Doses from Medical Radiation Sources

Michael G. Stabin, PhD, CHP

Introduction

Radiation exposures from diagnostic medical examinations are generally low and are almost always justified by the benefits of accurate diagnosis of possible disease conditions. There is no direct evidence of radiation ever causing any harm at the exposure levels encountered with diagnostic radiological examinations. Therapeutic uses of radiation naturally involve higher exposures and physicians will consider the risks of the treatment against the potential benefits. In diagnostic uses, we have only theoretical models that suggest the possibility of cancer risks, but these models all extrapolate results from higher exposures to these low levels, and no one is certain about whether or not any real risks are involved. The exposures are usually comparable to those that we receive routinely from natural radiation all around us, and the benefits of the medical exams are of course very significant.

Standardized radiation dose estimates can be given for a number of typical diagnostic medical procedures. It is impossible to give accurate radiation dosimetry for procedures involving radiation therapy; these need to be handled very carefully on a case-by-case basis. Doses are thus suggested below for some typical diagnostic radiology and nuclear medicine studies. It is important to note that these are only typical values. Doses will change, depending on a number of variables, including the specific machine and manufacturer (in the case of radiology), study techniques (in the case of radiology on the settings of the machine used to produce the radiation, in nuclear medicine on the amount of activity administered and the patient's metabolism), and other issues.

Typical Doses from Diagnostic Radiology Exams

As noted above, the tables below give dose estimates for typical diagnostic radiology exams. For comparison, we all receive about 3 mSv of exposure annually to natural background radiation.

Plain Film X Rays

Single Radiographs	Effective Dose, mSv
Skull (PA or AP)1	0.03
Skull (lateral)1	0.01
Chest (PA)1	0.02
Chest (lateral)1	0.04
Chest (PA and lateral)5	0.06
Thoracic spine (AP)1	0.4
Thoracic spine (lateral)1	0.3
Lumbar spine (AP)1	0.7
Lumbar spine (lateral)1	0.3
Abdomen (AP)1	0.7
Abdomen6	0.53
Pelvis (AP)1	0.7
Pelvis or hips6	0.83
Bitewing dental film6	0.004
Limbs and joints6	0.06

The following table shows the dose an individual might receive if undergoing an entire procedure, e.g., a lumbar spine series typically consists of five films.

Doses Received Undergoing an Entire Procedure

Complete Exams	Effective Dose, mSv
Intravenous Pyelogram (kidneys, 6 films)1	2.5
Barium swallow (24 images, 106 sec fluoroscopy)1	1.5
Barium meal (11 images, 121 sec fluoroscopy)1	3.0
Barium follow-up (4 images, 78 sec fluoroscopy)1	3.0
Barium enema (10 images, 137 sec fluoroscopy)1	7.0
CT head1	2.0
CT chest1	8.0
CT abdomen1	10
CT pelvis1	10
CT (head and chest)5	11
PTCA (heart study)6	7.5–57
Coronary angiogram6	4.6–15.8
Mammogram6	0.13
Lumbar spine series6	1.8
Thoracic spine series6	1.4
Cervical spine series6	0.27

The following table shows typical doses from nuclear medicine exams.

Typical Doses from Nuclear Medicine Exams

Nuclear Medical Scan	Activity, MBq	Radiopharmaceutical	Effective Dose, mSv
Brain3	740	99mTc DTPA	3.6
Brain2	1,850	15O water	2.0
Brain3	740	99mTc HMPAO	6.9
Hepatobiliary3	185	99mTc SCO	1.7
Bone3	740	99mTc MDP	4.2
Lung Perfusion/Ventilation3	185 & 370	99mTc MAA & 133Xe	2.3
Kidney3	740	99mTc DTPA	3.6
Kidney3	740	99mTc MAG3	5.2
Tumor3	110	67Ga	11
Heart3	1,100	99mTc sestimibi	9.9
	1,100	99mTc pertechnetate	14
Heart2	74	201Tl chloride	10
	1,100	99mTc tetrofosmin	7.6
Various2	370	18F FDG	7.0

The Pregnant or Breast-Feeding Patient

Special attention is paid to the pregnant, potentially pregnant, or breast-feeding patient. The developing embryo or fetus is particularly sensitive to radiation. If an examination that involves radiation exposure can be postponed or replaced with another study, this is always desirable. If the study is needed, precautions to eliminate or reduce the dose to the embryo/fetus should be followed. Most radiation therapy studies are contraindicated in pregnancy, but at times may be necessary. Any women of childbearing years should be given a pregnancy test before any therapeutic study involving radiation is undertaken. Breast-feeding patients are of concern in nuclear medicine studies (diagnostic or therapeutic), because the compounds given to the mother may be taken up and excreted into the breast milk, and thus possibly ingested by the nursing infant.

Doses from some important nuclear medicine exams for exposures to the fetus occurring in early pregnancy are shown in the following table. An article by J.R. Russell and colleagues⁷ gives doses at other stages of pregnancy and for other radiopharmaceuticals.

Doses from Nuclear Medicine Exams for the Fetus Nuclear Medical Scan Activity, MBq Radiopharmaceutical Early Pregnancy Fetal Dose, mSv Bone 740 99mTc MDP 4.2 Lung Perfusion 185 99mTc MAA 2.0 Thyroid 30 123I NaI 0.6 0.55 131I NaI** 0.04 Tumor 190 67Ga Citrate 18 Lung Ventilation 1,100 133Xe Gas 0.0054 Heart 74 201Tl chloride 10 Kidney 740 99mTc MAG3 5.2 740 99mTc DTPA 3.6 Heart 1,100 99mTc sestimibi 9.9 Liver 350 99mTc disofenin/ mebrofenin 6 Infection 200 99mTc White Blood Cells 0.76 20 111In White Blood Cells 2.6 Liver/Spleen 300 99mTc Sulfur Colloid 0.54 Bone 740 99mTc HDP 3.9 Brain/Thyroid 1,100 99mTc Pertechnetate 14 Heart/blood flow 930 99mTc Red Blood Cells 6.0

** This is for diagnostic use of 131I for thyroid scanning. 131I is widely used for therapy of hyperthyroidism and thyroid cancer. Its use is generally contraindicated in pregnancy, as large doses to the fetus and fetal thyroid may result.

The following table shows estimated fetal radiation dose for 0, 3, 6, and 9 months gestational age based upon "typical" exposure values.

Estimated Fetal Radiation Dose Based on "Typical" Exposure Values

Study	Fetal Dose mSv
	Early Pregnancy	3-Month	6-Month	9-Month
AP Pelvis	1.44	1.31	1.27	1.57
PA Pelvis	0.40	0.16	2.32	1.00
Lateral Pelvis	0.53	0.32	0.48	0.52
AP T-Spine (wide FOV)	0.018	0.011	0.069	0.13
AP T-Spine (narrow)	0.012	0.008	0.046	0.089
Lateral T-Spine	0.006	0.006	0.017	0.032
AP Lumbar Spine	2.25	1.97	3.94	9.26
Lat Lumbar Spine	1.13	0.62	0.84	0.85

In the case of the breast-feeding mother who receives a radiopharmaceutical, an article in 2000 in the Journal of Nuclear Medicine⁸ discussed the issues associated with possible exposures of the nursing infant. The authors noted that individual levels of activity in breast milk vary widely and that the best approach is to make individual measurements of breast milk activity and individual-specific projections of dose and suggested interruption schedules. Nonetheless, they also offered a general set of recommendations for possible interruption of breast-feeding for a number of compounds, for which some experience with breast milk excretion had been reported in the literature. The following table summarizes these recommendations.

Summary of Recommendations for Radiopharmaceuticals Excreted in the Breast Milk8 Administered Pharmaceutical Activity, MBq Counseling?* Advisory 67Ga Citrate 185 Yes Cessation 99mTc DTPA 740 No   99mTc MAA 185 Yes 12 hr 99mTc Pertechnetate 1,110 Yes 48 hr 131I NaI 5,550 Yes Cessation 51Cr EDTA 1.85 No   99mTc IDA agents 300 No   99mTc Glucoheptonate 740 No   99mTc HAM 300 No   99mTc MIBI 1,110 No   99mTc MDP 740 No   99mTc PYP 740 No   99mTc Red Blood Cells in vivo 740 Yes 12 hr 99mTc Red Blood Cells in vitro 740 No   99mTc Sulfur Colloid 444 No   111In White Blood Cells 18.5 No   123I NaI 14.8 Yes Cessation** 123I OIH 74 No   123I mIBG 370 Yes 48 hr 125I OIH 0.37 No   131I OIH 11.1 No   99mTc DTPA Aerosol 37 No   99mTc MAG3 740 No   99mTc White Blood Cells 185 Yes 48 hr 201Tl Chloride 74 Yes 96 hr
*		"No" means that no interruption of breast-feeding need be suggested, given the criterion of a limit of 1 mSv effective dose to the infant and these amounts of administered activity. "Yes" means that some interruption is required, as noted in the next column.
**		This requirement may be unduly restrictive, but was recommended because of documented cases in which significant levels of radioactive contaminants (124I, 125I and others) were found in commercial products. If no contaminants are present, little or no interruption of feeding may be necessary.

Doses in Radiation Therapy

In radiation therapy, much higher doses are given, with the intent of destroying cancer tissues. The trick is to give enough dose to kill the unhealthy tissues while not giving too much to normal, healthy tissues. This is accomplished in a number of ways. With external radiation, many techniques are used to focus the radiation dose in the area of interest and give lower doses to normal tissues. Small sources may be placed very near to or in direct contact with cancer tissues (brachytherapy) and only left in place for defined periods of time. Therapy is also performed with internal radioactive sources, like are used in diagnostic nuclear medicine. These sources are labeled to special molecules that are designed to be taken up preferentially by cancer cells, and less by other organs and tissues, and thus lead to a positive outcome without compromising the health of the patient. It is not possible to give specific dose calculations for these cases. Each situation is studied carefully by a radiation physicist before the therapy is given, and a specific dose plan is devised. Doses are typically on the order of hundreds or thousands times higher than in the diagnostic studies described above.

References

1. Wall BF, Hart D. Revised radiation doses for typical x-ray examinations. The British Journal of Radiology 70:437–439; 1997. (5,000 patient dose measurements from 375 hospitals)
    
2. International Commission on Radiation Protection. Radiation dose to patients from radiopharmaceuticals - Addendum 3 to ICRP Publication 53. Elsevier; ICRP Publication 106; 2008.
    
3. International Commission on Radiation Protection. Radiation dose to patients from radiopharmaceuticals: Addendum to ICRP 53. New York, NY: Pergamon Press; ICRP Publication 80; 1999.
    
4. International Commission on Radiation Protection. Radiological protection in biomedical research. New York, NY: Pergamon Press; ICRP Publication 62; 1993.
    
5. National Council on Radiation Protection and Measurements. Sources and magnitude of occupational and public exposures from nuclear medicine procedures. Bethesda, MD: National Council on Radiation Protection and Measurements; NCRP Report 124; 1996.
    
6. United Nations Scientific Committee on the Effects of Atomic Radiation. Sources and effects of ionizing radiation, Vol. 1: Sources. New York, NY: United Nations Publishing; 2000.
    
7. Russell JR, Stabin MG, Sparks RB, Watson EE. Radiation absorbed dose to the embryo/fetus from radiopharmaceuticals. Health Phys 73(5):756–769; 1997.
    
8. Stabin M, Breitz H. Breast milk excretion of radiopharmaceuticals: Mechanisms, findings, and radiation dosimetry. Continuing Medical Education Article, Journal of Nuclear Medicine 41(5):863–873; 2000.