Radiation Physics and Chemistry 104 (2014) 2330

Contents lists available at ScienceDirect

Radiation Physics and Chemistry

journal homepage: www.elsevier.com/locate/radphyschem

Radiation protection and dosimetry issues in the medical applications

of ionizing radiation
Pedro Vaz n
Instituto Superior Tcnico, Campus Tecnolgico e Nuclear, Unidade de Proteco e Segurana Radiolgica, Estrada Nacional 10, km 139.7,
2695-066 Bobadela LRS, Portugal

H I G H L I G H T S

The robustness and shortcomings of the system of radiation protection are discussed.
Pediatric exposures to ionizing radiation are identied as a major cause of concern.
Routine sub-mSv (below 1 mSv) CT exams are at reach during this decade.
Signicant progress in the justication of medical exams is mandatory.
The future relies on computational dosimetry, using MC simulations and voxel phantoms.

art ic l e i nf o

a b s t r a c t

Article history:
Received 11 July 2013
Accepted 3 February 2014
Available online 15 February 2014

The technological advances that occurred during the last few decades paved the way to the dissemination of CT-based procedures in radiology, to an increasing number of procedures in interventional
radiology and cardiology as well as to new techniques and hybrid modalities in nuclear medicine and in
radiotherapy. These technological advances encompass the exposure of patients and medical staff to
unprecedentedly high dose values that are a cause for concern due to the potential detrimental effects of
ionizing radiation to the human health. As a consequence, new issues and challenges in radiological
protection and dosimetry in the medical applications of ionizing radiation have emerged.
The scientic knowledge of the radiosensitivity of individuals as a function of age, gender and other
factors has also contributed to raising the awareness of scientists, medical staff, regulators, decision
makers and other stakeholders (including the patients and the public) for the need to correctly and
accurately assess the radiation induced long-term health effects after medical exposure. Pediatric
exposures and their late effects became a cause of great concern.
The scientic communities of experts involved in the study of the biological effects of ionizing
radiation have made a strong case about the need to undertake low dose radiation research and the
International System of Radiological Protection is being challenged to address and incorporate issues
such as the individual sensitivities, the shape of doseresponse relationship and tissue sensitivity for
cancer and non-cancer effects.
Some of the answers to the radiation protection and dosimetry issues and challenges in the medical
applications of ionizing radiation lie in computational studies using Monte Carlo or hybrid methods to
model and simulate particle transport in the organs and tissues of the human body. The development of
sophisticated Monte Carlo computer programs and voxel phantoms paves the way to an accurate
dosimetric assessment of the medical applications of ionizing radiation.
In this paper, the aforementioned topics will be reviewed. The current status and the future trends in
the implementation of the justication and optimization principles, pillars of the International System of
Radiological Protection, in the medical applications of ionizing radiation will be discussed. Prospective
views will be provided on the future of the system of radiological protection and on dosimetry issues in
the medical applications of ionizing radiation.
& 2014 Elsevier Ltd. All rights reserved.

Keywords:
Radiation protection
Dosimetry
Medical exposures
Computer tomography
Justication
Optimization

Tel.: 351 219946291.

E-mail address: pedrovaz@ctn.ist.utl.pt

http://dx.doi.org/10.1016/j.radphyschem.2014.02.007
0969-806X & 2014 Elsevier Ltd. All rights reserved.

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P. Vaz / Radiation Physics and Chemistry 104 (2014) 2330

1. Introduction
During the last 15 years, the radiological protection of the
patient emerged as of paramount importance in view of the
dissemination of the use of computer tomography (CT) in practically all medical specialities and of the increasing utilization of
interventional procedures. Of particular relevance are the pediatric
exposures resulting from the growing prescription of CT procedures to newborns, children and adolescents and the awareness
that such younger individuals feature a much higher radiosensitivity than those of adults and have their life spans over several
decades after exposure, enough time to allow late manifestation of
cancer effects.
General consensus exists about the outstanding progress that
has been achieved during the last decade, on the implementation
of the principle of optimization of protection, one of the three
pillars of the International System of Radiological Protection. The
IAEA International Action Plan (IAEA, 2002) approved shortly after
the Malaga Conference (IAEA, 2001) has been instrumental in
promoting the radiological protection of the patient and the need
for dose reduction in the medical exposures to ionizing radiation.
Such dose reduction has been achieved with the active involvement of several stakeholders, including the equipment manufacturers, namely the CT manufacturers who have developed
sophisticated systems such as Tube Current Modulation and
Automatic Exposure Control and incorporated them into the
equipment for routine clinical use. Signicant progress and technological advancements at the level of the detectors, electronics
and software were also implemented.
In recent years, an awareness emerged about the risks associated to the exposure of medical staff and their critical organs
such as the lens of the eye, the thyroid and the extremities, in
interventional procedures (radiology, cardiology, orthopedy, gastroenterology, urology, coronary angiography, etc.). This awareness
and the epidemiological evidence, during the last few years, about
the late manifestation of non-cancer effects associated to the
protracted or chronic exposures to ionizing radiation, led the ICRP
to review the dose limits to the lens of the eye in 2011 (ICRP
statement, 2011) and to draw the attention of the radiological
protection community to, amongst others, the cerebrovascular
effects associated to absorbed dose values signicantly smaller
than traditionally assumed.
The radiation safety of patients in radiotherapy treatments was
another topic that gained additional importance in view of the
incidents and accidents that occurred in several countries.
Last but not the least, the need to gain further scientic insight
into the risk versus dose relationship for low dose radiation
exposures and to better understand the risks associated to
protracted exposures, exploring novel approaches in radiobiology
and molecular biology and involving communities of experts such
as toxicologists, epidemiologists, geneticians, etc., in addition to
the communities of experts already involved was emphasized by
means of international collaborative efforts (MELODI, 2013) and
scientic projects.
Despite the aforementioned advances in the promotion and
implementation of the optimization principle, it is felt that major
efforts have to be devoted to the implementation of the principle
of justication, another pillar of the International System of
Radiological Protection. Discussion of this issue will be provided
in a later section, after a short description of the International
System of Radiological Protection in the next section, a review of
the medical exposures' dosimetric data and trends and of radiological protection and safety issues associated to CT and interventional procedures.
Last but not the least, a succinct discussion of the computational
dose assessment in the medical examinations and procedures in

order to characterize the radiation exposures of the medical staff and

the patient, will be presented. Such computational dosimetric
assessment can be achieved by performing Monte Carlo simulations
and biokinetic models calculations, in both cases using reference
(based on reference individuals) or patient-tailored (using patient
imaging data) voxel phantoms.

2. The International System of Radiological Protection

The current system of radiological protection is an outstanding
framework which uses the best available scientic knowledge and
incorporates state-of-the-art scientic methodologies for the
assessment of the risk associated to the exposures of individuals
and the environment to ionizing radiation, trying to avoid undue
exposures. It uses dose as a surrogate of risk and is based on the
linear non-threshold (LNT) hypothesis. It incorporates radiation
weighting factors and gender and age average tissue weighting
factors that lead to the assessment of the effective dose, a
dosimetric quantity that has proven to be very useful for regulatory purposes and for prospective dosimetric studies.
However, as the scientic knowledge and the associated risk
perception evolve, experts naturally discuss and question the
robustness of the system and its adequacy for the protection of
individuals to the biologically detrimental aspects of ionizing
radiation (HLEG, 2009). The adequacy of the LNT hypothesis for
low dose radiation doses is a recurrent and longstanding question
that should be addressed in the future.
In recent years attention has shifted from the traditional topics
(namely cancer effects) to emerging topics such as the individual
sensitivity and individual variability in cancer risk as a function of
age, gender, lifestyle, genetics and other factors, the non-cancer
effects induced by ionizing radiation and the shape of the dose
response curve for cancer. Fig. 1 extracted from reference HLEG
(2009), depicts the issues currently addressed by the International
System of Radiological Protection (boxes on the top part of the
gure) and issues that must be addressed in the future system.
The underlying questions about the International System of
Radiological Protection are associated to the level of under- or
over-protection it provides and the associated consequences. New
major ndings associated to the risks of exposures to low dose and
to protracted radiation exposures should translate into major
developments of the system of radiological protection to address
topics such as the medical exposures to ionizing radiation (namely
in diagnostic) and exposures to radon, amongst several other
topics.

3. Medical exposures: a hard look at the data

The table in Fig. 2, extracted from UNSCEAR (2008) displays the
time evolution through two decades, from 1988 to 2008, of the
number of medical radiological procedures and the effective dose
per capita, worldwide. As is clearly seen, the number of radiological procedures more than doubled whilst the annual effective
dose per inhabitant almost doubled.
Similar but more pronounced trends can be seen in the report
NCRP-160 (NCRP, 2009) for the USA, that pinpoints a signicant
increase of the population exposure to ionizing radiation due to
the medical applications of ionizing radiation, namely CT, nuclear
medicine, and interventional procedures. In the USA the number
of prescribed CT scans grew by approximately 10% per annum from
the 1990s until the middle of the last decade. Data is also available
for several countries (Bfs, 2010) pinpointing the major role played
by the increasing frequency of CT exams in the signicant increase
of the mean effective dose per inhabitant.

P. Vaz / Radiation Physics and Chemistry 104 (2014) 2330

25

Fig. 1. The diagrammatic representation of the International System of Radiological Protection: the four upper boxes list the topics addressed by the current system and the
two lower part boxes (marked with interrogation marks) the issues that must be addressed by a future system.

et al., 2012; Mathews et al., 2013) claim that evidence was found
for a signicantly higher cancer risk and incidence in individuals
who had undergone medical CT examinations in childhood and
adolescence.
4.1. Education and training

Fig. 2. Time evolution of the number of radiological procedures, collective dose

and annual dose per capita, worldwide. Data extracted from UNSCEAR reports.

Education and training of the medical staff is a key issue in

order to reduce the dose without compromising on the image
quality necessary for diagnostic. Additionally, the need to fully
justify the use of CT exams is another issue involving also the
referring practitioner, the radiologist and other stakeholders.

4. Issues associated to computer tomography procedures

4.2. Size Specic Dose Estimates
Traditional usage of CT has been mainly for pelvic, abdominal,
thorax, chest, head and neck, brain and spine examinations,
amongst others. In recent years a dissemination of the use of CT
was observed. CT is nowadays used for uoroscopy-guided procedures (CT-uoroscopy), CT guided biopsies, dental radiology and
maxillo-facial applications (Cone Beam CT), CT coronary angiography, CT (virtual) colonoscopy, breast CT, etc. Some experts are
currently advocating the use of CT for breast cancer screening
based on its costeffectiveness. As is well known, the typical
effective dose of CT exams ranges between a few times and up
to several tens or even few hundreds of times the effective dose
for the same examination using conventional X-rays. In recent
years, hybrid modalities have also emerged, such as PETCT and
SPECTCT.
The typical value of the effective dose associated to a thoracic
or abdominal CT exam ranges 810 mSv, whereas typical values for
a head CT ranges 24 mSv. Data from the BEIR-VII report (BEIR-VII,
2006) has been used to estimate that the lifetime attributable
cancer risk for a pediatric individual exposed to an absorbed dose
of 10 mGy is several times higher than the same risk for an adult
exposed to the same dose. Similar ndings can be found in several
other reports such as in EPA (2011). These data associated to the
growing frequency of pediatric examinations using CT raises the
concern of a potential public health problem and calls for a careful
assessment of the radiosensitivity-related issues associated with
the medical CT exposures. Moreover, two recent studies (Pearce

The establishment of diagnostic reference levels and Size

Specic Dose Estimates (SSDE) incorporating the inuence of the
patient dimensions has been advanced as a way forward (AAPM,
2011). Last but not the least, the use of CT is one of the medical
topics where risk communication is a key issue.
4.3. Dose reduction in CT
Since the advent of MDCT (Multi-Detector CT) in the early
2000s the ICRP has devoted a number of reports (ICRP121, 2013;
ICRP102, 2007; ICRP87, 2000) to the radiological protection issues
associated to Computer Tomography. The awareness on the need
to reduce the doses and to implement dose reporting systems has
grown and manufacturers have implemented technologies such as
Tube Current Modulation and Automatic Exposure Control that
allow an effective dose reduction to the patient. These days, submSv CT seems to be in range and will be available for normal
clinical utilization during this decade (Kalender, 2012).

5. Issues in interventional procedures

Interventional procedures are performed under uoroscopic
guidance and can be life-saving. They can be performed to unblock
an obstructed artery, to block the blood supply to a tumor, and to

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P. Vaz / Radiation Physics and Chemistry 104 (2014) 2330

perform a biopsy, amongst many other objectives. As advantages

featured by interventional procedures one can list the fact that
they avoid open surgery, save lives, reduce morbidity, shorten the
hospital stay and reduce the associated costs. As disadvantages,
the (potential) high dose to the patient skin and the (potential)
high dose to the staff (whole body dose and doses to organs such
as the thyroid, the lens of the eye, the extremities, etc.) can be
identied.
The specialists/medical doctors performing interventional procedures are interventional radiologists, cardiologists, electro-physiologists, vascular surgeons, orthopedic surgeons, urologists, and
gastroenterologists, amongst others.
During the last two decades different international organizations and national agencies issued a number of reports (ICRP121,
2013; ICRP120, 2013; ICRP117, 2010; ICRP85, 2000; IEC, 2010;
USFDA, 1994; WHO, 2000), aiming at promoting the awareness
and at helping in the implementation of dose reduction techniques
for the medical staff and for the patients during interventional
procedures.
Fig. 3, extracted from ICRP120 (2013), displays the time variation between 1992 and 2001 of some types of interventional
procedures.
Besides the high-dose that can result to the medical staff and to
the patient, one of the causes of concern derives from the fact that
some of these procedures are performed outside the radiology
departments of healthcare establishments, by staff not fully aware
and not properly educated or trained about the effects of ionizing
radiation and the need to optimize the protection and reduce the
doses. Dose reduction and optimization of the protection can be
achieved by factors such as the positioning of individuals inside
the room, the utilization of shielding (ceiling mounted curtains,
table curtains, table lateral shields), and the use of individual
protections such as thyroid collars and goggles with lead glass
(besides lead aprons). Eye lens and extremities dosimetry as well
as double dosimetry (dosimeters placed both under and above the
apron) is recommended in order to monitor the exposure of the
critical organs as well as the whole body doses to the staff.
Strikingly, not all concerned medical staff are aware, trained or

sensible to the importance of these factors in their protection

against the deleterious effects of ionizing radiation.
Several educational and training materials have been made
available by the IAEA (IAEA-RPOP, 2013) and a specic report on
E&T issues was also issued by the ICRP (ICRP113, 2009).
Moreover, studies were conducted (Ciraj-Bjelac et al., 2010)
addressing the risk of radiation induced cataracts amongst the
medical staff involved in interventional cardiology procedures. The
ICRP (ICRP statement, 2011) has undertaken extensive analysis of
the available epidemiological data and concludes that there are
some tissue reaction effects, particularly those with very late
manifestation, where threshold doses are or might be lower than
previously considered. For the lens of the eye, the threshold in
absorbed dose is now considered to be 0.5 Gy. This led to a drastic
reduction of the ICRP recommendation (ICRP103, 2007) of the
annual equivalent dose limit to the lens of the eye from 150 mSv
value to a 5 years average value of 20 mSv/year.
In the international arena, the ISEMIR project (ISEMIR, 2009),
conducted under the umbrella of the IAEA and the ORAMED
project (ORAMED, 2008), funded by the European Union have
studied different aspects associated to the radiological protection,
dosimetry and education and training issues of medical staff in
interventional procedures, providing recommendations.

6. Justication of medical procedures and exposures

Justication and appropriateness of medical exposures will
help reduce the imaging costs and the dose received by the
patient. However, studies undertaken in some countries
(Oikarinen et al., 2009;Lehnert and Bree, 2010;Hadley et al.,
2006) estimate that a signicant percentage (in excess of several
tens of percent for some CT exams) of the prescribed medical
exams using ionizing radiation are not justied.
It is nowadays felt that a major effort has to be devoted during
the coming years in order to obtain signicant advances in the
justication of the medical procedures. Such effort must involve
the international community of experts and all the stakeholders.

Fig. 3. Time variation, between 1992 and 2001 of the number of coronary angiography (left), PTCA (center) and coronary stenting (right) procedures in Europe.

P. Vaz / Radiation Physics and Chemistry 104 (2014) 2330

6.1. Three levels of justication of medical exposures to ionizing

radiation
The ICRP has indicated in its publication 105 (ICRP105, 2007)
the need to dene three levels of justication for a radiological
practice in medicine: one level associated to a generic justication
of the use of ionizing radiation, based on the benets clearly
overweighing the risks, another dealing with the justication of
specic procedures vis--vis the specied objective and a third
one considering the application of the procedure to the specic
individual. These levels of justication were implemented in the
recent version of the Basic Safety Standards of the IAEA.
6.2. AAA paradigm
A paradigm has been developed under the umbrella of the
IAEA, titled the 3 As (AAA), standing for Awarenees, Appropriateness, Audit (Malone et al., 2012). This approach incorporates
the fact that in some cases, a poor level of awareness of dose and
risk exists among some key groups involved, the need to develop
some robust and evidence-based referral guidelines or criteria of
acceptability and the widely accepted belief that clinical audits are
a key tool to ensure effective, transparent and accountable radiological practice, duly justied.
6.3. Referral guidelines, appropriateness criteria and guidelines for
clinical audit
A key role in the justication of the medical imaging procedures has to be played by the referring doctors and the radiologists, who prescribe the medical exam and administer the
radiation to the patient. In order to attain the objective and help
the referring practitioners, referral guidelines and appropriateness
criteria have been developed and adopted over time, such as the
European Union Referral Guidelines for imaging (RP118, 2000),
(RP118-update, 2008) the Referral Guidelines from the UK Royal
College of Radiologists (iREFER, 2012), and the appropriateness
criteria of the American College of Radiology (ACR, 2012). In other
countries similar initiatives have been adopted. The European
Union has published (RP159, 2009) guidelines for clinical audit.

7. Optimization of protection in the medical exposures

7.1. Diagnostic reference levels
ICRP Publication 60 (ICRP60, 1990) has some recommendations
on Diagnostic Reference Levels (DRLs) that were later expanded in
ICRP Publication 73 (ICRP73, 1996). DRLs are meant to be investigation levels, applying to an easily measured quantity, usually
the absorbed dose in air, or in a tissue equivalent material at the
surface of a simple standard phantom or representative patient.
ICRP-DRL (2001) has additional advice on the application of DRLs
in diagnostic and interventional radiology, and in 2007, ICRP
included a summary of these recommendations in ICRP105 (2007).
Despite signicant progress achieved in recent years in the
implementation of the principle of optimization, additional
advances can be obtained by further promoting the usage of
diagnostic reference levels (DRLs). The establishment of DRLs

paves the way to dosimetric audits

pinpoints, whenever appropriate, the need to promote the

optimization of the exposures, through reduction of the

patient doses
triggers the need to implement corrective actions, whenever
appropriate.

27

DLRs are typically set at the 75th percentile of the dose

distribution obtained from dosimetric surveys conducted amongst
a wide spectrum of healthcare institutions (large and small
facilities, public and private, etc.) using a specied dose measurement protocol and phantom. They are established both regionally
and nationally, and considerable variations have been seen across
both regions and countries (Matthews and Brennan, 2009). The
use of diagnostic reference levels has been shown to reduce the
overall dose and the range of doses observed in clinical practice.
For example, U.K. national dose surveys demonstrated a 30%
decrease in typical radiographic doses from 1984 to 1995 and an
average drop of about 50% between 1985 and 2000 (Hart and Wall,
2004;Shrimpton et al., 1999). Investigations triggered when a
reference dose is exceeded can often determine dose reduction
strategies for the specic diagnostic exam. Data points above the
75th percentile are, over time, moved below the 75th percentile,
with the net effect of a narrower dose distribution and a lower
mean dose.
7.2. Dose reduction to the patient and to the medical staff in
interventional procedures
In interventional procedures, the observed distribution of
patient doses is very wide, even for a specied protocol, because
the duration and complexity of the uoroscopic exposure for each
conduct of a procedure are strongly dependent on the individual
clinical circumstances. The establishment of DRLs, based on KAP
(Kerma Area Product) measurements, seems therefore appropriate
to promote the management of patient doses.
The denition of trigger levels, dose values above which the
likelihood of tissue reactions increases, has been followed in some
countries. It implies the assessment, through measurements, of
the patient skin dose and the clinical follow-up of the patients
after high dose (exceeding the trigger levels) interventional
procedures have taken place. These are examples of radiological
protection and safety measures that should be widely used in the
future in interventional procedures.
Furthermore, in interventional procedures, there is a need to
further promote eye lens dosimetry, extremity dosimetry, the
usage of thyroid collar and lead glasses and to perform double
dosimetry (use of dosimeters both under and over the apron). The
usage of shielding barriers (ceiling suspended barriers, table
curtains and lateral shields) will also contribute to reducing the
scatter dose to the medical staff. Training of staff in uoroscopy
techniques seems mandatory to reduce the dose received by the
patient, namely the skin dose, as well as the overall scatter dose
that the medical staff is exposed to.
In interventional procedures the need to increase the awareness of the medical staff, which requires further efforts in their
education and training, seems a must. Harmonization of practices,
requirements, regulations and legislation amongst different countries is needed in the aforementioned topics (usage of protections
for radiosensitive organs, double dosimetry, eye lens dosimetry,
usage of shielding barriers, etc.).
7.3. Dose reduction in CT
As for CT, the future is sub-mSv scanning, aiming at achieving
an effective dose to the patient below 1 mSv in CT-based medical
procedures. Dose reduction techniques are already available in the
modern tomographs, such as Tube Current Modulation and Automatic Exposure Control, amongst others. New developments in CT
technology that will allow achieving further reduction of the dose
to the patient are underway in topics related to the optimal
utilization of the X-ray spectrum, more efcient X-ray detectors,
X-ray beam collimation, dose management and image reconstruction.

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P. Vaz / Radiation Physics and Chemistry 104 (2014) 2330

There is a general consensus amongst experts (McCollough et al.,

2012; Kalender, 2012) and manufacturers that sub-mSv scanning has
become a reality for a few applications already and the goal of submSv CT scanning for most CT procedures can be reached within this
decade.

7.4. Image Gently, Image Wisely

The Image Gentlys campaign (ImageGently, 2013), launched in
2008, is an initiative of the Alliance for Radiation Safety in
Pediatric Imaging. The campaign goal is to change practice by
increasing awareness of the opportunities to promote radiation
protection in the imaging of children.
On the other hand, the Image Wiselys (ImageWisely, 2013) is a
joint program of the American College of Radiology, the Radiological Society of North America, the American Association of
Physicists in Medicine and the American Society of Radiologic
Technologists, aiming at promoting radiation safety in adult
medical imaging and to address concerns about the surge of public
exposure to ionizing radiation from medical imaging.
Both initiatives pledge to image wisely by optimizing
radiation dose.

8. Computational dosimetry
The advent of powerful processors and computing architectures and the development of sophisticated Monte Carlo computer
programs has rendered possible the evolution from the MIRD
phantoms in the late 1960s (Fisher and Snyder, 1967) and since the
late 1990s and beginning of the century to the implementation
and utilization of sophisticated voxel phantoms in radiation
dosimetry. Computational dosimetry became an emerging and
unavoidable discipline in the radiological protection and safety
studies in the framework of the medical applications of ionizing
radiation.

8.1. Computation of organ doses using voxel phantoms

The use of Monte Carlo, deterministic and hybrid methods in
support of medical dosimetry calculations has signicantly
increased during the last decade. The assessment of organ doses
in diagnostic and therapy applications, with detailed simulation of
the geometry of collimators, lters and other constituent of the
irradiation setup and an accurate representation of the spatial and
energy distribution of the radiation beams, is a complex task that
can be accomplished using Monte Carlo methods. A widespread
utilization of voxel phantoms, necessary for a more accurate
modeling of the anatomy of organs and tissues and for a detailed
calculation of organ doses was observed in recent years and a
variety of voxel phantoms for different genders, ages and races, for
pediatric subjects, for pregnant women, for animals, etc. is available. An exhaustive list of available computational human phantoms can be found in CCHP (2013). The ICRP has published
(ICRP110, 2009) the adult male (AM) and adult female (AF)
reference computational phantoms. Future dosimetry applications
will mandatorily use more and more sophisticated voxel phantoms. However, the increase of the level of detail (which translates
to the reduction of the voxel size, typically of a few mm3 and the
increase in the total number of voxels for the anatomic representation of the organs and the whole human body) is severely
constrained by the computational times, as well as by hardware
requirements (memory) and by the performance of the tracking
algorithms to perform the particle transport simulation.

8.2. Internal dosimetry and biokinetic models

In nuclear medicine and molecular imaging signicant progress
has been achieved in recent years with the development of
increasingly more sophisticated biokinetic models in order to
assess the organ doses and the time evolution of the incorporated
activity in each organ or compartment, the committed organ
equivalent doses and the committed effective doses. The combination of biokinetics models calculations and Monte Carlo simulations using voxel phantoms is an emerging trend in nuclear
medicine.
8.3. Microdosimetry and nanodosimetry
Further and signicant advances in understanding of the
biological effects of ionizing radiation will require the development of public domain, benchmarked and validated simulation
tools to perform radiation transport at the cellular (microdosimetry) and at the DNA level (nanodosimetry) in the coming years.
These advances are mandatory to respond to the requirements of
novel radiopharmaceuticals and targeted radiotherapies, as well as
to the assessment and modeling of the cellular mechanisms of
response to ionizing radiation and the damage caused by radiation
in the biological media. Signicant progress in low dose research
and associated topical areas (previously alluded to) also requires
these simulation tools.
8.4. Monte Carlo treatment planning in radiotherapy
Fig. 4 depicts a diagram of the time evolution of treatment
planning systems used in radiotherapy. In recent years, practically
all equipment manufacturers have developed Treatment Planning
Systems which incorporate versions of Monte Carlo simulation
programs specially developed to speed up the calculation time.
There was a signicant evolution from the Commercial Treatment
Planning Systems available a few years ago. The foreseeable nearto medium-term future developments and challenges in this area
will consist

in the implementation and utilization in routine clinical use, of

(almost) real time treatment planning systems performing

Monte Carlo simulations; this will require the deployment of
a considerable amount of computing power and sophisticated
computing architectures;
in the development of patient tailored geometries, using
patient-specic anatomy data (obtained from tomographic data
or from other imaging modalities) to build patient specic
voxel phantoms that will be input to the Monte Carlo based
treatment planning systems to perform patient specic dosimetric calculations.;
in attempts to model the organs and uids motion inside the
body, performing 4D Monte Carlo simulations.

9. Conclusions and outlook towards next decade

The future developments and improvements of the International System of Radiological Protection in the medical

Fig. 4. Time evolution of the treatment planning algorithms and systems in

radiotherapy.

P. Vaz / Radiation Physics and Chemistry 104 (2014) 2330

applications of ionizing radiation are tightly bound to the solution

of challenging topics in different areas. Specic topics where
signicant progress must be achieved, some of which could not
be addressed in this paper, are

The justication of medical procedures:

The need to engage the professionals, namely the

medical practitioners.
Further work in appropriateness criteria and referral
guidelines.
The optimization of protection:
The expansion of the use of DRLs.
The need to absorb the continuous technological
developments.
The involvement of industry and equipment manufacturers.
The awareness of the staff in interventional and nuclear
medicine procedures about the importance of occupational eye lens and extremity dosimetry and on the use
of adequate protective barriers.
The full assessment of the risk of pediatric exposures.
The development of strategies and methodologies for radiation
risk communication to patients.
(Further) Development of a radiological safety culture.
Education and training in radiological protection of the medical
staff (medical doctors, medical physicists, radiographers,
nurses, paramedical, etc.) and the remaining stakeholders,
including regulators, the competent authorities, trainers, the
patients, the general public, etc.
The radiation risk assessment in radiotherapy and hybrid
modalities.
Increasing complexity involving increasing probability for
errors.
Accidents in high-dose rate (HDR) brachytherapy.
Full assessment of second cancer induction.
The assessment of tissue reactions, especially during some
complex interventional procedures.
Patient exposure tracking in imaging, with special attention to
paediatrics.

Acknowledgments
The author wishes to thank the outstanding work of an endless
number of experts who have provided through published reports,
journal articles, books and other types of publications, web sites,
etc., signicant contributions in the topics addressed in this paper
and that could not be cited for obvious reasons.
References
AAPM, 2011. Size-Specic Dose Estimates (SSDE) in Pediatric and Adult Body CT
Examinations. American Association of Physicists in Medicine (AAPM Report
No. 204).
ACR, 2012. Appropriateness Criteria of the American College of Radiology (ACR).
American College of Radiology. Available at: http://www.acr.org/Quality-Saf
ety/Appropriateness-Criteria.
BEIR-VII, 2006. Health Risks from Exposure to Low Levels of Ionizing Radiation
BEIR VII Phase II. National Research Council of the National Academies The
National Academies Press, USA.
Bfs, 2010. Umweltradioaktivitt und Strahlenbelastung Jahresbericht 2009.
German Report, Bundesamt fr Strahlenschutz.
CCHP, Consortium of Computational Human Phantoms, 2013. http://www.virtual
phantoms.org/phantoms.htm.
Ciraj-Bjelac, O., et al., 2010. Risk for radiation-induced cataract for staff in
interventional cardiology: is there reason for concern? Catheter Cardiovasc.
Interv. 76 (826834).
EPA, 2011. EPA Radiogenic Cancer Risk Models and Projections for the U.S.
Population Report EPA 402-R-11-001. U.S. Environmental Protection Agency.

29

Fisher, H.L.J., Snyder, W.S., 1967. Distribution of Dose Delivered in the Body Size
from a Source of Gamma Rays Distributed Uniformly in an Organ. ORNL-4168.
Oak Ridge National Laboratory, Oak Ridge, USA, TN p. 245.
Hadley, J.L., Agola, J., Wong, P., 2006. Potential impact of the American College of
Radiology appropriateness criteria on CT for trauma. Am. J. Roentgenol. 186,
937942.
Hart, D., Wall, B.F., 2004. U.K. Population Dose From Medical X-ray Examinations.
HLEG, 2009. Report of High Level and Expert Group on European Low Dose Risk
Research. High Level and Expert Group on European Low Dose Risk Research.
IAEA, 2630 March 2001. Radiological protection of patients in diagnostic and
interventional radiology, nuclear medicine and radiotherapy. In: Proceedings of
an International Conference held in Mlaga, Spain. International Atomic Energy
Agency.
IAEA, 2002. International Action Plan for the Radiological Protection of Patients.
International Atomic Energy Agency Proceedings of Conference.
IAEA-RPOP, 2013. Training Material on Interventional Procedures. International
Atomic Energy Agency. Available at: https://rpop.iaea.org/RPOP/RPoP/Content/
AdditionalResources/Training/1_TrainingMaterial/index.htm.
ICRP102, 2007. Managing Patient Dose in Multi-Detector Computed Tomography
(MDCT) ICRP Publication 102. International Commission on Radiological Protection, Elsevier.
ICRP103, 2007. The 2007 Recommendations of the International Commission on
Radiological Protection, ICRP Publication 103. International Commission on
Radiological Protection, Elsevier.
ICRP105, 2007. Radiological Protection in Medicine, ICRP Publication 105. International Commission on Radiological Protection, Elsevier.
ICRP110, 2009. Adult Reference Computational Phantoms ICRP Publication 110.
International Commission on Radiological Protection, Elsevier.
ICRP113, 2009. Education and Training in Radiological Protection for Diagnostic and
Interventional Procedures, ICRP Publication 113. International Commission on
Radiological Protection, Elsevier.
ICRP117, 2010. Radiological Protection in Fluoroscopically Guided Procedures outside the Imaging Department, ICRP Publication 117. International Commission
on Radiological Protection, Elsevier.
ICRP120, 2013. Radiological Protection in Cardiology, ICRP Publication 120. International Commission on Radiological Protection, Elsevier.
ICRP121, 2013. Radiological Protection in Paediatric Diagnostic and Interventional
Radiology, ICRP Publication 121. International Commission on Radiological
Protection, Elsevier.
ICRP60, 1990. 1990 Recommendations of the International Commission on Radiological Protection, ICRP Publication 60. International Commission on Radiological Protection, Pergamon Press.
ICRP73, 1996. Radiological Protection and Safety in Medicine, ICRP Publication 73.
International Commission on Radiological Protection, Pergamon Press.
ICRP85, 2000. Avoidance of Radiation Injuries from Medical Interventional Procedures, ICRP Report 85. International Commission on Radiological Protection,
Pergamon Press.
ICRP87, 2000. Managing Patient Dose in Computed Tomography, ICRP Publication
87. International Commission on Radiological Protection, Pergamon Press.
ICRP-DRL, 2001. Diagnostic Reference Levels in medical Imaging: Review and
Additional Advice, ICRP Supporting Guidance 2. International Commission on
Radiological Protection, Pergamon Press.
ICRP Statement on Tissue Reactions, 2011. International Commission on Radiological Protection. A PDF document in the Web site of ICRP.
International Electrotechnical Commission, 2010. IEC, Medical Electrical Equipment
Part 243: Particular Requirements for Basic Safety and Essential Performance
of X-ray Equipment for Interventional Procedures, International Standard
60601243.
ImageGently, 2013. The Image Gently campaign. Alliance for Radiation Safety in
Pediatric Imaging. http://www.pedrad.org/associations/5364/ig/.
ImageWisely, 2013. Image Wisely. Radiation Safety in Adult Medical Imaging.
American College of Radiology. http://www.imagewisely.org/.
iREFER, 2012. Referral Guidelines from the Royal College of Radiologists, 7th
edition. Royal College of Radiologists, UK. Available at: http://www.rcr.ac.uk/
content.aspx?PageID=995).
ISEMIR, The Information System on Occupational Exposure in Medicine, Industry
and Research, 2009. International Atomic Energy Agency. Refer to http://
www-ns.iaea.org/tech-areas/communication-networks/norp/isemir-web.htm.
Kalender, W.A., 2012. New developments in CT technology. Presentation during the
Conference on Radiation Protection in Medicine. s.l., International Atomic
Energy Agency Proceedings of Conference.
Lehnert, B., Bree, R., 2010. Analysis of appropriateness of outpatient CT and MRI
referred from primary care clinics at an academic medical center: how critical is
the need for improved decision support? J. Am. Coll. Radiol. 7, 192197.
Malone, J., et al., 2012. Justication of diagnostic medical exposures: some practical
issues. British J. Radiol. 85 (2012), 523538.
Mathews, J.D., et al., 2013. Cancer risk in 680,000 people exposed to computed
tomography scans in childhood or adolescence: data linkage study of 11 million
Australians. Br. Med. J. 346, f2360, http://dx.doi.org/10.1136/bmj.f2360 (2013).
Matthews, K., Brennan, P.C., 2009. The Application of Diagnostic Reference Levels:
General Principles and an Irish Perspective.
McCollough, C.H. et al., 2012. Achieving Routine Submillisievert CT Scanning:
Report from the Summit on Management of Radiation Dose in CT.
MELODI, 2013. Strategic Research Agenda (SRA) of the MELODI (Multi-Disciplinar
European Low Dose Initiative) European Platform. The MELODI Association.
http://www.melodi-online.eu/doc/SRA4.pdf.

30

P. Vaz / Radiation Physics and Chemistry 104 (2014) 2330

NCRP, 2009. Ionizing Radiation Exposure of the Population of the United States.
Oikarinen, H., et al., 2009. Unjustied CT examinations in young patients. Eur.
Radiol. 19, 11611165.
ORAMED, 2008. The ORAMED (Optimization of Radiation protection for Medical
staff) Project. European Union. http://www.oramed-fp7.eu/.
Pearce, M.S., et al., 2012. Radiation exposure from CT scans in childhood and
subsequent risk of leukaemia and brain tumours: a retrospective cohort study.
Lancet 380 (9840), 499505 (4 August 2012).
RP118, 2000. Referral Guidelines for Imaging, Radiation Protection 118 Report.
European Commission.
RP118-update, 2008. Referral Guildelines for Imaging - Radiation Protecion 118
Report (update Mars 2008). European Commission.
RP159, 2009. European Commission Guidelines on Clinical Audit for Medical
Radiological Practices (Diagnostic Radiologiy, Nuclear Medicine and Radiotherapy). Radiation Protection 159 Report, European Commission.

Shrimpton, P., et al., 1999. Diagnostic medical exposures in the U.K. Appl. Radiat.
Isot. 50 (1), 261269.
UNSCEAR, 2008. Sources and Effects of Ionizing Radiation. UNSCEAR 2008 Report to
the General Assembly with Annexes. United Nations Scientic Committee on
the Effects of Atomic Radiation.
USFDA, 1994. Avoidance of Serious X-Ray-Induced Skin Injuries to Patients During
Fluoroscopically-Guided Procedures. U.S. Food and Drug Administration.
WHO, 2000. Efcacy and Radiation Safety in Interventional Radiology, WHO Report.
World Health Organization.