Radiation Effects from Fluoroscopic X RaysRecognizing radiation injury and effects Characteristics...
Transcript of Radiation Effects from Fluoroscopic X RaysRecognizing radiation injury and effects Characteristics...
1
Louis K. Wagner, Ph.D.
Department of Diagnostic and Interventional Imaging
1
Radiation Effects from Fluoroscopic X Rays
Louis K. Wagner, Ph.D.
Department of Diagnostic and Interventional Imaging
2
Louis K. Wagner, PhD is President and a principal partner of Partners in Radiation Management LTD, Co., a publishing and radiation management consultant company. The company markets the credentialing and CME program: “Minimizing Risks from Fluoroscopic X Rays”.
Radiation Effects from Fluoroscopic X Rays
3
Radiation Effects Fluoroscopy
What we will do in this presentation (objectives):1. Review the history of radiation effects in medicine with emphasis on fluoroscopy
2. Review the dose‐response effects from fluoroscopic radiation.
3. Develop perspectives regarding our professional responsibilities in light of this information
2011
4
Established Facts
1. Fluoroscopy has induced cancer in patients
2. Fluoroscopy has seriously injured patients
3. Fluoroscopy has caused cancer in medical staff
4. Fluoroscopy has caused skin injury in medical staff
5. Fluoroscopy has caused cataracts in medical staff
6. Medical staff have died from disease induced by medical fluoroscopy
7. Medical practitioners as a group are not well versed in the risks and exposures to patients from medical radiations
Reference: Vañó E et al, BJR 1998; 71, 728-733
How not to use a fluoroscope!
In workers, effects commonly due to long-term accumulation (chronic build-up) of radiation dose.
Effects from inappropriate use of fluoroscopy
Figure withheld
2
In patients, effects typically due to accumulation of high radiation doses in a short time period, except for…….
Figure withheld Figure withheld …potential hypothetical stochastic effects ‐‐
Induced neoplasmHeritable genetic effects
‐‐which are hypothesized as possible at any dose.
Priority of concerns for fluoroscopy :
1. Short‐term (weeks to months) debilitating deterministic effects (e.g., radiation injury)
2. Long‐term (years to decades) debilitating deterministic risks (e.g., cataract, osteonecrosis)
3. Long‐term stochastic risks (e.g., cancer) [Typically this is primary concern in abdominothoracic procedures in small children]
4. Short‐term cosmetic risks (e.g., epilation)
Special concern:
1. Pregnancy (pregnancy test required for many procedures that potentially deliver high doses to uterus – e.g., hysterosalpingogram)
Radiation Risk to Pediatric Patients is a Special Problem!
“Children are not small adults” ---Keith Strauss
What do these injuries have in common?
11
Figures withheld
Diagnosis of Radiation Injury• Skin absorbed dose must be high (beam
mostly fixed on same skin site)
• Must be located at entrance beam site
• Temporal patterns must fit with progression of injury
• Pattern must match collimation in size and shape (with consideration to movement of beam during procedure)
• Biopsy generally unnecessary and to be avoided if possible
12
3
Why do we not feel the effects of X rays that cause such
effects?
13
TissueHEAT
Why do we not feel the effects of X rays that cause such
effects?
14
Tissue
Beam of X rays
Erster Nobelpreis fuer Physik 190115
Dudley Field, Vanderbilt University
William Dudley, president of the Vanderbilt Athletic
Association & Dean of the Vanderbilt University Medical
School from 1885 until his death in 1914
“Dr. Wm. L. Dudley and I decided to make a preliminary test of photographing through the head… 21 days after the experiment all of the hair came out over the space under the x ray discharge.” Professor John Daniel - Science: April 10 1896 16
Who are these guys?
17
Developed fluoroscopy with CaWO4 fluorescent material in 1896
18
4
Mihran Krikor Kassabian 1870 - 1910
19 20
21 22
23
“The following facts are presented to substantiate the possibility that, in certain circumstances, it [ionizing radiation] may play a part in the development of mammary carcinoma.”
Patients were treated for TB by fluoroscopically guided artificial pneumothorax
24
5
25
Figure withheld
26
Figure withheld
Irradiation contributed to development of mammary cancers based on:
•Correlation between cancer site and site of radiation delivery
•Correlation with delivery of high radiation dose
•Unusual younger age of onset and
•Support from animal studies.
Conclusion
27
What Effect Did Federal Regulations Have on Safety during the 1960’s to 1980’s?
• Regulated Manufacturing of Medical Radiation Producing Devices• Put limits on fluoroscopy output• Established the five-minute timer• Placed requirements on self-shielding of X-ray tubes• Placed requirements on collimation• Placed Requirements on distance of X-ray source from patient• Placed requirements on radiation penetration through image receptor• Required that the beam not extend outside the useful imaged area
28
Result:
• Culture of safety gradually improved • Injury to personnel diminished to very small numbers• Radiation disease no longer evident in workers
But:
• Use of medical fluoroscopy was primarily diagnostic • Physicians generally left the room during acquisitions (cine or film changer series)
And:
Radiation outputs were self limited by early X-ray tube technology, slow film processing and time-consuming image management.
29
This led to:
A FALSE SENSE OF SECURITY
ABOUT THE SAFETY OF FLUOROSCOPY
30
Figure withheld
6
Today:
• Medical fluoroscopy extensively used to guide therapeutic procedures• Physicians often at patient side during digital acquisitions
And:
Radiation outputs are virtually limitless with immediate image processing
31
Renal angioplastyDandurand et al, Ann
Derm Vener 1999; 126: 413-417
Uterine embolizationCourtesy: Shope, FDA
TIPS placementNahass et al, Am J Gastroent
1998; 93: 1546-9
Radiofrequency AblationVañó, Br J Radiol 1998;
71, 510 - 516
Coronary AngioplastyCourtesy F Mettler MD
Radiation injury associated with wide range of complex procedures
Granel et al, Ann Dermatol Venereol 1998; 125; 405 -407Provided with
permission
From: Wagner and Archer. Minimizing Risks..
From: Koenig et al. AJR
From: D Wolf. Hautnah Derm
Injuries have occurred in a wide variety of anatomical locations
From: Pezzano M. Archives des Maladies du Coeur et des Vaisseaux 1992; 92: 1197 -1204.France
From: T Koenig, D Wolf et al. AJRGermany
From: Vano et al. BJRSpain Courtesy: Fred Mettler
Texas
Sovik E, Klow N-E. Acta Radiologica 1996; 37: 305-306.Scandanavia
Injuries have occurred around the world
Japan32
Courtesy of Kent Ogden, PhD
Figures withheld
Figures withheld
Figures withheld
Recognizing radiation injury and effectsCharacteristics of radiation injury
33
Fluoroscopically Guided Interventional Procedures: A Review of Radiation Effects on Patients’ Skin and HairStephen Balter, PhD, John W. Hopewell, DSc, Donald L. Miller, MD, Louis K. Wagner, PhD and Michael J. Zelefsky, MD
February 2010 Radiology, 254, 326-341.
Recognizing radiation injury and effectsCharacteristics of radiation injury
34
35
Not Scalp!!
• Coexisting diseases or conditions•Scleroderma; systemic lupus erythematosus; possibly rheumatoid arthritis; Hyperthyroidism; poor nutritional status; compromised skin integrity (diabetes mellitus – thought to negatively impact recovery from raidationdamage)
• Genetic factors• heterozygous for the ATM gene; Fanconi anemia; Bloom syndrome; xeroderma pigmentosum; Familial polyposis; Gardner syndrome; hereditary malignant melanoma; dysplastic nevus syndrome; Neurofibromatosis; Li-Fraumeni syndrome; Hereditary retinoblastoma
• Medication use• actinomycin D; doxorubicin; bleomycin; 5-fl uorouracil; methotrexate; when given in conjunction with radiation therapy: paclitaxel, docetaxel, and possibly tamoxifen can result in cutaneous toxicity
• Radiation history
36
Some aggravating physical or clinical factors
7
Radiation Risks
Deterministic Risks to Skin
Collagen vascular disease
Gironet et al, 1998, Ann Dermatol Venerol, 125, 598 - 600 Wagner et al, 1999, Radiology, 213,
773 - 776
29
Figures withheld
38
39 40
41
Transient erythema
Figure withheld
42
8
43
Note: This is an example of depilation in the scalp. I have no images of depilation in other body locations that are validated as caused by radiation
Figures withheld
44
45 46
47
Granel et al, Ann Dermatol Venereol 1998; 125; 405 - 407Vañó, Br J Radiol 1998; 71, 510 - 516.
From: Lichtenstein DA, Klapholz L, Vardy DA, et al. Chronic radiodermatitis following cardiac catheterization. Arch Dermatol 1996; 132: 663-667
Figures withheld
48
TJC Sentinel Event
9
4 mos after procedures
7 mos after procedures
9 mos after procedures
22 mos after procedures
23 mos after procedures
Three TIPS procedures in 1 week in type II diabetic. Total procedure time 13 - 16 hours. Three weeks later noticed 13-cm x 17-cm mottled oval discoloration on back. Initially diagnosed as strep infection, then as herpes I, then as allergic reaction to oral diabetic medications. Diagnosis of radiodermatitisobtained ten months after procedure!
Figures withheld
Several months after 3rd
angioplasty
5 months after third angioplasty
22 months after third angioplasty
From: Wolff D, Heinrich KW. Hautnah derm 1993; 5: 450-452.
Diagnostic study and PTCA with 51 minutes of fluoroscopy14 d afterward erythema on rt shoulder, turned into moist superficial ulcer with poor healing, degenerated into deep muscular ulcer, cutaneous skin graft required
At 5.5 mos At 14 mos
6
Figures withheld
9.5 wks after 1st procedure
23 wks after 1st procedure; 3 wks after 2nd procedure
6 wks after 2nd procedure
7 wks after 2nd procedure
8 wks after 2nd procedure
17.5 wks after 2nd procedure
26 wks after 2nd procedure
37 wks after 2nd procedure
39 wks after 2nd procedure
•no one knows...nor does anyone want to know...what do I do...please help me.•Happened during stent placement December 2008.@ well-known hospital, two lengthy procedures with-in 3 days. •No one advised me nor informed me that I was exposed to excessive radiation. I recently received my records,(Dec 2010). I had a long duration of radiation exposure and yet not one person told me so. •I went through months of infection and pain and to this day it still hurts and unbearable itching. •In January 2010 I had a quad by pass and the surgeon said,and I quote, "in my opinion,when they placed the stents on wednesday and there was a serious problem,they should not have replaced the stents on friday but rather done a bypass“•I understand that I may be looking at cancer down the road. I don't know,I'm not a doctor. What kind of test can be made to keep a eye on this? Who should be responsible for any damage?•I had a endoscopy in February 2010 and the doctor said he thinks the radiation has thinned the wall of my esophagus and must watch it closely. Attached are photos I had taken through different stages and the wound appears to be getting red once again. Please if you can be of any help,please call me or Email me.
Recent communications on radiation injury
53
• As you know, radiation is the gift that keeps on giving.
• After several weeks of having a different kind of pain on top of his usual ongoing pain, K had an MRI, showing rib fractures, posterior T9, possible nonunion, and a fracture at posterior T8.
• With his debilitating ongoing pain, K does very little in the way of physical activity so it is baffling to try to figure a cause of two fractured ribs. The doctor who did the surgery for K's latissimus flap diagnosed it as osteoradionecrosis.
• Ribs T9 ad T8 are in direct line of what he figures to be the strongest blast of radiation from K's two heart ablation procedures
• It has been over four years since his first ablation procedure and over three years since the latissimus flap surgery.
• At this point K is not certain what his next step will be to fix the fractured ribs; there are a few options, none of which are attractive to him.
• In your studies have you come across a delay in radiation injury to the ribs? And if so, do you know how the injury was addressed? Or once the radiation starts its grip on the ribs, how long will it continue to cause damage? If you are aware of anyone who has gone through, or is going through, this particular injury, could you please ask that they contact us?
Recent communications on radiation injury
54
10
Dose in bone at diagnostic energies is about 3-4 times
greater than that in soft tissue due to the photoelectric interaction in calcium
56
Five weeks after procedure
9 ½ Months after procedure
i really don't know how much more of this i can stand!!!!..do you have any idea looking at the photos, what i might be up against? it is so amazing but it seems i know more about my condition than all the doctors i have been to HOW CAN THAT BE???? do you have any stats on how many people suffer thru this????
Former major league professional athlete
From Vlietstra et al., J Interventional Cardiology 2004
From Wong et al., New Eng J Med 2004
Wagner – Archer, Minimizing Risks from Fluoroscopic X Rays, 3rd ed, Houston, TX, R. M. Partnership, 2000
Vano et al, Brit J Radiol1998, 71, 510-516
57
Figures withheld
58
7th July (treatment was on the 15th June)
19th July
Radiation RisksInduced Cataract
Reference: Vañó E et al, BJR 1998; 71, 728-733
Threshold < 0.7 GyOnset depends on dose
32
PA orientation delivers only exit doseShield eyes from lateral beam using collimation
Radiation-induced cataract in medical personnel
59
Figures withheld
Cataracts among Chernobyl Clean-up Workers: Implications Regarding Permissible Eye Exposures
Worgul BV, Kundiyev YI, Sergiyenko NM, Chumak VV, Vitte PM, Medvedovsky C, Bakhanova EV, Junk AK, Kyrychenko OY, Musijachenko NV, Shylo SA, Vitte OP, Xu
S, Xue X, Shore RERadiation Research 167, 233-243, 2007
•Prospective study of 8607 Chernobyl clean-up workers assessed at 12 and 14 years after exposure•Cohort young and prevalence of cataracts prior to clean-up assumed similar to prevalence of age-dependent cataract in non-cleanup cohorts. •Baseline reference was individuals exposed to less than 100 mGy.•Dose response effect found•Threshold for induction of Stage 1 opacities ~350 mGy, perhaps less, and not in excess of 700 mGy.
60