REPORT MEDICAL RADIATION EXPOSURE STUDY IN MALAYSIA

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

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. Wahid

Malaysian 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

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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 MEMBERS

33. Zuridah binti Bodong

34. Nordiana binti Md Din

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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

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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.

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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.

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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).

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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).

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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.

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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.

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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.

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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.

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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

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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

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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

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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.



2

Table 1.1: Overall summary from UNSCEAR year 2000-2005 survey (UNSCEAR, 2008).

UNSCEAR 2008 – Overall Summary

Source Collective Dose (man Sievert)

Worldwide average dose (mSv)

Typical range of individual doses (mSv)

Comments

Total natural 15,000,000 2.4 1-10 Sizeable population at 10-20 mSv

Medical diagnosis

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

Occupational exposure

29,000 0.005 0-20 Highest collective doses to exposures from natural radiation (e.g. radon in mines)

Nuclear power public exposure

1,300 0.0002 Up to 0.3 near nuclear installations

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



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



4

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).



5

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



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)



7

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



8

(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.



9

(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.



10

(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)



11

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.


__________________________________________________________________________________________________ Chapter 2: Diagnostic, Interventional and Dental Radiology, Literature Review

12

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



13

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



14

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



15

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



16

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.



17

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.


__________________________________________________________________________________________________ Chapter 2: Diagnostic, Interventional and Dental Radiology, Methodology

18

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.



19

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;

Energy imparted

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



20

(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)


Bone Mineral Densitometry Entrance Surface Dose (mGy) Effective Dose (mSv)

Dental - Intraoral

Dental - Panoramic

Entrance Surface Dose (mGy)

Air Kerma-Area Product

(mGy.m2)



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



21

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



22

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.



23

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



24

Pelvis/Hip Skull

AP Lateral Others (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.

2ESDESD ESD Dose, Surface Entrance 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)



25

Gastrointestinal Lower

Gastrointestinal Upper

Micturating Cystourography (MCU)

Interventional

Radiology

Cerebral

Extracorporeal Shock Wave Lithotripsy (ESWL)

Percutaneous Transluminal Coronary Angioplasty (PTCA)

Vascular

Others



26

Figure 2.4: Orientation markings on the reversed side of the Gafchromic® film.

X-ray tube

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.



27

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.

AKAP reading

0 mGy (Control)

3258 mGy



28

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



29

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

Brain

Spine/Musculo-skeletal (including Cervical, Thorax, Lumbo-Sacral Spine)

Chest

Abdomen

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:



30

Kgcs= D m

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.


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



31

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.


Intraoral

Panoramic


__________________________________________________________________________________________________ Chapter 2: Diagnostic, Interventional and Dental Radiology, Data Analysis

32

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.



33

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.

Medical

Radiation Exposure Survey Central

Database

Dose Calculation

Program

Background Information

Survey

Radiation Dose Survey

Statistical Analysis

Output / Result

Input Dose



34

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);



35

(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.


__________________________________________________________________________________________________ Chapter 2: Diagnostic, Interventional and Dental Radiology, Result and Discussion

36

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.



37

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.

2009

2008

2007



38

(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



39

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

2009

2008

2007



40

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



41

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



42

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



43

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)

IAEA 4BSS

(1996)

UK 5IPSM

(1992)

USA 6CRCPD

(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.



44

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



45

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).



46

Figure 2.15: Number of cases for fluoroscopy (conventional studies).

Figure 2.16: Number of cases collected for fluoroscopy (interventional studies).



47

(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)


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



48

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



49

Table 2.15: Peak Skin Dose (mGy) for various fluoroscopy examination types in conventional and interventional studies.

Exam. Type Peak Skin Dose (mGy)


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


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


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



50

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



51

Table 2.16: Mean Skin Dose (mGy) for various fluoroscopy/angiography examination types in conventional and interventional studies.

Exam. Type Mean Skin Dose (mGy)


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


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


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



52

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



53

(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)

3Sapiin et al.

(2004)

4Van de Putte et al.

(2000)

5Tsalafoutas

et al. (2003)

6Vano et 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


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


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.



54

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



55

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).



56

Table 2.19: CTDIw (mGy) for various examination types in CT.

Exam. Types CTDIw (mGy)


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)


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


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



57

Table 2.21: Effective dose (mSv) for various examination types in CT.

Exam. Types Effective Dose (mSv)


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


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.



58

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



59

(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

16.3 N/A 70 N/A

Thorax 21.3 N/A N/A N/A

Others 12.3 N/A N/A N/A



60

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

389.0 N/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



61

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)


2 – 3.9 cm 1.43 1.21 0.10 4.85 0.86 0.77 1.89



62

Breast thickness Mean Glandular Dose (mGy)


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



63

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.



64

Table 2.28: Entrance Surface Dose (mGy) for different examination types in bone mineral densitometry.



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



65

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.



66

Table 2.30: Entrance Surface Dose (mGy) for intraoral examinations in dental radiology.



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



67

Table 2.31: Air Kerma-Area Product (mGy.m2) for panoramic examinations in dental radiology.

Exam. Type AKAP (mGy·m2)


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.



68

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)

IAEA 4BSS

(1996)

UK 5IPSM

(1992)

USA 6CRCPD

(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.


__________________________________________________________________________________________________ Chapter 3: Nuclear Medicine, Literature Review

69

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



70

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



71

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



72

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.



73

(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.



74

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



75

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).


__________________________________________________________________________________________________ Chapter 3: Nuclear Medicine, Methodology

76

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



77

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

Max Usual

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 80 Liver & spleen imaging (SPECT)

Tc-99m Labelled colloid 200

Lung perfusion studies Tc-99m Isotonic solution 200 Lung imaging (SPECT) Tc-99m MAA 200 Myocardial imaging Tc-99m Phosphonate &

phosphate compound 600

Myocardial imaging (SPECT) Tc-99m Phosphonate & phosphate compound

800

Renal imaging Tc-99m DMSA 160 Renal imaging/Renography Tc-99m DTPA gluconate &

glucoheptonate 350

Thyroid imaging Tc-99m TcO4 - 200

Thyroid imaging I-123 20 Thyroid 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



78

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



79

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.



80

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.



81

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

Start R

eject Data /

Query G

eneration



82

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.



83

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.



84

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 SPECT Imaging

PET/CT Imaging

Therapeutic Procedures

Equipment Information

Part C Questionnaire

Survey

Personnel Information

• Demographic • Frequency • Dosimetry



85

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.



86

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).



87

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


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.


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


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.



88

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.


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,



89

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.



90

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.



91

Figure 3.6: Screen shot of the database “System Parameter” menu.

Figure 3.7: Screen shot of the database “Hospital Maintenance” menu.



92

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.



93

Figure 3.10: Screen shot of the database “Inquiry” menu.

Parameter Tables Relationship

Figure 3.11: Parameter tables relationship of the database.



94

Hospital Tables Relationship

Figure 3.12: Hospital tables relationship of the database.

Figure 3.13: Overall relationship of the database.



95

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


__________________________________________________________________________________________________ Chapter 3: Nuclear Medicine, Data Analysis

96

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



97

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.

Medical

Radiation Exposure

Survey Central

Database

Dose Calculation

Program

Background Information

Survey

Radiation Dose Survey

Statistical Analysis

Output / Result

Input Dose



98

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


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



99

(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.



100

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.



101


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

~



102

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.


__________________________________________________________________________________________________ Chapter 3: Nuclear Medicine, Result and Discussion

103

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.


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.



104

(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.



105

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



106

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.



107

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.



108

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



109

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).



110

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.



111

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


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 11

Total 26 960 1385 2371 10 285 572 867



112

Table 3.6 (c): Gender and age distribution of patients undergoing PET/CT examination in nuclear medicine (2005-2007).

PET/CT

Examination


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).



113

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



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.


(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



115

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)



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



116

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)


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



117

Table 3.7 (e): Administered activities (MBq) in PET/CT (2005-2007).

Procedures Radio-pharmaceutical



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).



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.



119

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



120

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.



121

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.



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.



123

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



124

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



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



126

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



127

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.



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.



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.


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


850 800 800 1500 N/A N/A


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

Lung Perfusion

Tc-99m MAA 308 200 200 185 100 200

Lung Ventilation

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.



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.



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,

Rest 497 N/A N/A N/A N/A


509 N/A N/A N/A N/A


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

Lung Perfusion

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 10-731. 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.



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.



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,

Rest 832 600 589 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


850 700 N/A N/A N/A N/A 540 N/A


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-111 Pentetreotide

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

Lung Perfusion

Tc-99m MAA 308 280 421 N/A 100 172 120 185

Lung Ventilation

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



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.


__________________________________________________________________________________________________ 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


__________________________________________________________________________________________________ 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.


_______________________________________________________________________________________________________ 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.


_______________________________________________________________________________________________________ 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.


Effects and Risks of Ionizing Radiation. 2006. UNSCEAR 2006 Report to

the General Assembly, with annexes. New York. United Nation.


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.


_______________________________________________________________________________________________________ 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

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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

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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

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e-mail address

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General X-ray Measurement of entrance Surface Air Kerma per study Hospital: ………………………………….. Room: …………….

Date

Type of examination

Patient Data:

Patient ID

Ethnic Group M/ C/ I/ O

Sex Male / Female

Age

Weight kg

Height cm

Study Parameters:

Image No.

Projection (AP/PA/LAT/Oblique)

FFD (cm)

kVp mAs AEC used

(*Y/N)

Cassette size (cm x cm)

TLD ID Entrance Surface Air Kerma (mGy)

Remark

1

2

3

4

5 Y – Yes, N – No

UNSCEAR: Forms/Diagnostic/GenXray/ 1.0

user

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Appendix B

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Fluoroscopy Measurement of dose-area-product and entrance skin dose per study Hospital: ………………………………….. Room: …………….

Date

Type of examination Angiography (Diagnostic): Cardiac / Non-cardiac

Conventional: Upper Gastrointestinal / Lower Gastrointestinal / MCU / ERCP

Interventional: Cardiac (PTCA) / Cerebral / Vascular / ESWL / Others

Patient Data:

Patient ID

Ethnic Group M/ C/ I/ O

Sex Male / Female

Age

Weight kg

Height cm

Study Parameters:

Series No.

Study kV (mean)

mA Time (s)

mAs Frame Rate (fps)

Total Time

(s)

No. of Acquisition

DAP (mGy.m2)

Gafchromic Film Label

Remark

1

2

3

4


UNSCEAR: Forms/Diagnostic/Fluoro/ 1.0

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Computed Tomography (CT) Measurement of CTDI and effective dose per study Hospital: Room:

Date

Type of examination

Patient Data:

Patient ID

Ethnic Group M / C / I / O

Sex Male / Female

Age

Weight kg

Height cm

Information: FOV Field of View (cm x cm) Matrix Size eg. 512 x 512 , 1024 x 1024 TF (Table Feed) distance/rotation (mm) P Pitch Collimation/ Detector Selection Eg. 16 x 0.625, 4 x 2.5.

For single sliced CT, leave this empty. No. of Phases Number of scan with same parameters (only for

multiple phases)

*Study Parameters:

Series No.

Scan Area kV mA mAs Time (s)

FOV Matrix size

TF (mm)

P Collimation/Detector Selection

Recon Slice

Thickness (mm)

Scan Length (cm)

Spiral Mode (Y/N)

Remark (e.g. No.

of Phases)

1

2

3

4

5

*Do not record scout scan

UNSCEAR: Forms/Diagnostic/CT/ 1.0

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Mammography Measurement of Mean Glandular Dose per study Hospital: ………………………………….. Room: …………….

Date

Type of examination Screening / Clinical Diagnosis

Patient Data:

Patient ID


Age

Weight kg

Height cm

Information: CC Cranial-caudal view MLO Mediolateral oblique view FFD Focus-to-Film Distance Target/Filter eg., Mo/Mo, Mo/Rh, Rh/Rh, W/W AEC Automatic Exposure Control

Study Parameters:

Series No.

Projection (CC/MLO)

FFD (cm)

Target/ Filter kVp mAs(exp) AEC used (*Y/N)

Compressed Breast

Thickness (mm)

Mean Glandular Dose (mGy)

Remark

1

2

3

4


UNSCEAR: Forms/Diagnostic/Mammo/ 1.0

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Bone Mineral Density Examinations Measurement of entrance surface dose per study Hospital: ………………………………….. Room: …………….

Date

Patient Data:

Patient ID


Sex Male / Female

Age

Weight kg

Height cm

Information: Projection AP Spine / Left Hip / Right Hip Scan Mode Hi-Res, Fast / Hi-Res, Med / Low-Res, Med

Study Parameters:

Image No.

Projection (AP Spine / Left Hip /

Right Hip)

kVp mA Time (s)

Scan Mode TLD label Entrance Surface Dose

(mGy)

Remark

1

2

3

4

5 Y – Yes N – No

UNSCEAR: Forms/Diagnostic/BMD/ 1.0

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Dental Examinations Measurement of entrance surface dose per study Hospital: ………………………………….. Room: …………….

Date

Type of examination Intraoral / Panoramic / Dental CT

Patient Data:

Patient ID


Sex Male / Female

Age

Weight kg

Height cm

Study Parameters:

Image No.

FFD (cm)

kVp mAs AEC used

(*Y/N)

Film size (cm x cm)

TLD label Entrance Surface Dose

(mGy)

Remark

1

2

3

4

5 Y – Yes N – No

UNSCEAR: Forms/Diagnostic/Dental/ 1.0

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Diagnostic X-ray Examinations (Year 2005)

UNSCEAR: Forms/Survey/Diagnostic/2005 1 of 3

General X-ray Estimated number of

examinations performed annually (a)

Estimated average patient dose

Estimated effective dose (mSv)(If

available) Age and sex distribution (%)

0-15 years 16-40 years >40 years Examination Conven-

tional Digital

Entrance surface Dose (mGy)

±SD Mean ±SD Male Female Male Female Male Female

Chest Radiography 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 Pelvis/Hip Skull AP Lat Others (Towne, Caldwell, etc)

Abdomen/KUB

user

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Appendix C

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Mammography Estimated number of



Estimated effective dose (mSv)(If available) Age and sex distribution (%)

Examination

Conventional Digital Mean

glandular dose(mGy)

±SD Mean ±SD 16-40 years >40 years

Screening

Clinical diagnosis

Fluoroscopy

Estimated average patient dose Estimated effective

dose (mSv)(If available)

Age and sex distribution (%)

0-15 years 16-40 years >40 years Examination

Estimated number of



±SD

Kerma Area

Product (Gycm2)


Angiography (Diagnostic) Cardiac Non-cardiac

Conventional Studies Upper Gastrointestinal Lower Gastrointestinal MCU ERCP Cholecystography Urography

Interventional Cardiac (PTCA) Cerebral Vascular ESWL Others

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Diagnostic X-ray Examinations (Year 2005) Computed Tomography (CT)




Estimated number of examinations

performed annually (a) CTDI(vol) ±SD Mean ±SD

Male Female Male Female Male Female Brain Spine/Musculo-skeletal (Cervical, thorax, lumbo-sacral spine)

Chest Abdomen Pelvis Cardiac CT Other: …………………………

TOTAL of all medical examinations

Bone Mineral Density (BMD)






performed annually (a)



AP Spine Left Hip / Right Hip

(a) If the conventional/digital mix is not known, please check the box and put entries in the Conventional column


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tional Digital






Abdomen/KUB

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Examination


glandular dose(mGy)


Screening

Clinical diagnosis

Fluoroscopy





Estimated number of



±SD

Kerma Area

Product (Gycm2)





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tional Digital






Abdomen/KUB

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Examination


glandular dose(mGy)


Screening

Clinical diagnosis

Fluoroscopy





Estimated number of



±SD

Kerma Area

Product (Gycm2)





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Dental Radiology (Year 2005)

UNSCEAR: Forms/ Survey /Dental/2005 1 of 3

Dental Radiology






Entrance surface Dose

(mGy) ±SD Mean ±SD

Male Female Male Female Male Female Intraoral Panoramic Dental CT

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UNSCEAR: Forms/Survey/Dental/2006 1 of 3

Dental Radiology









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UNSCEAR: Forms/Survey/Dental/2007 1 of 3

Dental Radiology









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UNSCEAR: Forms/Equipment list/ 1.1

MINISTRY OF HEALTH UNSCEAR SURVEY PROJECT Equipment List Hospital:

No. Location (Room #) Model Manufacturer

Serial No.

Year of Purchase Other Specifications

1 2 3 4 5 6 7 8 9

General X-ray

10

1 No. of Slice = 2 No. of Slice = 3 No. of Slice = 4 No. of Slice =

Computer Tomography

5 No. of Slice =

1 2 3 4 5

Fluoroscopy

6

user

Typewritten Text

Appendix D

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UNSCEAR: Forms/Equipment list/ 1.1

7 8 9

10

1 HVL = ESAK =

2 HVL = ESAK =

3 HVL = ESAK =

4 HVL = ESAK =

Mammography

5 HVL = ESAK =

1 2 3 4

Bone Mineral Density

5

1 2 3 4

Dental

5

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Radionuclide Studies

Code Study Purpose EquipmentSkeletalS1 99m-Tc MDP WB Bone Planar scintigraphy To detect skeletal lesions at the earliest possible SPECT Gamma camera with

time, monitor the course of skeletal disease and planar collimator.evaluate metabolic activity of skeletal lesions.

S2 99m-Tc MDP Localised Bone Planar scintigraphy same as above same as aboveS3 99m-Tc MDP Localised Bone SPECT same as above same as aboveS4 99m-Tc Bilateral Hip Planar scintigraphy same as above same as aboveS5 99m-Tc MDP Bilateral Hip SPECT same as above same as aboveS6 99m-Tc Sn colloid WB Bone Marrow study To detect marrow space disease processes. same as aboveS7 99m-Tc Sn colloid Localised Bone Marrow study same as above same as aboveS8 99m-Tc MDP Bone Pinhole scintigraphy same as item S1 Gamma camera with

pinhole collimator.S9 99m-Tc MDP Flow & Equi. Bone Planar scintigraphy same as item S1 Gamma camera with planar

collimator.

CardiovascularC1 99m-Tc MIBI Exercise Myocardial Perfusion study To assess regional and global myocardial perfusion SPECT Gamma camera with

for diagnosis and management of coronary artery planar collimator.disease.

C2 99m-Tc MIBI DP Stress Myocardial Perfusion study same as above same as aboveC3 99m-Tc MIBI Rest Myocardial Perfusion study same as above same as aboveC4 99m-Tc RBC Rest Gated Ventriculography To examine the function of the heart's chambers SPECT Gamma camera with

including ventricular size, configuration and wall planar collimator.motion.

C5 99m-Tc RBC Exercise Gated Ventriculography same as above same as aboveC6 99m-Tc RBC Rest Gated SPECT Ventriculography same as above same as aboveC7 99m-Tc Cardiac First Pass study To provide quantitative, semi-quantitative and Gamma camera with planar

qualitative indices of cardiac function and anatomic collimator.information.

C8 99m-Tc Cardiac Gated First Pass study same as above same as aboveC9 99m-Tc PYP Myocardial Infarct Planar scintigraphy Localization of acute myocardial infarction. same as aboveC10 99m-Tc PYP Myocardial Infarct SPECT scintigraphy same as item C9 SPECT Gamma camera with

planar collimator.C11 201-Tl Exercise Myocardial Perfusion study same as item C1 same as aboveC12 201-Tl DP Stress Myocardial Perfusion study same as item C1 same as aboveC13 201-Tl Redistribution Myocardial Perfusion study same as item C1 same as aboveC14 201-Tl 24hr Redistribution Myocardial Perfusion study same as item C1 same as aboveC15 201-Tl 24hr (Re-inj) Redistr. Myocardial Perfusion same as item C1 same as above

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Appendix E

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A25

Code Study Purpose Equipmentstudy

C16 99m-Tc TET Exercise Myocardial Perfusion study same as item C1 same as aboveC17 99m-Tc TET DP Stress Myocardial Perfusion study same as item C1 same as aboveC18 99m-Tc TET Rest Myocardial Perfusion study same as item C1 same as above

Central Nervous SystemB1 99m-Tc HMPAO Cerebral Perfusion SPECT To diagnose abnormalities of regional cerebral blood SPECT Gamma camera with

flow. planar collimator.B2 99m-Tc Brain Blood Flow study Assess cerebral function. Gamma camera with planar

collimator.B3 99m-Tc WBC Cerebral SPECT Detection of sites of focal infection. SPECT Gamma camera with

planar collimator.B4 99m-Tc DTPA Planar Cisternography Assess CSF hydrodynamics, determination of Gamma camera with planar

patency of shunts or intraventricular blocks. collimator.B5 99m-Tc DTPA SPECT Cisternography same as above SPECT Gamma camera with

planar collimator.

Gastrointestinal & HepatobiliaryG1 99m-Tc Sn colloid Oesophageal Transit study Quantitate the motor function of oesophagus. Gamma camera with planar

collimator.G2 99m-Tc DTPA Gastric Emptying Time study Quantitating gastric emptying. same as aboveG3 99m-Tc Meckel's Diverticulum scintigraphy Localization of bleeding site in ectopic gastric same as above

mucosa.G4 99m-Tc Sn colloid Acute Gastrointestinal Bleed Localization of bleeding site. same as above

scintigraphyG5 99m-Tc RBC Gastrointestinal Bleed scintigraphy same as above same as aboveG6 99m-Tc BRIDA Hepatobiliary scintigraphy Assess biliary tree function. same as aboveG7 99m-Tc Sn colloid Accessory Spleen scintigraphy To detect presence of accessory spleen following same as above

scintigraphy splenectomy.G8 99m-Tc Heat Damaged RBC Accessory Spleen same as above same as above

scintigraphyG9 99m-Tc Sn colloid Gastrointestinal Reflux study Evaluate reflux oesophagitis. same as aboveG10 99m-Tc Sn colloid Liver/Spleen Planar scintigraphy To delineate various states of liver/spleen disease. same as aboveG11 99m-Tc Sn colloid Liver/Spleen SPECT scintigraphy same as above SPECT Gamma camera with

planar collimator.G12 99m-Tc RBC Liver Blood Pool Planar scintigraphy Localization of hemangiomas. Gamma camera with planar

collimator.G13 99m-Tc RBC Liver Blood Pool SPECT scintigraphy same as above SPECT Gamma camera with

planar collimator.G14 99m-Tc Sn colloid Peritoneal Shunt study To detect obstruction of LeVeen shunt. Gamma camera with planar

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A26

Code Study Purpose Equipmentcollimator.

Infection & OncologyI1 99m-Tc HMPAO Leucocyte Planar scintigraphy Detect sites of abscess and inflammation. Gamma camera with planar

collimator.I2 99m-Tc WBC Leucocyte scintigraphy same as above same as aboveI3 67-Ga WB Planar scintigraphy Detect sites of infection and tumours. same as aboveI4 67-Ga Localised SPECT same as above SPECT Gamma camera with

planar collimator.I5 67-Ga Localised Planar scintigraphy same as above Gamma camera with planar

collimator.I6 131-I WB Planar scintigraphy To detect metastasis from thyroid cancers. same as aboveI7 131-I Localised Planar scintigraphy same as above same as aboveI8 131-I Localised SPECT same as above SPECT Gamma camera with

planar collimator.I9 75-Se Selenomethyl Norcholestenol Adrenal Localization of adrenocortical and sympathomedulla Gamma camera with planar

scintigraphy disease. collimator.I10 131-I MIBG WB Planar scintigraphy Detect presence of adrenal pheochromocytoma, same as above

extra-adrenal metastatic deposits and catecholaminie secreting tumours.

I11 131-I MIBG Localised SPECT same as above SPECT Gamma camera withplanar collimator.

I12 131-I MIBG Localised Planar scintigraphy same as above Gamma camera with planarcollimator.

I13 99m-Tc V-DMSA WB Planar scintigraphy To detect medullary carcinoma. same as aboveI14 131-I Localised Pinhole scintigraphy Delineate thyroid gland Gamma camera with pinhole

collimator.I15 67-Ga Localised Pinhole scintigraphy same as item I5 same as aboveI16 99m-Tc HMPAO Leucocyte SPECT same as item I1 SPECT Gamma camera with

planar collimator.I17 99m-Tc HMPAO Leucocyte WB Planar scintigraphy same as item I1 Gamma camera with planar

collimator.I18 99m-Tc HMPAO Leucocyte Pinhole scintigraphy same as item I1 Gamma camera with pinhole

collimator.I19 111-In Pentetreotide Localised SPECT Localization of primary and metastatic neuro- SPECT Gamma camera with

endocrine tumours bearing somatostatin receptors. planar collimator.I20 111-In Pentetreotide WB Planar scintigraphy same as above Gamma camera with planar

collimator.I21 111-In Pentetreotide Localised Planar scintigraphy same as above same as aboveI22 99m-Tc Tetrofosmin Osteosarcoma scintigraphy To detect osteosarcoma same as above

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Code Study Purpose EquipmentI23 201-Tl Osteosarcoma scintigraphy same as above same as aboveI24 99m-Tc TET Tumour WB scintigraphy Localization of malignant tumours. same as aboveI25 99m-Tc TET Tumour SPECT same as above SPECT Gamma camera with

planar collimator.I26 99m-Tc TET Tumour Planar scintigraphy same as above Gamma camera with planar

collimator.I28 99m-Tc TET Cancer Breast SPECT Localization of malignant breast tissue. same as aboveI29 99m-Tc Nanocolloid Lymphoscintigraphy Demonstrate historeticular tissue of retroperitoneal, same as above

axillary, parasternal and cervical lymph nodes.I30 99m-Tc Scintimun Granulocyte same as item I1 same as above

Lacrymal & SalivaryL1 99m-Tc Dacryo Planar scintigraphy Define patency of lacrymal duct. Gamma camera with planar

collimator.L2 99m-Tc Salivary Gland scintigraphy To establish function of salivary gland. same as aboveL3 99m-Tc Salivary Gland Pinhole scintigraphy same as above Gamma camera with pinhole

PulmonaryP1 99m-Tc Technegas Lung Ventilation study To distinguish COPD related perfusion defects from Gamma camera with planar

those secondary to pulmonary embolization. collimator.P2 99m-Tc MAA Lung Perfusion study Evaluation of pulmonary arterial blood flow. same as aboveP3 99m-Tc DTPA Radioaerosol Lung Ventilation study same as item P1 same as aboveP4 99m-Tc Technegas Lung Ventilation SPECT same as item P1 SPECT Gamma camera with

planar collimator.P5 99m-Tc MAA Perfusion SPECT same as item P2 same as above

Renal & Urinary TractR1 99m-Tc DTPA Diuretic Renal study Provide sensitive indices of relative renal blood flow, Gamma camera with planar

glomerular filtration, tubular function and urinary collimator.excretion.

R2 99m-Tc DTPA Renal Transplant study same as above same as aboveR3 99m-Tc DTPA Captopril Enhanced Renal study same as above same as aboveR4 99m-Tc DMSA Renal Planar study Evaluation of functioning cortical renal parenchyma same as aboveR5 99m-Tc DMSA Renal SPECT same as above SPECT Gamma camera with

planar collimator.R6 99m-Tc DTPA Micturating Cystoscintigraphy Management of vesicoureteral reflux Gamma camera with planar

(Direct method) collimator.R7 99m-Tc DTPA Micturating Cystoscintigraphy same as above same as above

(Indirect method)R8 99m-Tc MAG3 Renal study same as item R1 same as above

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A28

Code Study Purpose EquipmentR9 99m-Tc DTPA Glomerular Filtration Rate Estimation of glomerular filtration rate Gamma well counterR10 99m-Tc/51-Cr EDTA GFR same as above same as above

Thyroid & ParathyroidT1 99m-Tc Thyroid scintigraphy To define functioning benign thyroid tissue and to Gamma camera with planar

detect presence and location of metastases from collimator.thyroid cancer.

T2 131-I Thyroid scintigraphy same as aboveT3 131-I Thyroid Uptake study Evaluate thyroid gland functionT4 131-I Thyroid Perchlorate Discharge test To detect defects in intrathyroidal iodide Thyroid uptake probe

organification.T5 201-Tl/99m-Tc Parathyroid scintigraphy To detect functioning parathyroid adenomas Gamma camera with planar

collimator.T6 131-I/99m-Tc TET Parathyroid scintigraphy same as above same as aboveT7 99m-Tc Thyroid SPECT same as item T1 SPECT Gamma camera with

planar collimator.T8 99m-Tc MIBI Parathyroid scintigraphy same as item T5 Gamma camera with planar

collimator.

OthersO1 Schilling Test (Vitamin B12 malabsorption) To differentiate malabsorption syndrome from Gamma well counter

pernicious anaemia.O2 51-Cr RBC Blood Volume study To estimate total blood volume and red cell mass. same as aboveO3 125-I Plasma Volume study To estimate plasma volume same as aboveO4 51-Cr Red Cell Survival & Sequestration study To determine functional half clearance time of 51Cr Gamma well counter & uptake

labelled isologous red cells and life span of red cells probe.in haemolytic anaemia.

Radionuclide TherapyZ1 131-I therapy for thyrotoxicosis Treatment of Graves' disease Radionuclide dose calibratorZ2 90-Sr Beta irradiation of Pterygium Prophylactic post-operative irradiation to reduce Strontium-90 ophthalmic

recurrence. applicator.Z3 89-Sr therapy for bone pains Control of bone pain in metastatic bone disease. Radionuclide dose calibratorZ4 153-Sm therapy same as above same as aboveZ6 131-I High Dose ablation Treatment of thyroid cancer same as aboveZ7 90-Y Zevalin therapy Treatment for relapsed or refractory, low grade or same as above

follicular B-cell non Hodgkin's lymphoma.Z8 90-Y microspheres therapy Selective internal radiation therapy for liver cancer. same as aboveZ9 188-Re therapy Treatment for disseminated skeletal metastasis. same as above

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A29

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

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Appendix F

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A30

UNSCEAR: Forms/Background/Nuclear Medicine/1.0 2 of 2

PET/CT

Model Manufacturer


E-mail address

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A31

NUCLEAR MEDICINE: DIAGNOSTIC DOSE SURVEY FORM

Hospital:

Date of Survey:

Patient Data:

Date of examination (dd/mm/yy)

Exam Name Scanning Room

No

Patient ID Sex / Age Ethnic group

Weight / Height

( kg / cm)


Activity (mCi)


Remarks

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

Legend: Exam name: BO - Bone, BR - Brain, C - Cardiac, G - Gastroenterology, LP - Lung Perfusion, LV - Lung Ventilation, R - Renal, T - Thyroid, others

Sex: M-male, F-female Ethnic group: M-Malay, C-Chinese, I-Indian, O-others

UNSCEAR: Forms/Nuclear Medicine: Diagnostic/1.1

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Appendix G

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A32

NUCLEAR MEDICINE: THERAPEUTIC DOSE SURVEY FORM

Hospital:

Date of Survey:

Patient Data:

Date of Treatment (dd/mm/yy)

Treatment Name Treatment Room No

Patient ID Sex / Age Ethnic group

Weight / Height

( kg / cm)


Activity (mCi)


Remarks

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

Legend: Treatment name: BM - Bone metastases, HT - Hyperthyroidism, PV - Polycythaemia vera, SY - Synovitis, TM - Thyroid malignancy, others

Sex: M-male, F-female Ethnic group: M-Malay, C-Chinese, I-Indian, O-others

UNSCEAR: Forms/Nuclear Medicine: Therapeutic/1.1

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A33

NUCLEAR MEDICINE: PET-CT DOSE SURVEY FORM

Hospital:

Room: Date of survey:

Patient Data:

CT protocol Date of exam.

(dd/mm/yy)

Patient ID Sex / Age

Ethnic group

Weight / Height

( kg / cm)

Clinical indication

Activity of 18-FDG (mCi)

kV mAs Rot. Time (s)

Nom S/thick

Pitch Scan length (mm)

Scan region


/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

Legend: Sex: M-male, F-female Ethnic group: M-Malay, C-Chinese, I-Indian, O-others

Nom. S/thickness for SSCT = slice thickness, for MSCT = no. of slice X slice thickness

Pitch = table travel distance / nom S/thickness Scan length = end scan – start scan. Minus sign must be included

Scan region: A - Abdomen, AP - Abdomen Pelvis, BPF - Brain posterior fossa, BR - Brain, C - Chest, PF - Posterior fossa, N - Neck, P - Pelvis, others

UNSCEAR: Forms/Nuclear Medicine: PET-CT/1.1

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A34

Nuclear Medicine Procedures (Year 2005)

Age and sex distribution (%) Activity administered (MBq)

0-15 years 16-40 years >40 years Examination or

treatment

Estimated number of procedures performed annually

Most common radio-

pharmaceutical

Percentage of examinations

performed using this material

Mean Min Max Male Female Male Female Male Female

DIAGNOSTIC EXAMINATIONS

Bone

C ardiac

Lung perfusion

Lung ventilation

Thyroid

Renal

Gastroenterology

Brain

PET

PET/CT combined

TOTAL of all examinations

THERAPEUTIC TREATMENTS

Thyroid malignancy

Hyperthyroidism

Polycythaemia vera

Bone metastases

Synovitis

Other: e.g. 90YCl

TOTAL of all treatments

UNSCEAR: Forms/Survey/Nuclear Medicine/2005 1 of 1

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Appendix H

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Nurhafizah-E6-L2

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A35




treatment


Most common radio-

pharmaceutical





Bone

C ardiac

Lung perfusion

Lung ventilation

Thyroid

Renal

Gastroenterology

Brain

PET

PET/CT combined



Thyroid malignancy

Hyperthyroidism

Polycythaemia vera

Bone metastases

Synovitis

Other: e.g. 90YCl


UNSCEAR: Forms/ Survey /Nuclear Medicine/2006 1 of 1

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A36




treatment


Most common radio-

pharmaceutical





Bone

C ardiac

Lung perfusion

Lung ventilation

Thyroid

Renal

Gastroenterology

Brain

PET

PET/CT combined



Thyroid malignancy

Hyperthyroidism

Polycythaemia vera

Bone metastases

Synovitis

Other: e.g. 90YCl


UNSCEAR: Forms/ Survey /Nuclear Medicine/2007 1 of 1

Nurhafizah-E6-L2

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A37

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ANNEX D: MEDICAL RADIATION EXPOSURES374

user

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Appendix I

Nurhafizah-E6-L2

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A38

Tab

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ANNEX D: MEDICAL RADIATION EXPOSURES 375

Nurhafizah-E6-L2

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Nurhafizah-E6-L2

Typewritten Text

A39


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A40

Tab

le15

(con

tinue

d)

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Typi

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ffect

ive

dose

per

proc

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e(m

Sv)

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pute

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atio

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Nurhafizah-E6-L2

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Nurhafizah-E6-L2

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le16

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Nurhafizah-E6-L2

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5-6.

20)

Cos

taR

ica

1ho

spita

lE

SD4.

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

(Isl

am.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

aysi

a[N

15,N

26]

12ho

spita

lsE

SD E4.

780.

043.

340.

040.

280.

031.

400.

097.

030.

4616

.510

.61.

0418

.7�

10.0

8.41

Peru

�E

SD3.

5(±

1.0)

�0.

4(±

0.3)

��

�7.

0(±

3.0)

��

8.5

(±2.

0)6.

0(±

3.0)

Tur

key

Loc

alE

SD4.

27(±

0.88

)�

0.32

(±0.

05)

0.70

(±0.

20)

7.45

(±0.

54)

�2.

81(±

1.49

)�

�10

.73

(±2.

01)

19.3

5(±

1.16

)

Hea

lth�

care

leve

lIII

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pt[H

28]

14ho

spita

lsE

SD0.

3�

0.5

��

�3.

3�

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51.

5

Gha

na[S

39]

12ho

spita

lsE

SD 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

nesi

a[L

19]

4ho

spita

lsE

SD3.

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

�E

SD9.

39(±

2)�

0.23

(±0.

2)0.

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0.2)

��

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��

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.2

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iland

[L19

]4

hosp

itals

ESD

ESD

1.37

(pre

.)(±

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)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)


Nurhafizah-E6-L2

Typewritten Text

A44

Tab

le16

(con

tinue

d)

Cou

ntry

/are

aSc

ope

ofda

taD

ose

quan

tity

a

Mea

nva

lue

ofdo

sequ

antit

ype

rra

diog

raph

b

Skul

lC

hest

Thor

acic

spin

eLu

mba

rsp

ine

Abd

omen

Pel

vis

AP

/PA

LAT

PA

LAT

AP

LAT

AP

LAT

LSJ

AP

AP

aE

SD:e

ntra

nce

surf

ace

dose

with

back

scat

ter

(mG

y);D

AP:

dose

-are

apr

oduc

t(G

ycm

2 );E

:eff

ectiv

edo

se(m

Sv).

bV

aria

tions

show

nin

brac

kets

(sta

ndar

dde

viat

ion

orra

nge)

.c

No

data

avai

labl

e.

Hea

lth�

care

leve

lIV

Eth

iopi

a[I

4]2

hosp

itals

ESD

ESD

��

1.34

(pre

.)(0

.94-

1.74

)0.

57(p

ost.)

(0.4

3-0.

70)

��

��

��

�5.

26(p

re.)

5.11�

5.41

)10

.57(

post

)(9

.74-

11.4

)

Uni

tdR

ep.o

fT

anza

nia

[M37

]5

hosp

itals

ESD

��

0.5

(±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

rex

amin

atio

nb

Upp

erG

Itr

act

Low

erG

Itr

act

Uro

grap

hyE

RC

PV

enog

ram

Swal

low

Mea

lE

nem

aC

olon

osco

py

Hea

lth�

care

leve

lI

Ger

man

y[B

9]N

atio

nal

DA

P13

.05

35.9

61.5

�20

.333

.77.

8

Icel

and

[W42

]5

hosp

itals

DA

P�

�(4

3.6�

77.4

)�

��

�

New

Zea

land

Nat

iona

lE

�3

90.

4�

4�

Nor

way

[O6]

Nat

iona

lD

AP

E7.

41 1.5

24.8

5.9

49.1

13.7

�18

.13.

831

.88.

3�

Rom

ania

[I18

]

[I28

]

5ho

spita

ls

21ho

spita

ls

DA

PE

DA

P

�37

.7(±

17.5

)3.

722

.0(2�

100)

32.2

(±3.

3)8.

1234

.7(2�

116)

��

��

Switz

erla

nd[M

45]

�D

AP

13.5

(±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


Nurhafizah-E6-L2

Typewritten Text

A45


Tab

le16

(con

tinue

d)

The

entr

ies

inth

isT

able

are

qual

ifie

das

follo

ws:

Arg

entin

a:Pa

irs

ofva

lues

repr

esen

tsur

veys

befo

rean

daf

ter

the

intr

oduc

tion

ofa

prog

ram

me

ofqu

ality

cont

rol.

Inte

rhos

pita

lvar

iatio

nin

brac

kets

.B

razi

l:Su

rvey

data

for

Para

náSt

ate

(with

apo

pula

tion

of9

mill

ion

and

aso

cial

and

econ

omic

prof

ileab

ove

the

aver

age

for

Bra

zil)

;dat

afo

rsk

ull,

lum

bar

spin

e,an

dpe

lvis

from

refe

renc

e[I

4].

Bra

zil:

Pair

sof

valu

esre

pres

ents

urve

ysbe

fore

and

afte

rth

ein

trod

uctio

nof

apr

ogra

mm

eof

qual

ityco

ntro

l.In

terh

ospi

talv

aria

tion

inbr

acke

ts.

Can

ada:

Surv

eyda

tafr

omM

anito

ba(4

%of

Can

adia

npo

pula

tion)

for

stan

dard

pres

sed

woo

dph

anto

ms

(uni

tden

sity

)un

der

man

uala

ndau

tom

atic

expo

sure

cont

rola

ndfo

rra

re�

eart

hin

tens

ifyi

ngte

chni

ques

.C

osta

Ric

a:D

ata

from

Hos

pita

lCal

deró

nG

uard

ia(s

ervi

ngon

e �th

ird

ofth

epo

pula

tion)

.C

zech

Rep

ublic

:Pa

irs

ofva

lues

repr

esen

tsur

veys

befo

rean

daf

ter

the

intr

oduc

tion

ofa

prog

ram

me

ofqu

ality

cont

rol.

Inte

rhos

pita

lvar

iatio

nin

brac

kets

.E

gypt

:M

axim

umre

com

men

ded

dose

sde

rive

dfr

omth

efo

llow

ing

publ

ishe

dm

axim

umen

tran

cesu

rfac

eex

posu

res:

26m

Rsk

ull;

45m

Rch

est;

272

mR

lum

bar

spin

e;12

5m

Rab

dom

en;1

25m

Rpe

lvis

[H28

].E

ston

ia:

Inte

rhos

pita

lvar

iatio

nin

brac

kets

.E

thio

pia:

Pair

sof

valu

esre

pres

ents

urve

ysbe

fore

and

afte

rth

ein

trod

uctio

nof

apr

ogra

mm

eof

qual

ityco

ntro

l.In

terh

ospi

talv

aria

tion

inbr

acke

ts.

Fin

land

:D

AP

and

Eda

tare

pres

entm

ean

valu

esfo

rco

mpl

ete

exam

inat

ions

.G

erm

any:

DA

Pda

tare

fer

toco

mpl

ete

exam

inat

ions

(rat

her

than

dose

spe

rra

diog

raph

).G

hana

:D

ata

for

AP

pelv

isal

soin

clud

esra

diog

raph

yof

the

abdo

men

.Ic

elan

d:D

ata

for

bari

umen

ema

exam

inat

ions

refe

rto

rang

eof

mea

nD

AP

valu

esob

serv

edin

surv

eyof

5ho

spita

ls.

Iran

(Isl

amic

Rep

.of)

:Pa

irs

ofva

lues

repr

esen

tsur

veys

befo

rean

daf

ter

the

intr

oduc

tion

ofa

prog

ram

me

ofqu

ality

cont

rol.

Inte

rhos

pita

lvar

iatio

nin

brac

kets

.Li

thua

nia:

Dat

afr

omV

ilniu

sU

nive

rsity

Hos

pita

l.M

oroc

co:

Dat

afr

omIA

EA

Coo

rdin

ated

Res

earc

hPr

ogra

mm

e.N

orw

ay:

Dat

afo

r‘U

pper

GI-

Mea

l’an

d‘L

ower

GI-

Ene

ma’

refe

rto

doub

leco

ntra

stte

chni

que

(cor

resp

ondi

ngda

tafo

rsin

gle

cont

rast

tech

niqu

e:14

.0G

ycm

2&

3.4

mSv

,and

32.3

Gy

cm2

&9.

0m

Sv,r

espe

ctiv

ely)

.P

eru:

Dat

am

ayre

fer

toco

mpl

ete

exam

inat

ions

.R

oman

ia:

Pair

sof

valu

esre

pres

ents

urve

ysbe

fore

and

afte

rth

ein

trod

uctio

nof

apr

ogra

mm

eof

qual

ityco

ntro

l.In

ter �

hosp

italv

aria

tion

inbr

acke

ts.

Sout

hA

fric

a:D

eriv

edfr

omfr

ee�

in�

air

data

calc

ulat

edfo

rav

erag

eex

posu

reco

nditi

ons.

Uni

ted

Rep

.of

Tanz

ania

:Su

rvey

data

for

500

patie

nts

per

exam

inat

ion

spre

adov

er4

refe

rral

hosp

itals

and

1re

gion

alho

spita

l;th

ese

hosp

itals

are

colle

ctiv

ely

resp

onsi

ble

for

near

ly50

%of

the

annu

alna

tiona

ltot

alof

patie

nts

exam

ined

with

x �ra

ys.

Thai

land

:Pa

irs

ofva

lues

repr

esen

tsur

veys

befo

rean

daf

ter

the

intr

oduc

tion

ofa

prog

ram

me

ofqu

ality

cont

rol.

Turk

ey:

Surv

eyda

tafr

omA

nkar

aU

nive

rsity

Hos

pita

land

Gül

hane

Mili

tary

Hos

pita

l.U

nite

dA

rab

Em

irat

es:

Surv

eyda

tafo

r‘H

ead’

exam

inat

ions

from

one

hosp

ital,

data

for

‘Che

st’

from

seve

nho

spita

ls.

Uni

ted

Kin

gdom

:In

ter �

hosp

italv

aria

tion

inbr

acke

ts.D

ata

from

refe

renc

e[B

56]

repr

esen

tmed

ian

valu

esfr

omre

gion

alsu

rvey

.U

nite

dSt

ates

:O

nth

eba

sis

ofen

tran

cesu

rfac

eex

posu

reof

0.12

mG

yfr

omN

EX

Tpr

ogra

mm

efo

r19

94.

Nurhafizah-E6-L2

Typewritten Text

A46


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

ProcedureTechnique 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]

Nurhafizah-E6-L2

Typewritten Text

A47


Table 18Patient dose per procedure a during interventional radiology

ProcedureFluoroscopy time

(min)Localized dose to

skin (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)

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Nurhafizah-E6-L2

Typewritten Text

A48

Table 18 (continued)


ProcedureFluoroscopy time

(min)Localized dose to

skin (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]

Biliary �

7.1 (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)

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38.2�

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[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)

HeadCervical

spineChest Abdomen Liver Kidneys Pelvis

Lumbarspine

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 - - - -

Nurhafizah-E6-L2

Typewritten Text

A49


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

�

�


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

Nurhafizah-E6-L2

Typewritten Text

A50


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 Surveymean

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)

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Nurhafizah-E6-L2

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A51

Table 34 (continued)


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

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A56


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q)(r

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Nurhafizah-E6-L2

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A59


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 InvestigationAdministeredactivity (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]



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

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Nurhafizah-E6-L2

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(con

tinue

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aPr

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ssi

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The

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:B

reas

ttum

ours

rece

ive

anad

ditio

nal1

0 �20

Gy

“boo

st”

with

eith

erel

ectr

ons

orbr

achy

ther

apy.


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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, Cerrahpaşa Hospital, and

Gülhane Military Hospital.United Arab Emirates: Doses for radical treatments only.

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174

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Nurhafizah-E6-L2

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REPORT MEDICAL RADIATION EXPOSURE STUDY IN MALAYSIA

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