
.98-
8.9)
7.50
(1.3
8-25
.3)
3.43
(0.7
7-11
.5)
12.0
(3.4
5-38
.4)
0.9
(0.7
1-2.
27)
4.7
(0.7
5-23
.2)
2.18
(0.1
2-7.
12)
2.54
(1.9
7-25
.8)
0.61
(0.4
0-10
.3)
Rom
ania
[I28
]21
hosp
itals
ESD
11.0
(1.0
31)
9.4
(1.2
28)
1.7
(0.3
6.0)
4.2
(0.7
13)
11.2
(2.0
41)
24.0
(3.5
97)
17.6
(2.0
71)
42.0
(4.4
162)
10.9
(2.1
37)
13.2
(1.9
35)
Rus
sian
Fede
ratio
nN
atio
nal
E0.
40.
60.
80.
31.
71.
20.
75
New
Zeal
and
Nat
iona
lES
D
DA
P
E
3.0
(±2.
04)
0.96
(±0.
65)
0.03
(±0.
02)
1.56
(±1.
04)
0.57
(±0.
37)
0.02
(±0.
05)
0.22
(±0.
25)
0.17
(±0.
2)0.
03(±
0.03
)
1.24
(±1.
92)
0.62
(±0.
67)
0.1
(±0.
11)
4.32
(±2.
67)
1.54
(±1.
01)
0.44
(±0.
26)
13.3
(±9.
72)
3.53
(±2.
68)
0.31
(±0.
21)
5.47
(±2.
89)
1.88
(±1.
16)
0.6
(±0.
33)
18.9
(±11
.6)
3.92
(±2.
33)
0.47
(±0.
29)
31.2
(±21
.8)
3.83
(±2.
79)
0.36
(±0.
24)
4.57
(±2.
57)
2.67
(±1.
61)
0.58
(±0.
33)
3.98
(±2.
33)
2.37
(±1.
49)
0.63
(±0.
38)
Slov
enia
Loca
lES
D E0.
290.
051.
020.
064.
890.
377.
220.
216.
110.
6315
.65
0.48
15.0
00.
143.
520.
044.
720.
65
Sout
hA
frica
[M22
,H29
]N
atio
nal
ESD
6.4
3.6
1.5
3.2
13.1
35.6
27.3
59.1
13.1
15.4
Uni
ted
Ara
bEm
irate
sLo
cal
E0.
680.
380.
020
(0.0
05-
0.02
8)
0.03
9(0
.008
40.
094)
Uni
ted
Kin
gdom
[H11
]N
atio
nal
ESD E
3.0
(0.5
10.0
)0.
03
1.5
(0.5
6-4.
43)
0.01
0.16
(0.0
1-0.
94)
0.02
0.57
(0.1
12.
6)0.
04
4.7
(1.3
18.0
)0.
40
13.0
(1.3
43.0
)0.
29
6.1
(1.4
31.0
)0.
69
16.0
(3.9
75.0
)0.
29
29.0
(4.2
84.0
)0.
29
5.6
(0.7
5-16
.6)
0.7
4.4
(1.0
16.0
)0.
66
Uni
ted
Stat
esN
atio
nal
ESD
0.15
ANNEX D: MEDICAL RADIATION EXPOSURES 379
Tabl
e16
(con
tinue
d)
Cou
ntry
/are
aSc
ope
ofda
taD
ose
quan
tity
a
Mea
nva
lue
ofdo
sequ
antit
ype
rrad
iogr
aph
b
Skul
lC
hest
Thor
acic
spin
eLu
mba
rspi
neAb
dom
enPe
lvis
AP/P
ALA
TPA
LAT
APLA
TAP
LAT
LSJ
APAP
Irel
and
[J10
]N
atio
nal
ESD
0.22
(0.0
2-0.
65)
6.47
(0.2
7-20
.3)
16.9
(1.8
67.1
)36
.9(1
.510
2)4.
75(0
.518
.3)
5.63
(1.2
26.5
)
Lith
uani
aN
atio
nal
ESD
2.11
2.73
0.81
1.39
22.8
35.5
37.4
20.4
321
.43
Nor
way
[O6]
Nat
iona
lD
AP
E0.
640.
127.
613.
48
Pana
ma
Nat
iona
lES
D0.
17(±
0.10
)2.
33(±
0.91
)3.
28(±
1.0)
Pola
ndN
atio
nal
ESD E
0.20
(0.1
6-2.
76)
0.06
(0.0
6-0.
49)
0.88
0.10
5.1
(0.7
-18.
5)0.
9(0
.63-
12.6
)
8.3
(1.2
-23.
2)2.
13(0
.98-
8.9)
7.50
(1.3
8-25
.3)
3.43
(0.7
7-11
.5)
12.0
(3.4
5-38
.4)
0.9
(0.7
1-2.
27)
4.7
(0.7
5-23
.2)
2.18
(0.1
2-7.
12)
2.54
(1.9
7-25
.8)
0.61
(0.4
0-10
.3)
Rom
ania
[I28
]21
hosp
itals
ESD
11.0
(1.0
31)
9.4
(1.2
28)
1.7
(0.3
6.0)
4.2
(0.7
13)
11.2
(2.0
41)
24.0
(3.5
97)
17.6
(2.0
71)
42.0
(4.4
162)
10.9
(2.1
37)
13.2
(1.9
35)
Rus
sian
Fede
ratio
nN
atio
nal
E0.
40.
60.
80.
31.
71.
20.
75
New
Zeal
and
Nat
iona
lES
D
DA
P
E
3.0
(±2.
04)
0.96
(±0.
65)
0.03
(±0.
02)
1.56
(±1.
04)
0.57
(±0.
37)
0.02
(±0.
05)
0.22
(±0.
25)
0.17
(±0.
2)0.
03(±
0.03
)
1.24
(±1.
92)
0.62
(±0.
67)
0.1
(±0.
11)
4.32
(±2.
67)
1.54
(±1.
01)
0.44
(±0.
26)
13.3
(±9.
72)
3.53
(±2.
68)
0.31
(±0.
21)
5.47
(±2.
89)
1.88
(±1.
16)
0.6
(±0.
33)
18.9
(±11
.6)
3.92
(±2.
33)
0.47
(±0.
29)
31.2
(±21
.8)
3.83
(±2.
79)
0.36
(±0.
24)
4.57
(±2.
57)
2.67
(±1.
61)
0.58
(±0.
33)
3.98
(±2.
33)
2.37
(±1.
49)
0.63
(±0.
38)
Slov
enia
Loca
lES
D E0.
290.
051.
020.
064.
890.
377.
220.
216.
110.
6315
.65
0.48
15.0
00.
143.
520.
044.
720.
65
Sout
hA
frica
[M22
,H29
]N
atio
nal
ESD
6.4
3.6
1.5
3.2
13.1
35.6
27.3
59.1
13.1
15.4
Uni
ted
Ara
bEm
irate
sLo
cal
E0.
680.
380.
020
(0.0
05-
0.02
8)
0.03
9(0
.008
40.
094)
Uni
ted
Kin
gdom
[H11
]N
atio
nal
ESD E
3.0
(0.5
10.0
)0.
03
1.5
(0.5
6-4.
43)
0.01
0.16
(0.0
1-0.
94)
0.02
0.57
(0.1
12.
6)0.
04
4.7
(1.3
18.0
)0.
40
13.0
(1.3
43.0
)0.
29
6.1
(1.4
31.0
)0.
69
16.0
(3.9
75.0
)0.
29
29.0
(4.2
84.0
)0.
29
5.6
(0.7
5-16
.6)
0.7
4.4
(1.0
16.0
)0.
66
Uni
ted
Stat
esN
atio
nal
ESD
0.15
ANNEX D: MEDICAL RADIATION EXPOSURES 379
Tabl
e16
(con
tinue
d)
Cou
ntry
/are
aSc
ope
ofda
taD
ose
quan
tity
a
Mea
nva
lue
ofdo
sequ
antit
ype
rrad
iogr
aph
b
Skul
lC
hest
Thor
acic
spin
eLu
mba
rspi
neAb
dom
enPe
lvis
AP/P
ALA
TPA
LAT
APLA
TAP
LAT
LSJ
APAP
Heal
th-c
are
leve
lII
Bra
zil
3ho
spita
lsES
D E
4.55
(3.0
8-7.
34)
0.33
0.02
1(±
0.01
)
1.01
0.03
2(±
0.02
)
6.82
(4.3
69.
38)
7.88
5.28
(4.3
5-6.
20)
Cos
taR
ica
1ho
spita
lES
D4.
45(±
2.3)
2.92
(±2.
4)1.
97(±
2.3)
5.33
(±5.
3)7.
14(±
4.6)
12.4
(±8.
9)10
.6(±
12.0
)27
.9(±
18.1
)7.
74(±
5.3)
6.39
(±3.
3)
Iran
(Isla
m.R
ep.o
f)[I
4]2
hosp
itals
ESD
ESD
0.21
(pre
.)(0
.19-
0.26
)0.
06(p
ost.)
(0.0
4-0.
09)
3.57
(pre
.)(2
.83-
4.25
)1.
87(p
ost.)
1.47
2.08
)
Mal
aysia
[N15
,N26
]12
hosp
itals
ESD E
4.78
0.04
3.34
0.04
0.28
0.03
1.40
0.09
7.03
0.46
16.5
10.6
1.04
18.7
10.0
8.41
Peru
ESD
3.5
(±1.
0)0.
4(±
0.3)
7.0
(±3.
0)8.
5(±
2.0)
6.0
(±3.
0)
Turk
eyLo
cal
ESD
4.27
(±0.
88)
0.32
(±0.
05)
0.70
(±0.
20)
7.45
(±0.
54)
2.81
(±1.
49)
10.7
3(±
2.01
)19
.35
(±1.
16)
Heal
thca
rele
velI
II
Egyp
t[H
28]
14ho
spita
lsES
D0.
30.
53.
31.
51.
5
Gha
na[S
39]
12ho
spita
lsES
D E
5.7
(2.7
9.1)
0.08
(±38
%)
0.74
(0.1
1.5)
0.10
(±61
%)
9.2
(3.1
16.0
)1.
61(±
52%
)
7.9
(2.0
13.1
)1.
71(±
40%
)
Indo
nesia
[L19
]4
hosp
itals
ESD
3.61
(±1.
24)
3.52
(±1.
48)
0.51
(±0.
18)
6.30
(±1.
50)
9.36
(±3.
0)9.
57(±
6.22
)3.
72(±
1.23
)
Mor
occo
ESD
9.39
(±2)
0.23
(±0.
2)0.
72(±
0.2)
12.3
10.2
Thai
land
[L19
]4
hosp
itals
ESD
ESD
1.37
(pre
.)(±
0.76
)0.
72(p
ost.)
(±0.
26)
1.10
(pre
.)(±
0.64
)0.
52(p
ost.)
(±0.
17)
0.26
(pre
.)(±
0.16
)0.
16(p
ost.)
(±0.
09)
0.97
(pre
.)(±
0.48
)0.
52(p
ost.)
(±0.
27)
2.81
(pre
.)(±
2.1)
1.21
(pos
t.)(±
0.65
)
7.97
(pre
.)(±
5.3)
4.08
(pos
t.)(±
3.5)
1.52
(pre
.)(±
1.09
)0.
93(p
ost.)
(±0.
47)
ANNEX D: MEDICAL RADIATION EXPOSURES380
Tabl
e16
(con
tinue
d)
Cou
ntry
/are
aSc
ope
ofda
taD
ose
quan
tity
a
Mea
nva
lue
ofdo
sequ
antit
ype
rrad
iogr
aph
b
Skul
lC
hest
Thor
acic
spin
eLu
mba
rspi
neAb
dom
enPe
lvis
AP/P
ALA
TPA
LAT
APLA
TAP
LAT
LSJ
APAP
aES
D:e
ntra
nce
surfa
cedo
sew
ithba
cksc
atte
r(m
Gy)
;DA
P:do
se-a
rea
prod
uct(
Gy
cm2 );
E:ef
fect
ive
dose
(mSv
).b
Var
iatio
nssh
own
inbr
acke
ts(s
tand
ard
devi
atio
nor
rang
e).
cN
oda
taav
aila
ble.
Heal
thca
rele
velI
V
Ethi
opia
[I4]
2ho
spita
lsES
D
ESD
1.34
(pre
.)(0
.94-
1.74
)0.
57(p
ost.)
(0.4
3-0.
70)
5.26
(pre
.)5.
115.
41)
10.5
7(po
st)(9
.74-
11.4
)
Uni
tdR
ep.o
fTa
nzan
ia[M
37]
5ho
spita
lsES
D0.
5(±
0.3)
7.7
(±3.
8)17
.5(±
8.5)
8.3
(±5.
6)6.
4(±
4.5)
PA
RT
B
Cou
ntry
Scop
eof
data
Dos
equ
antit
ya
Mea
nva
lue
ofdo
sequ
antit
ype
rexa
min
atio
nb
Upp
erG
Itra
ctLo
werG
Itra
ctU
rogr
aphy
ERC
PVe
nogr
amSw
allo
wM
eal
Enem
aC
olon
osco
py
Heal
thca
rele
velI
Ger
man
y[B
9]N
atio
nal
DA
P13
.05
35.9
61.5
20.3
33.7
7.8
Icel
and
[W42
]5
hosp
itals
DA
P(4
3.6
77.4
)
New
Zeal
and
Nat
iona
lE
39
0.4
4
Nor
way
[O6]
Nat
iona
lD
AP
E7.
41 1.5
24.8
5.9
49.1
13.7
18.1
3.8
31.8
8.3
Rom
ania
[I18
]
[I28
]
5ho
spita
ls
21ho
spita
ls
DA
PE
DA
P
37.7
(±17
.5)
3.7
22.0
(210
0)
32.2
(±3.
3)8.
1234
.7(2
116)
Switz
erla
nd[M
45]
DA
P13
.5(±
10.2
)68
.5(±
42.9
)37
.1(±
32.8
)
Uni
ted
Kin
gdom
[H11
][B
56]
Nat
iona
lR
egio
nal
DA
PD
AP
9.3
5.63
13.0
7.60
25.8
15.7
13.4
9.0
3.8
1.92
ANNEX D: MEDICAL RADIATION EXPOSURES 381
ANNEX D: MEDICAL RADIATION EXPOSURES382
Tabl
e16
(con
tinue
d)
The
entri
esin
this
Tabl
ear
equ
alifi
edas
follo
ws:
Arge
ntin
a:Pa
irsof
valu
esre
pres
ents
urve
ysbe
fore
and
afte
rthe
intro
duct
ion
ofa
prog
ram
me
ofqu
ality
cont
rol.
Inte
rhos
pita
lvar
iatio
nin
brac
kets.
Braz
il:Su
rvey
data
forP
aran
áSt
ate
(with
apo
pula
tion
of9
mill
ion
and
aso
cial
and
econ
omic
prof
ileab
ove
the
aver
age
forB
razi
l);da
tafo
rsku
ll,lu
mba
rspi
ne,a
ndpe
lvis
from
refe
renc
e[I
4].
Braz
il:Pa
irsof
valu
esre
pres
ents
urve
ysbe
fore
and
afte
rthe
intro
duct
ion
ofa
prog
ram
me
ofqu
ality
cont
rol.
Inte
rhos
pita
lvar
iatio
nin
brac
kets.
Can
ada:
Surv
eyda
tafro
mM
anito
ba(4
%of
Can
adia
npo
pula
tion)
fors
tand
ard
pres
sed
woo
dph
anto
ms(
unit
dens
ity)u
nder
man
uala
ndau
tom
atic
expo
sure
cont
rola
ndfo
rrar
eea
rthin
tens
ifyin
gte
chni
ques
.C
osta
Rica
:D
ata
from
Hos
pita
lCal
deró
nG
uard
ia(s
ervi
ngon
eth
irdof
the
popu
latio
n).
Cze
chRe
publ
ic:
Pairs
ofva
lues
repr
esen
tsur
veys
befo
rean
daf
tert
hein
trodu
ctio
nof
apr
ogra
mm
eof
qual
ityco
ntro
l.In
terh
ospi
talv
aria
tion
inbr
acke
ts.Eg
ypt:
Max
imum
reco
mm
ende
ddo
sesd
eriv
edfro
mth
efo
llow
ing
publ
ished
max
imum
entra
nce
surfa
ceex
posu
res:
26m
Rsk
ull;
45m
Rch
est;
272
mR
lum
bars
pine
;125
mR
abdo
men
;125
mR
pelv
is[H
28].
Esto
nia:
Inte
rhos
pita
lvar
iatio
nin
brac
kets.
Ethi
opia
:Pa
irsof
valu
esre
pres
ents
urve
ysbe
fore
and
afte
rthe
intro
duct
ion
ofa
prog
ram
me
ofqu
ality
cont
rol.
Inte
rhos
pita
lvar
iatio
nin
brac
kets.
Finl
and:
DA
Pan
dE
data
repr
esen
tmea
nva
lues
forc
ompl
ete
exam
inat
ions
.G
erm
any:
DA
Pda
tare
fert
oco
mpl
ete
exam
inat
ions
(rat
hert
han
dose
sper
radi
ogra
ph).
Gha
na:
Dat
afo
rAP
pelv
isal
soin
clud
esra
diog
raph
yof
the
abdo
men
.Ic
elan
d:D
ata
forb
ariu
men
ema
exam
inat
ions
refe
rto
rang
eof
mea
nD
AP
valu
esob
serv
edin
surv
eyof
5ho
spita
ls.Ir
an(Is
lam
icRe
p.of
):Pa
irsof
valu
esre
pres
ents
urve
ysbe
fore
and
afte
rthe
intro
duct
ion
ofa
prog
ram
me
ofqu
ality
cont
rol.
Inte
rhos
pita
lvar
iatio
nin
brac
kets.
Lith
uani
a:D
ata
from
Viln
iusU
nive
rsity
Hos
pita
l.M
oroc
co:
Dat
afro
mIA
EAC
oord
inat
edR
esea
rch
Prog
ram
me.
Nor
way:
Dat
afo
r‘U
pper
GI-
Mea
l’an
d‘L
ower
GI-
Enem
a’re
fert
odo
uble
cont
rast
techn
ique
(cor
resp
ondi
ngda
tafo
rsin
glec
ontra
sttec
hniq
ue:1
4.0
Gy
cm2
&3.
4m
Sv,a
nd32
.3G
ycm
2&
9.0
mSv
,res
pecti
vely
).Pe
ru:
Dat
am
ayre
fert
oco
mpl
ete
exam
inat
ions
.Ro
man
ia:
Pairs
ofva
lues
repr
esen
tsur
veys
befo
rean
daf
tert
hein
trodu
ctio
nof
apr
ogra
mm
eof
qual
ityco
ntro
l.In
ter
hosp
italv
aria
tion
inbr
acke
ts.So
uth
Afri
ca:
Der
ived
from
free
inai
rdat
aca
lcul
ated
fora
vera
geex
posu
reco
nditi
ons.
Uni
ted
Rep.
ofTa
nzan
ia:
Surv
eyda
tafo
r500
patie
ntsp
erex
amin
atio
nsp
read
over
4re
ferr
alho
spita
lsan
d1
regi
onal
hosp
ital;
thes
eho
spita
lsar
eco
llect
ivel
yre
spon
sible
forn
early
50%
ofth
ean
nual
natio
nalt
otal
ofpa
tient
sex
amin
edw
ithx
rays
.Th
aila
nd:
Pairs
ofva
lues
repr
esen
tsur
veys
befo
rean
daf
tert
hein
trodu
ctio
nof
apr
ogra
mm
eof
qual
ityco
ntro
l.Tu
rkey
:Su
rvey
data
from
Ank
ara
Uni
vers
ityH
ospi
tala
ndG
ülha
neM
ilita
ryH
ospi
tal.
Uni
ted
Arab
Emir
ates
:Su
rvey
data
for‘
Hea
d’ex
amin
atio
nsfro
mon
eho
spita
l,da
tafo
r‘C
hest’
from
seve
nho
spita
ls.U
nite
dKi
ngdo
m:
Inte
rho
spita
lvar
iatio
nin
brac
kets.
Dat
afro
mre
fere
nce
[B56
]rep
rese
ntm
edia
nva
lues
from
regi
onal
surv
ey.
Uni
ted
Stat
es:
On
the
basis
ofen
tranc
esu
rface
expo
sure
of0.
12m
Gy
from
NEX
Tpr
ogra
mm
efo
r199
4.
ANNEX D: MEDICAL RADIATION EXPOSURES 383
a Mean values of parameters (with range, standard deviation, or coefficient of variation in parentheses).b Ages 0.01-12 years. Calculated entrance surface doses: mean 99 mGy, range 10-526 mGy.c Mean length of cine film 28 m (maximum 85 m).d Range of cine film length: 25-100 m.e Mean time of cinefluorography (25-30 frames per second) was 60 seconds (standard deviation 30 seconds).f Mean number of frames: 689.g Range of cine film length: 16-43 m.h 61% of total DAP from radiography.i Data refer to right and left heart angiography.j Mean contributions to effective dose: 67% from fluoroscopy, 26% from cut films, and 7% from DSA.k Maximum dose to right ocular lens of 125 mGy; maximum dose to thyroid of 88 mGy.
Table 17Patient dose per procedure from diagnostic angiographic examinations
Procedure Technique Fluoroscopy time a
(min)Dose-area product a
(Gy cm2)Effective dose a
(mSv) Ref.
Coronary Children b
Cine film c
Cine film d
-Cinefluorography e
---Digital cine f
-No. frames a: 878 (302 SD)Cine film g
8 (70 max.)4.3 (1.5 15)
3.97 (SD 3.6)
9.8 ( ± 65%)
5.7
3.6 (3.3 SD)(3.1 5.6)
13.3 (1.4 98)41 (228 max.)
(21 40)16.1 h
55.930.4 ( ± 57%)
38.947.758.7 i
39.3 (18 SD)(23 79)
(2 9)3.1 (1 12)
10.6
5.68.99.4
(4.6 15.8)
[B48][H6][C22][L3][K5][Z12][B3][O6][B54][W41][P20][N29]
Cerebral DSA
DSA/conventional j
Carotid (DSA)DSA/conventionalDigital
Carotid
4.7
3.9 (1.2 11.8)15 ( ± 10)
12.1 (2.9 36)
7.8 (3.1 17.9)
48.5
27.4 (9.5 80)59 (12 120)74 (21 196)
55.250
98 (44 208)
3.6Eye/thyroid data k
10.6 (2.7 23.4)4 (1 12)
7.4 (2.1 19.6)1.6
[M9][H24][F15][S3]
[K23][M34][O6][V14][M46]
Abdominal Hepatic (DSA)Renal (DSA)Renal (DSA)Mesenteric and/or coeliac art.DSA/conventionalDigitalRenal angiographyRenal angiographyDigitalAortagramMesenteric
10.3 (2.3 28.6)12.1 (5.5 21)
5.114.7
1.0 ( ± 0.5)8.0 (1.8 27)5.1 (2.9 7.6)2.8 (0.5 9.3)6.7 ( ± 6.5)
137 (28 279)95 (41 186)
4365
57 (31 89)118 (21.6 301)39.8 (17.4 72)177 (90 327)
61 (8 192)98 (297 max.)
112 (352 max.)
23 (4 48)16 (6 34)
610
18.9 (3.5 48)6.4 (2.8 11.5)
8.2
[S3][S3]
[K26][K26][K23][M34][M34][M46][R17][W32][W32]
Peripheral Femoral (DSA)Aorto iliac + 1 legAorto iliac + 2 legsAorto iliac + thighsAortogram/femoral runoffFemoral arteriogramFemoral (DSA/conventional)Femoral (DSA)Femoral (DSA)FemoralFemoralLower limbsLower limbs (arteries)Lower limbs (veins)Lower limbVenography (arm)
3.7 (1.2 19)2.9 ( ± 2.8)4.5 ( ± 1.2)1.2 ( ± 0.4)
3.9 (1.8 10.8)2.4 ( ± 1.9)1.7 (0.4 6.7)2.3 (0.9 13.7)
7.2 (1.8 17.2)2.4 (13 8.3)3.7 ( ± 3.1)
42.9 (13 122)13 (2 52)
32 (19 68)47 (16 100)
2624.4 (5.6 100)74 (19.8 184)
1346.7 (3 114)
16 (8 91)30 (9 77)
35.54.9
78 (306 max.)23 (57 max.)
4 (1 16)
14.0 (7.0 21.8)4
2.79.0
3.1 ( ± 1.8)7.5 (0.5 18.2)
6.26.40.9
[S3][K23][K23][K23][C23][T8]
[H25][H25][C24][M34][M46][R17][O6][O6]
[W32][W32]
ANNEX D: MEDICAL RADIATION EXPOSURES 383
a Mean values of parameters (with range, standard deviation, or coefficient of variation in parentheses).b Ages 0.01-12 years. Calculated entrance surface doses: mean 99 mGy, range 10-526 mGy.c Mean length of cine film 28 m (maximum 85 m).d Range of cine film length: 25-100 m.e Mean time of cinefluorography (25-30 frames per second) was 60 seconds (standard deviation 30 seconds).f Mean number of frames: 689.g Range of cine film length: 16-43 m.h 61% of total DAP from radiography.i Data refer to right and left heart angiography.j Mean contributions to effective dose: 67% from fluoroscopy, 26% from cut films, and 7% from DSA.k Maximum dose to right ocular lens of 125 mGy; maximum dose to thyroid of 88 mGy.
Table 17Patient dose per procedure from diagnostic angiographic examinations
Procedure Technique Fluoroscopy time a
(min)Dose-area product a
(Gy cm2)Effective dose a
(mSv) Ref.
Coronary Children b
Cine film c
Cine film d
-Cinefluorography e
---Digital cine f
-No. frames a: 878 (302 SD)Cine film g
8 (70 max.)4.3 (1.5 15)
3.97 (SD 3.6)
9.8 ( ± 65%)
5.7
3.6 (3.3 SD)(3.1 5.6)
13.3 (1.4 98)41 (228 max.)
(21 40)16.1 h
55.930.4 ( ± 57%)
38.947.758.7 i
39.3 (18 SD)(23 79)
(2 9)3.1 (1 12)
10.6
5.68.99.4
(4.6 15.8)
[B48][H6][C22][L3][K5][Z12][B3][O6][B54][W41][P20][N29]
Cerebral DSA
DSA/conventional j
Carotid (DSA)DSA/conventionalDigital
Carotid
4.7
3.9 (1.2 11.8)15 ( ± 10)
12.1 (2.9 36)
7.8 (3.1 17.9)
48.5
27.4 (9.5 80)59 (12 120)74 (21 196)
55.250
98 (44 208)
3.6Eye/thyroid data k
10.6 (2.7 23.4)4 (1 12)
7.4 (2.1 19.6)1.6
[M9][H24][F15][S3]
[K23][M34][O6][V14][M46]
Abdominal Hepatic (DSA)Renal (DSA)Renal (DSA)Mesenteric and/or coeliac art.DSA/conventionalDigitalRenal angiographyRenal angiographyDigitalAortagramMesenteric
10.3 (2.3 28.6)12.1 (5.5 21)
5.114.7
1.0 ( ± 0.5)8.0 (1.8 27)5.1 (2.9 7.6)2.8 (0.5 9.3)6.7 ( ± 6.5)
137 (28 279)95 (41 186)
4365
57 (31 89)118 (21.6 301)39.8 (17.4 72)177 (90 327)
61 (8 192)98 (297 max.)
112 (352 max.)
23 (4 48)16 (6 34)
610
18.9 (3.5 48)6.4 (2.8 11.5)
8.2
[S3][S3]
[K26][K26][K23][M34][M34][M46][R17][W32][W32]
Peripheral Femoral (DSA)Aorto iliac + 1 legAorto iliac + 2 legsAorto iliac + thighsAortogram/femoral runoffFemoral arteriogramFemoral (DSA/conventional)Femoral (DSA)Femoral (DSA)FemoralFemoralLower limbsLower limbs (arteries)Lower limbs (veins)Lower limbVenography (arm)
3.7 (1.2 19)2.9 ( ± 2.8)4.5 ( ± 1.2)1.2 ( ± 0.4)
3.9 (1.8 10.8)2.4 ( ± 1.9)1.7 (0.4 6.7)2.3 (0.9 13.7)
7.2 (1.8 17.2)2.4 (13 8.3)3.7 ( ± 3.1)
42.9 (13 122)13 (2 52)
32 (19 68)47 (16 100)
2624.4 (5.6 100)74 (19.8 184)
1346.7 (3 114)
16 (8 91)30 (9 77)
35.54.9
78 (306 max.)23 (57 max.)
4 (1 16)
14.0 (7.0 21.8)4
2.79.0
3.1 ( ± 1.8)7.5 (0.5 18.2)
6.26.40.9
[S3][K23][K23][K23][C23][T8]
[H25][H25][C24][M34][M46][R17][O6][O6]
[W32][W32]
ANNEX D: MEDICAL RADIATION EXPOSURES384
Table 18Patient dose per procedure a during interventional radiology
Procedure Fluoroscopy time(min)
Localized dose toskin (Gy)
Dose-area product(Gy cm2)
Effective dose(mSv) Ref.
PTCA (Percutaneoustransluminal coronaryangioplasty)
11.5 (2.4 28)30 (9 70)
15(56 max.)
11 (92 max.)31.3
43.8 b
31 c (8 62)43 d (3 53)
18.7
21 ( ± 63%)12.4
18.5 (15.5 SD)
e
0.15 (0.05 0.3)1
0.46 c
0.39 d
(1 5)0.1 (1 max.)
1.1
0.038 (at spine)
0.5 (0.01 2.2)
0.14 (LAO proj.)
93 (33 402)28.5 (20 50.5)
42 (266 max.)
87.5 (67 122)110 (40 340)143 (83 SD)
91.837.6 ( ± 41%)
72.2
45.8102 (85 SD)
28.9 (7.5 57)
10
22
6.914.2
[N6][F4][P3][K5][H6][G4][G4][B6][B6][H7][V3][B9]
[B10][L4][P15][Z12][B3]
[B54][V14][W41][P20]
PTA (Percutaneoustransluminal angioplasty)
1419.7 (5.3 26)(21.8 68) f
6
24 b (5 45)
17.9 (6.9 57.3)(6.3 26.3)
0.4
0.3b
7568.5 (22 150)
65.143.5 (5 184)
140 b (73 223)67.3 (289 max.)
68 (15 338)(19 109)
10
12.5 b
[S14][F5][N6][F6][B9]
[H27][W32][M46][K50]
TIPS (Transjugularintrahepatic portosystemicshunt)
46
48.4 (21.7 100)32 (9 79)
59 (26 115)48
1.70.4
1.2 (5 max.)
354525 (273 1131)226 (111 354)
77 (7 240)220
182 (470 max.)
83.9 (43.7 181)27 (14 44)
8 (2 40)50
[M8][V3]
[M34][Z11][Z11][S14][W32]
Radiofrequency ablation 42 (27 108)50 (31 SD)
21.4 (142 max.)(190 max.)28 (3 109)
53 ( ± 50)
65 (5 195)28.9
0.9 (6.2 max.)(8.4 max.)
0.07 (1.4 max.)
1.3 ( ± 1.3)0.93 ( ± 0.62)1.0 (0.08 3.1)
116 (26 217)
103 (7 516)
56.4 g (12 184)77.5 h (13 367)97.3 i (9 532)
91.143.6
17
17 / 25 j
17.3
[N6][L4][B7][C3][F6][C9][H8][H8][H8][R16][P14][N25][B54][W41]
Valvuloplasty 53 k (40 120)
31.8
56 k
44 l
162 29.3
[S15][S15][B54]
Lysis 21 [M8]
Embolization 2537.4 (8.1 58)
(8.4 6.4) m
(17.5 90) n
23 o (1 75)
-----
(0.2 1.4) p
0.5 q
180121 (34 286)
114 o (7 394)
81.7 q
391 (93 918)
25
(6 43)
[S14][F5][N6][N6][F6][B8][V3][B9]
Table 18 (continued)
ANNEX D: MEDICAL RADIATION EXPOSURES 385
Procedure Fluoroscopy time(min)
Localized dose toskin (Gy)
Dose-area product(Gy cm2)
Effective dose(mSv) Ref.
a Mean values of parameters (with range, standard deviation, or coefficient of variation in parentheses).b Procedure carried out with laser.c Total occlusion.d Subtotal stenosis.e No data available.f Leg.g Atrioventricular.h Atrioventricular nodal reentry.i Wolff Parkinson White.j Values for males and females, respectively.k Children (1 16 years).l Infants (<1 year).m Liver.n Kidney.o Neurological.p Cerebral.q Hepatic.
a Reported range for survey of 22 scanners.b Published value for spine.c Reported range for survey of 4 scanners.d Published value for trunk.
Embolization (continued) 21 p (6 54)34.1 p (15.2 55.8)
43 o (31 74)24.3 m (5 48)
0.34 p (019 0.66)0.62 o (0.13 1.34)
0.44 m
122 p
105 p (57.2 201)116 o (29 243)79 m (55 100)
105 (352 max.)
10.6 p
10.5 p (5.7 20)1.67 o (0.44 3.44)
15.9m
20 o ( ± 14) adult68 o ( ± 51) child.
[M9][M34,M36]
[B17][H27][G12][G12][W32]
Biliary7.1 (0.6 26.3)30.4 (3.6 141)34.2 ( ± 11.5)
2.10.11 (0.01 0.37)
68.9 (30 163)43.1 (3.8 149)20.1 (1.2 122)150 (51 291)
43 (167)
6.9 (0.6 23.9)
38.2
[V3][M34,M36]
[M35][R17][W32]
Stent (superior vena cava) 17 ( ± 9) 2 (max.) 42 ( ± 29) 5.8 [O9]
Table 19Doses to patients from computed tomography
Country / area Year
Mean effective dose per procedure (mSv)
Head Cervicalspine Chest Abdomen Liver Kidneys Pelvis Lumbar
spine
Health-care level I
Australia [T17]Finland [S67]Germany [B58]Japan [N16]Netherlands [V15]New Zealand [P5]Norway [O12]Sweden [S68]United Kingdom (Wales) [H33]
199519941993199419931992199319911994
2.61.32.6-
0.8-5.0 a
1.82.02.11.6
5.2-
9 b
--
3.3-6
1.5
10.45.120.5
4.6-10.8 c
6-188.911.510 d
9.7
16.711.627.4
6.7-13.3 c
6-24 a
9.712.810 d
12.0
12.7----
6.511.910 d
10.3
-----
7.69.910 d
9.1
11.0----
6.99.810 d
9.8
5.25.09 b
-2-12 a
4.74.56 b
3.3
Health-care level II
Oman [G37] 1998 2.4 3.5 3.4 9.5 - - - -
ANNEX D: MEDICAL RADIATION EXPOSURES388
a Without backscatter.b Dose range given in parentheses.c Dose-width product [N23].
a Applied potential.b Focus to skin distance.
Table 22Doses to patients from dental x-ray examinationsData from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicated
Country Year Technique Condition of measurementTypical entrance surface dose a per
exposure (mGy)
Survey mean S.D. b
Health-care level I
CanadaGreece [Y11]
Denmark [H31]
United Arab Emirates
United Kingdom [N23]
United States
19951997
1993
1997
1998
1993
IntraoralIntraoral (50 kV)Intraoral (60 kV)Intraoral (65 kV)Intraoral (70 kV)Intraoral (D speed film)Intraoral (E speed film)IntraoralIntraoralIntraoral (All)Intraoral (E speed film)Intraoral (45-55 kV)Intraoral (60-70 kV)PanoralIntraoralCephalometric
Survey of 56 units
National surveyNational survey4 unitsRVG filmless systemSample of 6344 measurementsSample of 1577 measurementsSample of 2175 measurementsSample of 3105 measurementsSample of 387 measurementsNEXT programmeNEXT programme
2.56.54.93.11.94.93.22.770.723.32.65.02.2
57.4 mGy mm c
1.90.21
(1.6 3.6)4.93.71.20.94.33.6
(2.61 3.2)
(0.14 46)(0.14 21)(0.6 46)(0.2 9.6)
(2 328 mGy mm) c
Health-care level II
Brazil 1996 Intraoral Survey data for Paraná State 7.9 (0.9 61)
Table 23Variation with technique of the typical effective dose from dental radiography[N3]
Radiographic technique Effective dose (µSv)
Two bitewing films 70 kV a, 200 mm fsd b, rectangular collimation, E speed film70 kV, 200 mm fsd, circular collimation, E speed film50-60 kV, 100 mm fsd, circular collimation, E speed film50-60 kV, 100 mm fsd, circular collimation, D speed film
248
16
Single panoral film Rare-earth intensifying screensCalcium tungstate intensifying screens
714
ANNEX D: MEDICAL RADIATION EXPOSURES 389
a Entrance surface dose or entrance surface air kerma; backscatter factor is generally <1.1 for mammographic exposures.b Dose range given in parentheses.c Values represent surveys before and after the introduction of a programme of quality control; data from two hospitals.d Diagnostic data from four units with grid and one without grid; screening data from two units.e Without grid.f Mediolateral oblique view (mean breast thickness 57 mm).g Craniocaudal view (mean breast thickness 52 mm).h Data from one hospital. Values represent surveys (with mean breast thickness of 3 cm) before and after the introduction of a programme of quality
control.
Table 24Doses to patients from mammographyData from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicated
Country Year Technique Condition of measurement
Typical dose per film (mGy)
Entrance surfacedose a
Dose to glandulartissue
Surveymean S.D. b Survey
mean S.D.b
Health-care level I
Argentina c [I4]
Australia [H48]Belgium [P28]
Canada[F19]
Finland [S16]France [M7]
Germany [K49]
Greece [F7]
Italy [M6]
Japan [S81]New Zealand
[B12]Norway [O10]
PanamaSloveniaSpain [C40]
SwedenUnited Arab
Emirates d
United Kingdom [Y12]
[B66]
United States [S82]
[K43]
1993
19961997
19941999199319911993199219931990
1997
1994199619931994
199519961997199719961998
1991199619951995199219971999
400 speedfilm/screenScreeningScreeningScreening
-ScreeningScreeningScreeningScreeningW anode
Mo/W anodeGrid
Non-grid--
Screening-
ScreeningNon-grid
Grid--
ScreeningScreeningScreeningScreeningClinical
Clinical e
ScreeningScreeningScreeningScreening
---
Patient surveys
Patient survey (2 units; 2051 films)24 centres (4.5 cm phantom)24 centres (patient survey)Standard breast phantomSurvey in Ontario (phantom)4.5 cm Acrylic phantomSurvey in Bas-Rhin (phantom)Survey in Bas-Rhin (phantom)Patient survey (1678 women)Patient survey (945 women)4 cm Acrylic phantom4 cm Acrylic phantomTuscany region (phantom)Tuscany region (patients)4 cm compressed breastAverage breast thicknessPatient survey in Otago (phantom)Standard phantomStandard phantom-Standard phantom4.5 cm Acrylic phantomPatient surveyStandard breast phantomStandard breast phantomStandard breast phantomStandard breast phantomStandard breast phantomStandard breast phantomPatient survey (4 633 women)Patient survey (4 633 women)Standard breast phantomStandard breast phantomSurvey of 6 000 patients (phantom)
11.08 (pre)7.26 (post)
7.58.0
6.315.28.58.3611.08.55.27.99.5
5.976.826.15.7
2.42.9
3.1
4.225.05
(5 15)(1 25)
2.702.592.02.6
2.261.41.51.11.51.0
1.592.07
1.801.45
1.31.01.52.652.710.231.281.362.0 f
1.6 g
1.491.602.6
(0.4 7.2)0.40.5
(0.36 4.68)
0.48
0.560.66
0.47(0.7 8.5)(0.4 0.8)(0.7 2.0)
0.40.4
(0.7 3.2)(2.48 2.81)(2.66 2.76)
(0.6 2.6)(0.7 2.5)
Health-care level II
Iran (IslamicRepublic of) h [I4]Turkey
1993
1997 -
Patient surveys
Localized survey
5.45 (pre)4.27 (post)
3.29
1.94
0.23
ANNEX D: MEDICAL RADIATION EXPOSURES 389
a Entrance surface dose or entrance surface air kerma; backscatter factor is generally <1.1 for mammographic exposures.b Dose range given in parentheses.c Values represent surveys before and after the introduction of a programme of quality control; data from two hospitals.d Diagnostic data from four units with grid and one without grid; screening data from two units.e Without grid.f Mediolateral oblique view (mean breast thickness 57 mm).g Craniocaudal view (mean breast thickness 52 mm).h Data from one hospital. Values represent surveys (with mean breast thickness of 3 cm) before and after the introduction of a programme of quality
control.
Table 24Doses to patients from mammographyData from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicated
Country Year Technique Condition of measurement
Typical dose per film (mGy)
Entrance surfacedose a
Dose to glandulartissue
Surveymean S.D. b Survey
mean S.D.b
Health-care level I
Argentina c [I4]
Australia [H48]Belgium [P28]
Canada[F19]
Finland [S16]France [M7]
Germany [K49]
Greece [F7]
Italy [M6]
Japan [S81]New Zealand
[B12]Norway [O10]
PanamaSloveniaSpain [C40]
SwedenUnited Arab
Emirates d
United Kingdom [Y12]
[B66]
United States [S82]
[K43]
1993
19961997
19941999199319911993199219931990
1997
1994199619931994
199519961997199719961998
1991199619951995199219971999
400 speedfilm/screenScreeningScreeningScreening
-ScreeningScreeningScreeningScreeningW anode
Mo/W anodeGrid
Non-grid--
Screening-
ScreeningNon-grid
Grid--
ScreeningScreeningScreeningScreeningClinical
Clinical e
ScreeningScreeningScreeningScreening
---
Patient surveys
Patient survey (2 units; 2051 films)24 centres (4.5 cm phantom)24 centres (patient survey)Standard breast phantomSurvey in Ontario (phantom)4.5 cm Acrylic phantomSurvey in Bas-Rhin (phantom)Survey in Bas-Rhin (phantom)Patient survey (1678 women)Patient survey (945 women)4 cm Acrylic phantom4 cm Acrylic phantomTuscany region (phantom)Tuscany region (patients)4 cm compressed breastAverage breast thicknessPatient survey in Otago (phantom)Standard phantomStandard phantom-Standard phantom4.5 cm Acrylic phantomPatient surveyStandard breast phantomStandard breast phantomStandard breast phantomStandard breast phantomStandard breast phantomStandard breast phantomPatient survey (4 633 women)Patient survey (4 633 women)Standard breast phantomStandard breast phantomSurvey of 6 000 patients (phantom)
11.08 (pre)7.26 (post)
7.58.0
6.315.28.58.3611.08.55.27.99.5
5.976.826.15.7
2.42.9
3.1
4.225.05
(5 15)(1 25)
2.702.592.02.6
2.261.41.51.11.51.0
1.592.07
1.801.45
1.31.01.52.652.710.231.281.362.0 f
1.6 g
1.491.602.6
(0.4 7.2)0.40.5
(0.36 4.68)
0.48
0.560.66
0.47(0.7 8.5)(0.4 0.8)(0.7 2.0)
0.40.4
(0.7 3.2)(2.48 2.81)(2.66 2.76)
(0.6 2.6)(0.7 2.5)
Health-care level II
Iran (IslamicRepublic of) h [I4]Turkey
1993
1997 -
Patient surveys
Localized survey
5.45 (pre)4.27 (post)
3.29
1.94
0.23
Table 34 (continued)
ANNEX D: MEDICAL RADIATION EXPOSURES400
a Historical data.b Categorized in health-care level II in previous analyses.c Data for 1985 1990 represent historical data for Federal Republic of Germany.d Historical data were not included in previous analyses.e These revised data were received by the Committee after completion of the global analysis.
a Frequency-weighted average of national values from survey data. Values for 1991 1996 from Table 15.
Health care level IV
United Rep. of Tanzania 0.1
Average 0.1
Table 35Trends in average effective doses from diagnostic medical x-ray examinationsData from UNSCEAR Surveys of Medical Radiation Usage and Exposures
Examination
Average a effective dose per examination (mSv)
Health-care level I Health-care level II
1970 1979 1980 1990 1991 1996 1980 1990 1991 1996
Chest radiographyChest photofluoroscopyChest fluoroscopyLimbs and jointsLumbar spinePelvis and hipHeadAbdomenUpper GI tractLower GI tractCholecystographyUrographyMammographyCTAngiographyPTCA
0.250.520.720.022.22.10.501.98.99.81.93.01.81.39.2
0.140.520.980.061.71.20.161.17.24.11.53.11.04.36.8
0.140.651.10.061.80.830.070.533.66.42.33.70.518.81222
0.04
0.290.042.62.00.130.221.65.01.61.7
0.05
0.041.00.740.040.626.06.01.53.90.14.96.8
Tabl
e41
Aver
age
activ
ities
adm
inis
tere
din
diag
nost
icex
amin
atio
nsw
ithra
diop
harm
aceu
tical
s(1
991
1996
)Da
tafro
mUN
SCEA
RSu
rvey
ofM
edica
lRad
iatio
nUs
age
and
Expo
sure
sun
less
othe
rwise
indi
cate
d
PA
RT
A
Cou
ntry
/are
a
Aver
age
activ
ityad
min
iste
red
(MBq
)(ra
nge
orst
anda
rdde
viat
ion
inpa
rent
hese
s)
Bone
Car
diov
ascu
lar
Brai
n
99mTc
phos
phat
es99
mTc
othe
r99
mTc
MIB
I99
mTc
othe
r21
0 Tlch
lori
de99
mTc
DTP
A99
mTc
HM
PAO
99mTc
pert
echn
etat
eO
ther
Heal
th-c
are
leve
lI
Arg
entin
aB
elar
usB
ulga
riaC
anad
aC
hina
,Tai
wan
Pr.[
L6]
Cro
atia
Cyp
rus
Cze
chR
epub
licD
enm
ark
Ecua
dor
Finl
and
Fran
ce[E
10]
Ger
man
yIr
elan
dIta
lyJa
pan
[J11
]K
uwai
tLi
thua
nia
Net
herla
nds
New
Zeal
and
[L28
]Pa
nam
aPo
rtuga
l[E1
0]R
oman
iaSl
ovak
iaSl
oven
iaSp
ain
[E10
]Sw
eden
Switz
erla
ndU
nite
dA
rab
Emira
tes
Uni
ted
Kin
gdom
[A20
]
a
300
(150
450)
925
(±10
%)
545
(370
750)
555
(100
740)
630
730
(350
-121
0)63
7(1
8082
0)74
0(±
5%)
620
600
500
(40
660)
630
(555
740)
925
(740
-111
0)60
0(4
0060
0)
674
(50
920)
555
(292
618)
660
(480
840)
740
(260
740)
500
(370
740)
740
450
(60
600)
670
(150
-100
0)72
0(7
482
0)60
0
781
a(±
192)
720
a(6
80-7
60)
620
a
620
b(5
5574
0)74
0a
500
a(4
0080
0)
666
600
(±10
%)
680
615
(450
860)
110
0(±
5%)
1000
600
(185
740)
650
(600
700)
688
(341
-108
0)55
5(2
9281
8)
400
(37
555)
740
800
(400
-140
0)57
0(1
1074
0)74
0(7
00-1
000)
300
(400
SPEC
T)
877
(±19
2)
555
b
540
c
370
a(1
8574
0)60
01
100
710
c(7
31
110)
890
a
700
c
800
c(6
00-1
100)
740
a
925
c(5
5592
5)
585
c(2
5094
4)
740
a
740
a
800
c
89(±
11)
74 7080
(70
111)
7590
(80
100)
100
75
90(7
411
1)13
1
125
(100
150)
80(3
711
1)
100
74
80(6
012
0)80
(70
110)
93(8
095
)80
(550
740)
420
110
0(±
5%)
630
(555
740)
740
744
(710
750)
555
(424
686)
460
(330
590)
500
(800
SPEC
T)
740
(±5%
)
740
(460
860)
667
(125
945)
750
700
575
(550
600)
720
(555
925)
787
555
(185
555)
500
705
(450
907)
600
740
940
(600
100
0)61
0(3
7074
0)74
0(7
0076
0)
420
650
(600
700)
740
355
(210
500)
740
(200
740)
620
(460
930)
500
866
d(±
137)
740
d(7
0078
0)
555
d(1
8574
0)
1629
e(6
0-3
000)
655
d ;124
f
650
a(7
4055
5)
200
f
500
d(5
0074
0)
550
g(4
0057
0)93
0e
500
h
Ave
rage
719
622
100
482
721
419
ANNEX D: MEDICAL RADIATION EXPOSURES414
Tabl
e41
Aver
age
activ
ities
adm
inis
tere
din
diag
nost
icex
amin
atio
nsw
ithra
diop
harm
aceu
tical
s(1
991
1996
)Da
tafro
mUN
SCEA
RSu
rvey
ofM
edica
lRad
iatio
nUs
age
and
Expo
sure
sun
less
othe
rwise
indi
cate
d
PA
RT
A
Cou
ntry
/are
a
Aver
age
activ
ityad
min
iste
red
(MBq
)(ra
nge
orst
anda
rdde
viat
ion
inpa
rent
hese
s)
Bone
Car
diov
ascu
lar
Brai
n
99mTc
phos
phat
es99
mTc
othe
r99
mTc
MIB
I99
mTc
othe
r21
0 Tlch
lori
de99
mTc
DTP
A99
mTc
HM
PAO
99mTc
pert
echn
etat
eO
ther
Heal
th-c
are
leve
lI
Arg
entin
aB
elar
usB
ulga
riaC
anad
aC
hina
,Tai
wan
Pr.[
L6]
Cro
atia
Cyp
rus
Cze
chR
epub
licD
enm
ark
Ecua
dor
Finl
and
Fran
ce[E
10]
Ger
man
yIr
elan
dIta
lyJa
pan
[J11
]K
uwai
tLi
thua
nia
Net
herla
nds
New
Zeal
and
[L28
]Pa
nam
aPo
rtuga
l[E1
0]R
oman
iaSl
ovak
iaSl
oven
iaSp
ain
[E10
]Sw
eden
Switz
erla
ndU
nite
dA
rab
Emira
tes
Uni
ted
Kin
gdom
[A20
]
a
300
(150
450)
925
(±10
%)
545
(370
750)
555
(100
740)
630
730
(350
-121
0)63
7(1
8082
0)74
0(±
5%)
620
600
500
(40
660)
630
(555
740)
925
(740
-111
0)60
0(4
0060
0)
674
(50
920)
555
(292
618)
660
(480
840)
740
(260
740)
500
(370
740)
740
450
(60
600)
670
(150
-100
0)72
0(7
482
0)60
0
781
a(±
192)
720
a(6
80-7
60)
620
a
620
b(5
5574
0)74
0a
500
a(4
0080
0)
666
600
(±10
%)
680
615
(450
860)
110
0(±
5%)
1000
600
(185
740)
650
(600
700)
688
(341
-108
0)55
5(2
9281
8)
400
(37
555)
740
800
(400
-140
0)57
0(1
1074
0)74
0(7
00-1
000)
300
(400
SPEC
T)
877
(±19
2)
555
b
540
c
370
a(1
8574
0)60
01
100
710
c(7
31
110)
890
a
700
c
800
c(6
00-1
100)
740
a
925
c(5
5592
5)
585
c(2
5094
4)
740
a
740
a
800
c
89(±
11)
74 7080
(70
111)
7590
(80
100)
100
75
90(7
411
1)13
1
125
(100
150)
80(3
711
1)
100
74
80(6
012
0)80
(70
110)
93(8
095
)80
(550
740)
420
110
0(±
5%)
630
(555
740)
740
744
(710
750)
555
(424
686)
460
(330
590)
500
(800
SPEC
T)
740
(±5%
)
740
(460
860)
667
(125
945)
750
700
575
(550
600)
720
(555
925)
787
555
(185
555)
500
705
(450
907)
600
740
940
(600
100
0)61
0(3
7074
0)74
0(7
0076
0)
420
650
(600
700)
740
355
(210
500)
740
(200
740)
620
(460
930)
500
866
d(±
137)
740
d(7
0078
0)
555
d(1
8574
0)
1629
e(6
0-3
000)
655
d ;124
f
650
a(7
4055
5)
200
f
500
d(5
0074
0)
550
g(4
0057
0)93
0e
500
h
Ave
rage
719
622
100
482
721
419
ANNEX D: MEDICAL RADIATION EXPOSURES414
Tabl
e41
(con
tinue
d)
Cou
ntry
/are
a
Aver
age
activ
ityad
min
iste
red
(MBq
)(ra
nge
orst
anda
rdde
viat
ion
inpa
rent
hese
s)
Bone
Car
diov
ascu
lar
Brai
n
99mTc
phos
phat
es99
mTc
othe
r99
mTc
MIB
I99
mTc
othe
r21
0 Tlch
lori
de99
mTc
DTP
A99
mTc
HM
PAO
99mTc
pert
echn
etat
eO
ther
Heal
th-c
are
leve
lII
Jord
anM
exic
oPe
ruTu
rkey
750
(±10
%)
463
(185
740)
740
(700
800)
851
(638
-106
4)
148
(111
185)
740
(700
800)
122
1(8
58-1
584)
1000
a
379
b(1
1164
7)74
0c
(700
800)
75
97(7
911
5)
262
(80
444)
740
(700
800)
262
(80
444)
601
(368
834)
Ave
rage
730
740
7574
060
1
Heal
th-c
are
leve
lIII
Gha
na[A
16]
Mor
occo
Suda
n
446
560
740
a(5
5592
5)92
5a
92.5
(92.
511
1)40
9
561
0d
Ave
rage
546
93
Heal
th-c
are
leve
lIV
Ethi
opia
Uni
tedRe
p.of
Tanz
ania
555
600
(±5%
)66
6(3
7074
0)80
0(±
5%)
666
(370
740)
Ave
rage
598
679
666
PA
RT
B
Cou
ntry
/are
a
Aver
age
activ
ityad
min
iste
red
(MBq
)(ra
nge
inpa
rent
hese
s)
Lung
perf
usio
nLu
ngve
ntila
tion
Live
r/sp
leen
99mTc
MAA
Oth
er99
mTc
DTP
A99
mTc
aero
sol
Oth
er99
mTc
collo
id99
mTc
IDA
Oth
er
Heal
th-c
are
leve
lI
Arg
entin
aB
elar
usB
ulga
riaC
anad
aC
hina
,Tai
wan
Pr.[
L6]
Cro
atia
7418
5(±
10%
)12
014
8(1
1122
2)
181
d(±
78);
200
i
(±33
)92
5
37(1
774
)
988
d(±
281)
185
111
(±10
%)
150
148
(74
222)
333
140
229
d(±
107)
120
d(1
1112
9)
ANNEX D: MEDICAL RADIATION EXPOSURES 415 ANNEX D: MEDICAL RADIATION EXPOSURES416
Tabl
e41
(con
tinue
d)
Cou
ntry
/are
a
Aver
age
activ
ityad
min
iste
red
(MBq
)(ra
nge
inpa
rent
hese
s)
Lung
perf
usio
nLu
ngve
ntila
tion
Live
r/sp
leen
99mTc
MAA
Oth
er99
mTc
DTP
A99
mTc
aero
sol
Oth
er99
mTc
collo
id99
mTc
IDA
Oth
er
Cyp
rus
Cze
chR
epub
licD
enm
ark
Ecua
dor
Finl
and
Fran
ce[E
10]
Ger
man
yIr
elan
dIta
lyJa
pan
[J11
]K
uwai
tLi
thua
nia
Net
herla
nds
New
Zeal
and
[L28
]Pa
nam
aPo
rtuga
l[E1
0]R
oman
iaSl
ovak
iaSl
oven
iaSp
ain
[E10
]Sw
eden
Switz
erla
ndU
nite
dA
rab
Emira
tes
Uni
ted
Kin
gdom
[A20
]
150
188
(90
210)
112
(50
185)
870
(±5%
)10
5d
300
100
80(6
011
0)15
0(1
1118
5)
111
(74
185)
100
(80
100)
100
145
(56
286)
185
111
125
(55
195)
185
(80
185)
170
(120
222)
100
(27
150)
140
(70
230)
140
(111
260)
100
(200
SPEC
T)
460
e
240
d
74a
(37
84)
970
(600
120
0)
370
(±5%
)
8055
5(3
7070
0)74
01
480
(111
0-1
850)
81(3
713
6)92
5(6
6211
88)
175
(84
185)
200
(71
500)
222
(200
300)
80
13(7
80)
100
444
370
240
(15-
170
0)
396
e(2
0082
6)
580
d ;185
e
(450
750
min
1 )j
734
e(3
701
112)
140
e(1
0020
0)
390
e(1
10-7
50);
220
k(1
00-3
70)
400e ;6
000j (m
ax)
185
148
(80
230)
83(4
521
7)37
0(±
10%
)
110
(100
130)
150
(111
370)
185
(74
185)
80(8
010
0)80
196
(110
278)
241
(110
372)
185
140
(35
245)
185
170
(20
800)
120
(20
160)
148
(140
185)
80
150
110
(100
130)
185
180
100
(10
200)
180
d
148
d(1
1118
5)20
0d
9l(7
.410
.6)
185
d(4
018
5)(2
9650
0)d
Ave
rage
118
662
141
Heal
th-c
are
leve
lII
Jord
anM
exic
oPe
ruTu
rkey
150
130
(74
185)
185
(150
200)
159
(124
194)
100
046
3(1
8574
0)
925
185
a(1
5020
0)
150
111
(36
185)
185
(150
200)
148
(96
200)
131
(40
222)
Ave
rage
147
703
150
Heal
th-c
are
leve
lIII
Gha
na[A
16]
Mor
occo
Suda
n18
5d(1
8525
9)87 74
029
6d
(37
740)
Ave
rage
454
ANNEX D: MEDICAL RADIATION EXPOSURES416
Tabl
e41
(con
tinue
d)
Cou
ntry
/are
a
Aver
age
activ
ityad
min
iste
red
(MBq
)(ra
nge
inpa
rent
hese
s)
Lung
perf
usio
nLu
ngve
ntila
tion
Live
r/sp
leen
99mTc
MAA
Oth
er99
mTc
DTP
A99
mTc
aero
sol
Oth
er99
mTc
collo
id99
mTc
IDA
Oth
er
Cyp
rus
Cze
chR
epub
licD
enm
ark
Ecua
dor
Finl
and
Fran
ce[E
10]
Ger
man
yIr
elan
dIta
lyJa
pan
[J11
]K
uwai
tLi
thua
nia
Net
herla
nds
New
Zeal
and
[L28
]Pa
nam
aPo
rtuga
l[E1
0]R
oman
iaSl
ovak
iaSl
oven
iaSp
ain
[E10
]Sw
eden
Switz
erla
ndU
nite
dA
rab
Emira
tes
Uni
ted
Kin
gdom
[A20
]
150
188
(90
210)
112
(50
185)
870
(±5%
)10
5d
300
100
80(6
011
0)15
0(1
1118
5)
111
(74
185)
100
(80
100)
100
145
(56
286)
185
111
125
(55
195)
185
(80
185)
170
(120
222)
100
(27
150)
140
(70
230)
140
(111
260)
100
(200
SPEC
T)
460
e
240
d
74a
(37
84)
970
(600
120
0)
370
(±5%
)
8055
5(3
7070
0)74
01
480
(111
0-1
850)
81(3
713
6)92
5(6
6211
88)
175
(84
185)
200
(71
500)
222
(200
300)
80
13(7
80)
100
444
370
240
(15-
170
0)
396
e(2
0082
6)
580
d ;185
e
(450
750
min
1 )j
734
e(3
701
112)
140
e(1
0020
0)
390
e(1
10-7
50);
220
k(1
00-3
70)
400e ;6
000j (m
ax)
185
148
(80
230)
83(4
521
7)37
0(±
10%
)
110
(100
130)
150
(111
370)
185
(74
185)
80(8
010
0)80
196
(110
278)
241
(110
372)
185
140
(35
245)
185
170
(20
800)
120
(20
160)
148
(140
185)
80
150
110
(100
130)
185
180
100
(10
200)
180
d
148
d(1
1118
5)20
0d
9l(7
.410
.6)
185
d(4
018
5)(2
9650
0)d
Ave
rage
118
662
141
Heal
th-c
are
leve
lII
Jord
anM
exic
oPe
ruTu
rkey
150
130
(74
185)
185
(150
200)
159
(124
194)
100
046
3(1
8574
0)
925
185
a(1
5020
0)
150
111
(36
185)
185
(150
200)
148
(96
200)
131
(40
222)
Ave
rage
147
703
150
Heal
th-c
are
leve
lIII
Gha
na[A
16]
Mor
occo
Suda
n18
5d(1
8525
9)87 74
029
6d
(37
740)
Ave
rage
454
Tabl
e41
(con
tinue
d)
Cou
ntry
/are
a
Aver
age
activ
ityad
min
iste
red
(MBq
)(ra
nge
inpa
rent
hese
s)
Lung
perf
usio
nLu
ngve
ntila
tion
Live
r/sp
leen
99mTc
MAA
Oth
er99
mTc
DTP
A99
mTc
aero
sol
Oth
er99
mTc
collo
id99
mTc
IDA
Oth
er
Heal
th-c
are
leve
lIV
Ethi
opia
Uni
tedRe
p.of
Tanz
ania
111
118
0d(±
5%)
111
(111
185)
Ave
rage
111
111
PA
RT
C
Cou
ntry
/are
a
Aver
age
activ
ityad
min
iste
red
(MBq
)(ra
nge
inpa
rent
hese
s)
Thyr
oid
scan
Thyr
oid
upta
keRe
nals
can
99mTc
pert
echn
etat
e13
1 Iiod
ide
Oth
er99
mTc
pert
echn
etat
e13
1 Iiod
ide
123 Ii
odid
e99
mTc
DM
SA99
mTc
DTP
A99
mTc
MAG
3O
ther
Heal
th-c
are
leve
lI
Arg
entin
aB
elar
usB
ulga
riaC
anad
aC
hina
(Tai
wan
)[L6
]C
roat
iaC
ypru
sC
zech
Rep
ublic
Den
mar
kEc
uado
rFi
nlan
dFr
ance
[E10
]G
erm
any
Irel
and
Italy
Japa
n[J
11]
Kuw
ait
Lith
uani
aN
ethe
rland
sN
ewZe
alan
d[L
28]
Pana
ma
Portu
gal[
E10]
Rom
ania
248
(±10
7)11
1(1
01-1
21)
(37
74)
8014
8(1
11-2
22)
130
(70
180)
150
(37
370)
130
5011
0(2
713
0)11
1(7
418
5)
185
(74
185)
100
(80
180)
168
(23-
740)
463
(332
-594
)
90(3
414
6)
3(±
1)
148
(74
185)
758
(812
)
3.7
(±10
%)
185
1.1
(0.7
4-1.
85)
26
60(6
080
)
113
(21
200)
1.6
(0.6
2.6)
(110
)m
185
d(±
10%
)
150
d
12f
200
d
20f
7(±
3)
5027
(11
72)
192
2(±
1)0.
4(0
.35-
0.45
)
0.8 17 75
0.62
(0.4
1)86
(0.3
-370
0)3.
7(±
10%
)3
0.18
51.
1(0
.74-
1.85
)23
1.5
(1.1
2.6)
0.2
5.5
(220
)1.
85
1.3
(0.6
2)
20 6 8.8 20
60(4
080
)
150
74(3
711
1)75
188
(80
250)
200
7584
(26
185)
148
(111
180)
197
150
(100
150)
65(1
215
5)56
(30
82)
111
185
(85
285)
400
(±15
%)
150
74(3
711
1)22
025
0(1
1036
0)16
5(2
035
0)37
0(±
10%
)
200
(74
740)
84(2
618
5)14
8(1
1118
0)37
737
0(1
8537
0)
(40
350)
314
(22
617)
463
(432
594)
111
300
(100
500)
185
(85
285)
92(3
210)
370
(±10
%)
280
84(2
618
5)
370
(185
370)
8022
8(1
3044
4)18
5(1
0726
3)11
1
215d
(±12
2);6
n(±
2)18
5d(1
7419
6)
9n ;1
50d
(74
740)
f
25f
26n
(18.
537
)49
m
3.3
o(1
5)
111
f
1.5
n(0
.72.
3)
ANNEX D: MEDICAL RADIATION EXPOSURES 417 ANNEX D: MEDICAL RADIATION EXPOSURES418
Tabl
e41
(con
tinue
d)
Cou
ntry
/are
a
Aver
age
activ
ityad
min
iste
red
(MBq
)(ra
nge
inpa
rent
hese
s)
Thyr
oid
scan
Thyr
oid
upta
keRe
nals
can
99mTc
pert
echn
etat
e13
1 Iiod
ide
Oth
er99
mTc
pert
echn
etat
e13
1 Iiod
ide
123 Ii
odid
e99
mTc
DM
SA99
mTc
DTP
A99
mTc
MAG
3O
ther
aN
ofu
rther
info
rmat
ion
avai
labl
e.i
67G
a.b
Perte
chne
tate
.j
81mK
r.c
Red
bloo
dce
lls.
k12
7 Xe.
d99
mTc
.l
128 A
uco
lloid
.e
133 X
e.m
131 I,
125 I,
123 I.
f12
3 I.n
131 I.
g11
Cm
etio
min
.o
51C
rED
TA.
h99
mTc
ECD
.
Slov
akia
Slov
enia
Spai
n[E
10]
Swed
enSw
itzer
land
Uni
ted
Ara
bEm
irate
sU
nited
Kin
gdom
[A20
]
70(4
011
0)74
(37
74)
120
(10
220)
90(3
020
0)18
5(1
48-2
60)
80
1.8
(0.1
81.
8)5
(3.7
7.4)
1.1
2(0
.180
)2
(17)
20
13f(5
20)
7475
(50
100)
185
(148
260)
40
(0.1
81.
8)2
(1.5
3.7)
2(0
.26)
0.2
2
185
(80
370)
80
40(1
020
0)60
(20
130)
148
(140
185)
80
185
(80
370)
185
360
(10
800)
148
(140
185)
300
100
85(6
717
5)11
0(1
0015
0)
100
18.5
n
20f(5
40)
3o
Ave
rage
6517
3.1
140
236
127
Heal
th-c
are
leve
lII
Jord
anM
exic
oPe
ruTu
rkey
130
(74
185)
185
(150
-200
)13
4(9
916
9)
5.6
(3.8
7.4)
185
(150
200)
3.7
5.6
(3.8
7.4)
1(0
.51.
2)
140
370
(300
min
)16
1(1
1820
4)
740
170
(80
259)
740
(700
800)
321
(167
475)
170
(80
259)
Ave
rage
136
185
4.4
370
181
170
Heal
th-c
are
leve
lIII
Gha
na[A
16]
Mor
occo
Suda
n
9713
0(9
316
7)56
074
0
99 1800
111
d(7
422
2)
Ave
rage
173
Heal
th-c
are
leve
lIV
Ethi
opia
Uni
tedRe
p.of
Tanz
ania
1.7
(1.3
2)20
01.
7(1
.32)
7420
0
Ave
rage
1.7
1.7
7420
0
ANNEX D: MEDICAL RADIATION EXPOSURES418
Tabl
e41
(con
tinue
d)
Cou
ntry
/are
a
Aver
age
activ
ityad
min
iste
red
(MBq
)(ra
nge
inpa
rent
hese
s)
Thyr
oid
scan
Thyr
oid
upta
keRe
nals
can
99mTc
pert
echn
etat
e13
1 Iiod
ide
Oth
er99
mTc
pert
echn
etat
e13
1 Iiod
ide
123 Ii
odid
e99
mTc
DM
SA99
mTc
DTP
A99
mTc
MAG
3O
ther
aN
ofu
rther
info
rmat
ion
avai
labl
e.i
67G
a.b
Perte
chne
tate
.j
81mK
r.c
Red
bloo
dce
lls.
k12
7 Xe.
d99
mTc
.l
128 A
uco
lloid
.e
133 X
e.m
131 I,
125 I,
123 I.
f12
3 I.n
131 I.
g11
Cm
etio
min
.o
51C
rED
TA.
h99
mTc
ECD
.
Slov
akia
Slov
enia
Spai
n[E
10]
Swed
enSw
itzer
land
Uni
ted
Ara
bEm
irate
sU
nited
Kin
gdom
[A20
]
70(4
011
0)74
(37
74)
120
(10
220)
90(3
020
0)18
5(1
48-2
60)
80
1.8
(0.1
81.
8)5
(3.7
7.4)
1.1
2(0
.180
)2
(17)
20
13f(5
20)
7475
(50
100)
185
(148
260)
40
(0.1
81.
8)2
(1.5
3.7)
2(0
.26)
0.2
2
185
(80
370)
80
40(1
020
0)60
(20
130)
148
(140
185)
80
185
(80
370)
185
360
(10
800)
148
(140
185)
300
100
85(6
717
5)11
0(1
0015
0)
100
18.5
n
20f(5
40)
3o
Ave
rage
6517
3.1
140
236
127
Heal
th-c
are
leve
lII
Jord
anM
exic
oPe
ruTu
rkey
130
(74
185)
185
(150
-200
)13
4(9
916
9)
5.6
(3.8
7.4)
185
(150
200)
3.7
5.6
(3.8
7.4)
1(0
.51.
2)
140
370
(300
min
)16
1(1
1820
4)
740
170
(80
259)
740
(700
800)
321
(167
475)
170
(80
259)
Ave
rage
136
185
4.4
370
181
170
Heal
th-c
are
leve
lIII
Gha
na[A
16]
Mor
occo
Suda
n
9713
0(9
316
7)56
074
0
99 1800
111
d(7
422
2)
Ave
rage
173
Heal
th-c
are
leve
lIV
Ethi
opia
Uni
tedRe
p.of
Tanz
ania
1.7
(1.3
2)20
01.
7(1
.32)
7420
0
Ave
rage
1.7
1.7
7420
0
Tabl
e41
(con
tinue
d)
The
entri
esin
this
Tabl
ear
equ
alifi
edas
follo
ws:
Arge
ntin
a:O
nth
eba
sisof
data
from
asa
mpl
eof
25%
ofnu
clea
rmed
icin
ece
ntre
s.B
one
scan
salso
perfo
rmed
usin
g67
Ga
(204
±41
MB
q).
Can
ada:
Dat
afro
mLo
ndon
Hea
lthSc
ienc
esC
entre
,SW
Ont
ario
(rep
rese
ntin
g50
%of
the
serv
ices
prov
ided
topo
pula
tion
ofab
out1
mill
ion)
.C
ypru
sSu
rvey
data
rela
ting
to90
%of
popu
latio
n.G
hana
:D
ata
fort
hyro
idsc
anre
fert
oal
lthy
roid
studi
es.
Jord
an:
Surv
eyda
tafro
mon
eho
spita
l.Li
thua
nia:
Dat
afro
mV
ilniu
sOnc
olog
yC
entre
.M
oroc
co:
Bon
esc
ansa
lsope
rform
edus
ing
131 I(
mea
n11
1M
Bq;
rang
e92
.511
1M
Bq)
.Pe
ru:
Surv
eyda
tafro
mIP
EN(C
entre
ofN
ucle
arM
edic
ine,
serv
ing
popu
latio
nof
abou
t5m
illio
n).
Port
ugal
:D
ata
from
one
larg
ede
partm
enta
ndso
me
addi
tiona
ldat
a.Ro
man
ia:
Surv
eyda
tare
latin
gto
popu
latio
nba
seof
abou
t4.5
mill
ion.
Alte
rnat
ive
tech
niqu
eem
ploy
edfo
rbon
esc
ansu
sing
99mTc
phos
phat
es:m
ean
110
MB
q,ra
nge
6016
0M
Bq.
Slov
akia
:Su
rvey
data
rela
ting
topo
pula
tion
base
ofab
out2
mill
ion.
Switz
erla
nd:
Lung
vent
ilatio
nstu
dies
also
perfo
rmed
usin
g12
7 Xe
(mea
n22
0M
Bq;
rang
e10
037
0M
Bq)
.Tu
rkey
:Su
rvey
data
from
Gül
hane
Mili
tary
Hos
pita
l,H
acet
tepe
Uni
vers
ityH
ospi
tala
ndSa
msu
nO
ndok
uzM
ayis
Uni
vers
ityH
ospi
tal.
Uni
ted
Arab
Emir
ates
:Thy
roid
upta
kedo
nesim
ulta
neou
slyw
ithth
yroi
dsc
anus
ing
asin
gle
dose
.U
nite
dKi
ngdo
m:
Dat
are
pres
entr
ecom
men
ded
max
imum
usua
lact
iviti
es(d
iagn
ostic
refe
renc
ele
vels)
.
Tabl
e42
Typi
cale
ffect
ive
dose
sto
patie
nts
from
com
mon
type
sof
diag
nost
icnu
clea
rmed
icin
epr
oced
ures
Cou
ntry
Effe
ctiv
edo
sepe
rpro
cedu
re(m
Sv)
Bone
aC
ardi
ovas
cula
rLu
ngpe
rfus
ion
bLu
ngve
ntila
tion
Thyr
oid
scan
Thyr
oid
upta
keRe
nalc
Live
r/sp
leen
cBr
ain
c
Heal
th-c
are
leve
lI
Can
ada
[A15
]4.
34.
9(99
mTc
)11
.8(20
1 Tl)
1.5
1.0
(99mTc
)1.
7(12
3 I)0.
5(D
TPA
)1.
6(M
AG
3)1.
3(D
MSA
)
1.7
(Sco
lloid
)6.
9(H
MPA
O)
Chi
na,T
aiw
anPr
ovin
ce[L
6]3.
33.
2(99
mTc
)13
.3(20
1 Tl)
1.4
1.1
(99mTc
)14
.4(13
1 I)0.
841.
2(c
ollo
id)
2.1
(HID
A)
2.4
Ger
man
y[K
12]
3.5
4.6
(99mTc
)17
(201 Tl
)1.
10.
6(99
mTc
)0.
3(12
3 I)0.
7(D
MSA
)2.
3(H
IDA
)6.
6(H
MPA
O)
Rom
ania
[I36
]3.
41.
41.
1(99
mTc
)38
.4(13
1 I)31
.2(13
1 I)0.
1(13
1 I)1.
6(D
TPA
)9.
9(19
8 Au)
1.4
(col
loid
)2.
0
New
Zeal
and
[L28
]4.
33.
9(99
mTc
RB
C)
7.6
(99mTc
MIB
I)1.
60.
4(D
TPA
)2.
0(99
mTc
)2.
0(D
TPA
)0.
6(D
MSA
)1.
8(S
nco
lloid
)4.
8(D
TPA
)
ANNEX D: MEDICAL RADIATION EXPOSURES 419
Tabl
e42
(con
tinue
d)
Cou
ntry
Effe
ctiv
edo
sepe
rpro
cedu
re(m
Sv)
Bone
aC
ardi
ovas
cula
rLu
ngpe
rfus
ion
bLu
ngve
ntila
tion
Thyr
oid
scan
Thyr
oid
upta
keRe
nalc
Live
r/sp
leen
cBr
ain
c
a99
mTc
phos
phon
ates
.b
99mTc
MA
A.
c99
mTc
.d
35%
upta
ke.
eSP
ECT.
fU
ptak
ean
dsc
an.
Slov
akia
[F8]
6.5
7.4
(99mTc
RB
C)
20.3
(201 Tl
)1.
88.
94.
40.
52.
18.
8
Swed
en[M
87]
3.5
10(99
mTc
MIB
I)20
(201 Tl
)1.
10.
2(99
mTc
)2.
4(99
mTc
)72
d(3
MB
q13
1 I)6
d(0
.5M
Bq
131 I)
0.7
(MA
G3)
0.00
8(51
CrE
DTA
)8.
4(H
MPA
O)
Uni
ted
Kin
gdom
[A20
]3
(5e )
8(99
mTc
)18
(201 Tl
)1
(2e )
0.2
(81mK
r)0.
4(99
mTc
)0.
4(13
3 Xe)
1(99
mTc
)6
(131 I)
0.4
(123 I)
0.5
(99mTc
)
2(D
TPA
)0.
7(D
MSA
)0.
7(M
AG
3)0.
2(12
3 I)
0.8
(2e )(
collo
id)
5
Uni
ted
Stat
es[I
23]
4.4
10.4
(201 Tl
)2
(99mTc
)59
(131 I)
0.2
(123 I)
4.8
(DTP
A)
0.5
(131 I)
Heal
th-c
are
leve
lII
Iran
(Isla
m.R
ep.o
f)[M
10]
6.5
2.9
(99mTc
)6.
9(20
1 Tl)
2.5
1.4
(99mTc
)25
(131 I)
f14
.6(13
1 I)3.
3(D
TPA
)10
(DM
SA)
1.9
(Sco
lloid
)0.
6(11
3mIn
)12
.4(T
cO4)
5.9
(DTP
A)
Heal
th-c
are
leve
lIII
Gha
na[A
16]
2.85
1(99
mTc
)0.
40.
625.
4
ANNEX D: MEDICAL RADIATION EXPOSURES420
Tabl
e42
(con
tinue
d)
Cou
ntry
Effe
ctiv
edo
sepe
rpro
cedu
re(m
Sv)
Bone
aC
ardi
ovas
cula
rLu
ngpe
rfus
ion
bLu
ngve
ntila
tion
Thyr
oid
scan
Thyr
oid
upta
keRe
nalc
Live
r/sp
leen
cBr
ain
c
a99
mTc
phos
phon
ates
.b
99mTc
MA
A.
c99
mTc
.d
35%
upta
ke.
eSP
ECT.
fU
ptak
ean
dsc
an.
Slov
akia
[F8]
6.5
7.4
(99mTc
RB
C)
20.3
(201 Tl
)1.
88.
94.
40.
52.
18.
8
Swed
en[M
87]
3.5
10(99
mTc
MIB
I)20
(201 Tl
)1.
10.
2(99
mTc
)2.
4(99
mTc
)72
d(3
MB
q13
1 I)6
d(0
.5M
Bq
131 I)
0.7
(MA
G3)
0.00
8(51
CrE
DTA
)8.
4(H
MPA
O)
Uni
ted
Kin
gdom
[A20
]3
(5e )
8(99
mTc
)18
(201 Tl
)1
(2e )
0.2
(81mK
r)0.
4(99
mTc
)0.
4(13
3 Xe)
1(99
mTc
)6
(131 I)
0.4
(123 I)
0.5
(99mTc
)
2(D
TPA
)0.
7(D
MSA
)0.
7(M
AG
3)0.
2(12
3 I)
0.8
(2e )(
collo
id)
5
Uni
ted
Stat
es[I
23]
4.4
10.4
(201 Tl
)2
(99mTc
)59
(131 I)
0.2
(123 I)
4.8
(DTP
A)
0.5
(131 I)
Heal
th-c
are
leve
lII
Iran
(Isla
m.R
ep.o
f)[M
10]
6.5
2.9
(99mTc
)6.
9(20
1 Tl)
2.5
1.4
(99mTc
)25
(131 I)
f14
.6(13
1 I)3.
3(D
TPA
)10
(DM
SA)
1.9
(Sco
lloid
)0.
6(11
3mIn
)12
.4(T
cO4)
5.9
(DTP
A)
Heal
th-c
are
leve
lIII
Gha
na[A
16]
2.85
1(99
mTc
)0.
40.
625.
4
ANNEX D: MEDICAL RADIATION EXPOSURES420
ANNEX D: MEDICAL RADIATION EXPOSURES 421
a Figures in brackets are scaling factors for activity based on body weights shown. Doses calculated using age-specific coefficients from [I19].
Table 43Typical effective doses to patients from diagnostic PET imaging[A20]
Radionuclide Chemical form Investigation Administeredactivity (MBq)
Effective dose(mSv)
Dose to uterus(mGy)
11C11C13N15O15O18F18F18F
L-methyl-methionineL-methyl-methionineAmmoniaWater (bolus)Water (bolus)FDGFDGFluoride
Brain tumour imagingParathyroid imagingMyocardial blood flow imagingCerebral blood flow imagingMyocardial blood flow imagingTumour imagingMyocardial imagingBone imaging
400400550
2 0002 000400400250
22222
10107
11111775
Table 44Typical effective doses to paediatric patients from diagnostic nuclear medicine procedures[G47]
Radiopharmaceutical
Activity foradult
patient(MBq)
Effective dose per procedure by patient age a (mSv)
Adult70 kg[1.0]
15 years-old55 kg[0.9]
10 years-old33 kg[0.69]
5 years-old18 kg[0.44]
1 year-old10 kg[0.27]
99mTc-MAG3 (normal renal function)99mTc-MAG3 (abnormal renal function)99mTc-DTPA (normal renal function)99mTc-DTPA (abnormal renal function)99mTc-DMSA (normal renal function)99mTc-pertechnetate (no thryoid block)99mTc-IDA (normal biliary function)99mTc-HMPAO99mTc-leukocytes99mTc-erythrocytes99mTc-phosphates99mTc-MIBI (resting)201Tl-chloride123I-iodide (55% thyroid uptake)123I-iodide (total thyroid block)123I-MIBG (no impurity)67Ga-citrate
1001003003008080150500200800600400802020400150
0.70.61.61.40.71.02.34.72.25.33.63.3207.20.25.615
0.80.71.81.60.71.22.45.02.76.03.74.030
10.20.36.518.9
0.70.72.11.90.81.32.95.93.06.64.14.412912.10.39.122.8
0.60.51.81.80.81.43.05.72.96.74.24.895
16.30.38.823.1
0.60.52.22.00.81.43.76.53.47.64.95.486
18.80.310.127.9
Tabl
e57
Pres
crib
eddo
ses
topa
tient
sun
derg
oing
radi
atio
nte
leth
erap
yby
dise
ase
cate
gory
(199
1-19
96)
Data
from
UNSC
EAR
Surv
eyof
Med
icalR
adia
tion
Usag
ean
dEx
posu
res
unle
ssot
herw
isein
dica
ted
Cou
ntry
/are
a
Typi
cald
ose
ato
targ
etvo
lum
e(G
y)
Leuk
aem
iaLy
mph
oma
Brea
sttu
mou
rLu
ng/th
orax
tum
our
Gyn
aeco
lo-
gica
ltum
our
Hea
d/ne
cktu
mou
rBr
ain
tum
our
Skin
tum
our
Blad
der
tum
our
Pros
tate
tum
our
Tum
our
ofre
ctum
Beni
gndi
seas
e
Heal
th-c
are
leve
lI
Arg
entin
aA
ustra
liaB
elar
usB
ulga
riaC
anad
aC
roat
iaC
ypru
sC
zech
Rep
ublic
Den
mar
kEc
uado
rH
unga
ryIr
elan
dK
uwai
tN
ethe
rland
sN
ewZe
alan
dPa
nam
aR
oman
iaR
ussia
nFe
dera
tion
Slov
akia
Slov
enia
Swed
enU
nite
dA
rab
Emira
tes
Uni
ted
Stat
es[I
23]
14(1
020
)15
(11
22)
30(2
040
)24
(24
30)
25(1
230
)30 18
12(1
224
)12
25(±
25%
)
30(2
530
)18
(18
24)
15(6
28)
12(1
224
)(1
040
)
18(1
824
)5
(512
)
12(1
224
)
36(2
545
)34
(17
46)
40(3
046
)36
(36
44)
40(2
050
)48
(40
55)
40(3
545
)30
(30
40)
40(3
540
)40
(±10
%)
(30
60)
36(3
040
)40
(40
48)
40(8
50)
40(4
045
)(6
45)
(25
60)
36(3
540
)30
(20
40)
37(2
6b )
40(3
544
)
60(5
565
)53
(26
64)
50(3
070
)50
(40
60)
50(4
060
)52
(50
60)
5050
(50
60)
48(4
858
)60
(±16
%)
45(4
050
)50
(50
65)
66(6
468
)50
(865
)50
(50
60)
(40
70)
50(4
650
)50
(50
60)
49(3
5b )
50(4
565
)(4
550
)
66(4
570
)44
(22
63)
60(4
070
)56
(40
60)
40(1
760
)60
(52
68)
(20
60)
55(5
060
)(3
050
)50
(±10
%)
(40
55)
60(5
560
)64
(60
68)
50(8
60)
50(5
060
)(2
74)
(40
70)
6050
(30
60)
51(3
4b )
60(5
060
)
50(4
560
)49
(32
57)
40(4
060
)56
(50
60)
45(2
570
)60
(52
65)
45(4
550
)60
(45
65)
46c
50((
±30%
)
4046
(40
46)
46(4
248
)45
(27
65)
50(5
070
)(1
870
)(4
060
)60
(60
80)
50(5
060
)55
(35
b )45
(40
60)
70(4
575
)56
(28
67)
60(4
070
)60
(60
70)
60(5
070
)60
(60
70)
60(2
070
)60
(45
65)
64(6
268
)50
(±20
%)
60(4
066
)60
(60
66)
66(6
470
)60
(40
70)
60(6
070
)(2
87)
(40
70)
60(6
080
)60
(50
70)
59(3
7b )
66(6
066
)
65(4
065
)50
(29
58)
60(4
070
)55
(50
60)
50(2
060
)60
(50
66)
6060
(45
65)
5440
(±30
%)
4060
(55
60)
60(6
064
)50
(20
66)
50(4
060
)(1
660
)
56(5
660
)40
(30
50)
52(3
7b )
54(5
060
)
75(6
078
)45
(25
62)
65(6
070
)60
(50
70)
35(2
050
)60
(60
70)
5055
(50
60)
4850
(12
72)
35(3
550
)40
(30
40)
60(6
064
)40
(18
64)
50
(40
70)
60(6
070
)60
(50
70)
46(3
1b )
50(5
064
)
58(5
064
)49
(27
62)
60(4
060
)60
(50
70)
50(2
070
)60
(54
66)
66(2
066
)60
(55
60)
6050
(±20
%)
60(6
070
)60
(60
64)
60(6
064
)60
(30
64)
50(1
674
)(4
060
)60
50(4
060
)48
(31
b )64
(60
64)
70(5
076
)52
(33
62)
60(4
060
)60
(50
70)
60(5
066
)60
(60
65)
6465
(60
70)
50(±
10%
)
66(6
670
)60
(60
66)
65(6
068
)60
(60
70)
(12
70)
(40
60)
60(6
066
)50
(20
60)
64(3
5b )
64(6
066
)(6
072
)
55(4
560
)49
(26
54)
75(4
080
)60
(50
70)
50(4
060
)55
(55
65)
5450
(45
60)
46d
50((
±20%
)
50(4
550
)50
(50
54)
(45
60)
45(1
860
)50
(50
60)
(20
70)
(40
60)
50(5
060
)50
(20
60)
38(3
6b )
45(4
060
)
(15
75)
15(6
26)
5(1
50)
(620
)15
(840
)12
(618
)6
(48)
304
(15)
30(8
50)
15(1
520
)
(0.5
5)4
(420
)20
(20
50)
30(3
045
)
Ave
rage
1739
5449
5060
5348
5759
496
Heal
thca
rele
velI
I
Jord
anLi
byan
Ara
bJa
mah
iriya
Mex
ico
Peru
Tuni
siaTu
rkey
20(6
24)
18(1
824
)24
(18
24)
18(1
830
)35
22(1
030
)
35(2
540
)45
(45
50)
40(3
545
)44
(30
50)
(45
55)
34(2
058
)
50(4
250
)50
(50
60)
50(5
065
)60
(45
60)
50(5
075
)50
(45
70)
30(2
060
)30
(30
60)
55(5
065
)50
(30
60)
(45
65)
59(4
566
)
44(3
050
)50
(50
60)
80(5
080
)50
(45
55)
(20
60)
51(4
562
)
60(4
066
)66
(60
66)
75(5
075
)60
(50
75)
75(5
575
)63
(50
70)
50(3
060
)55
(50
60)
65(5
565
)60
(30
70)
5555
(45
60)
50(4
055
)45
(45
50)
65(5
565
)50
(45
55)
(65
75)
58(4
070
)
66(3
066
)60
(60
65)
65(6
570
)60
(55
65)
65(5
565
)61
(50
66)
60(3
060
)65
(60
65)
65(6
570
)70
(60
72)
65(5
565
)61
(50
60)
50(3
050
)60
(50
60)
65(6
570
)50
(45
55)
(35
65)
50(4
060
)
10(1
040
)
24(2
432
)
2014
(925
)
Ave
rage
2236
5057
6367
5760
6264
5318
ANNEX D: MEDICAL RADIATION EXPOSURES444
Tabl
e57
Pres
crib
eddo
ses
topa
tient
sun
derg
oing
radi
atio
nte
leth
erap
yby
dise
ase
cate
gory
(199
1-19
96)
Data
from
UNSC
EAR
Surv
eyof
Med
icalR
adia
tion
Usag
ean
dEx
posu
res
unle
ssot
herw
isein
dica
ted
Cou
ntry
/are
a
Typi
cald
ose
ato
targ
etvo
lum
e(G
y)
Leuk
aem
iaLy
mph
oma
Brea
sttu
mou
rLu
ng/th
orax
tum
our
Gyn
aeco
lo-
gica
ltum
our
Hea
d/ne
cktu
mou
rBr
ain
tum
our
Skin
tum
our
Blad
der
tum
our
Pros
tate
tum
our
Tum
our
ofre
ctum
Beni
gndi
seas
e
Heal
th-c
are
leve
lI
Arg
entin
aA
ustra
liaB
elar
usB
ulga
riaC
anad
aC
roat
iaC
ypru
sC
zech
Rep
ublic
Den
mar
kEc
uado
rH
unga
ryIr
elan
dK
uwai
tN
ethe
rland
sN
ewZe
alan
dPa
nam
aR
oman
iaR
ussia
nFe
dera
tion
Slov
akia
Slov
enia
Swed
enU
nite
dA
rab
Emira
tes
Uni
ted
Stat
es[I
23]
14(1
020
)15
(11
22)
30(2
040
)24
(24
30)
25(1
230
)30 18
12(1
224
)12
25(±
25%
)
30(2
530
)18
(18
24)
15(6
28)
12(1
224
)(1
040
)
18(1
824
)5
(512
)
12(1
224
)
36(2
545
)34
(17
46)
40(3
046
)36
(36
44)
40(2
050
)48
(40
55)
40(3
545
)30
(30
40)
40(3
540
)40
(±10
%)
(30
60)
36(3
040
)40
(40
48)
40(8
50)
40(4
045
)(6
45)
(25
60)
36(3
540
)30
(20
40)
37(2
6b )
40(3
544
)
60(5
565
)53
(26
64)
50(3
070
)50
(40
60)
50(4
060
)52
(50
60)
5050
(50
60)
48(4
858
)60
(±16
%)
45(4
050
)50
(50
65)
66(6
468
)50
(865
)50
(50
60)
(40
70)
50(4
650
)50
(50
60)
49(3
5b )
50(4
565
)(4
550
)
66(4
570
)44
(22
63)
60(4
070
)56
(40
60)
40(1
760
)60
(52
68)
(20
60)
55(5
060
)(3
050
)50
(±10
%)
(40
55)
60(5
560
)64
(60
68)
50(8
60)
50(5
060
)(2
74)
(40
70)
6050
(30
60)
51(3
4b )
60(5
060
)
50(4
560
)49
(32
57)
40(4
060
)56
(50
60)
45(2
570
)60
(52
65)
45(4
550
)60
(45
65)
46c
50((
±30%
)
4046
(40
46)
46(4
248
)45
(27
65)
50(5
070
)(1
870
)(4
060
)60
(60
80)
50(5
060
)55
(35
b )45
(40
60)
70(4
575
)56
(28
67)
60(4
070
)60
(60
70)
60(5
070
)60
(60
70)
60(2
070
)60
(45
65)
64(6
268
)50
(±20
%)
60(4
066
)60
(60
66)
66(6
470
)60
(40
70)
60(6
070
)(2
87)
(40
70)
60(6
080
)60
(50
70)
59(3
7b )
66(6
066
)
65(4
065
)50
(29
58)
60(4
070
)55
(50
60)
50(2
060
)60
(50
66)
6060
(45
65)
5440
(±30
%)
4060
(55
60)
60(6
064
)50
(20
66)
50(4
060
)(1
660
)
56(5
660
)40
(30
50)
52(3
7b )
54(5
060
)
75(6
078
)45
(25
62)
65(6
070
)60
(50
70)
35(2
050
)60
(60
70)
5055
(50
60)
4850
(12
72)
35(3
550
)40
(30
40)
60(6
064
)40
(18
64)
50
(40
70)
60(6
070
)60
(50
70)
46(3
1b )
50(5
064
)
58(5
064
)49
(27
62)
60(4
060
)60
(50
70)
50(2
070
)60
(54
66)
66(2
066
)60
(55
60)
6050
(±20
%)
60(6
070
)60
(60
64)
60(6
064
)60
(30
64)
50(1
674
)(4
060
)60
50(4
060
)48
(31
b )64
(60
64)
70(5
076
)52
(33
62)
60(4
060
)60
(50
70)
60(5
066
)60
(60
65)
6465
(60
70)
50(±
10%
)
66(6
670
)60
(60
66)
65(6
068
)60
(60
70)
(12
70)
(40
60)
60(6
066
)50
(20
60)
64(3
5b )
64(6
066
)(6
072
)
55(4
560
)49
(26
54)
75(4
080
)60
(50
70)
50(4
060
)55
(55
65)
5450
(45
60)
46d
50((
±20%
)
50(4
550
)50
(50
54)
(45
60)
45(1
860
)50
(50
60)
(20
70)
(40
60)
50(5
060
)50
(20
60)
38(3
6b )
45(4
060
)
(15
75)
15(6
26)
5(1
50)
(620
)15
(840
)12
(618
)6
(48)
304
(15)
30(8
50)
15(1
520
)
(0.5
5)4
(420
)20
(20
50)
30(3
045
)
Ave
rage
1739
5449
5060
5348
5759
496
Heal
thca
rele
velI
I
Jord
anLi
byan
Ara
bJa
mah
iriya
Mex
ico
Peru
Tuni
siaTu
rkey
20(6
24)
18(1
824
)24
(18
24)
18(1
830
)35
22(1
030
)
35(2
540
)45
(45
50)
40(3
545
)44
(30
50)
(45
55)
34(2
058
)
50(4
250
)50
(50
60)
50(5
065
)60
(45
60)
50(5
075
)50
(45
70)
30(2
060
)30
(30
60)
55(5
065
)50
(30
60)
(45
65)
59(4
566
)
44(3
050
)50
(50
60)
80(5
080
)50
(45
55)
(20
60)
51(4
562
)
60(4
066
)66
(60
66)
75(5
075
)60
(50
75)
75(5
575
)63
(50
70)
50(3
060
)55
(50
60)
65(5
565
)60
(30
70)
5555
(45
60)
50(4
055
)45
(45
50)
65(5
565
)50
(45
55)
(65
75)
58(4
070
)
66(3
066
)60
(60
65)
65(6
570
)60
(55
65)
65(5
565
)61
(50
66)
60(3
060
)65
(60
65)
65(6
570
)70
(60
72)
65(5
565
)61
(50
60)
50(3
050
)60
(50
60)
65(6
570
)50
(45
55)
(35
65)
50(4
060
)
10(1
040
)
24(2
432
)
2014
(925
)
Ave
rage
2236
5057
6367
5760
6264
5318
ANNEX D: MEDICAL RADIATION EXPOSURES444
Tabl
e57
(con
tinue
d)
aPr
escr
ibed
dose
forc
ompl
ete
cour
seof
treat
men
t.R
ange
orsta
ndar
dde
viat
ion
inpa
rent
hese
s.M
ean
dose
sfor
each
heal
th-c
are
leve
lare
frequ
ency
-wei
ghte
dav
erag
esof
natio
nalv
alue
s.Th
ese
dose
ssho
uld
notb
eus
edto
infe
rdet
erm
inist
icor
stoch
astic
risks
since
thes
ede
pend
inte
ralia
stron
gly
onirr
adia
tion
tech
niqu
e(d
ose
distr
ibut
ion)
and
fract
iona
tion.
bPa
lliat
ive
treat
men
t.c
Plus
brac
hyth
erap
y.d
Plus
boos
t.
Cou
ntry
Typi
cald
ose
tota
rget
volu
me
(Gy)
Leuk
aem
iaLy
mph
oma
Brea
sttu
mou
rLu
ng/th
orax
tum
our
Gyn
aeco
logi
calt
umou
rH
ead/
neck
tum
our
Brai
ntu
mou
rSk
intu
mou
rBl
adde
rtu
mou
rPr
osta
tetu
mou
rTu
mou
rof
rect
umBe
nign
dise
ase
Heal
thca
rele
velI
II
Mad
agas
car
Mor
occo
Suda
n
2424
(18
24)
30(2
030
)
4036
(36
40)
50(4
050
)
45 50 45
45(3
070
)45
(40
50)
45 4655
(50
60)
45 7055
(50
60)
45 6050 70
55(5
060
)
50 7055
(50
60)
45 7025
(20
30)
45(5
070
)45
(40
50)
25(2
030
)
Ave
rage
2945
4545
4948
4553
5445
4525
Heal
thca
rele
velI
V
Uni
ted
Rep
.ofT
anza
nia
30(2
030
)30
(20
30)
50(3
050
)30
(30
45)
64(3
064
)60
(30
60)
45(3
045
)60
(30
60)
60(3
060
)60
(30
60)
60(3
060
)6
The
entri
esin
this
Tabl
ear
equ
alifi
edas
follo
ws:
Arge
ntin
a:O
nth
eba
sisof
data
from
one
larg
ena
tiona
lcen
tre.
Aust
ralia
:Su
rvey
data
from
only
8of
31ra
diot
hera
pytre
atm
entc
entre
s(re
pres
entin
gab
out4
2%of
natio
nalp
ract
ice)
.C
anad
a:O
nth
eba
sisof
data
from
the
Nov
aSc
otia
Canc
erTr
eatm
enta
ndRe
sear
chFo
unda
tion
and
the
prov
ince
ofM
anito
ba(c
olle
ctiv
ely
repr
esen
ting
abou
t8%
ofth
epo
pula
tion)
.C
roat
ia:
Dat
afro
mon
ela
rge
cent
rese
rvin
gab
outo
ne-fi
fthof
popu
latio
n.C
ypru
s:Ta
rget
dose
of50
Gy
forb
reas
ttum
ourr
efer
sto
treat
men
twith
60Co
unit;
this
issu
pple
men
ted
bytre
atm
entw
ithx
rays
(targ
etdo
seof
14G
y);t
arge
tdos
eof
45G
yfo
rgyn
aeco
logi
calt
umou
rref
erst
otre
atm
entw
ith60
Coun
it;th
isis
supp
lem
ente
dby
treat
men
twith
xra
ys(ta
rget
dose
of15
Gy)
.Jo
rdan
:Su
rvey
data
from
one
hosp
ital.
Mad
agas
car:
Trea
tmen
tssh
own
forB
reas
t,Lu
ng/th
orax
,Gyn
aeco
logi
cal,
Hea
d/ne
ck,B
rain
,Ski
n,Bl
adde
r,Pr
osta
tean
dR
ectu
mtu
mou
rssu
pple
men
ted
byad
ditio
nali
rrad
iatio
nw
ithx
rays
.N
ewZe
alan
d:D
ata
from
50%
ofra
diot
hera
pyce
ntre
s(se
rvin
gab
outt
wo
third
sofp
opul
atio
n).
Peru
:Su
rvey
data
from
INEN
(Can
cerI
nstit
ute,
Lim
a,se
rvin
gpo
pula
tion
ofab
out7
mill
ion)
.U
nite
dRe
publ
icof
Tanz
ania
:D
ata
for‘
Lung
/thor
axtu
mou
r’in
clud
etre
atm
ents
ofth
eoe
soph
agus
.Tu
rkey
:Su
rvey
data
from
Hac
ette
peU
nive
rsity
Hos
pita
l,Çu
kuro
vaU
nive
rsity
Hos
pita
l,Is
tanb
ulU
nive
rsity
Hos
pita
l,Ce
rrah
paa
Hos
pita
l,an
dG
ülha
neM
ilita
ryH
ospi
tal.
Uni
ted
Arab
Emir
ates
:Dos
esfo
rrad
ical
treat
men
tson
ly.
Uni
ted
Stat
es:
Bre
astt
umou
rsre
ceiv
ean
addi
tiona
l10
20G
y“b
oost”
with
eith
erel
ectro
nsor
brac
hyth
erap
y.
ANNEX D: MEDICAL RADIATION EXPOSURES 445 ANNEX D: MEDICAL RADIATION EXPOSURES446
a Prescribed dose for complete treatment. Range or standard deviation in parentheses. Mean doses for each health-care level are frequency-weightedaverages of national values. These doses should not be used to infer deterministic or stochastic risks since these depend inter alia strongly onirradiation technique (dose distribution) and fractionation.
Table 58Prescribed doses to patients undergoing radiation brachytherapy by disease category (1991-1996)Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicated
Country / areaTypical dose a to target volume (Gy)
Head/neck tumour Breast tumour Gynaecological tumour Prostate tumour
Health-care level I
ArgentinaAustraliaBelarusBulgariaCanadaCyprusCzech RepublicDenmarkEcuadorIrelandKuwaitNetherlandsNew ZealandPanamaRussiaSlovakiaSloveniaUnited Arab Emirates
75 (68 78)30 (22 45)40 (30 50)60 (60 70)
60
65 (60 70)
30 (30 60)
60 (20 30 boost)45 (25 65)20 (20 30)
(30 50)20 (20 30)
10 (5 10)
10 (10 25)40 (30 40)40 (30 40)
12 (10 12)
30
(20 24)15
(20 40)15
60 (50 65)32 (15 42)45 (30 50)70 (30 70)45 (11 50)
3060 (60 70)
35 (plus teletherapy)35 (±15%)15 (10 20)36 (30 36)
(30 60)70 (15 70)20 (20 30)
(20 40)30 (10 60)
20 (15 20)
70
40 (30 60)
30 (25 40)
65 (60 70)
60
Average 44 16 45 35
Health care level II
MexicoPeruTunisiaTurkey
30 (20 40)
(55 75)21 (18 40)
15 (10 20)
20 (20 25)
30 (20 30)40 (30 80)
(20 60)24 (16 24)
Average 22 19 29
Health care level III
MoroccoSudan
24 2435 (30 40)
Average 24 24
The entries in this Table are qualified as follows:
Argentina: On the basis of data from one large national centre.Australia: Survey data from only 8 of 31 radiotherapy treatment centres (representing about 42% of national practice).Canada: On the basis of data from the Nova Scotia Cancer Treatment and Research Foundation and the province of Manitoba (collectively
representing about 8% of the population).New Zealand: Data from 50% of radiotherapy centres (serving about two-thirds of population).Peru: Survey data from INEN (Cancer Institute, Lima, serving population of about 7 million).Turkey: Survey data from Hacettepe University Hospital, Çukurova University Hospital, Istanbul University Hospital, Cerrahpa a Hospital, and
Gülhane Military Hospital.United Arab Emirates: Doses for radical treatments only.
ANNEX D: MEDICAL RADIATION EXPOSURES446
a Prescribed dose for complete treatment. Range or standard deviation in parentheses. Mean doses for each health-care level are frequency-weightedaverages of national values. These doses should not be used to infer deterministic or stochastic risks since these depend inter alia strongly onirradiation technique (dose distribution) and fractionation.
Table 58Prescribed doses to patients undergoing radiation brachytherapy by disease category (1991-1996)Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicated
Country / areaTypical dose a to target volume (Gy)
Head/neck tumour Breast tumour Gynaecological tumour Prostate tumour
Health-care level I
ArgentinaAustraliaBelarusBulgariaCanadaCyprusCzech RepublicDenmarkEcuadorIrelandKuwaitNetherlandsNew ZealandPanamaRussiaSlovakiaSloveniaUnited Arab Emirates
75 (68 78)30 (22 45)40 (30 50)60 (60 70)
60
65 (60 70)
30 (30 60)
60 (20 30 boost)45 (25 65)20 (20 30)
(30 50)20 (20 30)
10 (5 10)
10 (10 25)40 (30 40)40 (30 40)
12 (10 12)
30
(20 24)15
(20 40)15
60 (50 65)32 (15 42)45 (30 50)70 (30 70)45 (11 50)
3060 (60 70)
35 (plus teletherapy)35 (±15%)15 (10 20)36 (30 36)
(30 60)70 (15 70)20 (20 30)
(20 40)30 (10 60)
20 (15 20)
70
40 (30 60)
30 (25 40)
65 (60 70)
60
Average 44 16 45 35
Health care level II
MexicoPeruTunisiaTurkey
30 (20 40)
(55 75)21 (18 40)
15 (10 20)
20 (20 25)
30 (20 30)40 (30 80)
(20 60)24 (16 24)
Average 22 19 29
Health care level III
MoroccoSudan
24 2435 (30 40)
Average 24 24
The entries in this Table are qualified as follows:
Argentina: On the basis of data from one large national centre.Australia: Survey data from only 8 of 31 radiotherapy treatment centres (representing about 42% of national practice).Canada: On the basis of data from the Nova Scotia Cancer Treatment and Research Foundation and the province of Manitoba (collectively
representing about 8% of the population).New Zealand: Data from 50% of radiotherapy centres (serving about two-thirds of population).Peru: Survey data from INEN (Cancer Institute, Lima, serving population of about 7 million).Turkey: Survey data from Hacettepe University Hospital, Çukurova University Hospital, Istanbul University Hospital, Cerrahpa a Hospital, and
Gülhane Military Hospital.United Arab Emirates: Doses for radical treatments only.
Tabl
e70
Aver
age
aac
tiviti
esad
min
iste
red
(MBq
)in
ther
apeu
tictr
eatm
ents
with
radi
opha
rmac
eutic
als
(199
1-19
96)
Data
from
UNSC
EAR
Surv
eyof
Med
icalR
adia
tion
Usag
ean
dEx
posu
res
unle
ssot
herw
isein
dica
ted
Cou
ntry
/are
aTh
yroi
dm
alig
nanc
y
131 Ii
odid
e
Hyp
erth
yroi
dism
131 Ii
odid
e
Poly
cyth
aem
iave
ra32
Pph
osph
ate
Bone
met
asta
ses
Syno
vitis
89Sr
chlo
ride
32P
phos
phat
eO
ther
90Y
Oth
er
Heal
th-c
are
leve
lI
Arg
entin
aB
ulga
riaC
anad
aC
roat
iaD
enm
ark
Ecua
dor
Finl
and
[K59
]G
erm
any
Irel
and
Italy
Japa
nK
uwai
tN
ethe
rland
sN
ewZe
alan
d[L
28]
Pana
ma
Slov
akia
Slov
enia
Swed
enU
nite
dA
rab
Emira
tes
Uni
ted
Kin
gdom
[C27
]
447
7(±
1258
)3
300
(300
05
500)
(550
07
400)
470
6(3
452
596
0)
370
0(±
50%
)4
334
(350
05
550)
(100
08
000)
370
0(1
110
740
0)55
50(2
500
1110
0)3
330
740
05
500
(800
0m
ax.)
330
3(1
000
700
0)5
550
(293
48
166)
370
0(2
600
555
0)
680
0(4
000
740
0)3
700
(227
55
550)
433
(±12
2)18
5(3
001
500)
726
(±51
0)42
037
0(±
50%
)32
1(1
4842
5)(2
002
000)
400
(185
500)
555
(185
111
0)16
010
650
0(1
800
max
.)38
1(1
501
000)
463
(±13
1)26
0(1
8537
0)35
0(1
8555
0)52
5(2
401
500)
422
(200
462)
(74
370)
185
154
(110
222)
(150
200)
148
(111
185)
185
(250
400)
174
(120
259)
3720
0(1
6040
0)
166
150
148
150
150
148
150
150
150
150
(125
150)
136
51
300
d ,256
4(1
295
300
0)f
130
0d
130
0d
300
168
(148
185)
168
185
185
185
170
(110
220)
200
555
b
(15
30)c ,(
3518
5)d
Ave
rage
476
041
517
014
025
0
Heal
th-c
are
leve
lII
Jord
anM
exic
oPe
ruTu
rkey
370
0(±
20%
)3
700
(184
05
560)
555
0(5
000
600
0)3
238
550
(±20
%)
370
(185
555)
260
(200
300)
185
148
e(1
1118
5)
148
148
111
185
444
46f(3
755
5)3
885
(350
04
000)
f
Ave
rage
351
034
014
811
1
ANNEX D: MEDICAL RADIATION EXPOSURES458
Tabl
e70
(con
tinue
d)
Cou
ntry
/are
aTh
yroi
dm
alig
nanc
y
131 Ii
odid
e
Hyp
erth
yroi
dism
131 Ii
odid
e
Poly
cyth
aem
iave
ra32
Pph
osph
ate
Bone
met
asta
ses
Syno
vitis
89Sr
chlo
ride
32P
phos
phat
eO
ther
90Y
Oth
er
aR
ange
orsta
ndar
dde
viat
ion
inpa
rent
hese
s.b
Dat
are
late
tous
eof
166 H
o.c
Dat
are
late
tous
eof
169 Er
.d
Dat
are
late
tous
eof
186 R
e.e
Dat
are
late
tous
eof
90Y
.f
Dat
are
late
tous
eof
153 Sm
.
Heal
th-c
are
leve
lIII
Mor
occo
Suda
n3
700
(333
04
440)
371
029
6(2
2244
4)30
029
1
Ave
rage
370
030
0
Heal
th-c
are
leve
lIV
Ethi
opia
Uni
ted
Rep
.of
Tanz
ania
350
018
5(1
1137
0)35
0(±
2%)
Ave
rage
350
022
0
The
entri
esin
this
Tabl
ear
equ
alifi
edas
follo
ws:
Arge
ntin
a:O
nth
eba
sisof
data
from
asa
mpl
eof
25%
ofnu
clea
rmed
icin
ece
ntre
s.C
anad
a:D
ata
from
Lond
onH
ealth
Scie
nces
Cen
tre,S
WO
ntar
io(r
epre
sent
ing
50%
ofth
ese
rvic
espr
ovid
edto
popu
latio
nof
abou
t1m
illio
n).
Turk
ey:
Surv
eyda
tafro
mG
ülha
neM
ilita
ryH
ospi
tal,
Hac
ette
peU
nive
rsity
Hos
pita
l,an
dSa
msu
nO
ndok
uzM
ayis
Uni
vers
ityH
ospi
tal.
ANNEX D: MEDICAL RADIATION EXPOSURES 459
Tabl
e70
(con
tinue
d)
Cou
ntry
/are
aTh
yroi
dm
alig
nanc
y
131 Ii
odid
e
Hyp
erth
yroi
dism
131 Ii
odid
e
Poly
cyth
aem
iave
ra32
Pph
osph
ate
Bone
met
asta
ses
Syno
vitis
89Sr
chlo
ride
32P
phos
phat
eO
ther
90Y
Oth
er
aR
ange
orsta
ndar
dde
viat
ion
inpa
rent
hese
s.b
Dat
are
late
tous
eof
166 H
o.c
Dat
are
late
tous
eof
169 Er
.d
Dat
are
late
tous
eof
186 R
e.e
Dat
are
late
tous
eof
90Y
.f
Dat
are
late
tous
eof
153 Sm
.
Heal
th-c
are
leve
lIII
Mor
occo
Suda
n3
700
(333
04
440)
371
029
6(2
2244
4)30
029
1
Ave
rage
370
030
0
Heal
th-c
are
leve
lIV
Ethi
opia
Uni
ted
Rep
.of
Tanz
ania
350
018
5(1
1137
0)35
0(±
2%)
Ave
rage
350
022
0
The
entri
esin
this
Tabl
ear
equ
alifi
edas
follo
ws:
Arge
ntin
a:O
nth
eba
sisof
data
from
asa
mpl
eof
25%
ofnu
clea
rmed
icin
ece
ntre
s.C
anad
a:D
ata
from
Lond
onH
ealth
Scie
nces
Cen
tre,S
WO
ntar
io(r
epre
sent
ing
50%
ofth
ese
rvic
espr
ovid
edto
popu
latio
nof
abou
t1m
illio
n).
Turk
ey:
Surv
eyda
tafro
mG
ülha
neM
ilita
ryH
ospi
tal,
Hac
ette
peU
nive
rsity
Hos
pita
l,an
dSa
msu
nO
ndok
uzM
ayis
Uni
vers
ityH
ospi
tal.
ANNEX D: MEDICAL RADIATION EXPOSURES 459