Theocharis Berris

Calculation of organ doses from breast cancer radiotherapy: a Monte Carlo study

The current study aimed to: a) utilize Monte Carlo simulation methods for the assessment of radiation doses imparted to all organs at risk to develop secondary radiation induced cancer, for patients undergoing radiotherapy for breast cancer; and b) evaluate the effect of breast size on dose to organs outside the irradiation field. A simulated linear accelerator model was generated. The in‐field accuracy of the simulated photon beam properties was verified against percentage depth dose (PDD) and dose profile measurements on an actual water phantom. Off‐axis dose calculations were verified with thermoluminescent dosimetry (TLD) measurements on a humanoid physical phantom. An anthropomorphic mathematical phantom was used to simulate breast cancer radiotherapy with medial and lateral fields. The effect of breast size on the calculated organ dose was investigated. Local differences between measured and calculated PDDs and dose profiles did not exceed 2% for the points at depths beyond the depth of maximum dose and the plateau region of the profile, respectively. For the penumbral regions of the dose profiles, the distance to agreement (DTA) did not exceed 2 mm. The mean difference between calculated out‐of‐field doses and TLD measurements was 11.4%±5.9%. The calculated doses to peripheral organs ranged from 2.32 cGy up to 161.41 cGy depending on breast size and thus the field dimensions applied, as well as the proximity of the organs to the primary beam. An increase to the therapeutic field area by 50% to account for the large breast led to a mean organ dose elevation by up to 85.2% for lateral exposure. The contralateral breast dose ranged between 1.4% and 1.6% of the prescribed dose to the tumor. Breast size affects dose deposition substantially. PACS numbers: 87.10.rt, 87.56.bd, 87.53.Bn, 87.55.K‐, 87.55.ne, 87.56.jf, 87.56.J‐

International Atomic Energy Agency study with referring physicians on patient radiation exposure and its tracking: a prospective survey using a web-based questionnaire

Objectives To assess the following themes among referring physicians: (A) importance of acquiring information about previous diagnostic exposures; (B) knowledge about radiation doses involved, familiarity with radiation units and, age-related radiosensitivity; (C) opinion on whether patients should be provided information about radiation dose and (D) self-assessment of appropriateness of referrals. Design A prospective survey using a web-based questionnaire. Setting International survey among referring physicians. Participants Referring physicians from 28 countries. Main outcome measures Knowledge, opinion and practice of the four themes of the survey. Results All 728 responses from 28 countries (52.3% from developed and 47.7% from developing countries) indicated that while the vast majority (71.7%) of physicians feel that being aware of history of CT scans would always or mostly lead them to a better decision on referring patients for CT scans, only 43.4% often enquire about it. The majority of referring physicians (60.5%) stated that having a system that provides quick information about patient exposure history would be useful. The knowledge about radiation doses involved is poor, as only one-third (34.7%) of respondents chose the correct option of the number of chest x-rays with equivalence of a CT scan. In total, 70.9% of physicians stated that they do not feel uncomfortable when patients ask about radiation risk from CT scans they prescribe. Most physicians (85.6%) assessed that they have rarely prescribed CT scans of no clinical use in patient management. Conclusions This first ever multinational survey among referring physicians from 28 countries indicates support for a system that provides radiation exposure history of the patient, demonstrates poor knowledge about radiation doses, supports radiation risk communication with patients and mandatory provisions for justification of a CT examination.

Radiation Exposure Tracking: Survey of Unique Patient Identification Number in 40 Countries

OBJECTIVE The purposes of this study were to survey in 40 countries the availability and use of unique patient identification numbers for radiologic examinations to facilitate radiation exposure tracking and to address plans for nationwide use of PACS networks and regulations in support of tracking. MATERIALS AND METHODS The survey was conducted with a web-based questionnaire sent to contacts and counterparts of the International Atomic Energy Agency medical exposure projects unit. RESULTS A unique patient identification number was available in 33 of 40 countries (82.5%) that participated in the survey and is used in the medical record and for tracking of imaging examinations in 18 of the 33 (54.5%). PACS infrastructures connecting a few hospitals within a country are fairly widespread (32 of 40 countries [80%]), and a very good infrastructure connecting most hospitals in a country was available in 15% (6 of 40 countries). Approximately one half of the participating countries (21 of 40) have plans for establishing a national PACS. Regulations regarding tracking of patient x-ray radiation exposures were found to exist in 30% of the countries. CONCLUSION It is highly encouraging to note that most of the countries in which the survey was administered already have unique identification numbers for citizens and that nearly one half of these countries are using the number whenever a patient undergoes a medical imaging examination. Furthermore, nearly one half of respondents indicated that lack of technology rather than confidentiality was the reason for not using a patient identifier. That nearly one third of the countries-all 12 in Europe-support regulations requiring the tracking of patient radiation exposure is an important finding.

Radiological Protection in Cone Beam Computed Tomography (CBCT). ICRP Publication 129.

The objective of this publication is to provide guidance on radiological protection in the new technology of cone beam computed tomography (CBCT). Publications 87 and 102 dealt with patient dose management in computed tomography (CT) and multi-detector CT. The new applications of CBCT and the associated radiological protection issues are substantially different from those of conventional CT. The perception that CBCT involves lower doses was only true in initial applications. CBCT is now used widely by specialists who have little or no training in radiological protection. This publication provides recommendations on radiation dose management directed at different stakeholders, and covers principles of radiological protection, training, and quality assurance aspects. Advice on appropriate use of CBCT needs to be made widely available. Advice on optimisation of protection when using CBCT equipment needs to be strengthened, particularly with respect to the use of newer features of the equipment. Manufacturers should standardise radiation dose displays on CBCT equipment to assist users in optimisation of protection and comparisons of performance. Additional challenges to radiological protection are introduced when CBCT-capable equipment is used for both fluoroscopy and tomography during the same procedure. Standardised methods need to be established for tracking and reporting of patient radiation doses from these procedures. The recommendations provided in this publication may evolve in the future as CBCT equipment and applications evolve. As with previous ICRP publications, the Commission hopes that imaging professionals, medical physicists, and manufacturers will use the guidelines and recommendations provided in this publication for implementation of the Commissions principle of optimisation of protection of patients and medical workers, with the objective of keeping exposures as low as reasonably achievable, taking into account economic and societal factors, and consistent with achieving the necessary medical outcomes.The objective of this publication is to provide guidance on radiological protection in the new technology of cone beam computed tomography (CBCT). Publications 87 and 102 dealt with patient dose management in computed tomography (CT) and multi-detector CT. The new applications of CBCT and the associated radiological protection issues are substantially different from those of conventional CT. The perception that CBCT involves lower doses was only true in initial applications. CBCT is now used widely by specialists who have little or no training in radiological protection. This publication provides recommendations on radiation dose management directed at different stakeholders, and covers principles of radiological protection, training, and quality assurance aspects. Advice on appropriate use of CBCT needs to be made widely available. Advice on optimisation of protection when using CBCT equipment needs to be strengthened, particularly with respect to the use of newer features of the equipment. Manufacturers should standardise radiation dose displays on CBCT equipment to assist users in optimisation of protection and comparisons of performance. Additional challenges to radiological protection are introduced when CBCT-capable equipment is used for both fluoroscopy and tomography during the same procedure. Standardised methods need to be established for tracking and reporting of patient radiation doses from these procedures. The recommendations provided in this publication may evolve in the future as CBCT equipment and applications evolve. As with previous ICRP publications, the Commission hopes that imaging professionals, medical physicists, and manufacturers will use the guidelines and recommendations provided in this publication for implementation of the Commission’s principle of optimisation of protection of patients and medical workers, with the objective of keeping exposures as low as reasonably achievable, taking into account economic and societal factors, and consistent with achieving the necessary medical outcomes. 2015 ICRP. Published by SAGE.

Templates and existing elements and models for implementation of patient exposure tracking

There is wide interest currently in patient exposure tracking. This paper provides templates for implementation of tracking at the practice (hospital) level, multi-practice level, national level and international level. It provides suggestions for implementation in less-resourced countries. It includes elements such as patient identifier, dose quantities that should be covered and how to make sense from dose figures, availability of digital imaging and communications in medicine files with dose information or structured dose reports and capabilities of picture archiving and communication system (PACS). While tracking at several hospitals in a country connected by PACS and nationwide PACS is also a reality, tracking at the international level is currently a challenge. Guidance provided in this paper will facilitate its implementation at all levels.

ICRP Publication 129: Radiological Protection in Cone Beam Computed Tomography (CBCT)

The objective of this publication is to provide guidance on radiological protection in the new technology of cone beam computed tomography (CBCT). Publications 87 and 102 dealt with patient dose management in computed tomography (CT) and multi-detector CT. The new applications of CBCT and the associated radiological protection issues are substantially different from those of conventional CT. The perception that CBCT involves lower doses was only true in initial applications. CBCT is now used widely by specialists who have little or no training in radiological protection. This publication provides recommendations on radiation dose management directed at different stakeholders, and covers principles of radiological protection, training, and quality assurance aspects. Advice on appropriate use of CBCT needs to be made widely available. Advice on optimisation of protection when using CBCT equipment needs to be strengthened, particularly with respect to the use of newer features of the equipment. Manufacturers should standardise radiation dose displays on CBCT equipment to assist users in optimisation of protection and comparisons of performance. Additional challenges to radiological protection are introduced when CBCT-capable equipment is used for both fluoroscopy and tomography during the same procedure. Standardised methods need to be established for tracking and reporting of patient radiation doses from these procedures. The recommendations provided in this publication may evolve in the future as CBCT equipment and applications evolve. As with previous ICRP publications, the Commission hopes that imaging professionals, medical physicists, and manufacturers will use the guidelines and recommendations provided in this publication for implementation of the Commissions principle of optimisation of protection of patients and medical workers, with the objective of keeping exposures as low as reasonably achievable, taking into account economic and societal factors, and consistent with achieving the necessary medical outcomes.The objective of this publication is to provide guidance on radiological protection in the new technology of cone beam computed tomography (CBCT). Publications 87 and 102 dealt with patient dose management in computed tomography (CT) and multi-detector CT. The new applications of CBCT and the associated radiological protection issues are substantially different from those of conventional CT. The perception that CBCT involves lower doses was only true in initial applications. CBCT is now used widely by specialists who have little or no training in radiological protection. This publication provides recommendations on radiation dose management directed at different stakeholders, and covers principles of radiological protection, training, and quality assurance aspects. Advice on appropriate use of CBCT needs to be made widely available. Advice on optimisation of protection when using CBCT equipment needs to be strengthened, particularly with respect to the use of newer features of the equipment. Manufacturers should standardise radiation dose displays on CBCT equipment to assist users in optimisation of protection and comparisons of performance. Additional challenges to radiological protection are introduced when CBCT-capable equipment is used for both fluoroscopy and tomography during the same procedure. Standardised methods need to be established for tracking and reporting of patient radiation doses from these procedures. The recommendations provided in this publication may evolve in the future as CBCT equipment and applications evolve. As with previous ICRP publications, the Commission hopes that imaging professionals, medical physicists, and manufacturers will use the guidelines and recommendations provided in this publication for implementation of the Commission’s principle of optimisation of protection of patients and medical workers, with the objective of keeping exposures as low as reasonably achievable, taking into account economic and societal factors, and consistent with achieving the necessary medical outcomes. 2015 ICRP. Published by SAGE.

Peripheral organ doses from radiotherapy for heterotopic ossification of non-hip joints: Is there a risk for radiation-induced malignancies?

Radiotherapy, used for heterotopic ossification (HO) management, may increase radiation risk to patients. This study aimed to determine the peripheral dose to radiosensitive organs and the associated cancer risks due to radiotherapy of HO in common non-hip joints. A Monte Carlo model of a medical linear accelerator combined with a mathematical phantom representing an average adult patient were employed to simulate radiotherapy for HO with standard AP and PA fields in the regions of shoulder, elbow and knee. Radiation dose to all out-of-field radiosensitive organs defined by the International Commission on Radiological Protection was calculated. Cancer induction risk was estimated using organ-specific risk coefficients. Organ dose change with increased field dimensions was also evaluated. Radiation therapy for HO with a 7 Gy target dose in the sites of shoulder, elbow and knee, resulted in the following equivalent organ dose ranges of 0.85-62 mSv, 0.28-1.6 mSv and 0.04-1.6 mSv, respectively. Respective ranges for cancer risk were 0-5.1, 0-0.6 and 0-1.3 cases per 10(4) persons. Increasing the field size caused an average increase of peripheral doses by 15-20%. Individual organ dose increase depends upon the primary treatment site and the distance between organ of interest and treatment volume. Relatively increased risks of more than 1 case per 10,000 patients were found for skin, breast and thyroid malignancies after treatment in the region of shoulder and for skin cancer following elbow irradiation. The estimated risk for inducing any other malignant disease ranges from negligible to low.

Out-of-field organ doses and associated radiogenic risks from para-aortic radiotherapy for testicular seminoma.

PURPOSE The aims of this study were to (a) calculate the radiation dose to out-of-field organs from radiotherapy for stage I testicular seminoma and (b) estimate the associated radiogenic risks. METHODS Monte Carlo methodology was employed to model radiation therapy with typical anteroposterior and posteroanterior para-aortic fields on an anthropomorphic phantom simulating an average adult. The radiation dose received by all main and remaining organs that defined by the ICRP publication 103 and excluded from the treatment volume was calculated. The effect of field dimensions on each organ dose was determined. Additional therapy simulations were generated by introducing shielding blocks to protect the kidneys from primary radiation. The gonadal dose was employed to assess the risk of heritable effects for irradiated male patients of reproductive potential. The lifetime attributable risks (LAR) of radiotherapy-induced cancer were estimated using gender- and organ-specific risk coefficients for patient ages of 20, 30, 40, and 50 years old. The risk values were compared with the respective nominal risks. RESULTS Para-aortic irradiation to 20 Gy resulted in out-of-field organ doses of 5.0-538.6 mGy. Blocked field treatment led to a dose change up to 28%. The mean organ dose variation by increasing or decreasing the applied field dimensions was 18.7% ± 3.9% and 20.8% ± 4.5%, respectively. The out-of-field photon doses increased the lifetime intrinsic risk of developing thyroid, lung, bladder, prostate, and esophageal cancer by (0.1-1.4)%, (0.4-1.1)%, (2.5-5.4)%, (0.2-0.4)%, and (6.4-9.2)%, respectively, depending upon the patient age at exposure and the field size employed. A low risk for heritable effects of less than 0.029% was found compared with the natural incidence of these defects. CONCLUSIONS Testicular cancer survivors are subjected to an increased risk for the induction of bladder and esophageal cancer following para-aortic radiotherapy. The probability for the appearance of any other malignant disease to out-of-field organs was slightly elevated in respect to the nominal cancer incidence rates.

Comparison of methods for assessing geometric efficiency on multi-detector CT scanners

The aim of the current study was to compare the film method against the method based on a new CT slice detector in assessing geometric efficiency (GE) of x-ray beams utilized by a multi-detector CT (MDCT) scanner. Measurements of GE were performed using radiographic films and a solid state CT slice detector for all beam qualities, collimations and focal spot sizes available on an MDCT scanner. Repeatability of GE measurements was assessed. The radiographic film and the solid state detector methods were compared to each other in regard to efficacy in measuring free-in-air GE. The values of GE determined using the radiographic film method were found to range between 48.5% and 90.6%. Differences between values obtained with the radiographic film method and corresponding values obtained with the solid state detector were less than 10% exceeding 5% for only one case. Both methods show that wide beams have higher GE values compared to thin ones. The use of large instead of small focal spot was found to deteriorate GE values by up to 23.1%. Beam quality did not seem to influence GE of the various collimations. When thin beam collimations are employed, a considerable amount of the radiation is wasted for non-imaging purposes. Both film and solid state probe methods are capable of measuring GE of thin as well as wide collimations. The solid state detector is the easiest to use, however its usefulness is reduced by the fact that it cannot measure dose profiles of beam collimations available for step-and-shoot mode of operation.

Radiation Dose From Cone-Beam CT in Neuroradiology Applications

OBJECTIVE In view of increasing concern about radiation dose, this article aims to provide a summary of radiation doses in neuroradiologic applications of cone-beam CT. CONCLUSION The conventional wisdom that cone-beam CT incurs a much lower radiation dose than MDCT may not be uniformly true, especially in intraoperative use if operators are tempted to overuse the 3D imaging capabilities. The emerging nature of cone-beam CT warrants extra caution to avoid overexposure of patients.