ICRU74 2005 PatientDosimetry

doi:10.
1093/jicru/ndi016
PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING

Report Committee
J. Zoetelief (chairman), Faculty of Applied Sciences, Delft University of Technology,
Delft, Netherlands
D. R. Dance, The Royal Marsden NHS Foundation Trust, London, United Kingdom
G. Drexler, GSF-National Research Center for Environment and Health, Neuherberg, Germany and
State University of Rio de Janeiro, Rio de Janeiro, Brazil
H. Jarvinen, Radiation and Nuclear Safety Authority (STUK), Helsinki, Finland
M. Rosenstein, Clarksburg, Maryland, USA
Commission Sponsors
H. G. Paretzke, GSF-National Research Center for Environment and Health, Neuherberg, Germany
K. Doi, The University of Chicago, Chicago, Illinois, USA
A. Wambersie, Universite Catholique de Louvain, Brussels, Belgium
Consultants to the Report Committee
P. Allisy-Roberts, Bureau International des Poids et Mesures, Sevres, France
H. Bosmans, University Hospital Gasthuisberg, Leuven, Belgium
C. J. Moretti, National Physical Laboratory, Teddington, UK
J. Van Dam, University Hospital Gasthuisberg, Leuven, Belgium
E. Va~
n
o, Complutense University, Madrid, Spain
B. F. Wall, Radiation Protection Division, Health Protection Agency, Chilton, UK
The Commission wishes to express its appreciation to the individuals involved in the preparation of this report,
for the time and efforts which they devoted to this task and to express its appreciation to the organizations with
which they are affiliated.
All rights reserved. No part of this book may be reproduced, stored in retrieval systems or transmitted in any
form by any means, electronic, electrostatic, magnetic, mechanical photocopying, recording or otherwise,
without the permission in writing from the publishers.
British Library Cataloguing in Publication Data. A Catalogue record of this book is available at the British
Library.
ISBN 0199203208
Journal of the ICRU Vol 5 No 2 (2005) Report 74

Oxford University Press
doi:10.1093/jicru/ndi017
THE INTERNATIONAL COMMISSION ON RADIATION UNITS

AND MEASUREMENTS
INTRODUCTION
The International Commission on Radiation Units
and Measurements (ICRU), since its inception in
1925, has had as its principal objective the development of internationally acceptable recommendations regarding:
(1) quantities and units of radiation and radioactivity,
(2) procedures suitable for the measurement and
application of these quantities in clinical radiology and radiobiology, and
(3) physical data needed in the application of these
procedures, the use of which tends to assure
uniformity in reporting.
The Commission also considers and makes similar
types of recommendations for the radiation protection field. In this connection, its work is carried out
in close cooperation with the International Commission on Radiological Protection (ICRP).
POLICY
The ICRU endeavors to collect and evaluate the
latest data and information pertinent to the problems of radiation measurement and dosimetry and
to recommend the most acceptable values and techniques for current use.
The Commissions recommendations are kept
under continual review in order to keep abreast of
the rapidly expanding uses of radiation.
The ICRU feels that it is the responsibility of
national organizations to introduce their own
detailed technical procedures for the development
and maintenance of standards. However, it urges
that all countries adhere as closely as possible to
the internationally recommended basic concepts of
radiation quantities and units.
The Commission feels that its responsibility lies in
developing a system of quantities and units having
the widest possible range of applicability. Situations
may arise from time to time when an expedient
solution of a current problem may seem advisable. Generally speaking, however, the Commission
feels that action based on expediency is inadvisable

from a long-term viewpoint; it endeavors to base
its decisions on the long-range advantages to be
expected.
The ICRU invites and welcomes constructive comments and suggestions regarding its recommendations and reports. These may be transmitted to the
Chairman.
CURRENT PROGRAM
The Commission recognizes its obligation to provide guidance and recommendations in the areas of
radiation therapy, radiation protection, and the compilation of data important to these fields, and to
scientific research and industrial applications of
radiation. Increasingly, the Commission is focusing
on the problems of protection of the patient and
evaluation of image quality in diagnostic radiology.
These activities do not diminish the ICRUs commitment to the provision of a rigorously defined set of
quantities and units useful in a very broad range of
scientific endeavors.
The Commission is currently engaged in the
formulation of ICRU reports treating the following
subjects:
Approaches to the Dosimetry of Low-Dose Exposures to
Ionizing Radiation
Assessment of Image Quality in Nuclear Medicine
Bone Densitometry
Doses for Cosmic Ray Exposure for Aircrew
Dose and Volume Specifications for Reporting Intracavitary Therapy in Gynecology
Dosimetry Systems for Radiation Protection
Elastic Scattering of Electrons and Positrons
Image Quality and Patient Exposure in CT
Mammography------Assessment of Image Quality
Measurement Quality Assurance for Ionizing
Radiation
Prescribing, Recording, and Reporting Conformal Photon
Beam Therapy
Prescribing, Recording, and Reporting Proton Beam
Therapy
Requirements for Radiological Sampling
ROC Analysis
International Commission on Radiation Units and Measurements 2005
PATIENT DOSIMETRY FOR X-RAYS USED IN MEDICAL IMAGING
In addition, the ICRU is evaluating the possibility of expanding its program to encompass nonionizing radiation, particularly the quantities and
units aspects.
The Commission continually reviews radiation
science with the aim of identifying areas where the
development of guidance and recommendations can
make an important contribution.
THE ICRUS RELATIONSHIP WITH OTHER

ORGANIZATIONS
In addition to its close relationship with the ICRP,
the ICRU has developed relationships with other
organizations interested in the problems of radiation
quantities, units, and measurements. Since 1955,
the ICRU has had an official relationship with the
World Health Organization (WHO), whereby the
ICRU is looked to for primary guidance in matters
of radiation units and measurements and, in turn,
the WHO assists in the worldwide dissemination of
the Commissions recommendations. In 1960, the
ICRU entered into consultative status with the
International Atomic Energy Agency (IAEA). The
Commission has a formal relationship with the United Nations Scientific Committee on the Effects of
Atomic Radiation (UNSCEAR), whereby ICRU
observers are invited to attend annual UNSCEAR
meetings. The Commission and the International
Organization for Standardization (ISO) informally
exchange notifications of meetings, and the ICRU
is formally designated for liaison with two of the
ISO technical committees. The ICRU also corresponds and exchanges final reports with the following
organizations:
Bureau International de Metrologie Legale
Bureau International des Poids et Mesures
European Commission
Council for International Organizations of Medical
Sciences
Food and Agriculture Organization of the United Nations
International Committee of Photobiology
International Council of Scientific Unions
International Electrotechnical Commission
International Labor Office
International Organization for Medical Physics
International Radiation Protection Association
International Union of Pure and Applied Physics
United Nations Educational, Scientific and Cultural
Organization
The Commission has found its relationship with

all of these organizations fruitful and of substantial
benefit to the ICRU program. Relations with these

other international bodies do not affect the basic
affiliation of the ICRU with the International
Society of Radiology.
OPERATING FUNDS
In recent years, principal financial support has
been provided by the European Commission, the
National Cancer Institute of the U.S. Department
of Health and Human Services and the International
Atomic Energy Agency. In addition, during the last
10 years, financial support has been received from
the following organizations:
Belgian Nuclear Research Centre
Canadian Nuclear Safety Commission
Eastman Kodak Company
Electricite de France
Fuji Medical Systems
Hitachi, Ltd.
International Radiation Protection Association
International Society of Radiology
Ion Beam Applications
Italian Radiological Association
Japan Industries Association of Radiological Systems
Japanese Society of Radiological Technology
MDS Nordion
National Institute of Standards and Technology
Nederlandse Vereniging voor Radiologie
Philips Medical Systems, Incorporated
Radiation Research Society
Siemens
Varian
In addition to the direct monetary support provided by these organizations, many organizations
provide indirect support for the Commissions program. This support is provided in many forms,
including, among others, subsidies for (1) the time
of individuals participating in ICRU activities,
(2) travel costs involved in ICRU meetings, and (3)
meeting facilities and services.
In recognition of the fact that its work is made
possible by the generous support provided by all of
the organizations supporting its program, the Commission expresses its deep appreciation.
Andre Wambersie
Chairman, ICRU
Brussels, Belgium

PATIENT DOSIMETRY FOR X RAYS USED IN

MEDICAL IMAGING
CONTENTS
PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.1
1.2
1.3
1.4
1.5
1.6
1.7
Evolution of radiation dosimetry in medical x-ray imaging . . . . . . . . . .

Risks for the patient in radiological imaging and relevant
dosimetric quantities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.2.1 Acute deterministic effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.2.2 Late effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.2.2.1 Cancer induction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.2.2.2 Late effects in normal tissues . . . . . . . . . . . . . . . . . . . . . . .
1.2.2.3 Impairment of mental development . . . . . . . . . . . . . . . . . . .
1.2.2.4 Genetic risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.2.3 Relevant dosimetric quantities and dosimetric procedures . . . . . . . . . . .
1.2.4 Required accuracy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dosimetry in radiology: relevant quantities . . . . . . . . . . . . . . . . . . . . .
1.3.1 Calibration at the Standards Laboratory . . . . . . . . . . . . . . . . . . . . .
1.3.2 From air kerma free-in-air to absorbed dose in water in patient or phantom
1.3.3 Air kerma-area product (KAP) and dose----area product (DAP) . . . . . . . . .
1.3.4 Reporting patient irradiation in radiological imaging . . . . . . . . . . . . .
1.3.4.1 Radiological parameters of the exposure . . . . . . . . . . . . . . . .
1.3.4.2 Air kerma----area product (KAP) or dose----area product (DAP) . . . .
1.3.4.3 Monte Carlo computation . . . . . . . . . . . . . . . . . . . . . . . . .
1.3.4.4 Phantoms and in vivo measurements. . . . . . . . . . . . . . . . . . .
1.3.5 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Need for harmonization of quantities and terminology . . . . . . . . . . . . .
The two purposes of patient dosimetry . . . . . . . . . . . . . . . . . . . . . . . .
1.5.1 To set and check standards of good practice . . . . . . . . . . . . . . . . . . .
1.5.2 To assist in assessing detriment or harm . . . . . . . . . . . . . . . . . . . . .
Relationship between patient dose and image quality . . . . . . . . . . . . . .
Scope of the report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 9
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SPECIFICATION OF X-RAY BEAMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

2.1
2.2
2.3
2.4
2.5
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21
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24
QUANTITIES AND UNITS FOR MEASUREMENT AND CALCULATION IN MEDICAL

X-RAY IMAGING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.1
3.2
3.3
3.4
3.5
Photon spectrum .
Half-value layer . .
X-ray tube voltage
Total filtration . .
X-ray tube output .
Basic dosimetric quantities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Application-specific quantities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.1 Incident air kerma and incident air kerma rate . . . . . . . . . . . . . . . . . .
3.2.2 Entrance-surface air kerma and entrance-surface air kerma rate . . . . . . . .
3.2.3 Air kerma----area product and air kerma----area product rate . . . . . . . . . . .
3.2.4 Air kerma----length product . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.5 CT air-kerma index free-in-air . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.6 CT air-kerma index in the standard CT dosimetry phantoms . . . . . . . . . .
3.2.7 Weighted CT air-kerma index and normalized weighted CT air-kerma index
3.2.8 CT air kerma-length product . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Risk-related quantities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3.1 Absorbed dose in relation to deterministic effects . . . . . . . . . . . . . . . . .
3.3.2 Absorbed dose for assessment of stochastic effects (organ dose) . . . . . . . . .
3.3.3 Equivalent dose and effective dose . . . . . . . . . . . . . . . . . . . . . . . . . .
Dose-conversion coefficients for assessment of organ and tissue doses . . . .
Quantities recommended for establishment and use of diagnostic
reference levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.5.1 Incident air kerma and entrance-surface air kerma . . . . . . . . . . . . . . . .
3.5.1.1 Mean mammary glandular dose . . . . . . . . . . . . . . . . . . . . . .
3.5.2 Incident air kerma rate and entrance-surface air kerma rate . . . . . . . . . .
3.5.3 Air kerma----area product . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.5.4 CT Air kerma----length product, PDL,CT . . . . . . . . . . . . . . . . . . . . . . . .
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MEASUREMENT METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.1
4.2
4.3
Quality assurance of dosimeters . . . . . . . . . . . . . . . . . . . . . . . . .

4.1.1 Calibration of dosimeters in terms of air kerma free-in-air . . . . . . . .
4.1.2 Calibration of air kerma----area product meters . . . . . . . . . . . . . . .
4.1.3 Calibration of thermoluminescent dosimeters . . . . . . . . . . . . . . .
Measurement methods for specific dosimetric quantities . . . . . . . . .
4.2.1 Dosimeters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2.1.1 Ionization chamber dosimeters . . . . . . . . . . . . . . . . . . .
4.2.1.2 Thermoluminescent dosimeters . . . . . . . . . . . . . . . . . .
4.2.1.3 Scintillation dosimeters . . . . . . . . . . . . . . . . . . . . . . .
4.2.1.4 Film dosimeters . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2.2 Incident air kerma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2.3 Entrance-surface air kerma . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2.4 Air kerma----area product . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2.5 CT air-kerma index and CT air-kerma index in the standard CT head
and body dosimetry phantoms . . . . . . . . . . . . . . . . . . . . . . . .
4.2.5.1 Pencil ionization chamber dosimeter . . . . . . . . . . . . . . .
4.2.5.2 Thermoluminescent dosimeters . . . . . . . . . . . . . . . . . .
Features of measurements on patients and measurements with
physical phantoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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CONTENTS
4.4
Skin dose determination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4.4.1 Direct measurement of the maximum skin dose . . . . . . . . . . . . . . . .
4.4.1.1 Skin dose measurements on patients with thermoluminescent
dosimeters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.4.1.2 Skin dose measurements on patients with scinillation dosimeters
4.4.1.3 Skin dose measurements on patients with film dosimeters . . . .
4.4.2 Derivation of the skin dose from the air kerma----area product PKA . . . . .
4.4.3 Derivation of the skin dose directly from the radiological parameters
of the exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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5 METHODS FOR DETERMINING ORGAN AND TISSUE DOSES . . . . . . . . . . . . . . . . . . . . . . . 55

5.1
5.2
Dose measurements in physical phantoms . . . . . . . . . . . . . . . . . . .

Monte Carlo radiation transport calculations . . . . . . . . . . . . . . . .
5.2.1 Main features of the Monte Carlo technique . . . . . . . . . . . . . . . .
5.2.2 Main features of the computational models of the human body . . . . .
5.2.2.1 Mathematical phantoms . . . . . . . . . . . . . . . . . . . . . . .
5.2.2.2 Special features of the active bone marrow . . . . . . . . . . . .
5.2.2.3 Voxel phantoms . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.2.3 Uncertainties in Monte Carlo organ-dose calculations . . . . . . . . . .
5.2.4 Comparison of conversion coefficients calculated at different institutes
5.2.5 Comparison of measured and calculated organ doses . . . . . . . . . . .
5.2.5.1 Adult phantoms: organs in the x-ray field . . . . . . . . . . . .
5.2.5.2 Adult phantoms: organs outside the x-ray field . . . . . . . . .
5.2.5.3 Adult phantoms: active bone marrow . . . . . . . . . . . . . . .
5.2.5.4 Paediatric phantoms: head and neck . . . . . . . . . . . . . . .
5.2.5.5 Paediatric phantoms: whole body . . . . . . . . . . . . . . . . .
5.2.5.6 Adult phantoms: CT. . . . . . . . . . . . . . . . . . . . . . . . . .
5.2.6 Sources of data on dose-conversion coefficients . . . . . . . . . . . . . . .
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.
55
56
56
56
56
57
58
58
59
59
59
60
60
60
60
61
61
6 CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
APPENDIX A
BACKSCATTER FACTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
APPENDIX B
HANDBOOKS PRODUCED BY THE CENTER FOR DEVICES

AND RADIOLOGICAL HEALTH (CDRH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
APPENDIX C
REPORTS PRODUCED BY THE GERMAN NATIONAL RESEARCH

CENTER FOR ENVIRONMENT AND HEALTH (GSF) . . . . . . . . . . . . . . . . . . . . . 79
APPENDIX D
REPORTS PRODUCED BY THE HEALTH PROTECTION AGENCY (HPA) (FORMERLY

NATIONAL RADIOLOGICAL PROTECTION BOARD) (NRPB) . . . . . . . . . . . . . . . . 87
APPENDIX E
REVIEW OF MONTE CARLO CALCULATIONS FOR ASSESSMENT OF MEAN

GLANDULAR DOSE IN MAMMOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
APPENDIX F
PCXMC ------ A PC-BASED MONTE CARLO PROGRAM FOR CALCULATING

PATIENT DOSES IN MEDICAL X-RAY EXAMINATIONS . . . . . . . . . . . . . . . . . . . 99
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

PREFACE
The mission and main objective of the International Commission on Radiation Units and Measurements (ICRU) are to develop a coherent system of
radiological quantities and units that is accepted
worldwide and applied in all fields where ionizing
radiation is used. The ICRU also develops recommendations on how to measure radiation-related
quantities to ensure a reliable exchange of results.
In addition, within the framework of this mission,
there is often a need for the definition of new terms
and concepts that could be adopted universally. The
ultimate goal of the ICRU is to improve harmonization in the concepts and the methods used to describe
and to report radiation applications, and thereby
facilitate the exchange of information between centres using radiation in medicine, science, and industry. The foundation of the ICRU by the First
Congress of Radiology in 1925 was to solve exactly
this harmonization problem.
The present Report is the first report published
by the ICRU that deals with patient dosimetry for
x rays used in diagnostic medical imaging. The
impetus for this report derives from the broad and
systemic application of x rays for diagnostic and
interventional imaging. The increasing number of
patients that benefits from radiology and the
increasing number and types of procedures that are
applied to these patients have resulted in a dramatic
increase of the population dose, which, in developed
countries, often exceeds the natural radiation levels.
The situation in developing countries will sooner or
later exhibit the same trend (UNSCEAR, 2000).
The relation between image quality and patient
dose has always been a matter of concern for the
radiology community. To initiate the production of
objective information, the European Commission
conducted several trials for various types of examination currently performed in diagnostic radiology.
As an example, a first trial, involving 24 radiology
departments
from
10
European
countries
(1987/1988) compared entrance doses for PA chest
radiography. The entrance surface doses ranged
from 0.03 to 12 mGy, i.e., a ratio of about 400 (Maccia
et al., 1989). A second larger study (1991) involved
83 radiology departments from 16 countries. As
an example, in the second study, for PA chest radiographs, the mean entrance doses measured in
the participating departments ranged from 0.1 to
0.5 mGy, i.e., a ratio of 5 between the maximum
and the minimum mean doses (EC, 1996a). This
ratio was worse in the first study. Most interesting
is the fact that there was no correlation between the
quality of the image and the dose to the patient. The
quality of the images was evaluated by the information content of the film as assessed by a team of
experienced radiologists. Several other studies of
this kind were initiated (e.g., for breast, lumbar
spine), and quality criteria were established (CEC,
1990; EC, 1996b; ICRU, 2003).
A particular source of concern is that among the
different examinations some modern CT procedures
that are remarkably powerful in their diagnostic
capabilities deliver significant doses to large regions
of the body. The diagnostic power of the radiological
procedures to solve medical issues is of course the
first priority. Because of the increasing doses
delivered to an increasing number of patients, however, it becomes important and timely to optimize
the technical conditions, i.e., to reduce the patient
exposure for the same quality of diagnostic information. This is simply common sense and is in agreement with the recommendations of the radiation
protection commissions and agencies, and also of
national and international authorities.
An additional issue is the recent development and
rapid growth of interventional radiology, especially
in cardiology. The exposures are high for the patient
(and possibly also for the radiologists), and the number of reported cases of acute tissue reactions1 with
different severity is increasing. The need for accurate dosimetry becomes critical especially for the
skin, which is one of the tissues at highest risk.
For patient dosimetry in radiology, the required
accuracy depends on the clinical situation and the
dose range involved. It is, in general, much lower
than the accuracy required in radiation therapy. In
any case the quantities measured should always be
1
The ICRP has recently proposed (2005) to replace the

term deterministic effects by tissue reactions.
PATIENT DOSIMETRY FOR X RAYS USED IN MEDIUM IMAGING
x rays, emitted from a point source and characterized by half-value layers of 0.310 mm of Al, are
collimated to penetrate the volume of interest. The
use of different irradiation conditions, in terms of
incident radiation quality and beam geometry in
relation to the patients body, has led to the development of specific dosimetric methods and the definition of appropriate quantities quantities different
from those used for occupational and environmental
exposures.
Not surprisingly, the exposure conditions
assumed in deriving the relationships between the
effective dose and the operational quantities for
occupational and environmental exposures are not
appropriate for patient dosimetry in medical
imaging. In the first case one is dealing with whole
body irradiation by broad beams of photons or neutrons while, in the second case, strictly collimated
beams are used resulting in partial-body patient
irradiations.
Whereas some of the dosimetric concepts and techniques used in radiotherapy have been successfully
employed in medical x-ray imaging, additional dosimetric quantities and measurement methods are
required for patient dosimetry for procedures such
as fluoroscopy, CT, and mammography. Conversion
coefficients are often used in practice to relate directly measurable quantities to doses to different
critical organs or at specific reference points. When
deterministic effects are considered a possibility,
doses to the more heavily irradiated sites of the
body need to be critically evaluated.
The present Report provides a detailed framework
of recommendations for assessing patient dose in
radiological imaging. Moreover, this framework is
suitable for the accurate, harmonized exchange of
information as well as to provide an assessment to
avoid or reduce the severity of tissue reactions. This
report will be soon followed by a second one, exclusively focused upon CT dosimetry and its image quality. The recent development and rapid growth of CT
applications, and the specific issues that are raised,
deserve a special ICRU Report.
clearly identified. The relevant quantities to be

determined are those most closely related to the biological effects or risks of such effects. Presently, the
available data establish correlation between the biological effects and absorbed dose at the point or in
the volume of interest.
For the low doses delivered by most of the current
procedures in diagnostic radiology, cancer induction
(stochastic effect) is considered to be the main risk.
In contrast to diagnostic radiology, at the high doses
delivered, for example, during interventional radiology, acute effects become the major source of concern (deterministic effect). Late effects resulting
from acute effects constitute particularly dangerous
pre-cancerous lesions. This is well established for
the skin and is now being investigated for the rectum
after radiotherapy of prostate and cervix tumors.
Previous ICRU Reports have dealt with patient
dosimetry for external beam therapy with photons
(ICRU Report 42 1987; ICRU Report 50, 1993; ICRU
Report 62, 1999; ICRU Report 64, 2001), with electrons (ICRU Report 71, 2004a), protons (ICRU
Report 59, 1998b), and neutrons (ICRU Report 45,
1989a), for brachytherapy, and for b-ray applications (ICRU 38, 1985a; ICRU Report 58, 1997;
ICRU Report 72, 2004b). ICRU Reports 32 (1979)
and 67 (2002) dealt with patient dosimetry in
diagnostic nuclear medicine procedures.
Some aspects of the dosimetry of x rays generated
at tube voltages ranging from 5 to 150 kV were discussed in ICRU Report 17 (1970) but were not directed specifically at patient dosimetry in diagnostic or
interventional radiology.
In the field of radiation protection, the ICRU has
also provided advice on the determination of dose
equivalents from sources of radiation external to
the body (ICRU Report 39, 1985b; ICRU Report 43,
1988; ICRU Report 47, 1992a; ICRU Report 57,
1998a). The advice involved the use of operational
quantities suitable for practical measurements for
the evaluation of occupational exposures. In particular, these operational quantities introduced by the
ICRU facilitate an adequate and conservative estimate of effective dose, that is, the protection quantity
defined by the International Commission on Radiological Protection (ICRP) for use in its system of
radiological protection (ICRP Publication 60, 1991a).
Exposure to ionizing radiation due to medical
x-ray imaging entails the well-defined irradiation
of localized parts of the body. Diverging beams of
Andre Wambersie
Paul M. DeLuca
Johannes Zoetelief
September 2005

GLOSSARY
AEC
AP
BM
CC
CT
CTDI
DICOM
DRL
FID
FOV
FSD
GI
GSD
HVL
LAT
LAO
L LAT
LPO
LSJ
ML
MRI
OBL
PA
PMMA
RAO
R LAT
RPO
TLD
TMJ
automatic exposure control

anteroposterior view: x rays enter from the front of a patient
bone marrow
cranio-caudal view: x rays enter on the top of the head of a patient
computed tomography
computed tomography dose index
digital imaging and communications in medicine
diagnostic reference level
focal spot-to-image receptor distance
field of view
focal spot-to-surface distance
gastro-intestinal
genetically significant dose
half-value layer
lateral incidence of radiation
left anterior oblique view: x rays enter right rear side of patient and form an image on the left front
side
left lateral view: x rays enter from the right side of patient and form an image on the left side
left posterior oblique view: x rays enter right front side of patient and form an image on the left rear
side (All oblique views lie in a transverse plane and form a 45 angle with the AP/PA axis.)
lumbosacral joint
medio-lateral
magnetic resonance imaging
oblique
posteroanterior view: x rays enter rear of patient
polymethylmethacrylate plastic
right anterior oblique view: x rays enter left rear side of patient and form an image on the right front
side
right lateral view: x rays enter left side of patient and form an image on the right side
right posterior oblique view: x rays enter left front side of patient and form an image on the right
rear side
thermoluminescent dosimeter
temporomandibular joint

ABSTRACT
This report presents specifications of x-ray beams
and quantities, and units for dose measurement and
calculation in medical x-ray imaging, including
application-specific quantities, and new symbols. It
addresses measurement methods for normalization
quantities and for quantities recommended for the
establishment and use of diagnostic reference levels.
It presents methods for determining organ and tissue doses as well as doses in localized regions of
organs and tissues, including detailed information
on dose-conversion coefficients for x-ray imaging

fields. This is the first ICRU report dealing with
methods for patient dosimetry of x rays used in medical imaging. Whereas some of the dosimetric concepts and techniques used in radiotherapy have been
successfully employed for medical imaging using x
rays, additional dosimetric quantities and measurement methods are required for patient dosimetry
associated with procedures such as radiography, fluoroscopy, CT, and mammography.

EXECUTIVE SUMMARY
In Section 1 it is emphasized that medical
imaging was virtually the first application of
x rays. The health risks of irradiation became
evident only later. Appropriate quantities to measure the amount of irradiation of an object had to be
developed, leading to quantities like exposure, absorbed dose, and kerma. It is furthermore stressed
that there is a need for harmonization of quantities
and terminology for different applications in medical imaging using x rays. The two purposes of
patient dosimetry of x rays used in medical imaging
are to set and check standards of good practice and
to assess the risks of detriment or harm. Image
quality is stressed to be of paramount importance
in medical imaging but is the subject of other ICRU
Reports.
Specifications of x-ray beams used for medical
imaging are presented in Section 2. It is recommended to characterize the radiation quality of x-ray
beams used for medical imaging by a combination
of various parameters, including first and second
half-value layer, HVL1 and HVL2, the ratio of
HVL1 and HVL2, the tube voltage, and the total
filtration. In most cases a combination of three of
these parameters will be sufficient for characterization. The radiation intensity is also an important characteristic of an x-ray tube (including
filtration). For this purpose the x-ray tube output
is defined.
Quantities and units for dose measurement
and calculation in medical x-ray imaging are
dealt with in Section 3. Relevant basic dosimetric
qualities are presented in first instance. Several
application-specific qualities have been found useful for measurements in medical x-ray imaging,
but ambiguity remains in the names of quantities and their use. Therefore, application-specific
quantities and new symbols are defined. Concerning risk-related quantities, mean organ and tissue
doses are defined as well as absorbed dose to the
more heavily irradiated regions of tissues in relation to deterministic effects. Dose-conversion coefficients relate the specified dosimetric quantities to
a normalization quality. Both types of dosimetric
quantity are discussed in Section 4. Quantities are

also recommended for establishment and use of
diagnostic reference levels (DRLs). It should be
noted that the recommendations made here of dosimetric quantities for CT are of a provisional
nature.
Methods for assessing the patient dose of x rays
used in medical imaging are presented in Section 4.
Such methods are required for the determination of
normalization quantities used in dose-conversion
coefficients and of quantities recommended for
establishment and use of DRLs. Measurements of
these quantities rely mainly on the use of ionization
chambers or solid-state dosimeters, including TLDs.
For the low- and medium-energy x rays used in
medical imaging, the air kerma free-in-air is the
desired quality for calibration. Examples are given
of x-ray beam qualities recommended for calibration,
but it is noted that an international code of practice
for patient dosimetry in diagnostic radiology is presently being developed by the International Atomic
Energy Agency, including practical details of
calibrations.
Methods for determining organ and tissue doses
are the subject of Section 5. It is concluded that
assessment of organ and tissue doses, as well as
doses to the most heavily irradiated regions of the
body, mainly relies on Monte Carlo calculations.
Therefore, specific information is provided on the
application of Monte Carlo calculations of radiation
transport as employed for patient dosimetry in medical x-ray imaging. This section includes comparisons of dose-conversion coefficients calculated at
different institutes as well as comparisons of dose
measurements and calculations. It is noted that procedures for medical x-ray imaging vary from country
to country. Consequently, dose-conversion coefficients calculated by various authors commonly
refer to national or regional imaging procedures.
For similar exposure conditions, similar results are
obtained from calculations at different institutes
and from measurements. When a dose-conversion
coefficient is needed for a specific situation, the
best approach is to select a value from the available
data based on similarities in exposure conditions

(projection, view, and radiation quality) and a
patient model.
Appendix A presents information on backscatter
factors for irradiation conditions relevant for dosimetry for medical imaging using x rays. Appendices
B, C, and D provide dose-conversion coefficients that
reflect the differences in medical imaging using x

rays in the USA, Germany, and the UK, respectively. Appendix E treats dose-conversion coefficients
for mammography. Appendix F describes a PCbased Monte Carlo program for calculating patient
doses in radiography (excluding mammography) and
in fluoroscopy.

INTRODUCTION
1.1 EVOLUTION OF RADIATION DOSIMETRY

IN MEDICAL X-RAY IMAGING
The need for accurate measurement of x rays was
immediately evident in the early days of x-ray use in
medicine. This was not only because of the observed
biological effects induced by the exposure to x rays but
was also because of the instability in the generation of
x rays. The first measurement techniques made use of
the blackening of photographic emulsions and colour
changes of chemical compounds. However, no unit of
exposure existed and the development of instrumentation was, therefore, not very straightforward.
In 1905 at the Rontgen Congress in Berlin, a committee was founded to define a unit for the measurement of Roentgen rays. Only after the suggestion by
Villard (1908) to make use of the change in electrical
conductivity of air by irradiation with x rays for their
quantification was a promising direction of experimental attempts created. This resulted in 1925 in
the adoption, by the German Rontgen Society, of the
rontgen, R, as the unit of x-ray exposure. The same
year, at the First International Congress of Radiology in London, a joint meeting of the Physics and
Radiology Sections was devoted to a discussion on
international standards for x-ray work. It resulted in
the appointment of the International X-ray Unit
Committee, with the mission to establish a uniform
x-ray standard of intensity and an x-ray unit. This
Committee became later on the International Commission on Radiation Units and Measurements
(ICRU) (Taylor, 1958). The Second International
Congress of Radiology in Stockholm (1928) recommended the definition of the Rontgen, which is in
essence the unit proposed by the German physicists,
in which the term Rontgen-ray dose was replaced by
the term quantity of radiation. The initial definition
of the unit was rephrased by the ICRU in 1931 and
1937: the essence of the unit was not changed but the
physical quantity of which the rontgen is the unit
had not been clearly defined (Allisy, 1995).
Early measurements with ionization chambers in
diagnostic radiology were difficult for two reasons:
(i) The first problem was the lack of sensitivity and
the strong energy dependence of the instruments.
(ii) The second was the lack of standards and references to assist the interpretation of the results.
For further developments of x-ray dosimetry the
elaboration of an adequate standard dosimeter was
of major importance (Kustner, 1924) and led to the
development of sophisticated and precise instrumentation based on ionization of air. The way to
dose quantification and understanding of biological
and technical aspects of x-ray diagnosis was opened.
Patient and staff dosimetry reflected the impact of
theories on biological effects at the time, resulting in
the use of derived quantities. Skin dosimetry with
the entrance skin exposure, related to cosmetic and
deterministic damage, was used to discuss limits of
patient exposure (Braun et al., 1928). For radiation
dosimetry, in the time period between the late 1920s
and the early 1950s the quantity exposure was
replaced by the quantity of absorbed dose (Taylor,
1990).
In the 1950s interest was focused on the induction
of genetic effects and cancer, mostly leukaemia. Consequently, the anatomical sites included most often
in patient dose studies were the skin, the gonads,
and the active bone marrow (BM). The doses at the
skin could be directly measured with ionization
chamber dosimeters. The doses to the gonads and
the active BM were taken to be representative of
the totality of likely radiation effects. The absorbed
dose to the male gonads was usually taken to be the
same as that measured directly to the closely adjacent skin, whereas mean absorbed doses to the
female gonads or the active BM were related to
skin dose using the results of dose measurements
in physical phantoms. A large number of dosimeters
were required to obtain even approximate estimates
of the mean dose to widely distributed tissues such
as the active BM and many different exposure conditions were needed to simulate the most common
types of x-ray examination. Nationwide surveys
using these dosimetric techniques combined with
studies of the numbers of x-ray examinations took
place in several countries in the period from 1955 up
to the early 1970s. Attention was focused on providing estimates of the genetically significant dose
(GSD) (UNSCEAR, 1972; NAS/NRC, 1980) and the

mean active BM dose to the population.
Developments in solid-state dosimetry led to the
increasing use of small unobtrusive thermoluminescent dosimeters (TLDs) directly attached to the
patient, for the measurement of the entrance surface
dose (ESD), including backscattered radiation, at
the centre of the x-ray beam. Alternatively, exposure
was measured with ionization chambers positioned
free-in-air on the x-ray beam axis. The results were
converted to the exposure at the patient entrance
surface plane using the inverse-square law. The results of measurements of radiation incident on the
skin were variously reported as entrance exposure
in rontgens (free-in-air) or as entrance absorbed dose
in rads (ICRU, 1961). The material in which the
absorbed dose was measured was air, water, or soft
tissue. Measurements were made either free-in-air
or on the surface of a patient or a phantom. There is
approximate numerical agreement (to within 15 %)
between exposures expressed in rontgens and
absorbed dose to air, water, or soft tissue expressed
in rads, for the x-ray spectra used in medical
imaging. However, doses measured with the patient
or phantom present can be up to 60 % higher than
those measured free-in-air at the skin-entrance
plane because of the contribution of backscattered
radiation.
In the 1960s a special type of large-area transmission ionization chamber dosimeter became available
to measure the radiation incident on the patient in
terms of the product of the exposure and the area of
the x-ray beam in units of R cm2 (Arnal and Pychlau,
1961; Morgan, 1961; Cameron, 1971). The chamber
intercepted the entire useful beam, irrespective of
the collimator setting, so that its response was proportional to both the area of the beam and the exposure. This was thought to provide a more nearly
complete measure of the total exposure of the patient
and hence to be more closely related to the radiation
risk, which depends on the extent of the irradiated
volume within the patient as well as the exposure at
the centre of the x-ray beam. Moreover, there is
considerable practical advantage in the flexibility
afforded in the positioning of the chamber owing to
the approximate invariance of the product of exposure and beam area for all planes perpendicular to
the beam axis between the beam defining collimators and the patient. However, this device led to the
introduction of a quantity and unit (exposurearea
product and R cm2), unfamiliar to the practitioners
at that time, to add to those already used to express
the dose to the patient in diagnostic radiology.
It was soon appreciated that measurements of the
exposurearea product (or strictly the integral of the
exposure over the area of the beam), together with
data on the x-ray spectrum, could be readily converted into the total radiant energy in the beam. Hence
it could be used to make estimates of the total energy
imparted to the patient or the integral dose
(Carlsson, 1963) as it was then known. The integral
dose, defined as the mass integral of the absorbed
dose over the total body (expressed in units of g rad,
or erg), was seen to be more closely related to the
likely biological effects than the exposurearea
product. It had the considerable advantage over
organ doses that it could be derived directly from
exposurearea product measurements. As long as
other details of the exposure conditions were available, it allowed a reliable estimate of the energy that
was deposited in the patient. This fraction is critically dependent on the x-ray beam quality, the size
and position of the x-ray beam in the patient, the
thickness of the part being x-rayed, and the proportion of the beam intercepted by the patient. Because
the integral dose was often easier and more practical
to estimate than the doses to individual organs,
many studies in the 1960s and 1970s reported
doses to patients in this way.
In the 1980s the names and definitions of the
quantities and units used in diagnostic radiology,
as in other areas of radiation dosimetry, underwent
major changes following the publication of revised
recommendations by the ICRU (1980), which advocated adoption of the International System of Units.
As a result, exposure was replaced by air kerma (AK)
(unit: joule per kilogram with the special name
gray) as the quantity in which dosimeters were calibrated and linked to the national primary standards. Absorbed doses were also expressed in gray,
thus improving the numerical agreement between
the quantity measured by dosimeters and the
absorbed dose to soft tissue (to within 5 % for medical
x rays and most tissue-equivalent materials).
Exposurearea product (R cm2) was replaced by
kermaarea product (Gy cm2) or (absorbed)
dosearea product (DAP) (also Gy cm2) and integral
doses were expressed as the total energy imparted to
the patient in joules.
The limitations of the concept of the total energy
imparted to the body and its relation to possible
radiation effects became more apparent when computational methods of dosimetry became more
advanced. They allowed the mean absorbed doses
to individual tissues and organs of relevance to radiation protection to be calculated. Using simple geometrical models of the body and of typical medical
x-ray beams, Monte Carlo radiation transport codes
enabled researchers to calculate organ doses normalized to easily measured quantities such as the
entrance skin exposure, the ESD, or the DAP for a
wide range of medical x-ray exposure conditions.
10
INTRODUCTION
Figure 1.1. Acute dermatitis 3 weeks after excessive skin

irradiation (several Gy) during an interventional procedure
(placement of a porto-cave shunt). The lesion is well delineated
(12 cm in diameter) and located at the back of the patient, in the
upper right paralumbar area. One can notice the beginning of
re-epithelialization originating from the border of the lesion
(arrows 1) but also within the irradiated area. Inside the irradiated area, each white spot is a clone resulting from the proliferation of a surviving basal stem cell of the epidermis (only two
clones are shown by arrows 2) [P. Goffette, Imaging
Department, UCL University Clinics St Luc, Brussels, cited in
Wambersie et al. (2005), by permission of Oxford University
Press].
Figure 1.2. Chronic dermatitis on the skin of the same patient as

in Figure 1.1. One year after irradiation, sclerosis of the dermis,
numerous telangiectasiae, total loss of elasticity, fixation to the
deep tissue layers, frequent ulcerations [P. Goffette, Imaging
Department, UCL University Clinics St Luc, Brussels, cited in
Wambersie et al. (2005), by permission of Oxford University
Press].
whom the ICRP derived the risk coefficients. Furthermore, the conditions of a low dose and especially
a low dose rate, assumed by the ICRP, may arguably
not always be met in practice in radiology.
Better information on the relative radiosensitivities

of different organs and tissues became available in
the late 1980s (UNSCEAR, 1988; BEIR, 1990; ICRP,
1991b). This information combined with knowledge
of the mean absorbed doses to these organs and
tissues led to estimates of the total radiation risk
from the partial body exposures typical of medical
imaging.
There is, however, a need for a single dosimetric
quantity related to the total potential health detriment to provide a practical tool for optimization of
protection for the patient. Unless one particular
organ is completely dominant in determining the
totality of likely health effects, it is inconvenient to
assess the risk from a list of organ doses. The dose to
some organs may be increased and to others
decreased by the technique changes under consideration. For practical comparisons of radiation risks
for different techniques or procedures, some investigators have applied the concept of effective dose a
weighted sum of organ doses developed by the ICRP
primarily for use in its system of radiological protection (ICRP, 1991b) to medical exposures. However,
effective dose should not be used, for example by
using the nominal fatality coefficients (ICRP, 1991b),
for assessment of detriment from exposure due to
medical x-ray imaging. Such assessments could be
inappropriate because of potential differences in
health status, gender, and age between a particular
group of patients and the reference population for
1.2 RISKS FOR THE PATIENT IN

RADIOLOGICAL IMAGING AND RELEVANT
DOSIMETRIC QUANTITIES
The objective of dosimetry in radiological imaging
is the quantification of radiation exposure within an
approach to optimize the image quality to absorbed
dose ratio. The image quality should be understood
as the relevant information appropriate to the
clinical situation. Dosimetry also provides the
means to avoid excessive doses that could imply a
significant risk of induction of deterministic effects,
for example, for some cases in interventional radiology. The dosimetric quantities and dosimetric protocols relevant in radiological imaging are those
most closely related to the major (or more frequent)
risks for the patient.
Most of our knowledge on induced radiobiological
effects is based on the relation between absorbed
dose and biological effect. For radiation protection
and therapy applications, the absorbed dose has
sometimes to be weighted by appropriate factors to
predict the effects or risks (Hall, 2000; Wambersie
et al., 2002; Zoetelief et al., 2003a). International
recommendations and national and international
regulations are also based on absorbed dose or
weighted absorbed dose (ICRU Report 60, 1998c;
ICRP Publication 60, 1991b; IAEA, 1996a; EC,
1997).
11
1.2.1
Acute deterministic effects1
weighting factors could probably be selected taking

into account the characteristics of individual patients
undergoing radiology such as gender and age (e.g.,
the variation of susceptibility of the breast for breast
cancer induction).
Cancer induction is generally considered to be a
stochastic effect with the probability (and not the
severity) of effect increasing with dose. For cancer
induction, however, this traditional distinction
between deterministic and stochastic effects is likely
to have limitations. There is indeed evidence that
chronic radiation-induced lesions, such as sclerosis
or chronic dermatitis, are particularly dangerous
pre-cancerous lesions, although they are clearly
deterministic effects (Boice et al., 1985, 1988; Arai
et al., 1991; ICRP Publication 59, 1991a; Wambersie
et al., 1995).
In addition to the lethal cancers taken into
account in the weighting factors discussed above,
the incidence of non-lethal cancers is of importance.
In the early years of application of x rays in radiology, several cases of acute and severe skin reactions were reported. With the improvement of the
equipment, the use of safer working procedures, and
better training, the number and severity of these
accidents decreased rapidly and even became exceptional. In recent years, however, with the rapid
development of interventional radiology, acute skin
reactions became again a major concern for patient
safety (Figures 1.1 and 1.2).
At high dose (>2 Gy), the severity of the lesions
can be predicted from the local absorbed dose in the
skin and underlying dermis. Therefore, the skin
dose in the most heavily irradiated area is usually
the most relevant quantity to be determined in
interventional radiology. This implies that both the
maximum dose as well as the surface irradiated
above the tolerance dose be evaluated (ICRP Publication 59, 1991b). In interventional radiological
procedures, one of the main practical issues is often
the identification of the skin region that receives the
highest dose, as discussed in Section 3.
1.2.2
1.2.2.1
1.2.2.2
Late effects in normal tissues
An increasing number of data indicates that some

late effects in normal tissues, such as the heart,
represent a risk equally important as the risk of
cancer induction, for doses larger than several hundred mSv (Brenner et al., 2003; Preston et al., 2003;
Tubiana et al., 2005).
Late effects
Cancer induction
Cancer induction is generally considered to be the

main risk for patients after radiological imaging.
The quantitative approach of the risk assessment is
a more complex issue than for acute effects, because
we are dealing with (rather low) probabilities at low
doses (UNSCEAR, 2000). The risk of cancer induction in an organ or tissue is assumed to be related to
the average absorbed dose in that organ and
strongly depends on the type of organ or tissue. In
radiation protection, the relative risk of lethal cancer induction is assumed to be the product of the
organ dose and a weighting factor (wT), which
expresses the particular susceptibility of that organ
to cancer induction (Section 3.3; ICRP Publication
60, 1991b).
For the purpose of radiation protection, i.e., for the
management of radiation risk, the total risk of lethal
cancer induction for a person is assumed to be
related to the sum of the weighted organ doses.
This is known as the concept of effective dose, mainly
designed for occupational exposure (ICRP Publication 60, 1991b). The numerical values of the
weighting factors were selected for an average
adult population. In radiology, more appropriate
1.2.2.3
Impairment of mental development
Evidence has been reported that doses such as

those delivered by repeated computed tomography
(CT) examinations performed in sub-optimal conditions in children may significantly impair mental
development (Hall, 2002; Hall et al., 2004; Yamada
et al., 2004).
1.2.2.4
Genetic risk
For some radiological procedures involving the

gonads, the genetic risk has to be considered, especially for younger patients. A careful analysis, based
on a critical review of the available data, however,
concluded that the previous evaluation of the risk
was significantly overestimated. It has now become
possible to estimate risks for all classes of genetic
diseases (which was not the case until 1993) and that
the risks are small compared with the baseline
risks (Sankaranarayanan and Chakraborty, 2000;
UNSCEAR, 2001).
1.2.3 Relevant dosimetric quantities and
dosimetric procedures
On the basis of the discussion of the main
radiation-induced effects and risks, the following
The ICRP has recently proposed (2005) to replace the

term deterministic effects by tissue reactions.
12
INTRODUCTION
reconstruction with a reasonable accuracy to predict
the severity of the possible harm.
relevant dosimetric quantities and dosimetric procedures can be derived.

Absorbed dose, expressed in gray (Gy), is the relevant quantity to be determined and reported in
radiological imaging. In practice, it should be
determined in water (or water equivalent) and simulating or using patient geometry, i.e., taking into
account scattered radiation and shape of patient
contour.
Absorbed dose should be evaluated at the level of:
1.3 DOSIMETRY IN RADIOLOGY: RELEVANT

QUANTITIES
1.3.1 Calibration at the Standards
Laboratory
In diagnostic radiology, dosimetry is based on
calibrated instrument(s), usually ionization chamber(s). These instruments (used as local reference
in the department) are calibrated at National
Standards Laboratories, or at laboratories with
instruments directly traceable to National Standards Laboratories. The calibration coefficients in the
certificates are expressed in terms of air kerma freein-air. The manufacturers also express their calibrations in these terms. Any change in the situation is
unlikely in the foreseeable future.
Skin, because the skin is the most heavily

exposed tissue. Reports on skin dose should
include the site location, maximum dose, and
skin surface irradiated above the tolerance level
that should be specified;
The most heavily irradiated organs, taking into
account the specific susceptibility of the organs for
cancer induction and late effects as discussed
above.
Depending on the radiological procedure that is
performed, dose should be evaluated for the following organs: female breast, heart, thyroid, gonads
(depending on age), brain (especially in children),
and also dose to the embryo. The maximum dose
and the average organ dose should be evaluated.
The susceptibility of the female breast for cancer
induction strongly varies with age. The average
dose to the glandular tissue is probably more significant than the average dose to the organ as a whole.
The use of CT raises specific problems that will be
discussed in Section 3.2.
1.2.4
1.3.2 From air kerma free-in-air to

absorbed dose in water in patient or
phantom
Conversion coefficients are used to obtain
absorbed doses in organs or tissues and at selected
clinically relevant points (Figure 1.3). These conversion coefficients depend on a number of factors that
are discussed in detail in the present report. They
are based in part on ICRU Report 57 (ICRU, 1998a).
1.3.3 Air kerma-area product (KAP) and
dosearea product (DAP)
Required accuracy
The output of an x-ray tube can be monitored with

a transmission ionization chamber. The chamber is
mounted on radiological tubes, downstream relative
to the collimator (Figure 1.3). The increasing use of
this monitoring device is partly a consequence of the
EC Directive (EC, 1997).
The signal of the chamber is calibrated in terms of
KAP (or absorbed DAP), at a specified distance freein-air. It is expressed in mGy m2. As more convenient
multiples, the radiology community would prefer
Gy cm2. The transmission chamber acts as a
monitor, like in radiation therapy, and should be
calibrated against the reference dosimeter of the
department.
From the radiological parameters (Section 1.3.4.1),
the readings of the reference chamber, and the KAP
(or DAP), it is possible to derive useful information:
The required accuracy for dose determination

depends on the dose level and potential risk. An
accuracy requirement of 7 %, at an expanded uncertainty using a coverage factor of 2 corresponding to
the confidence level of 95 %, is recommended for
comparative risk assessments as well as for quality
assurance (AAPM, 1992). When there is a risk of
deterministic effects similar accuracy will be needed.
For calibration the expanded standard uncertainty
should not exceed 5 % (AAPM, 1992). These requirements can, in general, be achieved.
An accuracy of 3050 % can be accepted in the
cases where organ doses are low. For comparison,
in occupational exposure or radiation protection, an
accuracy of 50 % may also often be accepted in some
situations. In contrast, in radiation therapy, an
accuracy on dose, at the reference point, better than
5 % is aimed for in the case of radical treatment.
In the case of an accidental acute effect (e.g., skin
burn), sufficient information should be available to
the staff of a department of radiology to allow dose
Doses at reference points, for example, entrance

(skin) dose on the beam axis at a given distance,
and at specified points in organs.
Mean organ doses.
13
Figure 1.3. Calibration of dosimeters to be used in a diagnostic radiology. (1) The reference dosimeter used in diagnostic radiology is
calibrated (directly or through transfer dosimeters) at a Standards Laboratory in air kerma free-in-air (left). (2) In diagnostic radiology,
the dosimeter can be used to measure the entrance surface dose (skin dose) provided appropriate conversion coefficients are applied, i.e.,
from air kerma free-in-air to absorbed dose in water including backscatter (right). In addition to skin dose, the chamber can also be used to
determine the dose at any point in the patient. (3) The transmission chamber, regularly calibrated (Section 4.2.4), is used as a monitor. It
provides the DAP or the air kermaarea product (KAP), depending on how it is calibrated. From the radiological parameters (Section
1.3.4.1), the readings of the reference and KAP dosimeters, in principle, organ doses can be computed for any organ using complex Monte
Carlo programs. The resulting conversion coefficients are valid within strict limits and specific for each radiological procedure (from
Wambersie et al., 2006, by permission of Oxford University Press).
and position, and irradiated region, should be recorded for the standard medical imaging procedures. In
recent equipment, in particular in direct digital radiology systems (flat panel detectors), recording of
these parameters is made automatically (Figure 1.4).
To the extent that the tube output remains constant relative to these parameters, this set of
information allows evaluating doses at reference
points where previous calibration has been performed at the surface or inside a phantom. Information obtained on the phantom can then be used to
evaluate the dose to the patients, but only for routine
procedures and with the necessary care.
The ICRU recommends that the radiographic conditions of the irradiations be reported as completely
as possible. When these are carefully reported, it will
be possible later on to apply better conversion coefficients when available and to derive more relevant
quantities.
This, however, requires sophisticated Monte Carlo

programs, which produce conversion coefficients
valid only for well-defined procedures and within
strict (geometric) limits that should be specified
(Chapter 5; Appendices B, C, D, and F; Struelens,
thesis, 2005).
As part of a quality assurance program, it is
important to check regularly the reproducibility of
the response of the transmission chamber with a
calibrated dosimeter.
A normalization quantity is a dosimetric quantity
that can be readily measured or calculated in the
clinical situation. Normalization quantities are used
to derive a specified dosimetric quantity, for example,
mean organ dose, using an appropriate conversion
coefficient. To date KAP or DAP, (Section 2), are commonly used as normalization quantities, but various
other quantities can also be used (Section 3.4).
1.3.4 Reporting patient irradiation in
radiological imaging
1.3.4.1
1.3.4.2 Air kermaarea product (KAP) or

dosearea product (DAP)
Radiological parameters of the exposure
KAP or DAP provides a continuous monitoring of

the x-ray tube output and an indication of the
absorbed dose at reference points at the skin and
the possibility to calculate organ doses for standard
Radiological parameters, such as tube voltage

(kV), tube currentexposure time product (mAs),
filtration, exposure time (for fluoroscopy), field size
14
INTRODUCTION
Figure 1.4. Correlation between radiological parameters, transmission monitor readings [air kermaarea product (KAP) or dose area
product (DAP), and clinically relevant dosimetric quantities (see arrows 3 and 1, respectively). This correlation should be checked at
regular intervals depending on the type of radiological examination, the irradiated organs and level of exposures, and the type of patients
(pregnant women, children, etc.]. The radiological parameters include tube voltage (kV), tube currentexposure time product (mAs),
filtration, field size (at a given distance), and exposure time for fluoroscopy (Section 1.3.4.1). The clinically relevant dosimetric quantities
include the skin (entrance) dose on the beam axis, skin surface (and regions) irradiated above the tolerance dose for induction of
deterministic effects at clinically relevant points and/or organs. Left part Regular checks of the correlation between the radiological
parameters and the readings of the KAP (or DAP) dosimeter (arrows 2) guarantee output stability and the reliability of both dosimetric
approaches. It improves the confidence in the two sets of dosimetric results. Right part In the absence of a KAP (or DAP) meter, regular
checks of the correlation (arrow 3) between the radiological parameters and the readings of the reference ionization chamber, at reference
points, may also provide some guarantee on the stability and reliability of the dosimetry. This latter procedure, however, should be limited
to simple, routine, and well-defined radiological examinations and is not recommended for examinations of pregnant women and children.
Courtesy: A. Wambersie.
phantoms to doses for individual patients or patient

series requires appropriate care, but some programs
allow the introduction of individual patient parameters (gender, age, shape, dimensions, organ size
and location, etc.) (Tapiovaara et al., 1997).
Patient measurements may be considered as a
validation (in clinical conditions) of phantom measurements to derive the doses. However, in radiology
such measurements are often not a realistic scenario
for every type of procedure on a systematic base.
They are, however, strongly recommended on a limited series of patients for standard procedures.
procedures. KAP or DAP can be used as normalization quantities to derive relevant dosimetric
quantities, such as organ doses, using conversion
coefficients (Sections 1.3.3 and 3.4).
Continuous monitoring of KAP relative to the
radiographic parameters of exposure listed previously (Section 1.3.4.1) improves the confidence in
both approaches.
1.3.4.3 Monte Carlo computation
Sophisticated Monte Carlo programs have been
designed to calculate doses at specified points or
average organ doses in phantoms starting from the
radiographic parameters and/or the KAP or DAP
(Figure 1.5). The results from these approaches are
available mainly for standard, well-established
radiological procedures. The use of such Monte
Carlo codes needs considerable expertise when
applied for specific or uncommon procedures.
1.3.5
Discussion
In radiological imaging, one of the dosimetric

issues is the fact that several quantities are used to
quantify the magnitude of the exposure of the
patient to ionizing radiation. There is some ambiguity (and even disagreement) in their names and
applications in radiological procedures (e.g., kerma
versus absorbed dose, air versus water, free-in-air or
with backscatter).
The numerical values of the different quantities
may be close to each other and within dosimetric
uncertainties (even within clinical accuracy
1.3.4.4 Phantoms and in vivo measurements

Different types of phantoms have been designed
(ICRU Report 44, 1989b; ICRU Report 48, 1992b).
Transfer of doses derived from measurements using
15
Figure 1.5. Visual representation of the photon tracks (primary and scattered radiation) and energy distribution (colour code: light gray,
2040 kV; medium gray, 4060 kV; dark gray, 6080 kV) of a Monte Carlo simulation for a PA view of a pelvic exposure, as part of an
angiographic examination of the lower limbs. The exposure was assumed to be performed at a peak tube voltage of 80 kV, a total filtration
of 4.6 mm Aleq, and a focus-to-skin distance of 55 cm. As model for the patient, the mathematical phantom BODYBUILDER was used.
Conversion coefficients can be retrieved between different calculated values, such as a specific organ dose or DAP/KAP. Reproduced with
permission from Dr. L. Struelens.
requirements). This cannot be used as an excuse for

not specifying clearly the involved quantities.
There is still debate concerning the relevant
quantity to select in radiology: (i) the standards
laboratories (and manufacturers) calibrate the ionization chambers in air kerma free-in-air; (ii) the
radiological community is using the concept of
absorbed dose; (iii) a device informing the practitioner of the quantity of radiation produced by the
equipment during the radiological procedure (in
practice a transmission chamber) is now imposed
by regulation in several countries (EC, 1997).
This situation is very similar to the situation in
radiation therapy. In each radiation therapy department, there is a reference dosimeter (ionization
chamber) calibrated for 60Co gamma rays or a few
MV x rays. Conversion coefficients are available for
photon and electron beams of higher energies (ICRU
Report 64, 2001; ICRU Report 71, 2004). A transmission chamber used as a monitor is regularly calibrated against the reference dosimeter in specified
conditions.
It is the responsibility of the local medical physics

team to select and apply the appropriate conversion coefficients and to check the reproducibility
of the responses of the different dosimetric
systems. Similar working procedures and sharing
of responsibilities can be applied in a radiology
department.
The medical and radiobiological community, radiologists, and radiation oncologists currently relate
the biological effects to the absorbed dose. A large
experience has been built using absorbed dose as a
quantification of the magnitude of exposure and
dose-effect relationships. It would not be safe or
wise to modify this well-established approach.
When using ionization chambers calibrated in AK,
it is thus important to select the appropriate conversion coefficients. In that respect, the ICRU Report 74
where this issue is carefully discussed is thus timely.
In the European and national regulations and
recommendations, the quantities absorbed dose and
weighted absorbed dose (equivalent dose, effective
dose, etc.) are used. This may interfere with the
16
INTRODUCTION
names are used in practice for the same quantity,
for example, entrance surface air kerma, air kerma,
and entrance air kerma. The same abbreviation ESD
is used for both entrance surface dose (absorbed dose
determined free-in-air most likely expressed in air)
and entrance skin dose (absorbed dose most likely
expressed in skin tissue).
The kermaarea product is often used for dose
assessment for more complex examinations, including radiography and fluoroscopy. Although the name
does not state this explicitly, the kerma is usually
expressed in air free-in-air and the backscatter from
a patient or a phantom is not to be included.
In interventional radiology, the value of the
kermaarea product for a complete examination
has been used as an indicator for the occurrence of
stochastic effects, whereas information on the maximum dose at skin entrance (that is, the dose at the
location of the skin where it is highest) is of importance with respect to the possible occurrence of deterministic effects. The maximum dose at skin entrance
is also referred to as the peak skin dose (Miller et al.,
2002) and defined as the highest dose delivered to
any portion of the patients skin.
For the assessment of organ doses and quality
assurance in CT, the CTDI has been defined as the
integral of the absorbed dose profile along a line
parallel to the axis of rotation of the scanner divided
by the nominal slice thickness (Shope et al., 1981). In
the literature, different methods can be found for the
practical assessment of CTDI. These include differences in the boundaries of integration, the use of a
phantom or measurement free-in-air, and differences in the material in which the absorbed dose is
expressed, for example, polymethylmethacrylate
(PMMA) or air.
The present situation in patient dosimetry for
medical x-ray imaging clearly indicates the need
for dose quantities recommended for the different
applications and the need for using the same, selfconsistent, system for names, symbols, and units.
selection of the quantities in the radiological departments (EC, 1997; ICRP Publication 73, 1996).
Dosimetry for CT raises specific issues. For CT,
skin dose and dose at a point do not have the same
significance as for conventional radiography, and
specific indexes thus need to be introduced. The CT
dose index (CTDI) has been defined for the assessment of organ dose and QA (Sections 3.2 and 4.2.5).
Several methods were published for the practical
assessment of CTDI (IEC, 1999; EC 2000).
For interventional radiology, where the avoidance
of deterministic effects becomes important, doseconversion coefficients relating the absorbed
dose to the more heavily irradiated site at the
surface of the body to normalization quantities
(Section 3.4) are not yet commonly available, except
for some coronary procedures. In particular, the
point (place on skin) where the maximum dose is
obtained may not always be known in advance
(Section 3.3.1).
1.4 NEED FOR HARMONIZATION OF
QUANTITIES AND TERMINOLOGY
Various quantities and terminologies have been
used for the specification of dose on the central
beam axis at the point where the x-ray beam enters
the patient (or a phantom representing the patient).
These include the exposure at skin entrance (ESE),
the input radiation exposure, the entrance surface
air kerma (ESAK), the entrance air kerma, the AK,
the ESD, the entrance skin dose (ESD), and the
integral skin dose (ISH and EC, 1998).
ICRU Reports 33 and 60 (1980, 1998c) recommended the use of the International System of Units (SI).
In ICRU Report 33 it is stated that the special unit
of exposure, the rontgen, should be dropped by
1985 and be replaced by the SI unit C/kg. Consequently, the approximate numerical equivalence
of exposure, AK, and absorbed dose to air was lost.
As a result of the introduction of the SI, exposure has
been replaced by air kerma (free-in-air) as the
quantity in which dosimeters are calibrated at
standards laboratories.
Sometimes it seemed to be the convention that
kerma implies absence of backscatter and absorbed
dose implies the presence of backscatter. However,
the presence or absence of backscatter cannot be
derived from the definitions of kerma and absorbed
dose (ICRU, 1998c). Calibrations of dosimeters are
generally made in terms of air kerma free-in-air.
Therefore, it is often assumed that kerma is
expressed only in air. However, the ICRU (1998c)
explicitly states that one can refer to a value of
kerma for a specified material at a point in free
space, or inside a different material. Different
1.5 THE TWO PURPOSES OF

PATIENT DOSIMETRY
In medical x-ray imaging there are two fundamental reasons for measuring or estimating the
patient dose. First, measurements provide a means
for setting and checking standards of good practice,
as an aid to the optimization of the radiation protection of the patient and of image quality. Second,
estimates of the absorbed dose to tissues and organs
in the patient are needed to assess radiation
detriment so that radiological techniques can be
justified and cases of accidental overexposure
investigated.
17
tissue doses can be derived from measurements

inside physical phantoms.
1.5.1 To set and check standards of

good practice
It is well known from the results of numerous
surveys that there is considerable variation in the
doses delivered to patients from the same type of xray examination conducted in different facilities or
even within a single facility. Without some form of
patient dose monitoring, it is difficult to know the
performance of an x-ray facility and to judge how it
compares with generally accepted practice. As an aid
to the optimization of the radiation protection of the
patient, reference values, variously called reference
dose values (EC, 1996c), DRLs (ICRP, 1996), or guidance levels (IAEA, 1996a), can be specified for particular x-ray imaging tasks. Local performance can
be checked against these reference values by periodic measurement as part of a quality assurance
program. For these purposes, clearly defined quantities are required, which can be easily measured
with readily available instruments of sufficient precision and accuracy. Consequently, dosimetric
quantities associated with the primary x-ray beam
(e.g., AK at a specified point on the beam axis) or
closely related radiation quantities suited to particular applications (e.g., KAP, CT kerma index or CTDI)
have become established quantities used to set and
check standards of good practice.
1.6 RELATIONSHIP BETWEEN PATIENT

DOSE AND IMAGE QUALITY
It is important to ensure that efforts to reduce
patient doses do not also reduce doses to the image
receptor to such an extent that the quality of the
images is degraded to an unacceptable level. Image
quality can be affected by inadequate doses in four
distinct ways:
(i) In the non-digital imaging systems used in conventional radiography and fluoroscopy, optical
density or brightness of the image depends on
the dose and dose rate received by the image
receptor, respectively. Too low a dose or dose
rate can result in images that are too faint to be
clearly discerned.
(ii) Dose reduction by increasing the tube voltage
and thereby allowing a reduction in tube current or exposure time to maintain the same
dose to the image receptor can degrade image
quality by decreasing contrast.
(iii) As medical imaging systems have become more
sensitive, needing only lower doses to achieve
images of satisfactory density or brightness,
there is an increased likelihood that random
variations in the photon fluence rate reaching
the image receptor will give a disturbing
mottled appearance to the image. This socalled quantum mottle is preferably the dominant source of image degradation in sensitive
digital and non-digital imaging systems.
(iv) The sensitivity of the imaging system can often
be improved by increasing the thickness of the
sensitive layer of the image receptor so that it
absorbs more of the incident x-ray energy. For
the majority of image receptors that re-emit the
absorbed energy in the form of visible light,
thicker sensitive layers result in wider spatial
dispersion of the emitted light before the image
is recorded. Greater sensitivity, and hence the
possibility of using lower doses, is consequently
gained at the expense of poorer spatial resolution in the image.
1.5.2 To assist in assessing detriment or

harm
For the justification of a practice or for the investigation of cases of accidental over-exposure, the
absorbed dose to the patient should be expressed in
a manner that can be directly related to the potential
health risks. For stochastic radiation effects, the
ICRP (1991b) has recommended that the mean
absorbed dose to individual organs or tissues is the
quantity of interest. If deterministic effects are considered possible, for example, in some cases of interventional radiology, the absorbed dose to the more
heavily irradiated sites at the surface of the body,
such as the skin in the primary beam, is the radiation quantity of interest.
Organ or tissue doses cannot be directly measured
in patients but can be derived from other directly
measurable radiation quantities using appropriate
conversion coefficients. Extensive tabulations of
such conversion coefficients for reference patients
and reference irradiation conditions have been published, are available in computer readable form, or
can be calculated (Appendices BF). These coefficients relate organ doses to practically measurable
normalization quantities, some of which are the
same as the quantities used for setting and checking
standards of good practice. Alternatively, organ and
Procedures for checking that doses have not been

reduced to such an extent that inadequate optical
density, excessive noise, poor spatial resolution, or
lack of contrast prevents reliable diagnosis should be
an essential component of x-ray department quality
assurance programs. A range of phantoms that can
be used to assess image quality in diagnostic radiology are described in ICRU Report 48 (1992c). More
18
INTRODUCTION
application specific quantities, risk related quantities, dose-conversion coefficients, and quantities
recommended for establishment and use of DRLs.
Section 4 discusses the methodology to be used for
the measurement of specific dose quantities including incident AK, ESAK, KAP and various quantities
to be used for CT dosimetry. It considers the choice
and calibration of dosimeters, the practical measurement technique, the measurement uncertainty, and
the advantages and disadvantages of phantombased and patient measurements. The derivation of
backscatter factors, which can be used to relate
incident AK and ESAK to ESD, is treated in
Appendix A. The conversion coefficients used to
estimate organ and tissue doses are covered in Section 5. Two approaches to determine the conversion
coefficients are considered: measurements in physical phantoms and computational methods. The latter use Monte Carlo techniques to simulate radiation
transport through computer-based models of the
patient. This is usually the more useful approach.
The main features of the computational method and
the associated uncertainties in the conversion coefficients are discussed. Results of such calculations
are available from a number of sources for conventional projection imaging, CT, and mammography.
Conclusions, including recommendations on the
selection of the most appropriate conversion coefficient for a particular examination or procedure, are
presented in Section 6. Organ dose-conversion coefficients from different sources are considered in
Appendices BF.
fundamental methods for assessing the quality of

medical images are published by Doi et al. (1982;
1986) and presented in ICRU Reports 41 and
54 (1986, 1995). In addition, an ICRU report has
been recently published on Chest radiographyAssessment of Image Quality (ICRU Report 70,
2003) and one is underway in Mammography
Assessment of Image Quality.
1.7
SCOPE OF THE REPORT
The present Report is primarily concerned with

methods of patient dosimetry in medical x-ray
imaging. Methods are described for dosimetry performed to set or check standards of good practice and
as a step towards the assessment of detriment or
harm. In many situations the dosimetric quantity
of interest can be directly measured. In other cases,
however, it is not practicable to measure a quantity
of interest directly (e.g., organ or tissue dose).
Instead it is obtained indirectly by application of an
appropriate conversion coefficient to a quantity that
can be measured directly.
All aspects of patient dosimetry require knowledge of the properties of the x-ray beam. The basic
features of the x-ray beams used for medical imaging
and their specification and measurement are, therefore, discussed in Section 2. The various dosimetric
quantities to be used for patient dosimetry are
defined and discussed in Section 3, and appropriate
notations are introduced. The discussion is divided
into five parts: basic dosimetric quantities,
19

SPECIFICATION OF X-RAY BEAMS
2.1
PHOTON SPECTRUM
The shape of the spectrum depends on the voltage

applied to the x-ray tube (kV), the waveform of
the generator, the target material and angle, and
the amount of inherent and added filtration in the
x-ray beam. For most diagnostic examinations, and
all interventional procedures, x-ray spectra from a
tungsten target are used (Figure 2.1). Aluminium
filtration is generally employed to remove the
low-energy end of the bremsstrahlung spectrum,
which would otherwise be absorbed in the superficial

tissues of the patient without contributing to the
final image. An additional filter of, for example, copper may also be used in some situations to further
harden the spectrum. To prevent the low-energy
characteristic x rays produced in the copper filter
from reaching the patient the aluminium filter
should be between the copper filter and the patient.
There are peaks in the tungsten spectra due to Ka
and Kb characteristic radiation for peak tube voltages >69.5 kV, corresponding to the energy of the
RELATIVE NUMBER OF PHOTONS
X-ray tubes used in medical x-ray imaging employ

peak voltages of between 25 and 150 kV to accelerate electrons from a heated cathode towards an
anode target. X rays are produced either as a result
of radiative energy loss by electrons slowing down in
the target material (bremsstrahlung) or by radiative
transitions of electrons within the atoms of the
target (characteristic x rays). The former have a
continuous range of energies from that of the most
energetic electron downwards whereas the latter
occur at discrete energies characteristic of the target
material.
The radiation quality of an x-ray beam can be
characterized by the x-ray spectrum. X-ray spectra
can be measured by using spectrometers based on
scintillation counters, germanium or silicon detectors, or by crystal diffraction. These techniques,
however, require considerable expertise and are
time-consuming to perform. Therefore, it is recommended that the radiation quality of x-ray beams
used for medical imaging be characterized by a combination of various parameters. These include first
half-value layer (HVL; symbol HVL1); the second
HVL (HVL2); the ratio of HVL1 to HVL2, referred to
as the homogeneity coefficient; the tube voltage and
the total filtration. In most cases, the quality of an
x-ray beam can be adequately specified by means of
the combined information on tube voltage, HVL1,
and HVL2, or the tube voltage, HVL1, and total
filtration.
The yield is also an important characteristic of an
x-ray tube (including filtration). For this purpose the
x-ray tube output is defined in Section 2.5.
20
40
60
80
PHOTON ENERGY; E /keV

20
40
60
80

Figure 2.1. Typical photon fluence x-ray spectra used for medical
imaging (IPEM, 1997). Top tube voltage: 80 kV constant potential, tungsten anode; filtration: 3 mm Al, anode angle 16 ; HVL1:
2.98 mm Al. Bottom tube voltage: 28 kV constant potential,
molybdenum anode; filtration: 0.03 mm Mo, anode angle 12 ,
behind 2 mm thick PMMA compression plate; HVL1: 0.32 mm
Al. Reproduced with permission from Dr. J. Th. M. Jansen.
tungsten K-edge, but the spectrum is dominated by

the bremsstrahlung contribution.
In x-ray mammography, a spectrum of much
lower energy, for example, from a molybdenum
target, is used to obtain good soft-tissue contrast.
This spectrum is modified by a K-edge filter (generally molybdenum although rhodium is used in some
situations) and shows strong peaks corresponding to
the Ka and Kb characteristic radiation, which for the
molybdenum target have average energies of 17.4
and 19.6 keV, respectively (Figure 2.1). The K-edge
filter reduces the low-energy end of the bremsstrahlung spectrum and much of the bremsstrahlung
spectrum at energies above the K-edge, which for
molybdenum is at 20 keV.
A combination of calculations and measurements
has been used to produce catalogues of x-ray spectra
for specified values of tube voltage, filtration, target
material, target angle, and waveform (Birch et al.,
1979; Seelentag et al., 1979; Iles, 1987). More
recently, the Institute of Physics and Engineering
in Medicine (IPEM) prepared a catalogue of diagnostic x-ray spectra and other data available on
CD-ROM (IPEM, 1997). This allows calculation of
x-ray spectra based upon the method of Birch et al.
(1979) in cases where an appropriate spectrum cannot be found in one of the available catalogues. Such
information on the spectral distribution of the
photon fluence is required when calculating the
response of detectors or the air kerma or absorbed
dose in different materials when exposed to the
relatively broad photon spectra typical of x rays
used in medical x-ray imaging. It is important to
check calculated values for first and second HVL
against measurements.
2.2
spectra can sometimes result in the same value of

HVL1, as illustrated by Figure 2.2. It should be noted
that two of the spectra shown have very low filtration and would not be legal for use in medical x-ray
imaging in many countries. In the figure, photon
spectra are shown for four x-ray beams having similar values of HVL1, but generated at different tube
voltages and having different filtration. The x-ray
spectra are rather different and may cause different
dosimeter responses and different dose distributions
in an irradiated medium, for example, phantom or
patient.
For measurement of the HVL the recommendations of the ICRU (1964) should be followed. It has
been shown that a narrow beam and a sufficiently
large distance between the absorber and measuring
device should be used to obtain the correct HVL.
The instrument used for attenuation measurements
should have weak energy dependence over the
range concerned. The use of a monitor is advisable
to facilitate a correction for variations in the output
of the x-ray tube. The monitor should be positioned
so that its readings are independent of the thickness
of the absorber. By limiting the field diameter, the
amount of scattered radiation recorded will be
reduced, but the field dimensions must be larger
than the sensitive volume of the measuring device.
The collimator must be of sufficient thickness to
absorb the primary beam. A radiographic method
may be used to check the alignment.
The variation of the measured HVL with field
diameter and with detectorabsorber distance is
presented elsewhere (ICRU, 1964). As a general
rule the absorbing material should be placed approximately midway between the source and the
detector, the minimum sourcedetector distance is
50 cm at a maximum field diameter of 5 cm. If
greater accuracy is required, the method described
by Trout et al. (1960) should be used for which a
unique value can be determined by measuring the
HVL for three collimator sizes. A linear extrapolation of a plot of HVL against the field diameter will
yield the zero-field-area value.
HVL
Routinely, the practical determination of x-ray

beam quality relies on simple attenuation measurements, usually in aluminium, to determine the HVL.
The first, HVL1, is the thickness of a specified material, which attenuates the beam of radiation to an
extent such that the radiation quantity is reduced
to half its initial value (ICRU, 1970). The use of
different radiation quantities such as exposure or
absorbed dose will lead to different HVL1 values.
For the characterization of x-ray beams used for
medical imaging, the air kerma, Ka, or the air
kerma rate, K_ a , is recommended for the determination of the HVL. In the definition of HVL the contribution of all scattered radiation, other than any
that might be present initially in the beam concerned (see Section 2.4), is to be excluded. The HVL
alone is often not an adequate specification of the
x-ray beam quality because markedly different
2.3
X-RAY TUBE VOLTAGE
The x-ray tube voltage may be measured using

either invasive or non-invasive equipment. Both
approaches have advantages and disadvantages.
Invasive measurements can be made, for example,
by means of a frequency-compensated high-voltage
divider combined with a storage oscilloscope. The
calibration of the high-voltage divider should ideally
be traceable to a primary or secondary voltage
standard. For connection to the oscilloscope, highimpedance probes and low-impedance cables have
22
SPECIFICATION OF X-RAY BEAMS
20
40
60
80
100
120
20
40
60
80
100
120
100
120
20
40
60
80
100
120
20
40
60
80
Figure 2.2. Calculated spectra (IPEM, 1997) of filtered x-ray beams with almost the same HVL1 but generated at different tube voltages
in a tungsten anode (constant potential, anode angle 16 ) and with different filtration. Top left tube voltage, 60 kV; filtration, 4.3 mm
Al; HVL1, 2.74 mm Al; HVL2, 3.5 mm Al. Top right tube voltage, 75 kV; filtration, 2.9 mm Al; HVL1, 2.74 mm Al; HVL2, 3.9 mm Al;
Bottom left tube voltage, 90 kV; filtration, 2.0 mm Al; HVL1, 2.72 mm Al; HVL2, 4.3 mm Al. Bottom right tube voltage, 110 kV;
filtration, 1.2 mm Al; HVL1, 2.68 mm Al; HVL2, 4.8 mm Al. Reproduced with permission from Dr. J. Th. M. Jansen.
integrated or the peak signal cannot measure or

indicate the waveform, and it is desirable to additionally use an oscilloscope or similar device.
For both invasive and non-invasive devices
calibration facilities are essential, but primary or
secondary standard devices are not available in all
countries. While the quality of the calibration inevitably plays an important role, it must be appreciated that the vagueness of the term peak voltage is
also a contributory factor (Kramer et al., 1998).
Therefore, a new quantity termed the practical
peak voltage has been proposed (IEC, 1996; Kramer
et al., 1998). This quantity is based on the concept
that the radiation generated by a high voltage of
any waveform produces the same contrast as radiation generated by an equivalent constant potential
generator. The constant potential producing the
same contrast for a specified contrast configuration
and specified x-ray tube properties as the waveform
under test is the practical peak voltage. This quantity is derived from the contrast produced by a
reference x-ray tube irradiating a 10 cm thick
to be used. The oscilloscope probes should preferably

be calibrated in conjunction with the oscilloscope,
for the range of voltages to be measured.
In the past, the x-ray peak tube voltage has been
checked with an uncertainty of 12 kV using a modified Ardran and Crookes test cassette (Jacobson
et al., 1976). Although the test film produced with
this cassette can be evaluated visually, reliable results can only be obtained by using a densitometer
to read the patches on the film.
Non-invasive electronic devices for measurement
of the x-ray tube voltage are generally based on
attenuation measurements (Gard, 1996) but spectrometric methods may also be used. Methods differ as
to which value is indicated, for example, peak voltage or average voltage. Different instruments are
usually required for general radiology and mammography. They need careful calibration against a
primary or secondary standard. The measured
value of the x-ray tube voltage will be influenced by
the degree of beam filtration and may be dependent
on the air kerma rate. Devices that rely on the
23
The HVL can be used to estimate the total

filtration of x-ray tubes used in medical imaging.
The uncertainty of the total filtration will be within
10 % (Gilmore and Cranley, 1990) provided that the
HVL1 can be measured within 0.06 mm Al, the tube
voltage within 1.9 kV, the tube voltage ripple within
5 %, and the effective target angle is known within
1.8 . This procedure presumes the availability of
accurate data relating HVL1 to tube total filtration
such as presented in IPEM Reports 64 (1991) and 78
(1997).
PMMA phantom covered partially with a piece of

1 mm Al as a contrast medium (Kramer et al., 1998).
The result of the contrast-equivalent peak voltage
is insensitive to small differences in the contrast
geometry.
The experimental results of Baorong et al. (2000)
demonstrated that a contrast-equivalent x-ray tube
voltage can be determined with an accuracy ranging
from 200 V to 3 kV, depending on the magnitude
of the tube voltage in the range of 40150 kV. The
reference contrast geometry of 1 mm Al on 10 cm
PMMA selected on the basis of calculations (Kramer
et al., 1998) also appears suitable from experimental
evidence.
2.4
2.5
X-RAY TUBE OUTPUT
The x-ray tube output may be used in conjunction

with the inverse-square law to calculate the air
kerma incident on a patient or a phantom if the
tube-current exposuretime product is known
(Section 3.2.1). The x-ray tube output, Y(d), is
defined as the quotient of the air kerma, Ka(d), at a
specified distance, d, from the x-ray tube focal spot
(usually 1 m) by the tube-current exposuretime
product, PIt. Thus
TOTAL FILTRATION
The materials of the x-ray tube window and any

permanent filters will attenuate the x rays produced
in the target (focal spot) of the x-ray tube. The thickness of these materials is called the inherent filtration and often expressed in an equivalent thickness
of aluminium. There may be additional filtration
from the radiolucent mirror of the light-beam system
and from other parts of the collimator system.
Often additional (aluminium) filtration is applied
to remove the lower-energy photons, which will contribute only to patient dose and not to the image. The
total filtration is the sum of the inherent and the
additional filtration.
Y d Ka d=PIt :
2:1
Unit: J/(kg/C), or Gy/mAs.

The magnitude of the x-ray tube output will
depend upon the design of the tube, tube voltage,
and filtration and may change as the tube ages.
24

3 QUANTITIES AND UNITS FOR MEASUREMENT AND

CALCULATION IN MEDICAL X-RAY IMAGING
In the first part of this section, basic dosimetric
quantities relevant for medical x-ray imaging are
introduced. The following subsection presents
quantities used for specific applications such as
radiography, fluoroscopy, and CT. Risk-related
quantities are given in Section 3.3. Dose-conversion
coefficients relating mean organ doses, or absorbed
dose to a localized region of tissue, to readily
measurable dosimetric quantities are presented in
Section 3.4. Quantities recommended for the establishment and use of diagnostic reference levels are
given in the final section.
3.1
BASIC DOSIMETRIC QUANTITIES
The energy carried by the photons in an x-ray

beam can be specified in terms of the energy fluence.
The energy fluence, C, is the quotient of dR by da,
where dR is the radiant energy incident on a sphere
of cross-sectional area da (ICRU, 1998c)
C
dR
:
da
3:1
Unit: J/m2.
The conversion of energy refers to the transfer of
energy from ionizing particles to secondary ionizing
particles. The quantity kerma relates to the kinetic
energy of all the charged particles liberated by
uncharged particles; the energy expended against
the binding energies, usually a relatively small
component, is, by definition, not included.
The kerma, K, is the quotient of dEtr by dm, where
dEtr is the sum of the initial kinetic energies of all
the charged particles liberated by uncharged particles in a mass dm of material (ICRU, 1998c), thus
K
dEtr
:
dm
these particles
K
3:3
For x rays used for medical imaging the kerma is

usually expressed in air. The air kerma, Ka, is
related to the energy fluence by the mass energy
transfer coefficient for air, (mtr /r)a. Thus for photons
of a single energy, Ka is given by
Ka Cmtr /ra :
3:4
Unit: J/kg, special name gray (Gy).

When the photons are not monoenergetic, which is
usually the case in medical x-ray imaging, a mean
value of (mtr /r)a should be used, weighted according
to the energy distribution of the energy fluence.
The kerma rate, K_ , is the quotient of dK by dt,
where dK is the increment of kerma in the time
interval dt, thus
dK
:
3:5
K_
dt
Unit: (J/kg)/s, or Gy/s.
The absorbed dose, D, can be used to quantify the
deposition of energy by ionizing radiation. It is
defined in ICRU Report 60 (1998c) as the quotient
of d by dm, where d is the mean energy imparted to
matter of mass dm, thus
D
d
:
dm
3:6

Under conditions of charged particle equilibrium,
the absorbed dose to material t is related to the
energy fluence by the mass energy absorption coefficient in that material (men/r)t. Thus for photons of a
single energy Dt is given by
3:2

Kerma is defined at a point and concerns the initial transfer of energy by uncharged particles to
matter. For uncharged particles of a single energy,
kerma is related to the energy fluence by the mass
energy transfer coefficient, mtr /r of the material for
Cmtr
:
r
Dt Cmen =rt :
3:7
Again, when the photons are not monoenergetic, a

mean value of (men/r)t should be used, weighted
according to the energy distribution of the energy
fluence.
All the energy that has been transferred from
the ionizing photons to the kinetic energy of the
numerically equal to the absorbed dose. Thus
secondary electrons is not necessarily absorbed locally by the irradiated material as the electrons slow
down. A small fraction g of the electron energy is
converted directly into photon energy (mostly
bremsstrahlung), but this fraction is negligible for
materials of low atomic numbers Z and for the electron energies associated with medical x-ray imaging
[for example, g 6:6 104 for 100 keV electrons in
air (ICRU, 1984)]. Strictly,
men
1 gmtr
:
r
r
K D Cmen =r Cmtr =r:
3:9
Despite this equivalence of kerma and absorbed

dose, it is the air kerma measured free-in-air on the
central axis of the x-ray beam at a specified distance
from the focal spot that is the most common method
for specifying the output of x-ray tubes used for
medical imaging. For x-rays used in medical imaging, calibrations are made in terms of air kerma
because this is the dosimetric quantity supported
by the international metrology system and for
which primary standards have been developed.
The absorbed dose rate, D_ , is defined by the ICRU
(1998c) as the quotient of dD by dt, where dD is
the increment of absorbed dose in the time interval
dt, thus
3:8
The transfer of energy (kerma) takes place at a

point whereas the subsequent deposition of energy
to matter (absorbed dose) is spread over distances
determined by the range of the secondary electrons.
If g is negligible and charged-particle equilibrium
exists, i.e., the number, energy, and direction of
the electrons entering a volume of interest are the
same as for those leaving it, then the kerma will be
numerically equal to the absorbed dose, when
expressed in the same material. In medical x-ray
imaging, charged-particle equilibrium is readily
achieved in low atomic number materials such as
soft tissue, since the range of the secondary electrons
is very short compared with the mean free path of
the x-ray photons, which produced them. As a consequence, the photon fluence changes imperceptibly
over the distance in which the electron energy is
imparted to the medium.
Discontinuities in charged-particle fluence caused
by out-scattered electrons of low energy will occur at
locations of rapid density or Z changes such as
boundaries between soft and bony tissues. For x
rays used in medical imaging, a fluence enhancement by a factor as large as 100 at the media
interface should be accounted for, decaying exponentially over a range of some mm or tens of mm (Regulla
et al., 1998).
For colon examinations, the influence of the contrast modification through a barium (29 % weight/
volume barium sulfate) meal or by insufflating air
has been investigated for a limited number of projections (Schultz et al., 2001). Inflation of the intestines with air has little influence on the radiation
burden, i.e., it yields about 1 % higher value for the
dose-conversion coefficient of the examination compared to the normal situation. The barium meal
decreases the dose-conversion coefficient of the
examination by up to about 18 %. Ignoring this
decrease results in a slight overestimation of the
dose, thus being safe with respect to radiation protection of the patient.
In the case of charged-particle equilibrium and in
the absence of bremsstrahlung losses, the kerma is
dD
D_
:
dt
3:10
Unit: (J/kg)/s, or Gy/s

The exposure, X, is defined by the ICRU (1998c) as
the quotient of dQ by dm, where dQ is the absolute
value of the total charge of the ions of one sign produced in air when all the electrons and positrons
liberated or created by photons in air of mass dm
are completely stopped in air, thus
X
dQ
:
dm
3:11
Unit: C/kg.
The exposure relates to the first stage of the interaction process in the same way as air kerma. Exposure is essentially the ionization equivalent of air
kerma. When bremsstrahlung losses are negligible,
the relationship between them is given by
Ka
XWa
,
e
3:12
where Wa is the mean energy required to produce an

ion pair in air and e is the elementary charge. The
establishment of complete charged-particle equilibrium (which may be difficult to achieve to the level
needed for accurate calibration, particularly for
higher photon energies) is not required.
3.2
APPLICATION-SPECIFIC QUANTITIES
Several practical dosimetric quantities have been

found useful for measurements in medical x-ray
imaging. However, ambiguity exists in names of
quantities and their use (Section 1.2). Owing to
the equivalence of numerical values of absorbed
dose and kerma in the same material for the x-ray
energies used in medical imaging, quantities have
often been alternatively referred to in terms of
26
MEDICAL X-RAY IMAGING MEASURING UNITS AND CALCULATION

x-ray tube focal spot approximately in accordance
with the inverse-square law. This is in contrast to
the situation modelled in some occupationaldosimetry calculations where broad unidirectional
beams are assumed and the air kerma is constant
for all points in the radiation field incident on the
body. Radiation backscattered from within the
patient or a phantom representing the patient will
make a significant contribution to the kerma or dose
at the entrance surface; backscatter factors range
from 1.25 to 1.60 for general radiology (PetoussiHenss et al., 1998). Consequently, the distance of
the point of measurement from the patient or phantom needs to be specified.
The first four (pairs of ) kerma (or dose) quantities
listed above refer to the same position (that is,
the point where the central axis of the x-ray beam
intercepts the plane corresponding to the entrance
surface of the patient or phantom, Figure 3.1). However, the first two pairs are to be determined free-inair, i.e., in the absence of the patient or phantom and
the third pair is to be determined in the presence of
the patient or phantom.
Because almost all these quantities will be measured with instruments calibrated in terms of air
kerma, it is considered to be appropriate and more
consistent with practice elsewhere (Section 1.2) to
absorbed dose (usually abbreviated to dose) or in

terms of kerma. Commonly used names for these
quantities are
Exposure at skin entrance
Exposure rate at skin entrance
Entrance surface kerma
(or dose)
Entrance surface kerma
(or dose) rate
Entrance surface dose
(or kerma)
Entrance surface dose
(or kerma) rate
Kerma (or dose)area product
Kerma (or dose)area
product rate
CT dose (or kerma) index
(free-in-air)
(free-in-air)
(free-in-air)
(free-in-air)
(with backscatter)
(with backscatter)
(free-in-air)
(free-in-air)
(free-in-air or
in phantom)
It is necessary to specify the position of the point of

measurement or calculation of the quantities with
respect to the x-ray tube focal spot and the patient
or phantom. Because diverging radiation beams are
invariably used in medical imaging, the kerma
and dose will decrease with distance from the
x-ray tube
focal spot
position
collimator
air kerma area product PKA meter
focal spotto-surface
distance
dFSD
focal spotto-image receptor

distance
dFiD
- incident air kerma Ka,i (no backscatter)

- entrance surface air kerma Ka,e
(including backscatter)
organ dose DT
table
image receptor
absorbed dose to tissue at a point in the patient Dt
Figure 3.1. Simple exposure arrangement for radiography showing some of the dosimetric and geometric quantities recommended in the
present Report for determination of patient dose.
27

Table 3.1. Recommended application specific quantities
for dosimetry in medical x-ray imaginga.
name them in terms of air kerma, except when measured or calculated inside a phantom or a patient. In
the latter case absorbed dose is the preferred quantity. Additional qualifying words are used to indicate
the position of measurement and whether backscattered radiation from the patient is to be included
or not. To indicate whether backscatter is included
or not in the air kerma the terms incident (no backscatter) and entrance surface (including backscatter)
are used. For the first four quantities, subscripts are
added to the symbol for the quantity. The first subscript specifies the material in which the quantity
is expressed, for example, air indicated by a.
The second subscript indicates the measurement
condition i.e., incident or entrance surface quantity
indicated by i or e. Thus incident air kerma and
entrance surface air kerma are denoted as Ka,i and
Ka,e, respectively.
The air kermaarea product is the integral of
the air kerma over the area of the x-ray beam in a
plane perpendicular to the beam axis. If the air
kerma is constant over the beam area, the integral
becomes equal to the product of the air kerma and
the area, hence the name air kermaarea product.
The symbol recommended in this Report for the
air kermaarea product is PKA. The symbol P indicates that the quantity is a product and the subscript
KA indicates that the factors in the product are
the air kerma and area. The air kermaarea
product rate, P_ KA , is defined as the quotient of the
increment in the air kermaarea product by the time
interval dt.
Like the air kermaarea product, the air
kermalength product can be defined as the integral
of the air kerma along a line. This quantity is useful
in CT where the line is chosen to be parallel to the
axis of rotation of the CT scanner. If the air kerma is
constant over a length L and equal to zero elsewhere
along the line, the integral becomes equal to the
product of the air kerma and the length, hence the
name air kermalength product. The symbol recommended in the present Report for the air kerma
length product is PKL. The symbol P indicates that
the quantity is a product and the subscript KL
indicates that the factors in the product are the air
kerma and length. Similarly the doselength product, PDL, can be defined.
Also for dosimetry in CT, the CT air kerma index
(symbol CK) for measurements free-in-air can be
defined as the air kermalength product, PKL
divided by the nominal slice thickness, T or the
sum of slice thicknesses in the case of a multiple
slice scanner. As the nominal slice thickness is
used (rather than the actual slice thickness), the
symbol CK is used instead of air kerma with a relevant subscript.
Quantity name
Symbol
Field of application
Incident air kerma
Ka,i
Incident air kerma rate

Entrance surface air kerma
K_ a;i
Ka,e
Entrance surface air kerma rate

Air kermaarea-product
K_ a;e
PKA
Air kermaarea-product rate
P_ KA
Air kermalength product

CT air kerma index
PKL
CK
Radiography and
fluoroscopy
Fluoroscopy
Radiography and
fluoroscopy
Fluoroscopy
Radiography and
fluoroscopy
Radiography and
fluoroscopy
CT
CT
All quantities are used to assess stochastic effects. Quantities

Ka,i and Ka,e are also useful to monitor the maximum skin dose,
also referred to as the peak skin dose (Miller et al., 2002), for
deterministic effects in interventional radiology.
Absorbed-dose measurements in CT are often

made in special head and body dosimetry phantoms
(ICRU, 1992c) and the CTDI (symbol CD) is used,
which is defined similarly to the CT air kerma
index, as the doselength product, PDL, divided
by the nominal slice thickness T. It should be
stressed, however, that problems occur for measurement of the dose to air because the phantom material
(PMMA) and the material in which the dose is
expressed (air) differ (Section 4.2.5). Therefore, the
CT air kerma index in-phantom (symbol CK,p) should
be used instead of the CTDI and, similarly, the air
kermalength product in-phantom (symbol PKL,p)
instead of the doselength product.
Recommended names, symbols, and field of
application of these quantities are given in
Table 3.1. More detailed definitions are given
below.
3.2.1 Incident air kerma and incident
air kerma rate
The incident air kerma is the air kerma from the
incident beam on the central x-ray beam axis at the
focal spot-to-surface distance, dFSD, i.e., at the skinentrance plane (Figure 3.1). Only the primary radiation incident on the patient or phantom and not the
backscattered radiation, is included. In the present
Report it is given the symbol Ka,i.
Unit: J/kg, special name: gray (Gy).
The incident air kerma is approximately related to
the air-kerma free-in-air at any other distance, d,
from the tube focal spot, Ka(d), by the inverse-square
law. Thus
Ka;i Ka dd=dFSD 2 :
28
3:13

It is stated approximately because there are
several small corrections due to attenuation in air,
scatter in air, and x-ray source structures. The incident air kerma can be easily calculated from the x-ray
tube output, Y(d) (Section 2.5), provided the dFSD
and the tube-current exposuretime product are
known for the specified radiation quality.
The incident air kerma rate, K_ a;i , is the quotient of
dKa,i by dt, where dKa,i is the increment of incident
air kerma in the time interval dt, thus
dKa;i
K_ a;i
:
dt
small beam areas,

Z
PKA Ka AdA Ka A:
3:18
The PKA has the useful property of being approximately (when air attenuation and scatter and extra
focal irradiation can be neglected) invariant with
distance from the x-ray tube focal spot, as long as
the plane of measurement or calculation is not so
close to the patient or phantom as to receive a significant contribution from backscattered radiation.
Usually, the position of the plane does not need to
be specified.
The air kermaarea product rate, P_ KA is the quotient of dPKA by dt, where dPKA is the increment of the
air kermaarea product in the time interval dt, thus
P_ KA dPKA =dt:
3:19
3:14
Unit: J/(kg/s), or Gy/s.

3.2.2 Entrance-surface air kerma and
entrance-surface air kerma rate
The entrance-surface air kerma is the air kerma
on the central x-ray beam axis at the point where
the x-ray beam enters the patient or phantom
(Figure 3.1). The contribution of backscattered
radiation is included. In the present Report it is
given the symbol Ka,e.
Unit: J/kg, special name: gray (Gy).
The entrance-surface air kerma is related to
the incident air kerma by the backscatter factor,
B. Thus
Unit: Jm2/(kg s), or Gy cm2/s.

3.2.4
Air kermalength product
The air kermalength product is the integral of the

air kerma free-in-air over a line L parallel to the axis
of rotation of a CT scanner. In the present Report it
is given the symbol PKL. Thus
Z
3:20
PKL Ka L dL:
L
Ka;e Ka;i B:
3:15
Unit: (J/kg) m, or Gy cm.

If the air kerma free-in-air Ka(L) is constant over a
length L and equal to zero elsewhere,
Z
3:21
PKL Ka L dL Ka L:
The backscatter factor depends on the x-ray spectrum, the x-ray field size, and the thickness and
composition of the patient or phantom. Additional
information on back scatter factors, including tables,
is given in Appendix A.
The entrance-surface air-kerma rate, K_ a;e , is the
quotient of dKa,e by dt, where dKa,e is the increment
of entrance surface air kerma in the time interval dt,
thus
K_ a;e
dKa;e
:
dt
For measurements inside the standard CT dosimetry phantoms, the air kermalength product inphantom, PKL,p, can be defined similarly to PKL.
3.2.5
CT air-kerma index free-in-air
This quantity relates particularly to the fanshaped beams used in CT. The CT air kerma index
is the integral of the CT axial air kerma profile,
Ka(z), along the axis of rotation of the CT scanner, z
for a single rotation with a single slice divided by the
nominal slice thickness T. In the present Report it is
given the symbol CK,
Z
1 1
PKL
:
3:22
CK
Ka z dz
T 1
T
3:16
Unit: J/(kg/s), or Gy/s.

3.2.3 Air kermaarea product and
air kermaarea product rate
The air kermaarea product is the integral of the
air kerma free-in-air over the area A of the x-ray
beam in a plane perpendicular to the beam axis. In
the present Report it is given the symbol PKA. Thus
Z
PKA Ka A dA:
3:17
Unit: J/kg, or Gy.

For a multi-slice scanner with Ni slices of thickness Ti, CK becomes
Unit: J/(kg/m2), or Gy cm2

If the air kerma free-in-air Ka(A) is constant over
the beam area, which is approximately valid for
CK
29
PKL
:
Ni Ti
3:23
3.2.6 CT air-kerma index in the standard

CT dosimetry phantoms
CK,PMMA,w in the standard CT dosimetry phantoms,

is defined (EC, 2000)
For measurements inside the standard PMMA CT

dosimetry phantoms, the CT air-kerma index,
CK,PMMA, can be defined similarly to CK. The
CK,PMMA is the integral of the CT axial air-kerma
profile, Ka,PMMA(z), inside the PMMA head or body
phantom along an axis, z parallel to the axis of rotation of the CT scanner, for a single rotation divided
by the nominal slice thickness T. In the present
Report it is given the symbol CK,PMMA
Z
PKL;PMMA
1 1
:
CK;PMMA
Ka;PMMA z dz
T 1
T
3:24
CK;PMMA;w
CK;PMMA;100;c 2CK;PMMA;100;p
: 3:26
3
Unit: J/kg, or Gy.

Similar to the European guidelines on quality
criteria for CT (EC, 2000), it is recommended that
CK,PMMA,100 be determined at the centre
CK,PMMA,100,c and at 10 mm below the surface
CK,PMMA,100,p of the standard CT dosimetry phantoms and that CK,PMMA,100,p should represent an
average of measurements at four locations around
the periphery of the phantom.
The subscript n is used to denote the value of
CK,PMMA,w that has been normalized to unit tubecurrent exposuretime product, PIt (after EC, 2000)
Unit: J/kg, or Gy.

The phantoms are to be placed centrally in the
gantry of the CT scanner with their longitudinal
axis coinciding with the axis of rotation of the scanner. Different approaches have been proposed for the
region of integration in Eq. (3.24) and the material in
which the absorbed dose is used instead of the air
kerma.
The performance standard for CT systems in the
USA specified an integration distance of 14 times the
nominal slice thickness and PMMA as the phantom
material in which absorbed dose, DPMMA, is measured as well as expressed (Shope et al., 1981; FDA,
1997). The IEC (1999) and EC (2000) recommend an
integration length of 100 mm, which is now also
common practice in the USA. The IEC (1999) allows
for multiple slices of the same thickness in a single
rotation. Both the IEC (1999) and the EC (2000)
recommend that the absorbed dose be expressed in
air, Da. Following the IEC and EC approach, the CT
air-kerma index in-phantom for an integration
length of 100 mm, CK,PMMA,100, is defined as
Z 50 mm
Ka;PMMA z dz
,
3:25
CK;PMMA;100
Ni Ti
50 mm
n CK;PMMA;w
CK;PMMA;w
,
PIt
3:27
where PIt is the tube-current exposuretime

product (unit: mAs).
Unit: J/(kg/C), or Gy/(mAs).
3.2.8
CT air kermalength product
The CT air kermalength product in the standard

head or body CT dosimetry phantom for a complete
conventional (serial CT) examination is defined as
X
PKL;CT
3:28
n CK;PMMA;wj Tj Nj PItj ,
j
where j represents each serial scan sequence forming part of an examination and Nj is the number of
slices, each of thickness Tj (cm) and tube-current
exposuretime product PIt j (mAs), in a particular
sequence.
Unit: J/kg, or Gy.
Any variations in applied tube voltage setting during the examination will require corresponding
changes in the value of nCK,PMMA,wi used.
In the case of helical (spiral) scanning
X
PKL;CT
3:29
n CK;PMMA;wi Ti Ii ti ,
where Ni is the number of slices of thickness Ti

produced in a single rotation. The FDA, IEC, and
EC approaches use the same standard CT dosimetry
phantoms for head and body, respectively (ICRU,
1992c; IEC, 1999).
where, for each of i helical sequences forming part of

an examination, Ti is the nominal irradiated slice
thickness (cm), Ii is the tube current (mA), and ti is
the total acquisition time (s) for the sequence.
Quantity nCK,PMMA,wi is determined for a single rotation as in serial scanning.
3.2.7 Weighted CT air-kerma index and

normalized weighted CT air-kerma index
The CK,PMMA,100 values in the centre
(CK,PMMA,100,c) and at the periphery (CK,PMMA,100,p)
of the standard CT dosimetry phantoms for head or
body, respectively, may be used to provide an indication of the average air-kerma in-phantom over a
single rotation (after EC, 2000). For the present
purpose the weighted CK,PMMA, denoted by
3.3
RISK-RELATED QUANTITIES
The fundamental dosimetric quantity in radiological protection is the absorbed dose D. At low dose
levels, the mean absorbed doses in organs or tissues
30

in the human body are taken to be indicators of the
probability of subsequent stochastic effects; at high
dose levels, absorbed doses to the more heavily irradiated sites within the body are taken to be indicators of the severity of deterministic effects (ICRP,
1991b, 2000). In view of the obvious difficulties in
measuring the distribution of absorbed dose within
the body during medical x-ray imaging, more practical dosimetric quantities have evolved which can
be directly measured or readily estimated from closely related measurements. The risk-related quantities can be obtained from the practical dosimetric
quantities using the dose-conversion coefficients in
Section 3.4.
where Dt is the absorbed dose at a point in tissue

material t, or as the energy imparted (ICRU, 1998c)
to the tissue, T, divided by its mass
3.3.1 Absorbed dose in relation to

deterministic effects
3.3.3
DT
T
:
mT
3:31
The mean absorbed dose in a specified organ or

tissue is further simply referred to as organ dose.
The subscript T can be replaced by a specific organ,
for example, stomach, Dstomach. In mammography,
the mean absorbed dose to the radiosensitive tissues
in the breast, i.e., the glandular tissues, provides a
sufficient measure for assessment of the radiation
risk (ICRP, 1987).
Equivalent dose and effective dose
The probability of stochastic events is found to

depend not only on the absorbed dose but also on
the type and energy of the radiation depositing the
dose (ICRP, 1991b). The ICRP has, therefore, recommended that for radiological protection purposes,
organ dose should be weighted for radiation quality
by a radiation weighting factor, wR. Values of wR
have been selected by the ICRP to be representative
of the relative biological effectiveness of specified
types and energies of radiation incident on the surface of the body in inducing stochastic effects at low
doses (ICRP, 1991b). The present weighted absorbed
dose has been given the name equivalent dose and
the symbol HT. The special name of sievert (symbol
Sv) has been given to the unit of equivalent dose;
1 Sv 1 J/kg. The ICRP uses a radiation weighting
factor of unity (1 Sv/Gy) for photons of all energies,
so for the x rays used in medical imaging organ dose,
DT, expressed in Gy is numerically equal to equivalent dose, HT, expressed in Sv.
The radiation weighting factor is intended to do no
more than to provide a rough indication of the
changes in the biological effectiveness with radiation
quality, but it was often interpreted to imply spurious precision, which the ICRP (1991b) hopes no
longer will be the case. Deviations in radiobiological
effectiveness (RBE) from unity can occur. For
instance, for the low-energy photons employed in
mammography, Brenner and Amols (1989) suggest
an RBE of about 2 compared to higher-energy
gamma rays and of 1.3 compared to 80 kV x rays.
The relationship between the probability of stochastic effects and equivalent dose also depends on the
organ or tissue irradiated. In medical x-ray imaging
more than one organ is often irradiated. It might
therefore be useful to combine the doses to different
tissues in such a way that the combined value is
likely to correlate well with the total of the stochastic
effects. For the radiological protection of workers
The threshold doses for deterministic effects are

not approached in most applications in diagnostic
radiology. However, this is not the case for, e.g.,
interventional radiology where cases of erythema,
more serious skin injuries and epilation have been
reported following extensive periods of fluoroscopic
imaging (ICRP, 2000). If deterministic effects are
considered to be a possibility, the absorbed dose to
the more heavily irradiated regions of tissues at the
surface of the body is the radiation quantity of interest. The more heavily irradiated tissues will usually
comprise those localized areas of the skin that lie
within the primary x-ray beam for the longest time
during these interventional procedures. The mean
absorbed dose DT,local or Dskin,local (see also the following section) in the localized region of tissue of
interest is then the required quantity, where the
subscript skin,local denotes the tissue region in
which the absorbed dose is determined, also the
material in which the dose is expressed should be
indicated. The present quantity is also referred to as
peak skin dose (Miller et al., 2002).
3.3.2 Absorbed dose for assessment of
stochastic effects (organ dose)
Absorbed dose, D is defined in Section 3.1 at a
point. The ICRP has recommended that the appropriate dosimetric indicator for the probability of
stochastic radiation effects is the average absorbed
dose in a tissue or organ (ICRP, 1991b). In ICRU
Report 51 (1993b) the mean absorbed dose in a specified organ or tissue T has been given the symbol DT
and is defined either as the integral of the absorbed
dose Dt over the mass of the tissue divided by its
mass mT
Z
1
DT
Dt dm,
3:30
mT mT
31
for example by applying the nominal fatality coefficients (ICRP, 1991b), for assessment of detriment
from exposure due to medical x-ray imaging. Such
assessments could be inappropriate because of
potential differences in health status, gender, and
age between a particular group of patients and the
reference population for whom the ICRP derived the
risk coefficients. Furthermore, the conditions of low
dose and especially of low dose rate may not always
be met in practice in medical imaging. For an assessment of the risk due to induction of stochastic
and deterministic effects by medical x-ray imaging
detailed knowledge is required of organ doses,
absorbed-dose distribution, and the age and gender
of the group of patients concerned, rather than
effective dose. Therefore, in the present Report
effective dose is not further discussed.
and the whole population, the ICRP (1991b) has

defined the factor by which the equivalent dose in a
tissue or organ has to be weighted, called the tissue
weighting factor, wT. The tissue weighting factor
represents the relative contribution of that organ
or tissue to the total detriment due to these
effects resulting from uniform irradiation of the
whole body.
The effective dose E (ICRP, 1991b) is defined as
the sum of the weighted equivalent doses in all the
tissues and organs of the body
X
E
wT HT :
3:32
T
As it is desirable that a uniform equivalent dose to

the whole body should give an effective dose numerically equal to that uniform equivalent dose (ICRP,
1991b), the sum of the tissue weighting factors is
normalized to unity
X
wT 1:
3:33
3.4 DOSE-CONVERSION COEFFICIENTS FOR

ASSESSMENT OF ORGAN AND TISSUE DOSES
A conversion coefficient, c, relates a dosimetric

quantity to some other quantity, i.e., the normalization quantity, which can be readily measured or calculated in the clinical situation. In general
The values of the tissue weighting factor proposed

by the ICRP are independent of the type and energy
of the radiation incident on the body. These simplifications may be no more than approximations of the
true biological situation (ICRP, 1991b). The consequences following an absorbed dose also depend
on the distribution of the dose in time. The effect of
all exposure conditions other than those dealt with
by the radiation and tissue weighting factors is covered by using different values of the coefficients
relating equivalent dose and effective dose to the
probability of stochastic effects, rather than by
using additional weighting factors in the definitions
of the quantities (ICRP, 1991b).
The values of both the radiation and tissue weighting factors depend on current knowledge of radiobiology and may change from time to time (ICRP,
1991b). Although such changes are infrequent they
can cause confusion. The definitions of equivalent
dose and effective dose are not confined to any particular set of these weighting factors. If values of
weighting factors other than those recommended
by the ICRP (1991b) are used, this fact should be
clearly stated and the values should be explicitly
given when the quantities are introduced.
For the estimation of the likely consequences of an
exposure of a known population, it will be sometimes
better to use absorbed dose and specific data relating
to the relative biological effectiveness of the radiations concerned and the probability coefficients
relating to the exposed population (ICRP, 1991b).
In medical x-ray imaging, both the irradiation conditions and the exposed group of patients are in
principle known. Effective dose should not be used,
specified dosimetric quantity

:
normalization quantity
3:34
For stochastic effects, the specified dosimetric

quantity is either the mean absorbed dose in an
organ, DT or in a specialized tissue of interest, such
as glandular tissue in the breast. For deterministic
effects, the specified dosimetric quantity is the
absorbed dose to the more heavily irradiated regions
of tissues at the surface of the body; the tissue of
interest is usually the localized region of skin that
lies in the primary x-ray beam and receives the highest absorbed dose for an interventional procedure. In
all cases, the subscript T, for the general case, may
be replaced with the specific tissue or organ of interest when it is deemed helpful, for example, Dstomach
for the specific organ, DG for glandular tissue in the
breast, and Dskin,local for the skin region in the primary beam receiving the highest absorbed dose.
For general radiology of adults and children, the
specified dosimetric quantity is the organ dose, DT.
The incident air kerma, Ka,i, the entrance surface air
kerma, Ka,e, or the air kermaarea product, PKA, is
used as a normalization quantity. Thus
cT;Ka;i
DT
:
Ka;i
3:35
Unit: (J/kg)/(J/kg), or Gy/Gy, or

cT;Ka;e
32
DT
:
Ka;e
3:36

Unit: (J/kg)/(J/kg), or Gy/Gy, or
cT;PKA
DT
:
PKA
(ICRP, 1991b) can be specified. These have been

variously called reference dose values (EC, 1996a),
diagnostic reference levels (ICRP, 1996), or guidance
levels (IAEA, 1996a).
The ICRP (1996) introduced the concept of
diagnostic reference levels (DRLs) for patients. For
diagnostic radiology, the ICRP states that these
levels, which are a form of investigation level,
apply to an easily measured quantity at the surface
of a simple standard phantom or a representative
patient. The ICRP characterizes an investigation
level as a threshold set by operating management
that calls for local investigation (often very simple) if
exceeded. The ICRP recommends that diagnostic
reference level (DRL) values should be selected by
professional medical bodies and reviewed at intervals that represent a compromise between the necessary stability and the long-term changes in the
observed distributions.
In Europe, DRLs are being introduced in legislation. In the Council Directive 97/43/Euratom (EC,
1997) it is stated that Member States of the European Union shall promote the establishment and use
of diagnostic reference levels for diagnostic x-ray
examinations. EC (1997) states that the appropriate
regulatory authorities within each Member State
are required to ensure that guidance on the establishment and use of DRLs is available, having regard
to European DRLs where available.
Finally, it is stressed that DRLs are aimed at
the management of patient doses consistent with the
clinical imaging information that is required.
This means that in individual cases, the exceeding
of DRLs may be justified in terms of a clinical
requirement, for example, need for additional
diagnostic information, or the unexpected difficulty
of a procedure.
In practice, DRLs have frequently been set using
the distribution of dosimetric quantities observed in
national surveys, by taking the third quartile value
(75 % of the results are equal to or below this value)
of the observed distribution (Shrimpton et al., 1986;
IPSM, NRPB and CoR, 1992; IAEA, 1996a). Periodic
monitoring of the dosimetric quantities (IPSM,
NRPB and CoR, 1992) in the UK for common conventional x-ray examinations has shown that the
mean and third quartile values of the observed distributions dropped by about 30 % since an earlier
national survey in the 1980s (Shrimpton et al., 1986;
Hart et al., 1996c).
The present report adopts the term DRL from the
ICRP (1996). Local performance can be checked
against DRLs by periodic measurement as part of a
quality assurance program. The dosimetric quantities used for DRLs are presented in this section. In
interventional radiology, a combination of various
3:37
Unit: (J/kg)/(Jcm2/kg), or Gy/(Gy/cm2).

In mammography, the specified dosimetric quantity is the mean glandular dose, DG. Conversion coefficients are available relating the incident air kerma,
Ka,i to DG. Thus
cG;Ka;i
DG
:
Ka;i
3:38
Unit: (J/kg)/(J kg), or Gy/Gy.

For CT, when stochastic effects are of interest, the
specified dosimetric quantity is the organ dose, DT,
and the CT air kerma index, CK, may be used as
normalization quantity. Thus
cT;CK
DT
:
CK
3:39
Unit: (J/kg)/(J kg), or Gy/Gy.

In relation to deterministic effects that may occur
in interventional radiology, the specified dosimetric
quantity should be the maximum absorbed dose to
the localized region in the primary x-ray beam, for
example, skin region. The measurement of the present quantity is complicated, however, because the
skin location of maximum dose is not usually known
a priori. To date, only Ka,i, has been used as a normalization quantity in conversion coefficients for
deterministic effects in interventional radiology
(Stern et al., 1995a). The dose-conversion coefficients are given by Eq. (3.36), with DT being replaced
by mean absorbed dose to a localized region of tissue
in the primary beam, DT,local.
3.5 QUANTITIES RECOMMENDED
FOR ESTABLISHMENT AND USE OF
DIAGNOSTIC REFERENCE LEVELS
Numerous surveys have shown wide variations
in the magnitude of absorbed dose to the patient
for the same type of x-ray procedure performed at
different facilities or even within the same facility
(Adrian Committee, 1960; NEXT, 1978; Wochos
et al., 1979; Burkhardt, 1984; Shrimpton et al.,
1991; EC, 1996c; CRCPD, 2002). This has focussed
attention on the possibility of using reference
values as guidance for the levels that can be
achieved using good radiographic technique and
appropriate x-ray equipment, particularly to
foster elimination of values at the high end of the
distributions. As an aid to the optimization of
absorbed dose to the patient, reference values
33
quantities is considered useful, for example, fluoroscopy time, total number of images and air
kermaarea product.
coefficients are model-dependent. They are discussed in Appendix E.

3.5.2 Incident air kerma rate and
entrance-surface air kerma rate
3.5.1 Incident air kerma and

entrance-surface air kerma
Incident air kerma rate and entrance surface air

kerma rate, K_ a;i and K_ a;e , for a specified series of
patients or a specified phantom are recommended
quantities for the establishment and use of DRLs in
fluoroscopy. They provide a useful measure for comparing patient dose rates for a given projection when
the beam areas and directions and the radiation
qualities are similar.
Incident air kerma and entrance surface air

kerma, Ka,i and Ka,e, for a specified series of patients
or a specified phantom are recommended quantities
for the establishment and use of DRLs in medical
x-ray imaging for simple examinations, i.e., projection radiography. They give no indication of the
extent of the beam or of the area of the patient
being irradiated. They provide a useful measure for
comparing patient doses for a given projection when
the beam areas and directions, and the radiation
qualities are similar.
Incident air kerma and entrance surface air
kerma, Ka,i and Ka,e, are also useful quantities for
interventional radiology when deterministic effects
in skin or other surface tissues are considered. In
this case, they are not used as a DRL, but as a direct
indicator of the maximum absorbed dose in the localized tissues such as skin, also referred to as peak
skin dose (Miller et al., 2002). The ICRP has found
Ka,i to be very useful in monitoring, prior to (through
clinical protocols) and during procedures (with inplace measurement devices), when threshold levels
for deterministic effects are likely to be approached
or exceeded (ICRP, 2000).
3.5.1.1
3.5.3
Air kermaarea product
The air kermaarea product PKA for a specified

series of patients or a specified phantom is a
recommended quantity for the establishment and
use of DRLs for general radiography and for
complex procedures involving radiography and
fluoroscopy. Quantity PKA includes a measure of
the area of the beam as well as the incident air
kerma. It provides a useful measure for comparing
patient doses for a given procedure when the
beam areas and directions, number of images,
fluoroscopy time, and the radiation qualities are
similar. However, when these parameters are not
reasonably similar, comparison of PKA values as
a measure of the resulting organ doses can be
misleading.
Mean mammary glandular dose
3.5.4
For mammography, DG is the recommended

quantity for the establishment and use of DRLs. It
is not measured directly, but is derived from Ka,i or
Ka,e for a specified series of patients or a specified
phantom using conversion coefficients. Values of
conversion coefficients are available as a function of
HVL1 for compressed breasts of various thickness
and composition as well as for reference phantoms.
It is important to note that these conversion
CT air kermalength product, PKL,CT
The CT air kermalength product PKL,CT determined for the standard CT dosimetry phantoms is
proposed by the EC (2000) as a quantity for establishment and use of DRLs for a complete CT
examination. Since there is only limited experience
with the use of the CT air kermalength product
for establishment and use of DRLs, this quantity
is recommended provisionally in the present
Report.
34

MEASUREMENT METHODS
Methods are required for the measurement of normalization quantities used in the dose-conversion
coefficients and of quantities recommended for
establishment and use of DRLs. Measurements of
these quantities rely on the use of (i) ionization
chambers, or (ii) solid-state dosimeters, including
those employing radiothermoluminescence. Calibration procedures and accuracy requirements for
these dosimeters when applied to measure x rays
used in medical imaging are discussed first.
4.1 MEASUREMENT AND QUALITY

ASSURANCE OF DOSIMETERS
The general properties of an instrument type are
characterized during type testing, when the
response to different radiation energies, angles of
incidence, doses, dose rates, and other influencing
parameters are measured. International standards
for type testing is usually applied (IEC, 1997, 2000),
which specify test methods and performance
requirements.
Before use, a given instrument must be calibrated
to determine the relationship, under specified conditions, between the value indicated by the instrument
and the known value of the quantity of interest
(BIPM, IEC, ISO and OIML, 1984). Thereafter recalibrations should be made at intervals not exceeding 2 years, and whenever the instrument has been
repaired or its performance is suspect (AAPM, 1992;
Robertson et al., 1992).
The complexity of the calibration procedure
depends on the particular type of instrument and
its intended use. Re-calibration at one radiation
quality, namely, the reference quality, is often sufficient, as it is unlikely that the dependence of the
response on radiation energy would change significantly. Re-calibration at a single or a few points on
the measurement range will usually be sufficient.
However, sometimes it will be important to check
comprehensively the dependence of the response on
the dose rate, particularly if the dosimeter is used at
widely varying dose rates. In the case of ionization
chambers, it is also important to apply a correction
for temperature and pressure at the time of
calibration, unless the chamber is sealed to the

atmosphere or if the electrometer device automatically corrects for the density of air. If the electrometer
device automatically corrects for the density of air,
the calibration of accuracy of this correction needs
to be checked. Corrections for ion recombination are
usually insignificant but must be considered when
using very high instantaneous dose rates. Corrections for humidity do not have to be applied.
Simple constancy checks and checks of the various
functions are recommended before each use of the
instrument. Constancy checks may be carried out
using a special check source, in a reproducible
source-detector geometry. Standard uncertainty
due to statistical means (type A uncertainty) should
be 3 % at maximum.
The results of calibration are generally expressed
using a calibration coefficient N
N
K
,
M
4:1
where M is the reading of the instrument, corrected

for influence quantities such as temperature and
pressure, in the known calibration field and K is
the value of the desired quantity in the field. The
desired quantity in any unknown field can then be
obtained by multiplying the reading of the instrument in this field by the calibration coefficient N.
For most dosimeters used in medical imaging, the
desired quantity, K of Eq. (4.1), for the calibration is
the air kerma free-in-air, Ka, in units of gray. The
value obtained for the desired quantity at the time of
calibration must be traceable to the international
measurement system, i.e., it must be related to
appropriate primary standards through an unbroken
chain of comparisons. The calibration of a field
instrument is performed under well-defined conditions by comparison of the reading of the instrument
with that of a reference instrument. The reference
instrument is usually a secondary standard or a tertiary standard, calibrated by comparison with a
primary standard or a secondary standard, respectively. Requirements for the characteristics and performance of reference and field instruments have
been published by the AAPM (1992).
used. For CT, x-ray tubes with a tungsten target

and added copper filtration should be used. For
mammography, x-ray tubes with a molybdenum target and molybdenum filter should be used.
The radiation quality is a description of the radiation field by a set of identifying characteristics,
such as x-ray tube voltage, total filtration, and
HVL (Section 2.2). For the reasons described above,
special radiation qualities closely simulating the
actual field conditions have been established, for
both attenuated and unattenuated beams in conventional radiology, for CT, and for beams in mammography (IEC, 2004). The attenuated beam qualities
are specified to simulate the beam, which has passed
through the patient. It is recommended that these
radiation qualities be used. Examples for radiography, CT, and mammography are given in
Tables 4.1, 4.2, and 4.3, respectively.
The requirement for traceability of calibrations
with a small uncertainty necessitates the use of the
same radiation qualities in all steps, i.e., for the
measurements and comparisons with the primary
standard and for the measurements and comparisons
with the reference standard (secondary and tertiary
standards). If the reference standard is calibrated
using other radiation qualities, then the uncertainty
of the calibration of a field instrument and the usefulness of adopting the special diagnostic qualities
will depend on the quality of the reference standard,
mainly on the constancy of its response with x-ray
energy.
Air kerma rates used during the calibration
should ideally cover the complete range of air
kerma rates stated for the instrument, i.e., the
range within which the instrument will meet its
specified performance. Air kerma rates up to
10 mGy/s, 100 mGy/s, and 500 mGy/s are usually
needed for dose measurements for conventional
diagnostic radiology, mammography, and CT,
respectively.
The expanded uncertainty of the calibration
should be estimated and shown to be within the
requirement of 5 %. An example of the uncertainty
estimation is given in Table 4.4. This example
is referring to a modern primary standards
laboratory.
Guidance on the estimation of the uncertainties
can be found elsewhere (ISO, IEC, OIML, BIPM,
1992; IAEA, 1994). An international code of
practice for patient dosimetry in diagnostic radiology is presently being developed by the IAEA
(Pernicka et al., 2001). It will include practical
details of calibrations at the standards laboratory
and field measurements. Values for the upper
lmits for the uncertianties for calibration of
dosimeters for medical x-ray imaging at Secondary
The uncertainty of dose measurements in medical

x-ray imaging, for comparative risk assessments
as well as for quality assurance, should not exceed
7 % (AAPM, 1992). The requirement is given in
terms of the expanded uncertainty1 using a coverage
factor of 2. For a more detailed discussion of uncertainties see ISO, IEC, OIML, BIPM (1992), and
IAEA (1994, 2000). For a normal distribution of
uncertainties, the use of a coverage factor of 2
corresponds to the confidence level of 95 %. Considering all steps that contribute to the measurement
uncertainty, this implies that the expanded uncertainty of the calibration should not exceed 5 %
(AAPM, 1992).
Standards laboratories have established welldefined conditions for the calibration of instruments.
However, the actual radiation field in which the
instrument is used may differ in energy and spatial
distribution from that of the calibration field. Hence,
depending mainly on the instrument design, the calibration coefficient obtained may not accurately
apply to the radiation field during the actual measurements. Because of this extra uncertainty, special
calibration conditions closely simulating the actual
measurement conditions in diagnostic radiology
have been developed and recommended (IEC, 2004;
Section 4.1.1).
In a few cases the calibration of dosimeters at the
well-defined conditions of the standards laboratory
is neither possible nor feasible. Air kermaarea
product meters, which are part of a defined mechanical set-up of the x-ray equipment, should be calibrated in situ. For TLDs, it is more appropriate to
carry out the calibration at the actual field conditions. The calibration of air kermaarea product
meters is discussed in more detail in Section 4.1.2
and that of TLDs in Section 4.1.3.
4.1.1 Calibration of dosimeters in terms of

air kerma free-in-air
For the calibration of dosimeters used in medical
imaging, in terms of air kerma free-in-air, an appropriate arrangement of x-ray generator and tube,
collimators, shutter, filters, and monitor chamber is
needed (IAEA, 1994). For the calibration of dosimeters used for medical imaging except mammography,
x-ray tubes with a tungsten target should be
1
The expanded uncertainty is equal to the combined standard uncertainty multiplied by the coverage factor. The
combined standard uncertainty is obtained by combining
in quadrature the standard deviations corresponding to
the uncertainties estimated by statistical means (type A
uncertainties) and by non-statistical means (type B uncertainties) cf. Table 4.4.
36
MEASUREMENT METHODS
Table 4.1. Examples of standard radiation qualities for the calibration of dosimeters in general radiography (Reproduced
from IEC, 2004, with permission from IEC)*. An emitting target of tungsten for the x-ray tube is specified. RQR qualities
refer to unattenuated beams and RQA qualities to attenuated beams.
Radiation
quality
Approximatea x-ray
tube voltage/kV
Added filtration/mm Al
(simulating
patient thickness)
Nominal first
HVL/mm Alb
Homogeneity
coefficient
RQR 2
RQR 3
RQR 4
RQR 5c
RQR 6
RQR7
RQR 8
RQR 9
RQR 10
RQA 2
RQA 3
RQA 4
RQA 5d
RQA 6
RQA 7
RQA 8
RQA 9
RQA 10
40
50
60
70
80
90
100
120
150
40
60
60
70
80
90
100
120
150
1.42
1.78
2.19
2.58
3.01
3.48
3.97
5.00
6.57
2.2
3.8
5.4
6.8
8.2
9.2
10.1
11.6
13.3
0.81
0.76
0.74
0.71
0.69
0.68
0.68
0.68
0.72
4
10
16
21
26
30
34
40
45
Approximate means: adjust the tube voltage.

The purity of the aluminium should be at least 99.8 % (ICRU, 1964).
c
This value is generally selected as the reference radiation quality for unattenuated beams for general radiography applications.
d
This value is generally selected as the reference radiation quality for attenuated beams for general radiography applications.
*The author thanks the International Electrotechnical Commission (IEC) for permission to reproduce information from its International
Standard IEC 61267. All such extracts are copyright of IEC, Geneva, Switzerland. All rights reserved. Further information on the IEC is
available from www.iec.ch
b
Table 4.2. Examples of standard radiation qualities for

the calibration of dosimeters in CT (Reproduced from IEC,
2004, with permission from IEC)*. An emitting target of
tungsten for the x-ray tube is specified.
Radiation
quality
RQT 8
RQT 9c
RQT 10
Approximatea
x-ray tube
voltage/kV
Added filtration/
mm Cu (simulating
patient thickness)
Nominal
first HVL/
mm Alb
100
120
150
0.2
0.25
0.3
6.9
8.4
10.1
Table 4.3. Examples of standard radiation qualities for the

calibration of dosimeters in mammography (Reproduced
from IEC, 2004, with permission from IEC)*. An emitting
target of molybdenum for the x-ray tube is specified. RQRM qualities refer to unattenuated beams and RQA-M
qualities to attenuated beams.

The purity of the aluminum should be at least 99.8 % (ICRU,
1964).
c
This value is generally selected as the reference radiation quality
for CT.
*See Table 4.1.
b
Radiation
quality
Approximatea
x-ray tube
voltage/kV
Added filtration/mm
Al (simulating
patient thickness)
Nominal
first HVL/
mm Alb
RQR-M1
RQR-M2c
RQR-M3
RQR-M4
RQA-M1
RQA-M2
RQA-M3
RQA-M4
25
28
30
35
25
28
30
35
2
2
2
2
0.28
0.31
0.33
0.36
0.56
0.60
0.62
0.68
4.1.2 Calibration of air kermaarea

product meters

The purity of the aluminium should be at least 99.8 % (ICRU,
1964).
c
This value is generally selected as the reference radiation quality
for mammography (both RQR-M and RQA-M series).
*See Table 4.1.
The calibration of air kermaarea product meters

should be carried out every time a meter is installed
on a different x-ray set, whenever ionization chambers or electrometers are changed, or at least once a
year if the instrument is permanently installed on

the same equipment (IPSM, NRPB and CoR, 1992).
The response of the meter, i.e., the indicated value
divided by the true PKA value at the entrance plane
Standards Dosimetry Laboratories will be recommended by the IAEA.
37

Table 4.4. Estimated relative uncertainties for the calibration of a dosimeter for medical x-ray imaging using the standard
radiation qualities RQR.
Type A uncertaintya
(1 SD) %
Uncertainty component
Type B uncertaintyb
(1 SD) %
Measurement of air kerma with the reference instrument (secondary or tertiary standard)
Air kerma calibration coefficient of the reference instrument
0.56
Constancy of the air kerma calibration coefficient
Reading accuracy
0.50
Differences in calibration spectra
Correction for temperature and atmospheric pressure
0.03
Correction for ion recombination
Measurement of air kerma with the instrument to be calibrated
Positioning at the calibration distance
Non-uniformity of the calibration field
Correction for temperature and atmospheric pressure
Reading accuracy
0.81
0.29
0.58
0.00
0.06
0.06
0.03
0.50
Square root of the sum of squares

Combined standard uncertaintyc
Expanded uncertainty with coverage factor of 2d
0.90
1.04
1.38
2.76
The uncertainty at one standard deviation estimated by statistical means (ISO, IEC, OIML, BIPM, 1992; IAEA 1994).
The uncertainty at one standard deviation estimated by non-statistical means (ISO, IEC, OIML, BIPM, 1992; IAEA 1994).
c
The combination in quadrature of the standard deviations corresponding to type A and type B uncertainties.
d
The combined standard uncertainty multiplied by the coverage factor (ISO, IEC, OIML, BIPM, 1992; IAEA 1994).
b
be determined using a densitometer measuring the

area bounded by the line on a suitably exposed film
where the optical density falls to 50 % of its maximum value. Examples of calibration procedures
are given by IPSM, NRPB and CoR (1992), and by
Larsson et al. (1996, 1998).
Type testing of air kermaarea product meters
(IEC, 2000) by the manufacturers should establish
that the response is uniform over the entire area of
the ionization chamber and is sufficiently unaffected
by changes in x-ray quality and dose rate. If the
calibration or type testing is performed at a standards laboratory, the radiation qualities given in
Table 4.1 should be used. The expanded uncertainty
of the calibration should not exceed 5 %, so that the
calibrated instrument is capable of measurements
with the required uncertainty of 7 % for the x-ray
qualities and dose rates encountered in practice.
Experience with the ageing of air kermaarea product meters, for example, when installed at interventional radiology systems and submitted to very large
doses during several years, is still limited.
of the patient, will depend on whether the chamber

is installed on an overtable or undertable x-ray
tube. In the latter case the table will attenuate the
x-ray beam before it reaches the patient. Scatter
conditions may also differ from one installation to
another. There may be inhomogeneities in the x-ray
field due to the heel effect and extra focal radiation,
whose magnitude will be equipment-dependent.
Consequently, air kermaarea product meters,
which are part of a defined mechanical set-up in
the equipment, cannot be calibrated at a standards
laboratory but must be calibrated in situ (IPSM,
NRPB and CoR, 1992).
The desired quantity for air kermaarea product
meters is not simply air kerma but the air
kermaarea product, PKA in units of Gy cm2. The
traceability chain is established through the air
kerma calibration of the reference instrument, as
for simple dosimeters, and through the use of a sufficiently accurate method to measure the beam area.
Calibration of air kermaarea product meters
should be performed with an x-ray field size not
larger than about 10 cm 10 cm to avoid significant
non-uniformity in the dose rate across the beam. The
x-ray tube should be positioned at its customary distance from the table (Wall, 1989). Calibration measurements should be made at a position 20 cm above
the table, where a reference dosimeter and a film
cassette can be conveniently positioned to measure
the air kerma and the field area at the same plane
perpendicular to the beam axis. The beam area can
4.1.3
Calibration of TLDs
The sensitivity of TLD systems needs to be

checked regularly by measuring the response to xray exposures of known magnitude and quality. The
magnitude is to be determined in terms of the air
kerma obtained by a reference dosimeter that has
been calibrated in a manner that is traceable to
38
MEASUREMENT METHODS
1
0.95
Relative response
0.9
0.85
0.8
0.75
C80
Free-in-air
C60
Free-in-air
Mo/Mo PMMA-phantom
0.7
Mo/Mo Free-in-air
0.65
0.6
15
30
45
60
75
90
Angle of radiation incidence (degree)

Figure 4.1. Calculated relative response of a 3.2 mm 3.2 mm 0.9 mm LiF TLD-700 detector as a function of orientation of the detector
during irradiation in Mo-filtered 28 kV (Mo anode), 80 kV (C60; HVL1 2.76 mm Al) and 120 kV (C80; HVL1 6.31 mm Al) x-ray beams.
0 angle indicates radiation incident perpendicular to the largest surface of the detector. For the 28 kV x rays data are presented for
irradiation free-in-air and for irradiation at a depth of 5 mm in a PMMA phantom. The statistical (type A) standard uncertainties are less
than 1, 2.5, 1, and 1 % for Mo/Mo free-in-air, Mo/Mo in-phantom, C60, and C80, respectively. C60 and C80 are beam qualifications of
Seelentag et al. (1979) (Zoetelief et al., 2000).
to measure Ka,e on patients, calibration on a phantom might be more appropriate. In the latter
case Ka,e should be derived from Ka,i obtained
with a reference dosimeter calibrated in terms of
air kerma and employing air kerma based backscatter factors, B according to Eq. (3.15). A set of backscatter factors was selected by Petoussi-Henss et al.
(1998) to be used for the calibration of dosimeters onphantom. When used for measurement of Ka,e on
patients, TLDs are usually encapsulated to protect
them against dirt, grease, etc. Consequently, the
TLDs should be calibrated inside the encapsulation
used.
The response of a given TLD can be affected by the
shape and size of the detector and packaging and is
dependent on the direction of the incoming radiation
(McKinlay, 1981; Oberhofer and Scharmann, 1981;
Horowitz, 1984; McKeever et al., 1995), differing
upon exposure free-in-air or in-phantom (Figure 4.1;
Zoetelief et al., 2000). Therefore, the direction of the
radiation during calibration should be the same as
that during the patient dose measurements. For
example, for measurement of the CT axial air
kerma profile for CT using stacks of TLD chips, the
calibration of the TLD chips should be based on calibration normal to the side of the stack.
the national primary standard of air kerma. These

regular TLD calibration measurements should be
carried out at a dose and with an x-ray spectrum
typical of those to which the TLDs will be exposed
during patient-dose measurements. An air kerma
of 10 mGy and an x-ray spectrum generated at a
tube voltage of 80 kV with 3.0 mm Al total filtration will usually be appropriate for measurements
for conventional radiography.
It will also be necessary to make at least one series
of measurements to establish how the response per
unit of air kerma varies over the entire range of air
kerma, air kerma rates, and x-ray qualities for
which the TLDs are to be used. Ideally, this variation should be so small that if the response of the
TLDs is determined at one suitable air kerma value,
air kerma rate, and x-ray quality, it could be used
without correction for measurements under any
other conditions, within the required accuracy of
7 %. However, this may not be possible in practice,
and appropriate energy response or other correction
factors may have to be applied to keep the uncertainties within tolerance.
Calibrations of TLDs are usually performed
free-in-air in terms of air kerma. As TLDs applied
in medical x-ray imaging are commonly employed
39
4.2 MEASUREMENT METHODS FOR

SPECIFIC DOSIMETRIC QUANTITIES
4.2.1
radiation qualities will, however, overcome the latter problem. Ionization chambers and their energy
response for mammography beams have been published by DeWerd et al. (2002).
Dosimeters
For dosimetry in medical x-ray imaging, ionization chamber systems and TLD systems are most
commonly used. Suitable ionization chamber dosimeters have advantages over TLD systems in that
their accuracy, precision, and energy independence
are better. In addition, ionization chambers can be
read out directly, contrary to TLDs, which have to be
transported to a reading system after irradiation.
Advantages of TLDs are their small size, which
make them suitable for dose measurements on
patients, and their capacity of storing dose information over longer periods of time. This makes them
suitable for dosimetry at a distance, for example, at a
central laboratory, TLDs being transported by mail.
Scintillation as well as film dosimeters have also
been used for measurements on patients (Section
4.4), their main characteristics are presented in
this section.
4.2.1.1
4.2.1.2
TLDs
Discussion of general aspects of thermoluminescent dosimetry can be found elsewhere (McKinlay,

1981; Oberhofer and Scharmann, 1981; McKeever
et al., 1995; Zoetelief et al., 2000, 2003b). TLDs
have to be read out and annealed carefully to obtain
reliable results. TLDs can be stuck directly and
unobtrusively to the patients skin with very little
interference in patient mobility or comfort. They will
adequately measure the radiation backscattered
from the patient, and they are unlikely to obscure
useful diagnostic information on images made. TLDs
are available in a variety of physical forms and in
different materials. Solid chips are the most convenient form for application to dosimetry in medical
x-ray imaging.
Lithium fluoride and lithium borate are the most
commonly used phosphors for dosimetry in medical
imaging, combining the desirable features of a relatively flat energy response, low fading characteristics, and reasonable sensitivity. With careful use and
proper calibration they should be capable of measuring doses down to 500 mGy with an expanded uncertainty of <10 % (with a coverage factor of 2). At
100 mGy, the expanded uncertainty is increased to
<25 %. Smaller uncertainties at low doses can be
achieved with the considerably more sensitive calcium fluoride phosphor, but this material is less airequivalent and exhibits a marked variation in energy
response that requires careful calibration at appropriate x-ray qualities to achieve accurate measurements. The sensitivity and the accuracy of lithium
fluoride TLDs at doses <50 mGy can be considerably
improved by using deconvolution techniques to separate out the individual peaks in the glow curve (Bos
et al., 1993, 1994). Alternatively, high-sensitivity
material doped with magnesium, copper, and phosphorus (Wu et al., 1984; Fill and Regulla, 1998; Saez
et al., 1999) can be used. The main characteristics
(see, e.g., Vij, 1993; McKeever et al., 1995) of four
TLD phosphors are shown in Table 4.5. The energy
dependence of six commonly used chips is shown in
Figure 4.2 (Zoetelief et al., 2000).
Ionization chamber dosimeters
General information on dosimetry using ionization chambers can be found elsewhere (ICRU, 1970,
1973; Boag, 1987; IAEA, 1996b). More detailed
information relevant to medical imaging has been
published by Dutreix and Bridier (1985), for
example. Some aspects, specific to medical x-ray
imaging are presented below. Free-in-air air kerma
measurements are best made with suitably designed
ionization chambers of typically between 0.6 and
180 cm3 volume. The chambers should have airequivalent walls so that their energy response in
terms of air kerma is substantially uniform for all
relevant x-ray spectra. The leakage current should
be very small compared with the ionization current
produced by the minimum dose rate to be measured
and the response should not be affected appreciably
by ion recombination at high dose rates. Dosimeters
should be calibrated in a manner traceable to a
national primary standard of air kerma as described
in Section 4.1.
There are special requirements for ionization
chambers used for air-kerma measurements in
mammography: these are a thin entrance wall to
reduce attenuation at low photon energies, and ideally a structure that does not appreciably disturb the
primary radiation field. Thin entrance window
chambers with small volumes generally have a
rather massive construction on the exit side, which
implies that the charge produced in the cavity contains a significant contribution from scattered radiation. Calibration at appropriate mammographic
4.2.1.3
Scintillation dosimeters
General characteristics of scintillation dosimeters

can be found in Knoll (2000), for example. The
energy dependence of plastic scintillation dosimeters in the energy range used in radiology has been
studied by several authors. Wagner and Pollock
40
MEASUREMENT METHODS
The radiological film dosimeter is known to have a
very poor tissue-equivalence, because of the high
atomic number of the film emulsion. Two types of
slow KODAK films have been investigated with
respect to their use in interventional radiology. The
X-OMAT-V film, with a long tradition as a radiotherapy portal dose verification film, shows an increase
in sensitivity by a factor of 20 at peak tube voltage of
70 kV compared with 60Co gamma rays (1.17 and
1.33 MeV) (Vano et al., 1997). The more recent
EDR2 film does not show a significant variation in
sensitivity between peak tube voltages of 60 and
110 kV (Guibelalde et al., 2003).
Using X-OMAT-V films doses of up to 500 mGy can
be explored and the corresponding linear dose range
is from 20 to 200 mGy. For the EDR2 film, doses up to
1000 mGy can be measured and the linear dose range
is from 50 to 500 mGy (Guibelalde et al., 2003). The
EDR2 film is, thus, more suitable for higher-dose
radiological procedures than the X-OMAT-V film.
The tissue-equivalence of the radiochromic film is
considerably better than that of the radiological film,
consequently less variation of its response as a function of energy is expected. Nevertheless, a sensitivity
variation of up to 5 % between peak tube voltages of
60 and 100 kV has been observed by Giles and
Murphy (2002). For the radiochromic film dosimeter
the dose dependence has been found to be linear up
to an absorbed dose of 10 Gy (Giles and Murphy,
2002). This type of film is thus particularly suited
to evaluate the high doses delivered to the most
heavily irradiated regions, for example, the skin
during some interventional radiological procedures.
Relative TL response, normalised to 1 MeV photons
100
CaF2:Dy
10
CaSO4:Dy
Al2O3:C
LiF:Mg,Ti
1
Li2B4O7:Mn,Si
BeO
0.1
10
100
Photon energy (keV)
1000
Figure 4.2. Calculated energy responses relative to air of some

commonly used TL chips. Calculations were performed, assuming
a thickness of 0.9 mm for all detectors (Zoetelief et al., 2000).
(1999) found for this type of dosimeter a sensitivity

variation as a function of energy within 5 %
between peak tube voltages of 60 and 125 kV. This
value is confirmed by De Sousa et al. (2000), who
found a sensitivity variation of 10% between tube
voltages of 60 and 140 kV and 25 % between 50 and
140 kV. According to Waite and Fitzgerald (2001) the
variation of the sensitivity of scintillation dosimeters
above tube voltages of 90 kV was similar to that of a
calibrated ionization chamber but deviated at lower
tube voltages values.
The sensitivity of a scintillation dosimeter as a
function of absorbed dose has also been investigated.
Linear dependence of the signal as a function of dose
was observed for absorbed dose up to 60 mGy (De
Sousa et al., 2000) and up to 20 Gy (Wagner and
Pollock, 1999). For doses <0.3 mGy the accuracy
markedly decreases (De Sousa et al., 2000).
4.2.2
Incident air kerma
There are usually several steps required to determine incident air kerma. The most commonly used
method of determining Ka,i relies on the measurement of the x-ray tube output, Y(d) (Sections 2.5 and
3.2.1). To derive Ka,i, Y(d) has to be corrected for the
focal spot-to-surface distance, dFSD, and combined
with the recording of the post-exposure PIt after
examination of a patient or a phantom. The method
is usually suitable only for x-ray machines with a
post-exposure display of PIt or units with manual
exposure only. Alternatively, Ka,i can be derived
from a measurement of Ka,e by applying an appropriate backscatter factor [Eq. (3.15); Appendix A].
The incident air kerma, Ka,i, can be derived from
the air kerma free-in-air at a distance, d, from the
x-ray tube focal spot, Ka(d)
4.2.1.4 Film dosimeters

General characteristics of film dosimeters can be
found in Knoll (2000), for example. Two types of film
have been explored for patient dosemetry in interventional radiology, i.e., radiological film, with a
year-long tradition in this field, and radiochromic
film, which has been introduced more recently.
Ka;i Ka d
41
d2
,
d2FSD
4:2
where dFSD is the focal spot-to-surface distance.

Employing Eq. (2.1) the following relation is
obtained
Ka;i Y dPIt
d2
:
d2FSD
The recommendation in specific radiotherapy

dosimetry protocols for low-energy x rays (e.g.,
IAEA, 1987; IPSM, 1991; Ma et al., 2001) is to derive
Ka,e from measurement of Ka,i and application of an
appropriate backscatter factor through Eq. (3.15).
The same approach can be used here. Backscatter
factors for radiology range from 1.25 to 1.60 for
typical x-ray spectra and field sizes used for adults
(Petoussi-Henss et al., 1998). An important exception is for mammography where the lower energy
spectrum and smaller field size result in backscatter
factors of 1.10. The derivation of appropriate values for the backscatter factor is discussed in more
detail in Appendix A.
The entrance surface air kerma Ka,e for a patient
or a phantom for a specific type of radiograph, for
example, for a PA view of the chest or for a mediolateral oblique view of the breast, can be obtained as
follows. TLDs should be encapsulated to protect them
from dirt and exposure to visible light and to facilitate fixing to the surface of a patient or phantom. The
encapsulation material should be thin and should not
contain elements of high atomic numbers, which are
often used in dyes, to avoid significant absorption of
the low-energy x rays sometimes encountered in
radiology, for example, in mammography. For the
relevant radiation quality, the TLDs should be calibrated inside the encapsulation and at the same
orientation with respect to the x-ray beam as during
medical exposure. The encapsulated TLDs should be
positioned on the patients skin or on top of the
phantom as close as possible to where the centre of
the x-ray beam enters the patient or phantom. Then
the examination should be made in the normal way.
For mammography it has been proposed (EC, 1996b)
that the TLDs be positioned on the upper inner
quadrant of the breast, where the risk of obscuring
clinically important details is less than in the centre
of the beam. When too low a read-out is expected, for
example, for chest radiography, repeated exposures
of the TLDs should be made. Repeated exposures of
the same TLDs should be ideally made for a sample
of sufficient size to represent average patients. The
read-out of the TLDs corrected for background and if
necessary fading and multiplied by the calibration
coefficient results in the value of Ka,e.
4:3
The output can be measured free-in-air in the

centre of the x-ray beam at a distance, d, from the
focal spot (d is usually 1 m). Measurements of Ka(d)
should preferably be made in the manual exposure
mode for the range of exposure conditions met in
clinical practice and the corresponding values of PIt
recorded. In mammography, measurements are
often not made in the centre of the field but closer
to the chest wall edge (EC, 1996b). Because the air
kerma rates can differ appreciably for the same
exposure conditions from one x-ray tube to another,
it is necessary that output measurements are made
on the x-ray tube under study.
For a specific type of radiograph of a patient, for
example, for a posteroanterior (PA) view of the
chest and the exposure conditions (tube voltage,
anode material and angle, filtration) used in practice
for the type of radiograph in question, the postexposure PIt is obtained. The relevant value of Y(d)
is derived from a series of output measurements at
various x-ray tube voltages and filtrations, if necessary by interpolation. The value of Ka,i for a particular radiograph of a patient can then be derived
according to Eq. (4.3).
If automatic exposure control (AEC) is used and
the post-exposure PIt is not indicated, Ka,i can only
be determined by using a phantom (Section 4.3)
representing the patient. The phantom should provide the same amount of attenuation as an average
patient and, ideally, should result in the same
x-ray spectrum incident on the AEC device detector.
The air kerma measurement should be made at some
distance from the phantom surface so as to exclude
the contribution from backscattered radiation
and the chamber should not shield the AEC detector.
The incident air kerma Ka,i can then be calculated
using Eq. (4.2).
4.2.3
Entrance surface air kerma
Measurements of Ka,e can be made directly on the

patient or a phantom with TLDs. The practical and
theoretical problems related to the use of ionization
chambers for the measurement of Ka,e are considerable. When using phantoms, it may be necessary to
recess a larger dosimeter, for example, an ionization
chamber, in the surface of a phantom so that its
effective centre lies in the plane of the surface and
provides good results (Harrison, 1982; PetoussiHenss et al., 1998).
4.2.4
Air kermaarea product
Quantities PKA and P_ KA are most easily measured

using a specially designed ionization chamber,
which is mounted on the collimator housing, where
it affords minimum interference with the medical
imaging task. The chambers are of parallel-plate
design, set perpendicular to the beam axis and are
of sufficient area to encompass the largest beam size.
42
MEASUREMENT METHODS
The plates are often made to be transparent to visible light to allow use of a light beam collimator. The
electrometer and display unit are connected to the
chamber by a long cable so that the display can be
positioned for easy access to read and reset. The
response of the PKA meter will depend on whether
the chamber is installed on an overtable or undertable x-ray tube (Section 4.1.2).
The requirements for air kermaarea product
(PKA) meters are similar to dosimeters in general,
as described in Section 4.1. This means that
re-calibration should be made at intervals not exceeding 2 years, and whenever the instrument has been
repaired or its performance is suspect (AAPM, 1992).
Re-calibration at one radiation quality, the reference
quality, is often sufficient, as it is unlikely that
the dependence of the response on radiation energy
would change significantly. However, sometimes it
will be important to check comprehensively the
dependence of the response on the dose rate, particularly if the dosimeter is used at widely varying dose
rates. Corrections for ion recombination are usually
insignificant but must be considered when using
very high instantaneous dose rates. Simple constancy
checks and checks of the various functions are recommended before each use of the instrument.
Estimates of the uncertainty in the (in situ) calibration coefficient of a PKA meter are 6 % at the 95 %
confidence level (Shrimpton and Wall, 1982; Larsson
et al., 1996) for overtable geometry. For undertable
geometry, the table may reduce the calibration coefficient by 1520 % compared with the overtable
situation (Carlsson and Alm Carlsson, 1990).
Commonly, PKA meters consist of PMMA coated
with a conducting material. Carbon is often used for
this purpose as it is approximately air-equivalent,
however, to achieve light transparency other conducting materials are used. These materials contain high atomic number elements resulting in a
relatively strong energy dependence compared with
ionization chambers coated with graphite (Larsson
et al., 1996; Bednarek and Rudin, 2000). For example,
the addition of additional copper filtration may
affect the calibration coefficient by several per cent.
Experience with ageing of air kermaarea product
meters, for example, when installed at interventional radiology systems and submitted to very
large doses during several years is still limited. Simple constancy checks of the instrument should be
able to reveal ageing.
Some PKA meters are capable of distinguishing
between values accumulated during radiography
and fluoroscopy. If this distinction is made purely
on the basis of a threshold in P_ KA (difference in
tube current exposure time product rate between
fluoroscopy and radiography), errors can occur. For
example, when large beam areas are used during

fluoroscopy of thick or dense areas of the patient,
P_ KA approaches values seen during radiography.
Developments are in progress where the field size,
dFSD and Ka,i are also registered. Modern x-ray
equipment may have built-in PKA meters or will display the value of PKA after an exposure by internal
calculation using the exposure factors (tube voltage
and filtration, PIt) and the position of the beam limiting collimators. The value of PKA does not contain
information on the projection.
The assessment of organ doses from PKA measurements for procedures, involving both fluoroscopy
and radiography, is quite complex. This is illustrated
for colon examinations where the value of PKA has to
be related to individual radiographs and to intermediate fluoroscopy. Values of P_ KA and cumulative PKA
are shown in Figure 4.3. The standard colon examination was biphasic (Geleijns et al., 1997). First,
Figure 4.3. Air kermaarea product rate, P_ KA (top panel) and

cumulative air kermaarea product, PKA (bottom panel) as a
function of examination time (sample rate 0.1 s) measured during
a colon examination of one patient (Reproduced from Geleijns
et al., 1997, with permission from Radiological Society of North
America). The PKA values have to be related to images as presented in Table 4.4 and to fluoroscopy. The data in the present figure
correspond to Patient 4 in Figure 4.4.
43
Air kerma area product; PKA / Gy.cm2
30
25
20
15
10
0
1
10
11
12
13
Patient number
Figure 4.4. Air kermaarea products, PKA values for fluoroscopy (white) and images (black) during colon examination of 13 patients
(Geleijns, 2000, private communication). The data for the 13 patients have been ordered in accordance with the total PKA for the
examination. Reproduced with permission from Dr. J. Geleijns.
after insertion of a rectal cannula, a barium suspension of low density and high viscosity was administered and a single contrast study was performed.
Second, after partial evacuation, air was insufflated
for the double contrast study of the rectum and the
colon. From this information it has to be determined
whether the increase in P_ KA belonged to a continuous, prolonged signal, which is indicative of fluoroscopy, or to a short pulse, which is indicative of
radiography (imaging). If radiography was recognized, the PKA value for the radiograph was calculated from all PKA samples in the pulse, which
included the PKA sample acquired at the start of
the pulse (for which the value might be low).
Although a standard protocol for colon examination
was implemented (Table 4.6), deviations from the
protocol were common and had to be taken into
account during analysis. The PKA for each radiographic projection (image) and each fluoroscopy
interval can be estimated only after careful assignment of the corresponding projection (Table 4.6.) to
each peak in the P_ KA signal (i.e., to each radiograph).
The distribution of PKA over the various projections
is shown in Table 4.6. For fluoroscopy, it is assumed
that the exposure conditions can be mimicked by the
subsequent radiograph, except for differences in
radiation quality (i.e., tube voltage). Consecutive
PKA for fluoroscopy and radiographs (images) during
colon examination of 13 patients are shown in
Figure 4.4. The figure illustrates the differences
occurring in practice even when a standard protocol
is implemented.
4.2.5 CT air-kerma index and CT air-kerma

index in the standard CT head and
body dosimetry phantoms
Following the convention established in Section
3.2, CK refers to measurements free-in-air and CK,p
to measurements in-phantom.
4.2.5.1
Pencil ionization chamber dosimeter
For dosimetry in CT, pencil ionization chambers

are available with a diameter of 10 mm, a sensitive
length of 100 mm, and an active volume of 3 cm3.
An essential feature of these dosimeters is that their
response is designed to be uniform along the entire
length of the sensitive volume. They are usually calibrated in terms of air kerma by exposing the entire
sensitive volume to a uniform x-ray field. Thus they
indicate PKL/L when exposed to a CT slice or multiple slices free-in-air. Because the CK of Eq. (3.22)
rapidly falls to zero away from the position of the CT
slice, the pencil ionization chamber will also measure CK to a very good approximation. The relationship between CK, and PKL/L, the single slice CT axial
air kerma profile Ka(z), the chamber length L and
the nominal slice thickness T is shown in Figure 4.5.
By definition, the area under the single slice dose
profile (the dotted line) equals the areas of either
rectangle. For measurement inside a phantom, CK,p
is obtained in a similar way.
For a measurement of CK, the pencil ionization
chamber should be fixed so that it extends beyond
the table end. The chamber should be mounted in
44
MEASUREMENT METHODS
CK
b
a
Ka(z)
PKL/L
-L/2
Figure 4.7. Standard dosimetric phantoms for CT of the body

(A) and the head (B) [ICRU Report 48 (1992c)]. The PMMA
phantoms representing the body and the head have diameters of
32 cm (a) and 16 cm (c) and minimum lengths of 14 cm (b, d). They
contain cavities at the centre and the periphery to allow the
insertion of pencil ionization chambers.
0
DISTANCE TO CENTER OF SLICE , z
Figure 4.5. A single slice CT axial air kerma, Ka(z) profile with the
corresponding values of CK, PKL/L, L, and T, where L and T are
the chamber length and the nominal slice thickness, respectively.
By definition, the area under the single slice dose profile (the
dotted line) is equal to the area of either rectangle.
thickness, or the sum of the nominal slice thicknesses in the case of multi-slice scanners.
For a measurement of CK,PMMA, the CT dosimetry
phantoms (Figure 4.7) should be used. The phantom
should be fixed on the table in such a way that its
longitudinal axis coincides with the axis of rotation
of the gantry and that its centre corresponds to the
centre of the slice, or the centre of the slices for a
multi-slice scanner. The pencil ionization chamber
should be inserted in the phantom in such a way that
its centre corresponds to the longitudinal central
plane of the phantom for each of the five measurement positions, i.e., one at the centre and four at
1 cm below the surface (Figure 4.7). Unused holes
should be plugged.
For radiotherapy, similar problems arise for measurements inside phantoms with ionization chambers
calibrated in terms of air kerma free-in-air as for
dosimetry for x rays used in medical imaging.
According to the IAEA (1996b) an ionization chamber calibrated for the x-ray quality considered can be
used to derive the absorbed dose to water in a water
phantom by using the relation

m

Dw Mu NK en
ka;w ,
4:4
r w;a
gantry
axis of rotation
pencil ionization chamber
table
Figure 4.6. Schematic diagram of

measurement of CK.
gantry
the arrangement
for
such a way that its length axis corresponds to the

axis of rotation of the gantry and that its centre
corresponds to the centre of the slice, or the centre
of the slices for a multi-slice scanner (Figure 4.6).
The measurement with the ionization chamber
should be made for a single rotation. When the rotation differs from 360 this should be noted. The value
of CK is obtained from the ionization chamber reading as the air kerma multiplied by the length of
the chamber, L, and divided by the nominal slice
where Mu is the dosimeter reading corrected for

influence quantities such as temperature and pressure, NK the air kerma calibration coefficient for the
x-ray quality considered, m
en =rw;a the ratio of the
mean mass energy absorption coefficients of water to
that of air averaged over the energy fluence distribution of the photons at the point of measurement in
45
Figure 4.8. Illustration of the absorbed dose to air (left ordinate,

solid lines) and kerma to material m (right ordinate, broken lines,
m air, PMMA) in the vicinity of a PMMA/air interface. All
quantities are normalized to Kair 1. Black, red, and blue
curves refer to radiation qualities at tube voltage and HVL1 of
70 k and 2.5 mm Al, 100 kV and 3.97 mm Al, and 150 kV and
6.57 mm Al, respectively. The kerma to material m (m air,
PMMA) has a discontinuity at the interface. Courtesy: H.M.
Kramer (2005), private communication. The right for publication
was obtained from the Physikalisch-Technische Bundesanstalt.
Figure 4.9. Schematic diagram of the variation of the absorbed

dose to air and of the air kerma and the substance m kerma at
an interface of material m and air with effective atomic numbers
Zeff,m< Zeff,air. Courtesy: H.M. Kramer (2002), private
communication. The right for publication was obtained from the
Physikalisch-Technische Bundesanstalt.
measured in the phantom, Ka,PMMA is
the water phantom, and the overall correction ka,w

comprises the following components: kE,u the correction factor for the energy and angular dependence of
the response of the ionization chamber, pd the displacement correction factor which accounts for the
effect of the displacement of water by the air volume
of the shape of the ionization chamber, kst the correction factor for the influence of the stem of the
ionization chamber, ksl the correction factor, which
accounts for the effect of the protective sleeve needed
if a non-watertight ionization chamber is inserted
into a water phantom, kb is the correction factor for
yet unknown effects, the value of which is taken to
be unity.
Both the IEC (1999) and the EC (2000) recommended to measure the absorbed dose to air inside the
standard CT head and body phantoms. For a measurement inside an air cavity within a PMMA phantom the absorbed dose to air varies over its volume.
The exact nature of this variation and hence also
of the absorbed dose to air inside the cavity depends
on the range of the electrons produced in photon
interactions. For three x-ray qualities (IEC, 2004),
this illustrated in Figure 4.8 for the absorbed dose
to air in air at a PMMA/air interface. When the
commonly recommended detector, i.e., an ionization
chamber has a wall thickness sufficient to absorb the
most energetic electrons produced inside the PMMA,
air kerma can be measured inside the PMMA phantom. This is schematically shown in Figure 4.9.
When measurements are made inside a PMMA
phantom, Eq. (4.5) applies for the air kerma
Ka;PMMA Mu NK ka;PMMA ,
4:5
where ka,PMMA is in first approximation equivalent

to ka,w. The overall correction factor for a given ionization chamber, ka,PMMA, accounts for the differences between measurements free-in-air and at
depth in a PMMA phantom. The numerical values
of ka,PMMA and ka,w for an NE2571 (Nuclear Enterprises, Reading, UK) ionization chamber are expected to differ by <0.5 % as the displacement correction
factor for stemless chambers is decreasing by 0.5 %
between densities of 1.00 and 1.17 g cm3 for x rays
with HVL1 in excess of 3 mm Al (Ma and Nahum,
1995). The dependence of ka,w of an NE2571 ionization chamber on field size and depth for 80 kV x rays
at a HVL1 of 2.4 mm Al is small, i.e., 1 %
(Seuntjens and Verhaegen, 1996). Numerical values
of ka,w are almost only available for the NE2571
ionization chambers. A ka,w value for the NE2571
ionization chamber of 1.01 has been published by
the NCS (1997) for tube voltages between 80 and
120 kV and a HVL1 of 2.8 mm Al. Values are lacking
for the pencil ionization chambers used for dosimetry in CT. It is, however, expected that ka,PMMA
are only a few per cent different from unity as the
diameters of the pencil chambers and the NE2571
ionization chamber are not too much different.
The CK,PMMA value follows from the ionization
chamber reading multiplied by the chamber calibration coefficient for in-phantom measurements of
46
MEASUREMENT METHODS
air kerma and the length of the chamber, L, divided
by the nominal slice thickness, or the sum of the
nominal slice thicknesses in the case of a multislice scanner. Note that for multi-slice CT, the use
of a 100 mm long ionization chamber may in some
cases be less appropriate than for single slice CT.
This is because of the increase in irradiated combined slice thickness associated with the multi-slice
technique. When the rotation differs from 360 this
should be noted. Special attention should be given to
the orientation of the peripheral measurement positions. Thus the CK,PMMA,100,c can be obtained from
the measurement at the central position and
CK,PMMA,100,p as the average of measurements at
four peripheral positions. By using Eqs (3.263.28),
the CT air kermalength product, PKL,CT for a complete conventional (serial CT) examination can be
derived from CK,PMMA,100,c and CK,PMMA,100,p. In the
case of helical scanning, PKL,CT can be derived from
CK,PMMA,100,c and CK,PMMA,100,p by using Eqs (3.26),
(3.27), and (3.29).
measurement of the air kerma profile. In principle

TLDs can also be used for measurements in phantoms, but if several measurement positions are used
then this will require a large number of dosimeters.
Therefore, ionization chambers are preferred for inphantom measurements. A typical free-in-air single
slice dose profile measured with lithium fluoride or
lithium borate TLD chips, 0.8 mm thick and stacked
contiguously in a hollow cylindrical plastic capsule,
is shown in Figure 4.10A. For such a stack of n TLDs,
the CK is approximated by
Z
1 1
1
Ka zdz Sn Kaj h,
4:6
CK
T 1
T
where Kaj is the air kerma to the jth TLD from a total
of n TLDs and h is the extension (0.8 mm in this
example) of each TLD in the axial direction, and T is
the nominal slice thickness.
The value of CK, thus derived, is shown in
Figure 4.10B; for this particular scanner and slice
thickness, is 8 % higher than the peak of the dose
profile.
For the measurement of CK, the stack of TLDs
should be fixed so that it extends beyond the table
end (similar to the fixation of the pencil ionization
chamber shown in Figure 4.6). The stack of TLDs
should be mounted so that its length axis coincides
with the axis of rotation of the gantry and that its
centre corresponds to the centre of the slice, or the
centre of the slices for a multi-slice scanner. The
measurement with the stack of TLDs should be
4.2.5.2 TLDs
TLDs placed in a row within a suitable plastic
holder can be used to measure the CT axial air
kerma profile free-in-air. The TLDs should be contiguous in the region of the primary beam, but away
from this region, they can be separated by spacers. It
is noted that TLDs can be arranged in a stack or
placed side by side. The latter arrangement is applicable for measurement of CK but does not give a good
Figure 4.10. Typical free-in-air CT axial air kerma profile Ka(z) for a nominal slice thickness of 4 mm measured by TLDs (A) and the
resulting CK (B) (after Shrimpton et al., 1991; Survey of CT Practices in the UK, Part 2: Dosimetric Aspects, NRPB-R249; HMSO, London,
UK).
47
Standard dosimetric phantoms have simple reproducible geometry and are used to compare measurements under defined conditions of irradiation.
Standard phantoms as proposed by the ICRU
(1992c), but made out of PMMA, are used for dosimetry for mammography and for CT. The standard
mammography phantom described by the ICRU has
a thickness from 2 to 8 cm. However, often only one
thickness is recommended, for example, 4.5 cm (EC,
1996b). The cross-sectional dimensions recommended by the EC (1996b) are somewhat larger than
that described by the ICRU, i.e., either semicircular
with a radius of at least 100 mm or rectangular with
an area of at least 150 mm 100 mm.
It should be borne in mind that the phantoms
at best represent (parts of) average-sized adult
patients, and, therefore, do not allow accurate dose
assessments for individuals of different sizes or body
composition. However, the use of a phantom that
mimics the attenuation and beam hardening in a
specific part of a standard patient correctly has the
advantage that the number of measurements
required to derive the incident air kerma is considerably smaller than that for measurements with
patients.
made for a single rotation. When the rotation differs

from 360 , this should be clearly stated.
4.3 FEATURES OF MEASUREMENTS ON

PATIENTS AND MEASUREMENTS WITH
PHYSICAL PHANTOMS
Measurements of Ka,i, Ka,e, and PKA can be made
in the presence of patients or by using phantoms.
Measurements with patients have the advantage
that no specific phantoms have to be designed and
constructed. Patients vary in size, which will influence the measurement result. For mammography,
the tissue composition of the female breast, i.e., the
fraction of glandular tissue, is of importance. To
obtain a representative average value of, for
example, Ka,i, measurements have to be made for a
series of patients. Such measurements provide
insight into the dose variation among individual
patients and of actual clinical practice (Gentry and
DeWerd, 1996). To limit the number of patients, a
selection can be made on body mass (EC, 1996a) or in
the case of mammography, on compressed breast
thickness (EC, 1996a,b). For organ dose assessment,
it will be necessary to obtain information on the
gender of the patients involved, as the doseconversion coefficients can be gender-specific. Also
the age of the patients involved should be recorded.
An anthropomorphic (or body) phantom has the
shape of a human body or part of it (ICRU, 1992c).
It is constructed of various tissue substitutes
simulating the human body with respect to size,
shape, mass density, and radiation attenuation and
scattering. The use of anthropomorphic phantoms
for assessment of organ doses is discussed in
Section 5.1.
Phantoms are particularly useful for surveys of
patient doses and for quality control. For example,
the US Center for Devices and Radiological Health
(CDRH) has designed phantoms for specific examinations, i.e., the CDRH chest phantom (Conway
et al., 1984), and the CDRH abdomen and lumbosacral spine phantom (Conway et al., 1990). Both
phantoms are made out of PMMA and aluminium.
Havukainen and Pirinen (1993) from the Finnish
Radiation and Nuclear Safety Authority (STUK) followed a similar approach. They constructed PMMAAl phantoms for examinations of abdomen PA, chest
PA, lumbar spine PA, skull LAT and thoracic spine
anteroposterior (AP). The CDRH and STUK phantoms are designed to provide characteristics similar
to that of body parts of patients, with respect to both
attenuation and beam hardening. However, they do
not allow for dose measurements at depth in the
phantom.
4.4
SKIN DOSE DETERMINATION
A growing number of publications report on

deterministic effects in the skin of patients who
have undergone interventional radiological procedures (Sovik et al., 1996; Vano et al., 1998, 2001a;
ICRP, 2000; Geleijns and Wondergem, 2005; Van
Sonnenberg et al., 2005; Wambersie et al., 2005).
Measurement of the maximum skin dose, also
referred to as peak skin dose (Section 1.4), is, therefore, increasingly important. The main issue is that
the location of the most heavily irradiated regions of
the skin is not known in advance. In principle three
methods can be used for skin dose measurements.
4.4.1 Direct measurement of the
maximum skin dose
The most straightforward method for skin dose
determination is to put TLDs or other detectors on
the patients skin. However, the choice of the methods and dosimeters are not yet clearly established. In
this section an overview is given of the measurement
of the maximum skin dose Dskin,local during radiological examinations. Although most of the measurements were actually performed with TLDs,
scintillation dosimeters and film dosimeters have
also been used. Semiconductor dosimeters [diodes
or metal oxide semiconductor field effect transistors
(MOSFETs)] have been used only for phantom
48
MEASUREMENT METHODS
measurements. These latter dosimeters have not
been used on patients because the filters, needed to
compensate for the poor tissue-equivalence, appear
on the radiological image. Therefore, they are not
further discussed here.
radiology (Marshall et al., 1995; Ng et al., 1998;

Kemerink et al., 2001; Papageorgiou et al., 2001;
Vano et al., 2001a). The wide application of this
phosphor in personal dosimetry and in in vivo dosimetry in radiotherapy (Van Dam and Marinello,
1994) led to its application in radiology. It is commercially available, its characteristics are well established, and its energy dependence is acceptable.
Lithium borate, with weaker energy dependence
in the radiological range (Table 4.5 and Figure 4.2),
has also been used on patients (Maccia et al., 1988;
Gregan et al., 1998).
4.4.1.1 Skin dose measurements on patients

with TLDs
The basic characteristics of TL dosimeters are
presented in Section 4.2.2. Numerous skin dose
measurements were made with the standard phosphor LiF:Mg,Ti in diagnostic and interventional
Table 4.5. Main characteristics of four TLD phosphorsa (see, e.g., Vij, 1993; McKeever et al., 1995).
Phosphor
Dopant
Li2B4O7
Mn
LiF
Mg, Ti
LiF
Mg, Cu, P
CaF2
Dy
Relative energy response (30 keV/1 MeV)

Fadingb
Relative sensitivityc to 1 MeV photons
Detection threshold (mGy)
0.95
5 % month1
0.5
100
1.35
<5 % y1
1
50
1.3
<5 % y1
30
5
14.5
1 % d1
15
1
All four phosphors are commercially available as chips (dimensions: 3.2 mm 3.2 mm 0.9 mm).
Fading % loss at 20 C per year (y), month or day (d).
c
Read-out per unit air kerma compared with that of LiF: Mg, Ti.
b
Figure 4.11. Three-dimensional representation of the patient skin dose distribution (mGy) as measured with a grid of TLDs for a coronary
angiography in a biplane setting. Results from a Belgian multi-center study on skin doses of patients treated with prolonged cardiological
interventions. Study sponsored by the Federal Agency of Nuclear Control in Belgium. With permission from E. Bogaert, K. Bacher,
H. Thierens.
49

Table 4.6. Example of a standard protocol for biphasic colon examination (Reproduced from Geleijns et al., 1997, with
permission from Radiological Society of North America).
Viewa
PKAc/Gy cm2
Nominal tube
voltage/kV
HVL1/mm Al
dFIDb/cm
dFSDb/cm
Field size on
image cm cm
Full column, single contrast examination

Rectum and Sigmoid AP
Rectum and Sigmoid LPO
Rectum and Sigmoid Left decubitus LLAT
Rectum and Sigmoid AP (4 radiographs)d
Splenic Flexure
RPO
Hepatic Flexure
LPO
Cecum
AP (2 radiographs)
Colon
Supine AP (survey)
125
133
141
133
133
133
125
125
7.5
7.8
8.0
7.8
7.8
7.8
7.5
7.5
126
126
126
126
126
126
126
151
97
93
77
97
91
94
98
122
24 30
24 30
24 30
12 15
24 30
24 30
24 15
35 43
0.37
0.74
1.91
0.31
0.55
0.84
0.71
1.04
Double contrast examination

Rectum and Sigmoid PA
Rectum and Sigmoid LLAT
Rectum and Sigmoid LPO
Rectum and Sigmoid Caudal-cranial inclination
Rectum and Sigmoid AP
Rectum and Sigmoid RLAT
Splenic Flexure
RPO
Hepatic Flexure
LPO
Cecum
AP (2 radiographs)
Colon
Supine AP (survey)
Colon
Prone PA (survey)
96
109
102
102
96
109
102
102
96
96
96
6.1
6.6
6.3
6.3
6.1
6.6
6.3
6.3
6.1
6.1
6.1
126
126
126
126
126
126
126
126
126
151
151
93
77
93
79
97
70
91
94
98
122
122
24 30
24 30
24 30
24 30
24 30
24 30
24 30
24 30
24 15
35 43
35 43
0.45
2.51
0.74
0.92
0.61
2.95
0.83
0.70
0.65
1.11
0.73
Projection
Biphasic examination, i.e., single and double contrast

Double contrast views only
20.9
12.8
AP is anteroposterior, LLAT left lateral, LPO left posterior oblique, PA posteroanterior, RLAT right lateral, RPO right posterior
oblique.
b
dFID is focal spot-to-image receptor distance, dFSD focal spot-to-surface distance.
c
The air kermaarea products, PKA were measured on an overtable x-ray tube, 0.1 mm Cu filtration, fluoroscopy is performed at 110 kV.
d
Air kermaarea product, PKA is given for one single exposure.

with scintillation dosimeters
Two studies in interventional radiology deserve

special attention, because they illustrate the possibilities of TLD for tracing the location of the
maximum skin dose Dskin,local for complicated procedures. For 137 patients, undergoing various interventional procedures, Waite and Fitzgerald (2001)
placed LiF chips in arrays of 35 chips on the patients
skin and determined Dskin,local by interpolation. For
the same purpose, Geise et al. (1997) explored the
suitability of magnesium borate TLD arrays as
monitors in potential high-dose x-ray areas. After
irradiation, the signal is obtained through laser
stimulation. The dosimeters are arranged in radiolucent arrays covering a surface of 30 cm 30 cm,
with dots of TLD material 2 mm in diameter
positioned at 3 mm intervals in rows, spaced 3 mm
apart.
Results from a Belgian multi-center study on
assessment of local skin dose of patients treated
with prolonged cardiological interventions are shown
in Figure 4.11. Arrays of TLDs that are wrapped
around the patient (with spacing larger than 3 mm
for practical reasons) allow visualizing of the threedimensional distribution of the patient skin dose.
The basic characteristics of scintillation dosimeters are presented in Section 4.2.3. One of the potential advantages of scintillation dosimeters is realtime information. Although one would expect widespread clinical applications, only a limited number of
studies explored the possibilities of scintillation dosimeters in interventional radiology. Wagner and
Pollock (1999) used scintillation dosimetry for miscellaneous high-dose fluoroscopically guided procedures and Hwang et al. (1998) for cardiac
interventional radiology.
with film dosimeters
The basic characteristics of film dosimeters are
presented in Section 4.2.4. For complicated procedures, where the position of the peak skin dose is hard
to predict, film dosimeters offer unique possibilities.
When wrapped around the patient, the film provides
information on the dose distribution at the level of
the skin. The energy of the x-ray beam should not
50
MEASUREMENT METHODS
Figure 4.12 shows an illustration of the use of slow
films to measure patient skin dose during cardiac
interventional radiology. The use of additional thermoluminescent or optically stimulated luminescent
dosimeters at the positions of the film where the
highest doses are expected allows verification the
calibration of the film.
4.4.2 Derivation of the skin dose from the
air kermaarea product PKA
Skin dose can, under certain conditions, be
derived from the air kermaarea product
PKA. There are basically two methods to derive the
skin dose from the air kermaarea product. The first
method determines both quantities independently
on a significant number of patients and derives, by
pooling the data, conversion coefficients for calculating the skin dose. Waite and Fitzgerald (2001) correlated air kermaarea product PKA and skin dose
measurements (using TLD arrays) on a population
of patients undergoing percutaneous transluminal
coronary angioplasty (PTCA) and neurological procedures. The correlation between skin dose and air
kermaarea product was found satisfactory for the
neurological patients but was poor for the PTCA
patient group. Van de Putte et al. (2000) found also
a poor correlation for a population of patients undergoing cardiac procedures. As pointed out by the
authors, this can be explained by the fact that the
cardiac radiological procedures implied more
patient-to-patient differences in geometry.
Relying
purely
on
geometrical
factors
(Figure 4.13), the skin dose can be derived from the
air kermaarea product, provided the field area at
the level of the patients skin is known assuming
that conditions of scattered radiation are similar.
This method is straightforward when the collimation, as well as the focus-to-skin distance, is kept
constant throughout the full duration of the examination. This is valid for simple procedures, but not
for complicated examinations as used in interventional radiology for which multiple angulations,
field sizes, and focus-to-patient distances are often
applied. Although an inherent loss of accuracy cannot be avoided, useful information can be obtained
by assigning to each type of procedure a nominal
geometry and, on the basis of this geometry, to
derive the skin dose from the air kermaarea product readout. For different interventional radiological
procedures McParland (1998) analysed the uncertainties in the skin dose values, caused by realistic
deviations from the nominal geometry, and showed
that the estimated dose values were at least within
40 % and generally within 30 % of those actually
received.
Figure 4.12. Illustration of the use of slow films to measure

patient skin dose. Top: Practical set-up to measure skin dose
distributions. Thermoluminescent or optically stimulated luminescence dosimeters are attached to an envelope that contains a
slow film (KODAK EDR2), in the positions where the highest
doses were expected. The use of a double set of dosimeters was
used to verify the response of both technologies for this kind of
measurements. Dosimeters allowed verifying the calibration of
the film. Bottom: Example of slow film used to measure the skin
dose distribution in a patient during percutaneous transluminal
coronary angioplasty (PTCA). Note the wide distribution of the
radiation fields on the skin owing to the different orientations of
the x-ray beam. Collimation and the use of wedge filters are
clearly visible. Courtesy: E. Vano.
vary too much over the area of the detector and

during the procedure. These requirements are
more important for radiological film than for the
radiochromic film, as discussed previously (Section
4.2.1.4). The possibilities of the film for measurements on patients were illustrated for complicated
cardiac
interventional
radiology
procedures
(Guibelalde et al., 2003).
51
Figure 4.13. Derivation of skin dose from air kermaarea product and geometrical factors. Top left: The transmission chamber is calibrated
against a reference ionization chamber, which has been calibrated in air kerma free-in-air. The reference chamber is positioned, on the
beam axis, at a reference distance d0 of 60 cm from the tube focal spot. This point is chosen 20 cm above the position of the patient couch
and corresponds approximately to the point of entrance of the beam axis at the patient skin Beam dimensions of 10 cm 10 cm at the
reference distance d0 are selected (checked by film). The signal of the transmission chamber is expressed in terms of air kermaareaproduct in Gy m2 (or convenient multiples). Top right: For distances differing from the reference distance (e.g., d0 dx), the beam area is
increased by [(d0 dx)/d0]2 and the dose on the beam axis is decreased by the same factor. The air kermaarea product thus remains
unchanged. Bottom: The irradiation geometry is modified compared with that in the top: the tube is located under the couch and the
backscatter from the patient is introduced. The transmission chamber is calibrated against a reference ionization chamber, which has been
calibrated in absorbed dose to water (tissue), under patient (backscatter) conditions. As indicated above, the air kermaarea product
remains unchanged when modifying the distance between the tube focus and the entrance skin of the patient (for the indicated range).
Courtesy: A. Wambersie.
Another approach consists of real-time automatic

data acquisition of the fluoroscopy conditions: time
and geometric parameters. Kicken et al. (1999)
recorded continuously the field area at a reference
distance of 1 m. The field area at the level of the
patients was derived from this value using the
focus-skin distance, obtained electronically from
the focus-to-image receptor distance. The method
was applied on patients undergoing arteriography
of the lower limbs.
4.4.3 Derivation of the skin dose directly
from the radiological parameters of the
exposure
Figure 4.14. Photograph showing the ionization chamber attached
to the anthropomorphic head phantom used to measure entrance
skin dose [from Gkanatsios et al. (1997), with permission].
The skin dose was also derived by some authors

relying on the radiological parameters of the
52
MEASUREMENT METHODS
TLD measured in this area (not peak) 2.4 Gy
Calculated
from DICOM
2.7 Gy
cran and caud of

the patient
Total skin dose MAG30712; 08/01/03

40
20
0
-90
-40
-20
10
60
-40
right and left of the patient
Figure 4.15. Peak skin dose assessment using data from the DICOM header compared with results on skin dose using slow film and TLDs.
Top right: A slow film is positioned on the back of the patient to measure the skin dose distribution during an interventional cardiology
procedure guided by fluoroscopy. Top left: The details of the duly processed slow film (with the grey scale inverted) are shown. Note that in
this case, the film is clearly saturated and some TLDs positioned on the film to measure skin dose and to verify the calibration (dose versus
film density) give a dose value of 2.4 Gy. This is not necessarily the peak skin dose if the TLD was not at the position where the maximum
dose is imparted. Bottom left: A diagram with the doses in the different radiation fields obtained from the information contained in the
DICOM header of the series of images is shown. In some cases, this calculation allows to estimate with a better approach the peak skin
dose. In the reported case, the estimation from DICOM header gives a peak skin dose of 2.7 Gy (shown top right). Reproduced with
permission from E. Vano.
combining the different uncertainties was estimated

to be 10 %.
If fully digital systems are available then a
more automated approach becomes possible,
because the Digital Imaging and Communications
in Medicine (DICOM) header information contains tags for different data with respect to the
particular image. Software tools could extract the
necessary exposure details automatically. Such a
type of system was developed at the Complutense
University of Madrid (Vano et al., 2002).
Figure 4.15 shows an example of the local skin
doses due to different irradiation fields during a
cardiac interventional procedure obtained from
the information contained in the DICOM header
of a series of images. The results are compared
with skin doses derived from the use of a slow
film combined with TLDs.
exposure (Section 1.3.4.1). Such an approach needs

phantom calibration before clinical use. Gkanatsios
et al. (1997) introduced a commercial on-line patient
exposure meter that was installed in each plane
of a biplane neuroradiological imaging system
(Figure 4.14). A device, introduced by the authors,
can compute skin dose on the basis of selected technical parameters such as peak tube voltage, tube
current, and focus-to-patient distance.
Simulations of radiological procedures were also
performed on the phantom with an ionization chamber to measure the systems accuracy by comparing
the computed and measured dose. The deviation
between the two values did not exceed 5 % for a
group of neuroradiological patients.
For similar applications, ODea et al. (1999)
applied a method also based on an automated dosimetry system. The standard deviation obtained by
53

5 METHODS FOR DETERMINING ORGAN AND

TISSUE DOSES
For the assessment of the dose to patients to be
indicative of the stochastic radiation detriment,
estimates of DT for radiosensitive organs and tissues
in the body are required. It is possible to assess DT
for certain compact and superficial organs such
as the thyroid or testes from measurements with
TLDs at appropriate locations on the patients skin,
although corrections may be necessary to account
for the amount of attenuation through the organ or
through the overlying tissue. In interventional radiology, it will be useful to check DT,local (or Dskin,local)
for the skin in the primary x-ray beam in relation to
the threshold for induction of deterministic effects.
TLDs can be used to assess the local skin dose,
although predicting the location of the maximum
dose is difficult.
More generally, DT or DT,local can be measured
using appropriate physical models of the human
body that can be loaded with dosimeters and
exposed under conditions typical of particular examinations or procedures. Alternatively, computer
programs are available that simulate radiation
transport using a computational model of the
patient. They can be used to calculate DT with
much greater speed and flexibility than is possible
by measurement. Extensive tabulations and data
files on computer disk are available containing the
results of these calculations in the form of coefficients for converting the more readily measurable
normalization quantities (Section 3.4) into organ
doses for specific x-ray exposure conditions in
medical imaging.
Because these assessments are usually made
for particular practices or techniques that are
applied to a large number of patients, there is not
the same need for individually tailored patient-dose
estimates as occurs in radiotherapy. As a consequence, models for standard patients are frequently
used for dosimetry in medical x-ray imaging.
Both physical and computational phantoms have
been developed to represent adult and paediatric
patients. When individual patient dose determinations are required, e.g., for accidental overexposures,
the calculations based on standard phantoms are
useful as a first estimate. For an improved estimate,

the particular anatomical details of the patient
and the specific exposure conditions need to be
considered.
5.1 DOSE MEASUREMENTS IN PHYSICAL

PHANTOMS
Physical dosimetry phantoms are designed to
simulate the way in which a patient, or part of a
patient, will absorb and scatter ionizing radiation.
Measurements using the phantoms can then be representative of the dose distributions occurring in
clinical practice. Phantoms can be of varying degrees
of complexity and anatomical accuracy depending on
the purpose of the dose determinations (Section 4.3).
If the doses received by a number of radiosensitive
organs within the patient are to be measured, an
anthropomorphic phantom that accurately models
human anatomy is needed. Such phantoms are commercially available but it is important to be sure that
the materials used in their construction are sufficiently tissue-equivalent for the intended use.
Some have been designed specifically for radiotherapy applications and while they scatter and absorb
high-energy photons realistically, this may not be so
for photons of relatively low energies used in medical
x-ray imaging (Shrimpton et al., 1981). Requirements for physical dosimetry phantoms to be used
in medical x-ray imaging, together with descriptions
of commercially available products, are given in
ICRU Report 48 (1992c).
Reliable estimation of the mean dose to large or
widely distributed organs, like the lungs or the active BM, requires a large number of measurement
points within the phantom. The absorbed dose is
unlikely to be uniformly distributed throughout the
organ. Physical measurements are best made with
TLDs whose small size allows sufficient numbers
to be suitably distributed. Preparation and read-out
of the TLDs can be very tedious. Realistic heterogeneous phantoms simulating bony structure and
soft tissues are very expensive.
the marrow cavities is expected from increased photoelectron emission by surrounding bone (Spiers,
1963). The bremsstrahlung produced in the tissues
of the human body by secondary electrons is negligible for photons with energies <150 keV.
Organ doses are obtained by summing, in each
organ, all energy depositions from primary and scattered photons, and dividing by the total organ mass.
The result is the mean absorbed dose in the entire
organ regardless of the fraction of the organ irradi1
ated. The standard uncertainty of the mean is
dependent on the number of histories. A history
comprises the path of the primary photon, the secondary particles it produces in the regions of interest, and the locations and quantities of energy
deposition. According to the central limit theorem
(Feller, 1968), the standard uncertainty of the
mean decreases in inverse proportion to the square
root of the number of primary photons followed, i.e.,
the number of histories. The standard uncertainty of
the mean are computed as a measure of the reliability of the results from Monte Carlo calculations.
5.2 MONTE CARLO RADIATION TRANSPORT

CALCULATIONS
If a wide variety of clinical situations or exposure
conditions need to be considered, a mathematical
representation of the patient and theoretical calculation of DT may be more practicable than measurements with a physical anthropomorphic phantom.
Theoretical calculations of DT have mostly been performed using the Monte Carlo techniques described
in this section, which simulate the passage of
x-ray photons through the phantom. The parameters defining the x-ray beam can be easily modified
so that DT relative to a normalization quantity, for
example, Ka,i can be calculated for any desired x-ray
field. However, considerable level of scientific understanding is needed to use the codes properly.
5.2.1 Main features of the Monte Carlo
technique
The Monte Carlo technique is a computational
method based on the mathematical simulation of
physical processes. For application of the technique,
the physical processes need to be reformulated in
terms of the probabilities of the variables involved.
Probability functions and scoring functions need to
be defined. Once this is done, the complex problem
reduces to a simpler problem of random selection of
values of each variable from the probability functions. By calculating many cases (histories) reliable
average values can be obtained with an estimate of
their statistical uncertainties.
In patient dosimetry for medical x-ray imaging,
Monte Carlo calculations are used to simulate and
record the energy deposition of x-ray photons in computational models of the human body. The radiationinteraction histories of a large number of incident
photons are followed using known physical descriptions of the interaction processes and the resulting
energy depositions at the sites of interaction are
recorded. For medical x-ray imaging, the photon
interactions simulated are limited to the photoelectric effect and coherent and incoherent scattering
because the initial photon energies are <150 keV.
The energy given to the secondary electrons is usually assumed to be absorbed at the point of interaction. Consequently, the kerma is numerically equal
to the absorbed dose. The ranges of the secondary
electrons are small compared with the dimensions of
the relevant organs, and the absorbed dose does not
change abruptly with distance except at a boundary
where composition and density change. In general,
these boundary effects have little impact on the
determination of the average absorbed doses in the
tissues. The single exception is the active BM, where
a small increase in absorbed dose due to the size of
5.2.2 Main features of the computational

models of the human body
Two distinct types of computational model have
been developed, namely, mathematical and voxel
(volume pixel) phantoms. Both are described in
ICRU Report 48 (1992c).
5.2.2.1
Mathematical phantoms
A three-dimensional mathematical phantom representing a reference adult patient was originally

developed at the Oak Ridge National Laboratory,
USA, for use in the field of internal dosimetry (Snyder et al., 1969). It was based on the physique and
anatomy of the Reference Man (ICRP, 1975) and
formulae describing its outline and the shape and
disposition of internal structures and organs
appeared in Pamphlet No. 5 of the Medical Internal
Radiation Dose Committee (MIRD).
A revision of the MIRD-5 phantom was made by
Cristy (1980). In addition to including phantoms
representing children of various ages, Cristy uses
an improved model for the distribution of the active
BM, a more sophisticated heart model and adds
regions simulating the female breast to the trunk.
Kramer et al. (1982) developed male and female
adult phantoms, ADAM and EVA, having the appropriate gender specific organs and with EVA having
dimensions 0.83 times that of ADAM. A more realistic neck region was built into these phantoms to
Older texts use standard error.
56
METHODS FOR DETERMINING ORGAN AND TISSUE DOSES
Figure 5.1. Various cross sections of the female mathematical phantom EVA (based on data of Kramer et al., 1982). Horizontal
cross sections refer from top to bottom to various levels in the head, the chest region, the abdomen region, and the legs. Reproduced
with permission from Dr. F.W. Schultz.
evident in Figure 5.1. Exact delineation of the x-ray

beams used in medical imaging becomes more difficult than with realistic physical phantoms, leading
to greater uncertainty in the doses calculated for
small organs close to beam edges. However, the
mean doses to large organs are probably estimated
more accurately by the Monte Carlo technique where
the total energy deposited in the organ is calculated,
rather than by averaging dose measurements made
at a limited number of points within the organ.
improve estimates of thyroid doses from anteriorly

incident x rays. Jones and Wall (1985) used a hermaphrodite adult phantom based on Cristys adult
phantom with Kramers modified neck region and
breast tissue composed of 50 % fat and 50 % water
rather than the standard soft tissue composition
used in the other phantoms. In the earlier (before
1991) versions of these mathematical models the
oesophagus was missing, because this was only
introduced as a radiosensitive organ in ICRP Publication 60 (1991b).
All current mathematical phantoms consist of an
elliptical cylinder representing the trunk and arms,
two truncated circular cones representing the legs
and an elliptical cylinder capped by half an ellipsoid
representing the head. The skeleton and organs are
mostly generated from further truncated elliptical
cylinders or ellipsoids specified by quadratic inequalities. Such crude formulations for the organ boundaries permit reasonable computational efficiency in
carrying out the Monte Carlo calculations but produce the limitations in anatomical accuracy that are
5.2.2.2
Special features of the active BM
In the Monte Carlo procedure, energy deposition is

recorded in each of the sub-regions of the skeleton.
Absorbed dose to the active BM is derived from the
summation of energy depositions in each skeletal
region. The result is the absorbed dose weighted
over the total active BM regardless of the fraction
of the skeleton irradiated. This procedure is consistent with recommendations for partial organ irradiation when absorbed doses are <1 Gy (ICRP, 1969).
57
In the phantoms, the bone and marrow are mixed

homogeneously in the skeleton, that is, there is no
geometrical representation of the marrow sites as
separate sites of interaction. The composition and
density of the skeleton is that of a constant admixture of the two components, with each skeletal
region being assigned an appropriate mass of active
BM. The energy deposited in the active BM component of this admixture is based on the ratio of the
mass energy absorption coefficient for active marrow
to that of the overall skeletal region, and the fraction
of skeletal mass that is active BM (Rosenstein,
1976).
The increase in absorbed dose to active BM in
small cavities due to the increase in photoelectron
emission by surrounding bone is 220 % for monoenergetic photons in the range 20150 keV. The
increase depends on the photon energy and the size
of the trabecular cavities (Spiers, 1963). The range of
correction factors from one bone to another for a
given energy is less than 4 % of the average value.
Average values were generally used, since x-ray
fields encompass more than one skeletal component.
In the peak energy range found in most x-ray spectra
used in radiology, 3040 keV, the correction is of the
order of 10 % (Rosenstein, 1976).
5.2.2.3
Voxel phantoms
More realistic voxel phantoms are becoming

available based on whole-body CT or magnetic resonance imaging scans of real patients. Each organ or
tissue in these phantoms consists of volume elements derived from the scan data so that tissue
boundaries can be more accurately modelled than
with the simple geometric shapes of the earlier
mathematical phantoms. Spatial resolution is limited only by the chosen voxel size. So far the results
of Monte Carlo calculations in voxel phantoms for
diagnostic x-ray exposures are available for the
BABY and CHILD phantom (see, Figure 5.2; Zankl
et al., 1988; Veit et al., 1989). Adult voxel phantoms
have been developed (Zankl and Wittmann, 2001;
Petoussi-Henss et al., 2002) and will be used for
patient organ dose calculations.
Figure 5.2. The exterior surface (top) and selected internal organs
(bottom) of the child phantom (Zankl et al., 1988; Veit et al., 1989,
with permission).
radiography of adults Schultz et al. (1994) followed

in general 106 histories. A history comprises the
path of a primary photon, and of the secondary particles it gives rise to, through the regions of interest,
including the locations and quantities of energy
dissipation. The statistical uncertainty of the doseconversion coefficients is largely determined by that
of the computed DT, because the relative error in
the Ka,i is only about 0.1 %. The relative errors in
DT vary considerably: (a) for each individual organ,
depending on the exposure parameters (spectrum
and geometry); (b) between organs, depending on
whether an organ is inside or far away from the
5.2.3 Uncertainties in Monte Carlo

organdose calculations
Coefficients of variation, for example, relative
standard deviations on the mean, are computed as
a measure of the reliability of the statistical aspects
of the Monte Carlo calculations (Section 5.2.1). Often
more than one million primary photons are followed
to reduce the statistical uncertainties to reasonable
levels. For the calculation of dose-conversion coefficients, for example, DT per unit of Ka,i, for PA chest
58

primary beam, for example, from <0.3 to 0.9 % in
lungs to >19 to 48 % in the lower large intestines, in
the case of chest radiography.
Other sources of uncertainty in Monte Carlo calculations of this type are uncertainties in the basic
attenuation coefficients and inadequacies in the
description of the x-ray source and the patient. The
linear attenuation coefficients are derived from
atomic cross sections and differential scattering
cross sections, the elemental compositions of the tissues and the tissue densities. Hubbell and Seltzer
(1995) quote uncertainties of the order of 5 % for
elemental mass attenuation coefficients <5 keV
and only 2 % up to 10 MeV. Therefore, the elemental
attenuation data should not be a significant source of
error.
The elemental compositions and densities of all
the individual tissue types are not modelled in mathematical phantoms. In ADAM and EVA, four tissues
are considered (lung, skeletal, skin, and soft tissue),
and in voxel BABY and CHILD phantoms five and
six tissues, respectively. In more recent voxel phantoms, for example, GOLEM (Zankl and Wittmann,
2001), the number of tissues has been extended to
eight. A study comparing organ doses calculated
with phantoms composed of 4 and 18 distinct tissues,
respectively, indicates that the uncertainties made
by considering only a small number of tissues generally do not exceed 10 % for radiation qualities typical
of diagnostic radiology (Pani et al., 1987).
Of probably greater significance is the impossibility of describing accurately the juxtaposition of
human anatomy and x-ray beam configurations
with mathematical phantoms. For instance, the
lungs in the mathematical phantoms ADAM and
EVA are not curved at the mediastinum. Consequently, the whole lung can be imaged in a field,
which includes smaller fractions of, for example,
stomach, kidneys, liver, and pancreas than is the
case for real patients. Here the voxel type of human
body phantom offers a clear improvement, because
the organ shapes are replicated from the imaging of
real persons. Relatively small shifts, for example, 5
cm in height for chest radiography, can result in
considerable changes in organ doses, for example, a
factor of 3 for the dose to the spleen (Gosch and
Gursky, 1992; Schultz et al., 1994).
NRPB (Jones and Wall, 1985). For the five organs

receiving the highest doses, the agreement between
the GSF and Schultz et al. (1994) data for the ADAM
phantom is within 10 % when similar vertical beam
position and the same spectra are used. A comparison of conversion coefficients at 100 kV for the male
phantoms for lung and active BM between CDRH
and Schultz et al. shows excellent agreement when
the same vertical field positions are used (Schultz
et al., 1994). However, for the thyroid the differences
are larger (up to 50 %) and strongly dependent on
the vertical beam position. The comparison of the
Schultz et al. and NRPB data is complicated by the
fact that NRPB results refer to a hermaphrodite
phantom. The differences between the conversion
coefficients for ADAM and the hermaphrodite phantom (NRPB) remain generally within 20 % for the
five most heavily irradiated tissues.
For CT, the data published by the NRPB (Jones
and Shrimpton, 1993) for the Philips Tomoscan 350
scanner showed on average agreement within 10 %
with the data calculated for a mimicked hermaphrodite phantom by Jansen et al. (1995).
The data calculated by PCXMC (Tapiovaara et al.,
1997; Appendix F) are most directly comparable
with the organ dose-conversion coefficients calculated at the NRPB by Jones and Wall (1985) and
Hart et al. (1994b, 1996b), because they are based
on the same phantom models. In general, the agreement between the results of PCXMC and the NRPB
data is good. The differences between them typically
fall within the statistical uncertainty and are
generally <10 %.
5.2.4 Comparison of conversion

coefficients calculated at different
institutes
5.2.5.1
5.2.5 Comparison of measured and

calculated organ doses
A number of experimental comparisons were
made during the original work with the Monte
Carlo code (see Appendix B.2.1) at the US-Bureau
of Radiological Health (now the Center for Devices
and Radiological Health) by Rosenstein (1976), Beck
and Rosenstein (1979), and Chen et al. (1978). The
results of these comparisons are summarized below.
In addition, a comparison of measured organ doses
with values derived using calculated organ doseconversion coefficients is presented for CT (Geleijns
et al., 1994).
Adult phantoms: organs in the x-ray field
The central axis depth doses available at the time

for use in radiotherapy (Cohen et al., 1972) could be
used for dose assessment when small organs such
as the ovaries or testes are located centrally in a
radiation field (Rosenstein, 1976). The irradiation
conditions are comparable with those for the ovaries
For PA chest radiography, a comparison has been

made of the dose-conversion coefficients calculated
by Schultz et al. (1994) with those calculated at GSF
(Drexler et al., 1990), CDRH (Rosenstein, 1988), and
59

Table 5.1. The more significant differences in bone dosimetry approaches of Ellis et al. (1975) and of Rosenstein (1976).
Experimental approach (Ellis et a1., 1975)
Monte Carlo approach (Rosenstein, 1976)
Inflated lung model:

Volume and density 5000 cm3; 0.2 g/cm3
Beam quality:
e.g., HVL1 2.3 mm Al
(Peak tube voltage: 105 kV, 1 mm Al added filtration)
Relaxed lung model:

3378 cm3; 0.3 g/cm3
Beam quality:
e.g., HVL1 2.3 mm Al
(Peak tube voltage: 75 kV, 2.7 mm Al total filtration)
1976) were not directly comparable because of different anatomical and technical assumptions, but a
comparison was instructive (Kereiakes and Rosenstein, 1980). Even the same HVL1 does not yield the
same results. When the same spectra are used the
differences are smaller.
The more significant differences in the two
approaches are described in Table 5.1.
For identical x-ray fields and HVL1, the Ellis et al.
(1975) absorbed dose values were up to a factor of
23 higher. When the same beam quality from the
experimental approach was used in the Monte Carlo
code, the absorbed doses were a factor of 1.21.8
times higher than those obtained with the corresponding softer beam qualities. The effect of the differences in lung models was to increase the active
BM dose at those sites directly behind the lungs by
up to 25 %. These results accounted for much of the
difference obtained between the two approaches.
and testes in the Monte Carlo phantom for the AP

view, where the organs are surrounded by tissue and
not in direct contact with nor shielded by portions of
the skeleton. Additional comparisons can be made
for the thyroid in the AP view and the ovaries in
the PA view, but in these cases the inhomogeneities
in the Monte Carlo phantom affect the radiation
transport.
An additional experiment for absorbed dose to the
testes used an adult Alderson phantom (McDowell
et al., 1976). The Alderson phantom was constructed
of tissue-equivalent material, contained a full skeleton and simulated lungs, and had anthropometric
characteristics that closely matched the reference
man dimensions of the Monte Carlo phantom.
The agreement among the three sets of data for
the testes (AP view) was within 15 % in all cases and
generally within 3 %. Agreement between two sets of
data for the ovaries (AP view) was within 20 % in all
cases and generally within 11 % (Rosenstein, 1976).
5.2.5.4
5.2.5.2 Adult phantoms: organs outside

the x-ray field
A tissue-equivalent head and neck phantom

incorporating a skull of a child 6 years old was
used to obtain experimental absorbed doses to the
thyroid and brain for comparison to the results for
the Monte Carlo phantom for the 5-year-old child
(Beck and Rosenstein, 1979). The statistical uncertainty (at 2 SD) associated with the experimental
data was <20 %; the statistical uncertainty of the
computed data was <3 % for brain doses and <10 %
for thyroid doses. For the brain doses, the ratio of the
experimental to computed doses ranged from 0.66 to
0.94; for the thyroid doses, the ratios ranged from
1.13 to 1.21.
The experiment for absorbed dose to the testes

noted above included several irradiations in which
the testes were in close proximity (i.e., testes center
just within the field edge) or outside the x-ray field
(i.e., testes center 3, 5, or 9 cm outside the field edge).
This allowed a check of the radiation transport
calculation when scattered radiation conditions
prevailed. Agreement of the two sets of data was
generally within 30 % (Rosenstein, 1976).
In the same experiment (Rosenstein, 1976), irradiations were made with and without a lead shield
placed over the simulated testes to prevent external
photon scatter from the x-ray filter and intervening
air column to the testes. Such scatter is ignored in
the Monte Carlo calculation. Without the shield, the
absorbed doses to the testes were 2550 % higher
than with the shield. This external scatter contribution is <1 % of the total dose when the testes are in
the x-ray field.
5.2.5.3
Paediatric phantoms: head and neck
5.2.5.5
Paediatric phantoms: whole body
Tissue-equivalent phantoms that were nearly

identical to the mathematical child phantoms in
the Monte Carlo code were constructed for 1 and 5
year olds. Measurements of absorbed doses were
made at sites for the brain, each lobe of the thyroid,
each ovary, the testes, and several sections of the
skeleton, i.e., the spine, each upper arm, the pelvis,
and each upper leg (Chen et al., 1978). Ratios of the
experimental to computed results varied from 0.61
to 1.39. Most were between 0.75 and 1.25 and no
Adult phantoms: active BM
Data from the two BM dosimetry approaches

available at the time (Ellis et al., 1975; Rosenstein,
60

In addition, Table 5.2 provides information on the
application of the Monte Carlo code PCXMC for calculating dose-conversion coefficients. All conversion
coefficients rely on Monte Carlo simulation of the
radiation transport through mathematical or voxel
phantoms.
More nearly complete references to these sources
of dose-conversion coefficients with details of their
important features are given in Appendices BD,
grouped according to the organization where they
were developed, and in Appendices E and F
Appendix B
Figure 5.3. Organ doses from CT abdomen examinations
determined using TLD dosimetry and a RANDO phantom
(black) or using CK values and organ dose-conversion coefficients
of the NRPB (gray) and GSF (white) (Reproduced from Geleijns
et al., 1994, with permission of British Institute of Radiology).
RBM is red BM.
Appendix C
Appendix D
trend could be discerned for those comparisons lying

outside these limits.
Appendix E
5.2.5.6 Adult phantoms: CT
Anthropomorphic body phantoms have been used
for dosimetry in diagnostic radiology (see, e.g.,
Maccia et al., 1988; Geleijns et al., 1992, 1994).
Figure 5.3 shows the results of an experimental
method and two computational methods for the
determination of organ doses for CT abdomen investigations (Geleijns et al., 1994). Differences in organ
dose are observed for the different methods. It is
expected that these variations are mainly due to
differences between the phantoms used. When comparing the mathematical phantoms of the NRPB
(Jones and Wall, 1985) and GSF (Kramer et al.,
1982), it is noticed that they have very similar distribution of the radiosensitive organs. In the study of
Geleijns et al. (1994) an anthropomorphic RANDO
phantom was used to estimate organ and tissue
doses. The RANDO phantom is different in size compared with the mathematical phantoms employed by
NRPB and GSF and the estimated location of the
organs in the RANDO phantom differs significantly
in comparison with the distribution of organs in
the mathematical phantom. This explains the large
difference between the measured and calculated
values for the dose to the bladder.
Appendix F
Handbooks produced by the Center

for Devices and Radiological Health
(CDRH)
Reports produced by the German
Center for Health and the
Environment (GSF)
Reports produced by the Health
Protection Agency (HPA) (Formerly
National Radiological Protection
Board NRPB)
Review of Monte Carlo calculations
for assessment of mean glandular
dose in mammography
PCXMC A PC-based Monte Carlo
program for calculating patient dose
due to radiology
Appendices BD include sample pages from the

tabulations and example calculations of organ
doses for given x-ray examination conditions.
The information in Appendices BD is extensive
but not comprehensive. The variation in exposure
conditions for a particular examination or procedure
is large (radiation quality, field size, and location on
the body, view) and the number of types of examinations and procedures is large and varying. Often
practice in one country is different from that in
another country. Appendices B, C, and D reflect
practice in the US, Germany, and the UK, respectively. Differences in examinations or procedures can
even exist between radiologists in the same hospital.
It is, therefore, impossible to make comprehensive
calculations.
A comparison of organ dose-conversion coefficients
calculated at different institutes reveals that for
similar exposure conditions the values for the
internal organs located in the primary beam show
agreement within 10 % (Section 5.2.4). For similar
exposure conditions, comparisons of calculated and
measured DT also show acceptable agreement
(Section 5.2.5).
Differences in exposure conditions result in larger
differences in DT for the same type of medical
5.2.5.7 Sources of data on dose-conversion

coefficients
Important features of published tabulations of
coefficients for relating measurable normalization
quantities to organ doses are shown in Table 5.2.
61

Table 5.2. Important features of sources of dose-conversion coefficients for medical x-ray imaging.
Type of examination No. of
views
No. of No. of
Normalization Phantom
organs spectra quantity
Referencea
General radiology
8
16
26
24
1
1
1
1
12
14
90
10
17
3
Ka,i
Ka,i
Ka,e, PKA
Ka,i, PKA
Ka,i
Ka,i
Ka,i
Ka,i
Ka,i
CDRH 89-8031 (Rosenstein, 1988)

GSF 11/90 (Drexler et al., 1990)
NRPB-SR262 (Hart et al., 1994b)
Tapiovaara et al. (1997)
CDRH 85-8239 (Rosenstein et al., 1985)
Dance (1990, 2000)
Wu et al. (1991a, 1994)
Jansen et al. (1994)
CDRH 92-8282 (Rosenstein et al., 1992)
20d
Ka,i
24
6
20
Ka,i, PKA
Ka,I
20
26
72
Ka,i, PKA
5/6
16/11
1b
Ka,i
24
Ka,i, PKA
208
slices
104 slices
45 slices
66 slices
23
23
CKe
22
35
37
3
2
2
CK
CK
CK
54
40
68
c
Mammography
Fluoroscopy:
Upper GI tract
Coronary
Arteries
Fluoroscopy
Pediatric
radiography
Radiography/
Fluoroscopy
CT adult
CT Pediatric
6
1
1
1
12
17
3b
40
c
MIRD hermaphrodite
ADAM EVA
Cristy hermaphrodite
Cristy hermaphroditec
Reference
Breasts
ADAM
EVA
ADAM
EVA
Cristy hermaphroditec
0, 1, 5 years
hermaphrodite
0,1,5,10,15 years
hermaphrodite
Voxel baby
Voxel child
Christy
hermaphroditec
Cristy
hermaphrodite
ADAM EVA
Voxel baby
Voxel child
CDRH 95-8289 (Stern et al., 1995b)

BRH 79-8079 (Rosenstein et al., 1979)
NRPB-R279 (Hart et al., 1996a)
NRPB-SR279 (Hart et al., 1996b)
Zankl et al. (1988)
Zankl et al. (1989)
NRPB-R250 (Jones and Shrimpton, 1991)
NRPB-SR250 (Jones and Shrimpton, 1993)
GSF 30/91 (Zankl et al., 1991)
GSF 30/93 (Zankl et al., 1993)
For more complete information see Appendices BF.

Per view.
c
Views, spectra and phantom sizes can be freely selected.
d
Data are also given for the skin in the primary field (maximum dose).
e
Expressed in muscle tissue instead of air.
b
qualities (three values of tube voltage per type of

examination) for a series of common x-ray projections. For organs in the centre of the field, differences
of up to a factor of 2 were found; for organs at
the edge or outside the field the variations can be
larger.
When a dose-conversion coefficient is needed for a
specific situation, it is recommended to select a value
from the available data based on similarities in
exposure conditions (projection, view, field size, and
radiation quality) and patient model.
imaging task (Wise et al., 1999). When for the PA

chest examination the field is shifted vertically by
5 cm, differences of up to 60 % were found in organs
partly irradiated by the primary beam (Gosch and
Gursky, 1992; Schultz et al., 1994). For this examination differences in x-ray spectra, i.e., 130 kV
x rays versus 80 kV x rays, result in conversion
coefficients for the most heavily irradiated organ
(lungs) differing by a factor of 2 (Schultz et al.,
1994). In the publication by Drexler et al. (1990)
organ dose coefficients are given for various x-ray
62

CONCLUSIONS
The two purposes of patient dosimetry for medical

x-ray imaging are to set and check standards of good
practice and to assist in assessing detriment or
harm. The present situation in patient dosimetry
for medical x-ray imaging clearly indicates the
needs for dose quantities recommended for different
applications and for using the same, self-consistent
system for names, symbols, and units.
The radiation quality of an x-ray beam can be
characterized by the x-ray spectrum. Although xray spectra can be measured, it is recommended
that the radiation quality of x-ray beams used for
medical imaging be characterized by a combination
of various parameters. These include the first HVL,
HVL1, the second, HVL, HVL2, the ratio of HVL1 to
HVL2, referred to as the homogeneity coefficient, the
tube voltage and the total filtration. In most cases,
the quality of an x-ray beam can be adequately specified by means of the combined information on tube
voltage, HVL1, and HVL2, or the tube voltage, HVL1
and total filtration. The x-ray tube output is also an
important characteristic of an x-ray tube (including
filtration).
Several application-specific dosimetric quantities
have been found useful for measurements in medical
x-ray imaging. However, ambiguity exists in names
of quantities and their use. Because of the equivalence of numerical values of absorbed dose and kerma
in the same material for the x-ray energies used in
medical imaging, quantities have often been alternatively referred to in terms of absorbed dose or in
terms of kerma. Because almost all of these quantities will be measured with instruments calibrated
free-in-air in terms of air kerma, it is considered to
be appropriate and more consistent with practice
elsewhere to name them in terms of air kerma.
Recommended application-specific quantities for
dosimetry in medical x-ray imaging are summarized
in Table 3.1 and followed by more detailed
definitions.
At low dose levels, the mean absorbed doses in
organs or tissues in the human body are taken to
be an indication of the probability of subsequent
stochastic effects. At high dose levels, the absorbed
dose to the more heavily irradiated sites within the
body is taken to be an indicator of the severity of

deterministic effects. For an assessment of the risk
due to induction of stochastic and deterministic
effects by medical x-ray imaging detailed knowledge
is required of organ doses, absorbed dose distribution, and the age and gender of the group of patients
concerned, rather than effective dose.
A dose-conversion coefficient relates a specified
dosimetric quantity to some other quantity, i.e., the
normalization quantity, which can be readily
measured or calculated in the clinical situation.
For stochastic effects, the specified dosimetric
quantities are the organ doses, orin the case of
mammographythe mean glandular dose. Normalization quantities are Ka,i, Ka,e, PKA, or CK. In view of
the technical developments in CT, particularly large
volume scanning, basic measurements using a 10 cm
long detector (ionization chamber) will be most probably inadequate in the future. For interventional
radiology, dose-conversion coefficients with the aim
to avoid the occurrence of deterministic effects are
lacking until now except for some coronary procedures (Appendix B).
Diagnostic reference levels, DRLs, are introduced
as a form of investigation level in diagnostic radiology. DRLs are aimed at the management of patient
doses consistent with the clinical information that is
required. The dosimetric quantities recommended
for the establishment of DRLs are Ka,i, Ka,e, DG,
and PKA.
Methods are required for measurement of normalization quantities used in the dose-conversion coefficients (Section 5 and Appendices BF) and of
quantities recommended for establishment of
DRLs. Measurement of these quantities mainly
relies on the use of ionization chambers and solidstate dosimeters, including TLDs. Calibration procedures including requirement for stating uncertainties are considered essential. The air kerma
free-in-air is the desired dosimetric quantity for the
x rays used in medical imaging. The uncertainty of
dose measurements for comparative risk assessment
as well as for quality assurance should not exceed
about 7 % using a coverage factor of 2. This implies
that well-defined conditions for the calibration at
Appendix A includes specific information on

backscatter factors commonly required for dosimetry of low, for example, mammography, and
medium energy, and all other energies of x rays
used in medical imaging. Backscatter factors are
dependent on radiation quality, for example, HVL,
field size and to a lesser extent on the x-ray spectrum, target angle, focal spot-to-surface distance,
and phantom thickness and material.
Dose-conversion coefficients for specific procedures applied for x rays used in medical imaging are
presented in Appendices BE. A comparison of conversion coefficients calculated at different institutes
shows that differences are small, i.e., within the
statistical errors and generally less than 10 %
when the exposure conditions and mathematical
models of patients are similar. Larger differences
occur due to differences in mathematical models
simulating the patient. Similar conclusions can be
drawn from comparisons of measured and calculated
organ dose-conversion coefficients. Larger errors,
i.e., well in excess of 10 % occur for conversion coefficients concerning organs far away from the primary beam. This is not a practical problem since their
contribution to the radiation risk is much less than
that of organs receiving the highest doses.
When a dose-conversion coefficient is needed for
a specific situation, the best approach is to select
a value from the available data based on similarities in exposure conditions (projection, view, field
size, and radiation quality) and patient model.
Appendices B, C, and D reflect practice in the
USA, Germany, and the UK, respectively, whereas
Appendix E deals with mammography. Appendix F
provides information on a PC-based Monte Carlo
program for calculating patient doses in radiography, excluding mammography, and fluoroscopy.
It also allows variations in patient size.
standards laboratories must be established. In a few

cases calibration of dosimeters at a standards laboratory is neither feasible nor possible. This includes
air kermaarea product meters that should be calibrated in situ and TLDs that should be calibrated
based on the actual field conditions. For these types
of dosimeters specific information is provided.
Examples are given of radiation qualities used for
calibration of dosimeters in conventional radiology.
An international code of practice for patient dosimetry in diagnostic radiology is presently being
developed by the IAEA. It will include practical
details of calibrations at the standards laboratory.
Information is provided for measurement of
application-specific dosimetric quantities including
incident air kerma Ka.i, entrance surface air kerma
Ka.e, air kermaarea product, PKA, especially during
complex examinations involving both fluoroscopy
and radiography, and dosimetric quantities used in
CT. In this respect it should be borne in mind that
the quantities recommended for dosimetry in CT are
of a provisional nature.
Methods of determining organ and tissue doses
are summarized in Section 5. Dose measurements
in physical anthropomorphic phantoms have been
applied for this purpose but can be very tedious,
and realistic physical phantoms are very expensive.
Therefore, Monte Carlo methods are commonly used
to derive dose-conversion coefficients relating normalization quantities to mean organ and tissue
doses, as well as doses to localized areas of, for
example, skin. In addition, general information is
provided on Monte Carlo methods used for computation of radiation transport in anthropomorphic
mathematical phantoms or anthropomorphic voxel
phantoms. A comparison is made of conversion coefficients calculated at various institutes and between
measured and calculated organ doses.
64

APPENDIX A: BACKSCATTER FACTORS

Various sources of backscatter factors B for lowenergy x rays incident on homogeneous phantoms
are available in the literature. Some have been
derived for exposure conditions typical of radiotherapy practice (Chan and Doi, 1981; BJR, 1983;
Harrison et al., 1990; Klevenhagen, 1982, 1989;
Grosswendt, 1984, 1990, 1993; IPSM, 1991; Ma
et al., 2001) and others for exposure conditions typical of diagnostic radiology (Stanton et al., 1982;
Harrison, 1982; Petoussi-Henss et al., 1998). In addition, backscatter factors have been calculated using
Monte Carlo techniques for diagnostic x-ray fields
incident on anthropomorphic mathematical phantoms (computational models) of the whole body, containing simulated bone and lung structures within a
soft tissue-equivalent material (Hart et al., 1994a,b).
It should be noted that different definitions of the
backscatter factor B are used. For radiotherapy
applications, B is commonly defined as the ratio of
the water kerma at a point on the beam axis at the
surface of a sufficiently large (water) phantom to the
water kerma at the same point in the primary (i.e.,
incident) beam, with no phantom present. In alternative definitions the ratios of air kermas or of
absorbed doses, for example, IAEA (1987) are used.
For the x-ray energy range typically used in radiology, the quantities water kerma and absorbed dose
to water have effectively the same values.
Values of B are primarily a function of the x-ray
spectrum (HVL1) and field size but are also dependent to a lesser extent on the anode angle, focus-tosurface distance, dFSD, and phantom thickness and
material. Measurements at diagnostic radiology conditions by Harrison (1982) showed that for a given
HVL1, the value of B is dependent upon the peak
tube voltage. Qualitatively, for a given HVL1 a
higher peak tube voltage implies a broader spectrum
leading to a B modified by lower and higher energy
scatter. The effect reported by Harrison (1982)
amounts to 2% at maximum at a HVL1 of 2 mm
Al and tube voltages ranging from 60 to 100 kV.
The influence of the anode angle on B has been
qualitatively investigated by Carlsson (1993). The
smaller the anode angle the larger is the heel effect,
i.e., the lower is the fluence rate at the anode side of
the field. Furthermore, the smaller the anode angle

the more the anode material acts as a filter. This
latter effect, however, also influences the HVL1.
For large beam angles and a small anode angle, the
heel effect reduces the value of B. For radiology
(except mammography), it might be expected that,
because of the relatively large dFSD the influence of
anode angle on the value of B is most likely a few
percentage at maximum.
Calculations of Grosswendt (1990) demonstrate
an increase in B with increasing dFSD. For values of
dFSD in the range from 30 to 100 cm the variation in
B at a field size of 20 cm diameter is 3% at maximum. For values of dFSD >100 cm, the change in
B with dFSD will be even smaller. It is concluded
that the influence of changes in dFSD on the value
of B will generally be negligible for radiology
applications.
The thickness of the underlying phantom material
influences the magnitude of the backscatter factor.
Klevenhagen (1982) presents a set of equations
allowing the calculation of the backscatter factor
for given field size, HVL1, ,dFSD, and thickness of
underlying material. For practical purposes in radiology, it is concluded that a phantom thickness of 8
cm is sufficient to obtain a backscatter factor >95%
of the value with full backscatter for all field sizes
and radiation qualities. This is in agreement with
the conclusions of Stanton et al. (1982).
The elemental composition of a phantom also
influences B. Compared with a water phantom,
the use of tissue substitute materials generally
result in small, i.e., >5% corrections, dependent
on the radiation quality (Grosswendt, 1984). For
polymethylmethacrylate (PMMA), however, deviations >5% occur at a field size of 100 cm2 and a
radiation quality characterized by a HVL1 of 2 mm
Al. This is in agreement with findings of Stanton
et al. (1982) for measurements with PMMA, BR12
(average breast tissue substitute), and MS11 (water
substitute).
Backscatter factors for diagnostic radiology were
calculated by Petoussi-Henss et al. (1998) using
Monte Carlo methods. Values of B have been
obtained for cuboid (30 cm 30 cm surface and

Table A.1. Backscatter factors for water, ICRU tissue, and PMMA for some x-ray beams typical of diagnostic radiology at
three field sizes and a focus-to-surface distance dFSD of 100 cm (Reproduced from Petoussi-Henss et al., 1998 with
permission from the Institute of Physics).
Tube
Filter
voltage/kV
HVL/ Field 10 cm 10 cm
Field 20 cm 20 cm
Field 25 cm 25 cm
mm Al
Water ICRU tissue PMMA Water ICRU tissue PMMA Water ICRU tissue PMMA
50
60
70
70
70
80
80
80
90
90
90
100
100
100
110
120
120
130
150
150
150
1.74
2.08
2.41
2.64
3.96
2.78
3.04
4.55
3.17
3.45
5.12
3.24
3.88
5.65
3.59
4.73
6.62
4.32
4.79
6.80
8.50
2.5 mm Al
2.5 mm Al
2.5 mm Al
3.0 mm Al
3.0 mm Al 0.1 mm Cu
2.5 mm Al
3.0 mm A1
3.0 mm A1 0.1 mm Cu
2.5 mm Al
3.0 mm Al
3.0 mm Al 0.1 mm Cu
2.5 mm Al
3.0 mm Al
3.0 mm Al 0.1 mm Cu
2.5 mm A1
3.0 mm Al
3.0 mm Al 0.1 mm Cu
2.5 mm Al
2.5 mm Al
3.0 mm Al
3.0 mm Al 0.1 mm Cu
1.24
1.28
1.30
1.32
1.38
1.32
1.34
1.40
1.34
1.35
1.41
1.34
1.36
1.41
1.35
1.37
1.41
1.36
1.36
1.39
1.40
1.25
1.28
1.31
1.32
1.39
1.33
1.34
1.40
1.34
1.36
1.41
1.34
1.37
1.42
1.35
1.38
1.42
1.36
1.36
1.39
1.41
1.33
1.36
1.39
1.40
1.48
1.41
1.42
1.49
1.43
1.44
1.50
1.42
1.45
1.50
1.43
1.46
1.50
1.44
1.44
1.47
1.48
1.26
1.31
1.34
1.36
1.45
1.37
1.39
1.48
1.40
1.42
1.50
1.40
1.44
1.51
1.42
1.46
1.53
1.44
1.45
1.50
1.53
1.27
1.32
1.36
1.37
1.47
1.39
1.40
1.50
1.41
1.43
1.51
1.41
1.45
1.53
1.43
1.48
1.54
1.45
1.46
1.51
1.54
1.36
1.41
1.45
1.47
1.58
1.48
1.51
1.61
1.51
1.53
1.62
1.51
1.55
1.64
1.53
1.58
1.64
1.55
1.55
1.61
1.64
1.26
1.31
1.35
1.36
1.46
1.38
1.40
1.49
1.41
1.42
1.51
1.41
1.45
1.53
1.43
1.48
1.54
1.45
1.46
1.52
1.55
1.28
1.32
1.36
1.38
1.47
1.39
1.41
1.51
1.42
1.44
1.53
1.42
1.46
1.55
1.44
1.49
1.56
1.47
1.48
1.53
1.57
1.36
1.42
1.46
1.48
1.59
1.50
1.52
1.63
1.53
1.55
1.65
1.53
1.57
1.66
1.55
1.60
1.67
1.57
1.58
1.63
1.67
Table A.2. Backscatter factors calculated by Monte Carlo techniques in an anthropomorphic phantom (Hart et al., 1994a;
1994b).
HVL1/mm Al
2.0
2.5
3.0
4.0
Peak tube voltage/kV
60
80
80
110
Total filtration/mm Al
2.5
2.0
3.0
2.5
Projection
Lateral LSJa
11 cm 14 cm
AP Abdomen
26 cm 35cm
PA Chest
30 cm 38cm
1.23
1.25
1.27
1.29
1.31
1.37
1.41
1.45
1.23
1.27
1.30
1.34
LSJ is lumbosacral joint.
surface dose, for example, for skull radiographs or

PA projections through the chest. Table A.2 shows
backscatter factors for several x-ray projections,
field sizes, and beam qualities. Whereas there is
close agreement with corresponding values in
Table A.1 when the surface dosimeter overlies soft
tissue, there is a reduction in the backscatter factor
by 57% when the point of measurement overlies
lungs (PA chest).
For mammography, the situation is less complex
than for general radiology because the field size, xray spectra, anode angle, focus-to-surface distance,
and phantom thickness and material are less variable. Common conditions in mammography are that
the field size is larger than the phantom (or the
female breast), that a limited number of spectra
15 cm depth) phantoms of water, PMMA, and ICRU

tissue (elemental composition by mass 10.1% H,
11.1% C, 2.6% N, and 76.2 % O) at different field
sizes and dFSD for monoenergetic photons (range
0.011 MeV)
and various
x-ray
spectra
(Table A.1). The dependence of B on photon energy
and field size is significant. The results show that
PMMA is not tissue-equivalent in this energy range.
Backscatter factors have also been derived by
Hart et al. (1994a,b) by calculating the energy
absorbed in a small volume of material on the
entrance surface of an anthropomorphic phantom
that contains bone and lung structures, to allow for
the influence of underlying bone or soft tissue in the
x-ray field. Bone can lie close to the surface where
dosimeters may be attached for measuring entrance
66
APPENDIX A
Table A.3. Backscatter factors for a semi-circular PMMA phantom of 10 cm radius and 5 cm thickness, for three
mammographic spectra; dFSD: 65 cm; semi-circular field with 10 cm radius at the phantom surface (based on data of Kramer
et al., 2001).
Anode: Molybdenum
Filtration: 30 mm Molybdenum
Anode: Molybdenum
Filtration: 25 mm Rhodium
Anode: Rhodium
Filtration: 25 mm Rhodium
Peak tube
voltage/kV
HVL1/mm Al
Peak tube
voltage/kV
HVL1/mm Al
Peak tube
voltage/kV
HVL1/mm Al
24
25
26
28
30
32
34
35
36
38
40
0.282
0.295
0.306
0.325
0.340
0.353
0.364
0.369
0.373
0.381
0.388
1.08
1.09
1.09
1.09
1.10
1.10
1.10
1.11
1.10
1.11
1.10
24
25
26
28
30
32
34
35
36
38
40
0.328
0.343
0.356
0.375
0.391
0.403
0.412
0.416
0.420
0.427
0.433
1.09
1.09
1.10
1.10
1.11
1.11
1.11
1.12
1.11
1.12
1.12
24
25
26
28
30
32
34
35
36
38
40
0.297
0.316
0.330
0.362
0.391
0.418
0.441
0.452
0.462
0.481
0.497
1.09
1.09
1.10
1.11
1.11
1.12
1.12
1.13
1.13
1.13
1.14
et al. (2001). It was found that for field radii from 8

to 10 cm, dFSD from 60 to 70 cm, phantom thicknesses from 3 to 8 cm, and for a rectangular instead
of a semi-circular shape of phantom, this was
negligible. A PMMA phantom, a breast phantom
made of an homogeneous mixture of adipose and
glandular tissue and a phantom consisting of a 3
cm thick homogeneous mixture of adipose and
glandular tissue sandwiched by two 1 cm layers of
adipose tissue, all resulted in practically the same
value of B.
It can be concluded from the table that the variation in B for mammography is relatively small, that
is, 0.03 from the average value of 1.11. The dependence on phantom material is <5% between PMMA,
BR12, fat, and water (Doi and Chan, 1980; Stanton
et al., 1982).
and anode angles are applied, the focus-to-film

distances are generally 60 cm, that the phantoms
are constructed from PMMA or BR12. The phantoms
have generally sufficient thickness (i.e., in excess of
3 cm) to approximate full backscatter (Stanton et al.,
1982). Backscatter factors calculated for mammography are given in EC (1996b) and in Kramer et al.
(2001).
Table A.3 gives B for the most common spectra in
mammography. These values of B were calculated
(Kramer et al., 2001) for a semi-circular PMMA
phantom of 10 cm radius and 5 cm thickness; focusto-skin distance was taken to be 65 cm and the field
on the phantom surface was semi-circular with a
10 cm radius.
The impact of the variation of the exposure
parameters on B was also investigated by Kramer
67

APPENDIX B: HANDBOOKS PRODUCED BY THE

CENTER FOR DEVICES AND RADIOLOGICAL
HEALTH (CDRH)
B.1
GENERAL DESCRIPTION
The US Center for Devices and Radiological

Health, Rockville, Maryland (www.fda.gov/cdrh)
has produced five Handbooks that permit the
estimation of typical absorbed doses to tissues of
reference adult and paediatric patients from radiographic and fluoroscopic procedures. The Handbooks
also permit evaluation of the effect on tissue doses of
changes in technical parameters used in or among
facilities. Variations from a particular reference
patient due to anthropometric characteristics of
the human body and its internal organs are not
addressed. Therefore, assignment of organ doses to
individual patients is not recommended.
The specific Monte Carlo codes and anthropomorphic phantoms varied with the objectives of
each Handbook and the state-of-the art at the time
each Handbook was prepared. The following five
Handbooks are available.
1. Projections Common in Diagnostic Radiology
(Adults) CDRH 89-8031 (Rosenstein, 1988).
2. Projections Common in Pediatric Radiology
BRH 79-8079 (Rosenstein et al., 1979).
3. Mammography CDRH 85-8239 (Rosenstein
et al., 1985).
4. Upper Gastrointestinal Fluoroscopic Examinations CDRH 92-8282 (Rosenstein et al., 1992).
5. Fluoroscopic and Cineangiographic Examinations
of the Coronary Arteries CDRH 95-8289 (Stern
et al., 1995b).
The earlier Handbooks present tissue doses per
entrance skin exposure (free-in-air)
(DT/mrad)/(Xi/R). Any entry can be converted to
SI units as follows:
To obtain tissue doses per incident air kerma
(DT/mGy)/(Ka,i/mGy) divide the entry by 876.
To obtain tissue doses per incident air kerma
(DT/mGy)/(Ka,i/Gy) divide the entry by 0.876.
The choice of the conversion coefficient depends

on the relative magnitude of the Ka,i value one would
encounter in a particular radiographic or fluoroscopic procedure. The sample tabulations presented
in the present ICRU Report have been converted to
SI units as appropriate for the specific tabulation.
B.2 HANDBOOK CDRH 89-8031

(ROSENSTEIN, 1988): PROJECTIONS
COMMON IN DIAGNOSTIC RADIOLOGY
(ADULTS)
B.2.1
Main features of calculations
The details of the Monte Carlo procedure and

the anthropomorphic phantom used to produce the
Handbook are described by Rosenstein (1976). Significant features are the BRHGAM Monte Carlo
code (Warner, 1973), the hermaphrodite MIRD-5
phantom of the Medical Internal Radiation Dose
Committee (Snyder et al., 1969) with supplemental
calculations performed for an added simulation of
the female breasts (Peterson and Rosenstein, 1989),
the elemental compositions for skeletal, lung, and
soft tissue of Tipton et al. (1966), the elemental composition of active BM of Poll et al. (1972), the distribution of active BM in the skeletal components of
Ellis (1961), and the photoelectron enhancement
factors for absorbed dose in trabecular spaces of
Spiers (1963).
Except for the female breasts, tissue-air-ratios
were computed for the tissues of interest for monoenergetic photons in the range 20100 keV for 4 cm
4 cm plane-parallel beams normally incident on the
respective mid-plane of the phantom for AP, PA, and
right lateral incidence. The tissue-air-ratios are for
the particular reference phantom. The coefficients
of variation associated with the tissue-air-ratios are
provided in Rosenstein (1976). This approach was
chosen to accommodate the very large number of
The tissues or organs for which conversion

coefficients are tabulated are as follows.
possibilities for adult projections. Supplemental

tissue-air-ratios were obtained at a later date for
the addition of female breasts for single fields that
encompassed the breasts.
The tissue-air-ratios were then converted to DT per
unit Ka,i coefficients for a specific x-ray projection
using the pertinent information on x-ray spectra,
projection geometries, and field sizes and locations.
The tissue-air-ratios for 4 cm 4 cm grid elements
included in the x-ray field and for photon energies
included in the x-ray spectrum are combined to
simulate the desired conditions. A computer program, which performs the conversions of tissue-airratios to tissue doses for common radiographic
projections and simple fluoroscopic projections, and
its documentation are available (Peterson and
Rosenstein, 1989).
B.2.2
Lungs
Active BM1
Thyroid
Female breasts
Testes
Ovaries
Uterus (surrogate for the embryo; first two months
of pregnancy)
Total trunk tissue (excludes lungs and skeletal
tissue)
1
Dosimetrists term for red BM.
The coefficients are presented for 12 beam qualities expressed in terms of HVL1 (from 1.0 to 6.5 mm
Al in 0.5 mm Al steps) without identification of a
specific tube voltage. In preparing the tabulations,
27 diagnostic x-ray spectra were applied, 9 in each of
the categories shown below.
Scope of the handbook
The Handbook presents a series of 54 tabulations

of tissue dose-conversion coefficients for a variety
of common radiographic projections (e.g., chest) and
views (e.g., AP, PA, lateral) for reference adult male
and female patients (Rosenstein, 1988). The anthropometric characteristics of the reference patient
and the locations of the x-ray fields for each of the
projections are provided in the Handbook.
The projections (e.g., Skull) and views (e.g., AP)
tabulated are as follows.
Skull AP, PA, LAT

Facial bones PA
Temporalmandibular
joint, Zygomes PA
Mastoid, Mandible PA
Temporalmandibular
joint, Sella volume LAT
Cervical spine AP, LAT
Shoulder(s) AP, LAT
Scapula(e) AP, LAT
Humerus AP
Sternum LAT
Ribs, Barium swallow
AP, PA, LAT
Chest AP, PA, LAT
Thoracic spine AP, LAT
Full Spine AP, LAT
Range of peak
tube voltage/kV
Range of HVL1/
mm Al
4570
8090
98120
1.03.6
1.75.5
3.16.0
For the range of the peak tube voltage and conventional aluminum filtration combinations used in
diagnostic radiology, the data presented should have
uncertainties of <10 % when HVL1 alone is used to
describe beam quality (Rosenstein, 1988). Data are
also presented for the AP skull, PA chest, and AP
abdominal projections and views when an erbium
composite filter (3.2 mm erbium composite plus
2.0 mm Al) is used.
A sample tabulation for the AP thoracic spine for
the range of HVL1 from 2.5 to 4.0 mm Al is given
in Table B.1.
Additional information is provided in the
Handbook to permit corrections for the following
circumstances.
Cholecystography PA
Lithotripsy AP
Upper GI Tract AP,
PA, LAT
Upright abdomen AP
Lumber spine AP, LAT
Abdominal AP, PA, LAT
Sacrum, Coccyx AP, LAT
Sacroiliac joint AP
Pelvis, Lumbopelvic
AP, LAT
Urethrogram AP
Cystography AP
(a) When the testes are closer to the x-ray field edge
than indicated by the reference conditions;
(b) When more or less active BM is included in
the x-ray field because of the actual field
size and;
(c) When the testes, ovaries, or uterus are shielded, particularly for the AP view in the region
of the abdomen.
Hip(s) AP, LAT

Femur AP, LAT
The specifications for the projections and views

reflect practice in the United States.
70
APPENDIX B
Table B.1. Sample tabulation: Handbook of Tissue Doses
for Projections Common in Diagnostic Radiology (Adults)
(Rosenstein, 1988).
the newborn and the 1 year old is assumed to be

100 % active BM, and that of the 5 year old reflects
the gradual replacement with yellow marrow seen
with maturation.
The variety of x-ray projections and views and
the variation in technique factors are more limited
in paediatric radiology (Beck and Rosenstein, 1979).
For the paediatric cases, each calculation started
with the specified characteristics of the x-ray
projection and view (i.e., AP, PA, LAT or OBL),
including focus-to-image receptor film distance,
dFID , field size and location with respect to anatomical landmarks, and beam quality. X-ray spectra
were matched with the desired beam qualities
with respect to tube voltage and HVL1 (Beck and
Rosenstein, 1979). The distribution of x-ray photon
energies was input directly at the start of the Monte
Carlo computation.
(DT/mGy)/(Ka,i/mGy)
HVL1/mm Al
Male
Lungs
Active BM
Thyroid
Trunk tissue
Testes
Female
Lungs
Active BM
Thyroid
Trunk tissue
Breasts
Ovaries
Uterus
2.5
3.0
3.5
4.0
0.159
0.023
0.107
0.067
0.187
0.029
0.123
0.078
0.212
0.033
0.137
0.087
0.233
0.038
0.148
0.095
0.120
0.019
0.107
0.054
0.411
0.140
0.024
0.123
0.062
0.444
0.001
0.159
0.029
0.137
0.070
0.470
0.001
0.001
0.175
0.032
0.148
0.075
0.493
0.002
0.002
a
a
B.3.2
AP Thoracic Spine: dFID 102 cm; field size at film, 18 cm 43 cm.

a
(DT/mGy)/(Ka,i/mGy) < 0.001.
B.2.3

of tissue dose-conversion coefficients for a variety of
common radiographic projections and views in paediatric radiology (Rosenstein et al., 1979). The Handbook is for three reference patients: a newborn (birth
to 6 months), a 1 year old child and a 5 year old child.
The anthropometric characteristics of the three reference paediatric patients, the locations of the x-ray
fields for each of the projections and views, the anatomical limits of the x-ray fields, and the coefficients
of variation associated with the Monte Carlo calculations are provided in the Handbook.
The projections and views tabulated are as follows.
Application of the handbook
The information required to estimate tissue doses

from radiographic examinations is Ka,i and the HVL1
(mm Al). It is preferred that this information be
obtained for the x-ray equipment and for the physical parameters actually used at the facility.
B.2.4
Illustrative calculation
An average-sized woman who is not pregnant

undergoes a thoracic spine examination with one
AP radiograph. The examination is performed with
an HVL1 of 2.5 mm Al, a dFID of 102 cm, and a field
size of 18 cm 43 cm. The dose to the female breasts
due to this examination is
DBreast 5:3 mGy 0:411 2:18 mGy,
Townes* (all ages)

Skull AP, LAT
(all ages)
Skull PA (1 and
5 year old)
Neck AP, LAT
(1 year old)
Chest AP, PA, LAT
(all ages)
Chest OBL**
(5 year old)
Kidneys AP
(all ages)
B:1
where 5.3 mGy is the locally determined Ka,i, and

0.411 the organ dose-conversion coefficient for the
female breast derived from Table B.1.
B.3 HANDBOOK BRH 79-8079 (ROSENSTEIN
ET AL., 1979): PROJECTIONS COMMON IN
PAEDIATRIC RADIOLOGY
B.3.1
Bladder AP (5 year old)

Bladder OBL** (1 and
5 year old)
Erect abdomen AP
(5 year old)
Abdomen AP, PA, LAT
(all ages)
Pelvis AP (all ages)
Hip AP (5 year old)
Hip OBL** (1 and
5 year old)
*
Townes field incident at 30 caudal on the anterior skin
surface.
**
OBL views field incident at 45 to the normal on the anterior
skin surface (i.e., posterior oblique).
The details of the Monte Carlo procedure used to

produce the Handbook for paediatric patients are
the same as for the Handbook for adults. The details
of the newborn, 1 year old, and 5 year old anthropomorphic phantoms used to produce the Handbook
are described by Hwang et al. (1976a,b). The BM of
The specifications for these projections and views

71
The tissues or organs for which conversion coefficients are tabulated are as follows.
Table B.2. Sample tabulation: Handbook of Tissue

Doses for Projections Common in Pediatric Radiology
(Rosenstein et al., 1979).
Testes
Ovaries
Thyroid
AP abdomen
Newborn
dFID/cm
102
Field size at image receptor to:
Body part/cm cm
13 13
Film size/cm cm
20 25
Active BM
Lungs
Total body (includes all body tissues)
The coefficients are presented for three or four

beam qualities (i.e., HVL1 of 2.0, 2.5, 3.0, and
3.5 mm Al), as appropriate for the particular projection. The beam qualities listed are nominal values
and have been selected and matched to x-ray spectra
on the basis of an observed narrow range of tube
voltage, total filtration, and waveform. In preparing
the tabulations, six diagnostic x-ray spectra were
applied, as shown below.
Total filtration/
mm Al
HVL1/mm
Al collimation
2.7
2.7
2.7
3.7
2.5
2.5
2.1
2.4
2.7
3.0
3.1
3.4
2.5
Film
size
Body
part
Film
size
Testes
Newborn
1 year
5 year
Newborn
1 year
5 year
Newborn
1 year
5 year
Newborn
1 year
5 year
Newborn
1 year
5 year
Newborn
1 year
5 year
0.098
(0.120)
(0.143)
0.445
0.308
0.308
(0.006)
1.039
(1.221)
(1.221)
0.445
0.308
0.308
(0.029)
(0.010)
(0.003)
0.182
0.113
0.079
0.501
0.259
0.116
0.428
0.300
0.231
0.164
(0.120)
(0.143)
0.639
0.422
0.422
(0.006)
1.142
(1.221)
(1.221)
0.639
0.422
0.422
(0.029)
(0.010)
(0.003)
0.241
0.160
0.115
0.567
0.291
0.140
0.478
0.348
0.273
Active BM
Lungs
a
a
0.104
0.079
0.063
0.056
0.040
0.045
0.212
0.191
0.180
a
a
0.145
0.114
0.095
0.075
0.055
0.054
0.242
0.224
0.215
Values in parenthesis indicate differences in (DT/mGy)/(Ka,i/mGy)

as a function of HVL1 for the same collimation, i.e., body part or
film size, were not significant.
a
(DT/mGy)/(Ka,i/mGy) < 0.001.
B.4 HANDBOOK CDRH 85-8239

(ROSENSTEIN ET AL., 1985):
MAMMOGRAPHY
The information required to estimate tissue doses

from paediatric radiographic examinations is the
Ka,i and the HVL1 (mm Al). It is preferred that this
information be obtained for the x-ray equipment and
for the physical parameters actually used at the
facility.
B.4.1
The details of the Monte Carlo procedure used to

produce the Handbook for mammography are the
same as for the Handbooks for adults and paediatric
patients. The female breast is a variable composite
of adipose and glandular tissue, and the glandular
tissue is the tissue at risk for breast cancer. The
details of the simulated compressed reference
breasts used to produce the Handbook are described
by Rosenstein et al. (1985).
Tissue-air-ratios for a plane parallel x-ray field
(20 cm 25 cm) normally incident on and fully
encompassing each reference breast were computed
for 100 % glandular and 100 % adipose compositions.
Appropriate geometrical conversions are made for
A 1 year old girl is to undergo a single AP abdomen

radiograph. The examination is performed with an
HVL1 of 2.5 mm Al, a dFID of 102 cm, and a field size
of 18 cm 21 cm (imaging of body part). The dose to
the ovaries due to this examination is
2.0
Body
part
Total body
B.3.4
23 30
28 36
Age
HVL1/
mm Al
The selection of the paediatric projections and the

technique factors associated with each type of examination have been described by Beck and Rosenstein
(1979).
A sample tabulation for the AP abdomen projection and view for HVL1 of 2.0 and 2.5 mm Al is given
in Table B.2.
B.3.3
18 21
25 30
Organ
Thyroid
65
80
90
80
98
105
5 year old
102
(DT/mGy)/(Ka,i/mGy)
Ovaries
Peak tube
voltage/kV
1 year old
102
B:2

ovaries derived from Table B.2.
72
APPENDIX B
The specifications for these tabulations reflect
practice in the United States.
The five tabulations resulting from the Monte
Carlo calculations are presented as a function of
HVL1 (from 0.2 to 2.4 mm Al) without identification
of a specific tube voltage. In preparing the tabulations, 51 mammographic x-ray spectra were used, as
listed below.
the divergent x-ray field to obtain the tissue dose per

unit incident air kerma. The computations were for
monoenergetic photons with seven selected energies
from 9.5 to 55.5 keV, with additional data interpolated at 0.5 keV intervals. The coefficients of variation associated with the tissue-air-ratios for the
seven selected energies are provided in Anderson
and Rosenstein (1985). The tissue-air-ratio for any
intervening breast composition is derived from the
relevant mass fractions of glandular and adipose
tissue.
For a given breast composition, the tissueair-ratios for monoenergetic photons are then converted to tissue-air-ratios for a number of x-ray spectra that represent the tungsten, tungsten
molybdenum alloy and molybdenum target materials then used in mammography techniques (Fewell
and Shuping, 1978). Appropriate geometrical conversions are made for the divergent x-ray field to
obtain the tissue dose per unit incident air kerma.
The glandular tissue dose per unit incident air
kerma is obtained by multiplying the total breast
tissue dose by the ratio of the mass energy absorption coefficient of glandular tissue to that of the
selected overall breast composition. The calculations
are described by Rosenstein (1984) and Andersen
and Rosenstein (1985).
B.4.2
Target
type
No. of Range of
Range of
spectra tube
HVL1/mm
voltage/kV Al
Tungsten (W)
19
MoW alloy
14
Molybdenum (Mo) 18
2550
2050
3050
0.42.3
0.21.6
0.31.3
For the same target type and beam quality, but

different tube voltages, the individual values were
within 10 % of the average over the range of tube
voltages. For similar HVL1 using different target
materials, the individual values are within a few
percent of the average for the three target types
(Rosenstein, 1984). The values in the tabulations
result from smooth curves fitted to the results from
the individual x-ray spectra.
The tabulation that reproduces the experimental
results of Stanton et al. (1984) includes values for
tungsten targets and separate values for molybdenum or tungstenmolybdenum targets.
The portion of the tabulation for the CC view, 6 cm
uniform breast thickness, glandular tissue content
between 25 and 75 %, and HVL1 from 0.2 to 1.0 mm
Al, is given in Table B.3.
The Handbook presents tabulations of glandular

tissue dose-conversion coefficients resulting from
the Monte Carlo calculations for five reference
breasts and adds one tabulation that reproduces
the experimental results of Stanton et al. (1984).
The Handbook permits the user to compute glandular tissue dose for various techniques in mammography as a function of breast compression, breast
size, breast composition, and the quality of the x-ray
beam (Rosenstein et al., 1985).
The six tabulations are listed below; CC stands
for cranio-caudal and ML stands for medio-lateral.
B.4.3
The information required to estimate glandular

tissue dose from mammography examinations is
Ka,i and the HVL1 (mm Al). It is preferred that this
information be obtained for the mammography
equipment and for the physical parameters actually
used at the facility.
Firm compression (uniform breast thickness)

1. CC view: 3 cm to 8 cm uniform thickness;
50 % glandular tissue (Stanton et al., 1984)
2. CC view: 6 cm uniform thickness;
5100 % glandular tissue
Moderate compression (non-uniform breast
thickness)
3. CC view: small breast; glandular tissue 5100 %
4. CC view: medium breast; glandular tissue 5100 %
5. CC view: large breast; glandular tissue 5100 %
6. ML view: medium breast; glandular
tissue 5100 %
B.4.4
A women undergoes a single CC view mammogram. The breast is compressed to 6 cm and the
composition is 25 % glandular tissue. The examination is performed with an HVL1 of 0.6 mm Al,
a dFID of 76 cm, and a field size of 20 cm 25 cm.
The mean dose to the glandular tissue due to this
examination is
73
B:3

Table B.3. Sample tabulation: Handbook of Glandular
Tissue Doses in Mammography (Rosenstein et al., 1985).
ADAM and EVA phantoms for the relevant oblique

x-ray fields in divergent-beam geometry, with specific x-ray spectra representative of clinical practice.
(DT/mGy)/(Ka,i/mGy)
Glandular tissue content (by weight)
25 %
50 %
75 %
HVL1/mm Al
0.2
0.3
0.4
0.5
0.6
0.8
1.0
0.070
0.137
0.190
0.242
0.292
0.384
0.458
0.061
0.121
0.170
0.218
0.266
0.354
0.427
0.054
0.110
0.154
0.201
0.247
0.332
0.404
B.5.2

of tissue dose-conversion coefficients, one tabulation
for each of two views i.e., left posterior oblique (LPO)
and right anterior oblique (RAO) for each of the six
component anatomical projections of the Upper GI
fluoroscopic examination (Rosenstein et al., 1992).
Descriptions of the anatomical projections, the
oblique views, the locations of the projections on
the reference phantoms, the simulation of the contrast medium, and the coefficients of variation for
the Monte Carlo calculations are provided in the
Handbook and by Stern et al. (1995a).
The anatomical projections (e.g., Upper esophagus) and views (e.g., LPO) tabulated are as follows.
Craniocaudal view: Firm compression (uniform breast thickness),

thickness 6 cm.

ovaries derived from Table B.3.
B.5 HANDBOOK CDRH 92-8282 (ROSENSTEIN
ET AL., 1992): UPPER GASTROINTESTINAL
(UPPER GI) FLUOROSCOPIC EXAMINATION
B.5.1
Upper esophagus
Middle esophagus
Lower esophagus
Gastroesophageal junction
Stomach
Duodenum
The Monte Carlo procedure and the anthropomorphic phantoms (ADAM and EVA) used to produce the Handbook for Upper GI examinations is
the adaptation of the BRHGAM code (Warner, 1973)
by the GSF Forschungszentrum fur Umwelt und
Gesundheit (Kramer et al., 1982). The mathematical
phantom representing the reference male patient
(ADAM) is a modification of the original MIRD-5
phantom (Snyder et al., 1969), including an update
of the active BM distribution by Cristy (1981). The
reference female patient (EVA) is the ADAM phantom reduced uniformly to 83 % of its original size,
with the unique female tissues instead of the unique
male tissues (Kramer et al., 1982).
To better represent the upper GI simulations
an esophagus and a duodenum were added to the
phantom, and a double contrast medium was simulated in the esophagus, duodenum, and stomach
(Stern et al., 1995a). The contrast medium consisted
of a 1 mm thick lining of barium sulphatewater
against the inner organ walls, with air filling the
rest of the volume of the organ.
The dynamic upper GI fluoroscopic examination
was approximated with a set of six discrete x-ray
fields developed by Suleiman (1989). Each discrete
x-ray field is a projection of distinct anatomical portions of the upper GI tract: upper, middle, or lower
esophagus, gastroesophageal junction, stomach, and
duodenum. For each component projection,
a separate Monte Carlo calculation was made with
(LPO and RAO)

(LPO and RAO)
(LPO and RAO)
(LPO and RAO)
(LPO and RAO)
(LPO and RAO)
The specifications for these projections and views

Thyroid
Oesophagus
Female breasts
Lungs
Active BM
Stomach
Bladder
Liver
Testes
Ovaries
Uterus (surrogate for the embryo;
first 2 months of pregnancy)
Total trunk tissue (excludes lungs
and skeletal tissue)
Colon
The coefficients are presented for three beam
qualities (HVL1 of 4.0, 5.0, and 5.5 mm Al). These
beam qualities span the range of fluoroscopic x-ray
tube potentials and aluminum filtrations used in
clinical practice (Conway, 1994). The beam qualities
cited approximate those measured above a tabletop
present in the beam path of undertable x-ray tubes.
For the usual range of tube voltages and aluminum
filtration combinations used in Upper GI fluoroscopy, the results should have uncertainties of
<10 % when HVL1 alone is used to describe beam
74
APPENDIX B
fields provided in the Handbook. A practical method
of accomplishing this task is to videotape a clinically
representative examination and add a permanent
visual display of time and the sequence of frames.
The videotape can then be analysed and the clinical
examination subdivided into the fluoroscopic scan
segments and radiographic spot films corresponding
to the anatomical projections and views in the Handbook. The irradiation time associated with each of
the fluoroscopic scan segments can be evaluated from
the visual display. An example of this segmentation
is provided in the Handbook.
An example of the determination of Ka,i for each
of the discrete x-ray fields and the determination of
a separate representative beam quality for fluoroscopic scans and radiographic spot films is also
provided in the Handbook.
quality. In preparing the tabulations, three diagnostic x-ray spectra were applied, as shown below.
Peak tube voltage/kV
HVL1/mm Al
80
100
120
4.0
5.0
5.5
For the tabulated data, the dFID is 80 cm and the

dFSD is 50 cm. For the differences from these reference dFID and dFSD common in Upper GI fluoroscopy
(i.e., dFSD between 40 and 55 cm and dFID between 70
and 90 cm), differences from the tabulated entries
will be <20 % for entries of (DT/mGy)/(Ka/mGy) >0.1
and <35 % for entries of (DT/mGy)/(Ka/mGy) <0.1
A sample tabulation for the stomach (RAO) is
given in Table B.4.
B.5.3
B.5.4
A male patient undergoing an illustrative

examination of the stomach is presented in the
Handbook. The examination consists of various
parts, for instance, gastroesophageal junction (GE)
projection in LPO and RAO views for both scans and
films, stomach (ST) projection in LPO and RAO
views for both scans and films, and duodenum (DU)
projection in LPO view for both scans and films.
Here only ST projection in RAO for both scans and
films are shown. The example is developed fully in
the Handbook.
The ST RAO scans are performed with an HVL1
of 5.5 mm Al, a dFSD of 50 cm, a dFID of 80 cm, and a
field size of 22.9 cm 22.9 cm at image receptor
plane. The dose to the stomach due to this part of
the examination is
An upper GI fluoroscopic examination needs to be

analysed and simulated with the 12 specific x-ray

for the Upper Gastrointestinal Fluoroscopic Examination
(DT/mGy)/(Ka,i/mGy)
HVL1/mm Al
4.0
Tissue
Male
Thyroid
Oesophagus
Breast
Lung
Active BM
Stomach
Colon
Bladder
Liver
Testis
Uterus
Ovary
Trunk
5.0
Female
Male
5.5
Female
Male
Female
0.011
0.016
0.008
0.016
0.013
0.354
0.021
0.017
0.021
0.010
0.019
0.015
0.400
0.024
0.001
0.080
0.018
0.023
0.011
0.021
0.016
0.422
0.027
0.011
0.014
0.297
0.016
0.001
0.091
0.071
0.040
0.015
0.017
0.342
0.021
0.001
0.105
a
0.001
0.002
0.040
0.046
0.017
0.018
0.354
0.024
0.001
0.110
DStomach 4:5 mGy 0:354 1:59 mGy,
0.048
B:4

stomach taken from Table B.4.
The ST RAO films are performed with an HVL1
of 5.0 mm Al, a dFSD of 50 cm, a dFID of 80 cm,
and a field size of 22.9 cm 22.9 cm at image receptor. The dose to the stomach due to this part of the
examination is
0.084
0.002
0.003
0.046
0.002
0.002
0.048
DStomach 17:1 mGy 0:342 5:85 mGy,
Stomach, RAO: The patient is usually prone with the right

anterior side against the table. The patients sagittal planes are
angled at a nominal 30 from the central ray of the x-ray beam. A
distinguishing characteristic of this projection is that it is centred
on the stomach.
Field size at image receptor: 22.9 cm 22.9 cm
dFID: 80 cm
dFSD: 50 cm
Note: Entries apply to both single and double contrast procedures.
a
(DT/mGy)/(Ka,i/mGy) < 0.001.
B:5

stomach taken from Table B.4.
The total dose to the stomach due to ST RAO scans
and films is
DStomach 1:59 mGy 5:85 mGy 7:44 mGy:
75
The arterial projections are specified by view (e.g.,

RAO), angulation of image receptor (if different
from 0 ) in the transverse and saggital planes, and
location of the field centre (left or right ventricle).
The 12 tabulations are as follows.
B.6 HANDBOOK CDRH 95-8289 (STERN

ET AL., 1995B): FLUOROSCOPIC AND
CINEANGIOGRAPHIC EXAMINATION OF
THE CORONARY ARTERIES
B.6.1
The Monte Carlo procedure and the anthropomorphic phantoms (ADAM and EVA) used to produce the Handbook for examinations of the coronary
arteries is the adaptation of the BRHGAM code
(Warner, 1973) by the GSF Forschungszentrum
fur Umwelt und Gesundheit (Kramer et al., 1982).
The mathematical phantom representing the reference male patient (ADAM) is a modification of the
original MIRD-5 phantom (Snyder et al., 1969), with
the addition of an esophagus by Zankl et al. (1992)
and the addition of a supporting tabletop at the back
of the phantoms (Stern et al., 1995b). The reference
female patient (EVA) is the ADAM phantom reduced
uniformly to 83 % of its original size, with the unique
female tissues instead of the unique male tissues
(Kramer et al., 1982).
The simulated examinations of the coronary arteries are based on a series of distinct x-ray fields commonly used in coronary interventional radiology,
derived from analyses of practice at the Institut de
Cardiologie de Montreal (Lesperance, 1982; Haddadi
and Renaud, 1993). The scope of views and arterial
projections represented are generally applicable to a
broad range of examinations following a variety of
clinical protocols in many different venues. For each
arterial projection, a separate Monte Carlo calculation was made with ADAM and EVA for the relevant
complex oblique x-ray field in divergent-beam geometry, with specific x-ray spectra representative of
clinical practice (Stern et al., 1995b).
B.6.2
RAO 30 (left)

RAO 30 (right)
LAO 30 (right)
LLAT (left)
RAO 15 Caudal 25
(left)
RAO 15 Cranial 25
(left)
Cranial 20 (right)

LAO 45 Cranial 25 (left)
LAO 45 (left)
RAO 10 Cranial 40 (left)
Anterior (left)
Nominal conversion
coefficients
Entrance skin in primary field

Brain
Pancreas
Thyroid
Stomach
Thymus
Liver
Active BM
Kidneys
Oesophagus
Colon
Lungs
Small intestine
Female breasts Ovaries
Heart
Uterus (surrogate for the embryo)
Adrenals
Urinary bladder
Spleen
Testes
In extended coronary-artery examinations, cumulative absorbed doses to that portion of skin lying
directly in the path of the incident primary field may
approach or exceed the thresholds for deterministic
injury. Therefore, the SI units for the conversion
coefficients in this Handbook are expressed as
(DT/mGy)/(Ka,i/Gy). The entrance skin in the primary field is only a small fraction of the entire skin
tissue; the extent is delimited and the location is
determined by the collimation and irradiation geometry of the anatomical projections.
Except for the heart, the organs and tissues listed
are those with which cancer, genetic effects, or
in utero effects have been associated with irradiation
(ICRP, 1991b). The heart surrounds the ventricle
field centres and always lies within the field of view
(FOV). It receives the highest absorbed dose per unit
of incident air kerma of the internal organs. The
data for the heart are provided for reference purposes; there is no health effect yet established for
absorbed dose in the heart for the ranges that occur
in coronary-artery examinations.
The Handbook presents 12 tabulations of tissue

dose-conversion coefficients, 1 tabulation for each
of 11 arterial projections, and 1 tabulation that
provides nominal data that can be used for an examination consisting of several views, in lieu of the
individual tabulations. The nominal approach is
acceptable for coronary-artery examinations
because all the views share the point that the heart
is a relatively small, common, central region intercepted by the central ray of each different x-ray field.
Descriptions of the standard nomenclature used in
the anatomy of the coronary arteries and to identify
the arterial projections, the specifications for the
irradiation geometry and complex oblique views,
and the coefficients of variation for the Monte Carlo
calculations are provided in the Handbook (Stern
et al., 1995b).
76
APPENDIX B
for Fluoroscopic and Cineangiographic Examinations of
the Coronary Arteries (Stern et al., 1995b).
The coefficients are presented for three beam

qualities for each reference patient (i.e., ADAM,
HVL1 of 2.5, 4.0, and 5.5 mm Al; EVA, HVL1 of 2.0,
3.5, and 5.0 mm Al). The ranges of beam qualities
correspond to the those observed in the study conducted at the Institut de Cardiologie de Montreal
(Haddadi and Renaud, 1993) and that observed in a
nationwide survey of fluoroscopy practice in the United States (Conway, 1994). The beam qualities are
without the presence of a supporting tabletop. For
the usual ranges of tube voltage (kV) and aluminum
filtration combinations used in fluoroscopy and cineangiography of the coronary arteries, the results
should have uncertainties of <10 % when HVL1
alone is used to describe beam quality. In preparing
the tabulations, the following diagnostic x-ray spectra were applied, as shown below.
Peak tube
voltage/kV
ADAM
60
90
120
EVA
50
80
110
Total filtration/
mm Al
HVL1/mm Al
3.5
4.0
4.3
2.5
4.0
5.5
3.3
3.9
4.2
2.0
3.5
5.0
(DT/mGy)/(Ka,i/Gy)
Male
HVL1/mm Al
2.5
4.0
5.5
2.0
3.5
5.0
Entrance skin
in primary field
Brain
Thyroid
Thymus
Active BM
Oesophagus
Lung
Breast
Heart
Adrenal
Spleen
Pancreas
Stomach
Liver
Kidney
Colon
Small intestine
Ovary
Uterus
Urinary bladder
Testis
1000
1120
1180
950
1090
1170
0.003
0.12
2.2
6.1
14
34
0.020
0.50
6.5
12
33
53
0.041
0.85
9.9
16
47
65
30
36
4.9
5.4
2.4
4.4
3.2
0.071
0.091
62
62
11
14
6.3
9.7
6.8
0.31
0.40
86
78
15
20
9.3
14
9.3
0.56
0.72
0.003
0.021
0.002
0.044
0.004
0.001
0.075
1.6
5.2
11
31
3.0
23
32
3.8
3.8
1.7
3.5
2.7
0.043
0.050
0.007
0.005
0.001
0.018
0.53
6.7
12
32
55
9.4
63
64
11
13
6.3
9.9
7.1
0.32
0.39
0.076
0.071
0.023
0.045
1.1
12
17
51
71
15
95
87
17
22
10
15
11
0.67
0.82
0.19
0.17
0.054
Nominal conversion coefficients:

dFSD: 60 cm
dFID: 90 cm
FOV diameter at image receptor: 14 cm.
a
(DT/mGy)/(Ka,i/Gy) < 0.001.
When the actual diameter of the FOV at the image

receptor plane differs from that used in the reference
simulation by >20 %, the dose-conversion factor in
Table B.5 should be corrected by multiplication with
[FOV(actual)/FOV(tabulated)]2. The basis for the
correction is given in the Handbook (Stern et al.,
1995b).
The correction is not applicable to the entrance
skin in the primary field, because the absorbed dose
does not depend on the size of the area of the skin
irradiated.
A tabulation for the conversion coefficients is
given in Table B.5.
B.6.3
Female
The complete examination is characterized with

nominal values for four parameters.
(a) The HVL1;
(b) The total Ka,i for all the fluoroscopic plus cineangiographic segments (i.e., summed for all
skin-entrance planes, wherever these planes
are located);
(c) The FOV diameter at the image receptor plane;
and
(d) The highest cumulative Ka,i (i.e., fluoroscopic
plus cineangiographic) for any single skin
location. Such a skin region may be irradiated
in only one view or possibly in multiple views
that share a common locus of irradiation.
The Handbook can be used to perform a viewby-view or a nominal analysis of an examination.

To use the nominal approach, the coronary-artery
examination is characterized in an overall sense.
This permits a quick, but somewhat less accurate
way to estimate nominal tissue doses for a complete
examination without detailed specifications for the
particular views applied clinically.
B.6.4
The illustration below is for a left-heart study of

an adult male entailing a left ventriculogram in
biplanar mode followed by left and right coronary
77
angiography. In a typical application of the nominal

approach, the user will rely on estimated values of
the parameters for the entire examination that may
be truly nominal. In any case the estimates will be
developed at the level of detail and with the degree
of accuracy available to the user.
The left-heart study is performed with an HVL1
of 3.6 mm Al, a dFSD of 60 cm, a dFID of 90 cm, and a
FOV of 20 cm at image receptor plane.
The dose to the skin in primary field due to the
examination is
The dose to the active BM due to the examination is

DBM 1:6 Gy 10 mGy=Gy 2:0 32 mGy,
B:7
where 1.6 Gy is the Ka,i for all skin entrances planes,
10 the organ dose-conversion coefficient for the active BM derived by linear interpolation between the
reference values for HVL1 from Table B.5, and 2.0 is
a correction factor needed for the actual FOV (20 cm
rather than the 14 cm in the reference tabulation in
Table B.5).
The dose to the lung due to the examination is
DSkin;local 0:80 Gy 1090 mGy=Gy 870 mGy,

B:6
DBM 1:6 Gy 48 mGy=Gy 2:0 150 mGy,B:8
where 0.80 Gy is the highest Ka,i for any single skin

location and 1090 the organ dose-conversion coefficient for the local skin derived by linear interpolation between the reference values for HVL1 from
Table B.5.
where 1.6 Gy is the Ka,i for all skin entrances planes,

48 the organ dose-conversion coefficient for the lung
derived by linear interpolation between the reference values for HVL1 from Table B.5, and 2.0 is a
correction factor needed for the actual FOV.
78

APPENDIX C: REPORTS PRODUCED BY THE

GERMAN NATIONAL RESEARCH CENTER FOR
ENVIRONMENT AND HEALTH (GSF)
C.1
GENERAL DESCRIPTION
The GSF, Institute for Radiation Protection,

Medical Physics Department has produced several
reports containing tabulations of organ doseconversion coefficients for reference adult and paediatric patients for common radiographic and CT
examinations. The reports permit the calculation of
organ doses from measurable normalization quantities for specified technical parameters relating to
the examinations, using the general relation:
Organ dose organ dose-conversion coefficient
normalization quantity:
C:1
For standardized technical parameters, as given
in the European Guidelines on Quality Criteria for
Diagnostic Radiographic Images (EC, 1996a), the
organ doses are given.
The following material is available.
1. Projections Common
in Diagnostic Radiology
(Adults)
2. Projections Common
in Diagnostic Radiology
(Paediatric)
3. Organ Doses for
CT Examinations
of Adults
4. Organ Doses for
CT Examinations in
Pediatric Radiology
(GSF-Bericht 11/90,
Drexler et al., 1990).
(Zankl et al., 1988;
1989).
(GSF-Bericht 30/91,
Zankl et al., 1991).
(GSF-Bericht 30/93,
Zankl et al., 1993).
For the calculations on adult patients, genderspecific mathematical human phantoms have been
used, whereas the calculations in paediatric radiology have used voxel phantoms. The adaptation
of the data to individual patients is discussed.
Details are described in the GSF Report Series:
The Calculation of Dose from External Exposures
Using Reference Human Phantoms and Monte
Carlo Methods (Kramer et al., 1982; Drexler et al.,

1990; 1993; Zankl et al., 1991; 1993; 1997).
C.2 PROJECTIONS COMMON IN
DIAGNOSTIC RADIOLOGY (ADULTS)
GSF-BERICHT 11/90 (DREXLER
ET AL., 1990)
C.2.1
The organ dose-conversion coefficients are

obtained by applying a Monte Carlo calculation
method (Kramer et al., 1982; Veit et al., 1989) to
the modified MIRD-5 type mathematical male
ADAM and female EVA models (Kramer et al.,
1982). The main differences of the gender-specific
ADAM and EVA phantoms in comparison to the
MIRD-5 type phantoms are:
(i) the EVA phantom is representative of a reference adult female and contains the female
organs,
(ii) the ADAM phantom is representative of a
reference adult male and contains the male
organs,
(iii) the EVA phantom is significantly smaller than
the ADAM phantom.
(iv) the arms of both phantoms are removable,
(v) the phantoms have a chin so that less tissue
exists in front of the thyroid,
(vi) the skull of ADAM and EVA is improved with
regard to shape and size, and
(vii) an esophagus has been added (Zankl et al.,
1992).
In the Monte Carlo calculations the beam quality
is described by the spectral distributions of the
photons, which is a function of the tube voltage, the
total filtration, the target material, and the target
angle as determined by a computer program based
on semi-empirical methods (Birch and Marshall,
1979). In the tabulations of organ dose-conversion
coefficients, the beam quality is expressed in terms
of the constant tube voltage and the total filtration.

Table C.1. Radiographic examination of adults included
in Drexler et al. (1990).
Skulla AP, PA, LAT
Sinuses PA
Shoulder joint AP
Cervical spinea AP, PA, LAT
Thoracic spine AP, LAT
Ribs AP
Lunga AP, PA, left LAT,
right LAT
Stomach PA
Duodenum PA
Lumbar spine sacrum AP, LAT
Table C.2. Tissues or organs for which organ doseconversion coefficients are given for radiographic
examinations of adults.
Sacrum AP, LAT

Pelvis AP
Abdomen AP
Kidneys AP
Gall bladder PA
Bladder AP
Colon contrast enema
PA, LAT
Right hip joint AP
Left femur AP
Brain
Eye lenses
Thyroid
Breast
Lungs
Spleen
Pancreas
Stomach wall
Small intestine
The German edition (Drexler et al., 1993) contains in addition

data for the following.
At various dFSD.
Oesophagus
Adrenals
Liver
Kidneys
The beam geometry is given by the focus-tosurface distance dFSD, the focus-to-image receptor
distance dFID, the field size at the image receptor
plane, and the direction of incidence on the human
body. The organ dose-conversion coefficients for each
projection are calculated by simulating 2 106 incident photons for the exposure under consideration.
The exposure conditions have been selected to be in
close accordance with routine exposure conditions
common in Europe.
Details are described in the GSF Report Series:
The Calculation of Dose from External Exposures
Using Reference Human Phantoms and Monte Carlo
Methods (Kramer et al., 1982; Drexler et al., 1990;
1993).
C.2.2
Bladder wall
Muscle
Skin
Table C.3. Sample table from Drexler et al. (1990) showing

mean organ dose-conversion coefficients, i.e., mean organ
dose per unit Ka,i for the lung PA projection for adult
females (f ) and males (m).
Field size (f )
Field size (m)
Patient thickness (f )
Patient thickness (m)
Scope of the report
The Report of Drexler et al. (1990) presents a series of tabulations of organ dose-conversion coefficients for 40 common radiographic examinations
including techniques for pregnant women
(Table C.1). Additional organ dose tabulations are
provided for 28 projections with technical parameters as published in the EC Quality Criteria Document (1996a). The organs and tissues for which
organ dose-conversion coefficients are presented is
listed in Table C.2.
A sample tabulation for the lung PA projection is
given in Table C.3. Organ dose-conversion coefficients are provided for the ADAM and the EVA
phantoms. Each x-ray examination is investigated
for three tube voltages. A total filtration of 2.5 mm Al
is used for all the radiographic projections. The last
column in the table presents the coefficient of variation of the organ dose-conversion coefficients estimated from the Monte Carlo calculation.
C.2.3
Colon upper
Colon lower
Ovaries
Uterus
Testes
Active bone marrow
Skeleton
Skin entrance
Skin exit
35 cm 35 cm dFID
180 cm
150 cm
35 cm 40 cm dFSD
19 cm
Total filtration 2.5 mm Al
20 cm
125
c.va
Tube voltage/kV
90
140
Organ
Thyroid
Breast
Lungs
Spleen
Pancreas
Stomach wall
Small intestine
Colon (upper)b
Colon (lower)c
Active bone marrow
Skeleton
Surface (entrance)
Surface (exit)
0.06
0.54
0.25
0.17
0.07
d
d
d
0.11
0.30
1.24
0.04
0.06
0.13
0.57
0.18
0.12
0.06
d
d
d
0.12
0.32
1.24
0.05
0.10
0.68
0.33
0.25
0.11
d
0.01
d
0.16
0.35
1.27
0.07
0.10
0.19
0.72
0.24
0.17
0.10
d
0.01
d
0.17
0.38
1.32
0.08
0.12
0.73
0.35
0.27
0.12
0.01
0.01
d
0.17
0.36
1.35
0.09
0.12
0.22
0.76
0.26
0.19
0.11
0.01
0.01
d
0.18
0.39
1.34
0.10
0.035
0.006
0.002
0.009
0.012
0.013
0.02
0.035
0.001
0.001
0.001
0.04
Coefficient of variation.
Caecum Ascending Transverse.
c
Descending Sigmoid Rectum.
d
Less than 0.01.
b
coefficients cT,Ka,i given in the Report as,

DT cT,Ka,i Ka,i :
C:2
The value of Ka,i for the relevant radiographic projection and the applied tube voltage, field size, and
filtration are required to estimate the DT. For cases
where Ka,i is not known, the report presents a graph
to estimate Ka,i from tube voltage, filtration, tubecurrent exposure-time product, PIt, and the focal
Application of the report
Organ doses DT are determined from incident

air kerma Ka,i using the organ dose-conversion
80
APPENDIX C
Table C.4. Exposure parameters used as input data for the dose calculation of the BABY phantom.
Type of examination
Voltage/kV
Height of field/cm
Width of field/cm
dFIDa/cm
PKAa/mGy cm2
Ka,ia/mGy
Thorax AP
Abdomen AP
Pelvis AP
Skull AP
Skull LAT
65
70
70
70
65
13.8
20.0
11.6
22.9
19.8
14.5
16.3
13.9
15.1
20.1
150
100
100
100
100
6.93
19.4
7.9
69.8
51.3
39.7
76.2
56.5
275
179
dFID, focus-to-image receptor distance; PKA, dose-area product; Ka,i, incident air kerma.
phantoms are more realistic for dose calculations

than any other type of phantom available thus far.
They do not represent an average over all persons of
a certain age and gender, as the shape of the body
and the shape and locations of the organs vary for
people of the same age and gender, and even for
different attitudes (standing, sitting, lying).
However, because the shape and location of the
organs is accurate for a particular person in a certain
attitude, the phantoms constructed from these data
give the best approach to reality. For organ dose
calculations, the body is modelled using seven
types of tissue. The distribution of active BM in
bone is derived from the CT-numbers belonging to
each voxel, thus providing realistic modelling of
this tissue.
spot-to-surface distance, dFSD. In addition, recommendation is given in the Report on how to proceed,
when physical exposure parameters in a special
case considered differ from those assumed in the
tabulations.
C.2.4
Breast dose from a PA chest examination performed with a tube voltage of 125 kV, 2.5 mm Al
filtration, a PIt of 4 mAs, a dFSD of 150 cm, corresponding to a dFID of 180 cm and a field size of 35 cm
35 cm at dFID for the female phantom
DBreast 0:19 0:4 mGy 0:076 mGy,
C:3
where 0.19 is the organ dose-conversion coefficient

for breast from Table C.3 and 0.4 mGy the Ka,i, either
known from measurement or derived from the graph
in GSF-Bericht 11/90 (Drexler et al., 1990).
C.3.2
Organ doses for BABY and organ dose-conversion

coefficients for CHILD for the most common types of
examination in paediatric radiology have been published (Zankl et al., 1988; 1989) and are listed in
Tables C.5 (BABY) and C.7 (CHILD). The physical
exposure conditions for which they were determined
are shown in Tables C.4 (BABY) and C.6 (CHILD).
For BABY the tube voltage, the field sizes, and the
projections were chosen to be representative of
patients between the ages of 4 and 10 weeks who
had been x-rayed in the last 10 years in Munichs
University Children Hospital (Zankl et al., 1988).
For the thorax and pelvis examinations no grid was
used and the film was assumed to be in contact with
the body. For the other examinations grids were
used and the film was at 3.0 cm behind the surface.
Organ dose scaling factors enable the derivation of
organ doses for children deviating in size from the
original phantoms (Veit and Zankl, 1992, 1993).
The exposure conditions shown in Table C.6 for
CHILD are typical for the practice in Germany for
examinations of 57-year-old children with respect
to field size, tube voltage, filtration, focus-to-film
distance, and patient-to-film distance (Zankl et al.,
1989).
C.3 COMMON PROJECTIONS IN

DIAGNOSTIC RADIOLOGY (PEDIATRIC)
(ZANKL ET AL., 1988; 1989)
C.3.1
Scope of the publications
The features of the Monte Carlo program

employed are the same as that used for the adults.
The phantoms used are tomographic models of two
real patients, i.e., an 8-week-old girl BABY and a 7year-old girl CHILD. Details of these phantoms are
presented by Zankl et al. (1988) and Veit et al.
(1989).
To construct the GSF paediatric phantoms, wholebody CT data were used. For each phantom, scans of
a single patient were used, performed as contiguous
slices of 4 and 8 mm thickness for the BABY and
CHILD, respectively. The baby was 8 weeks old
when it was scanned and thus represents babies
from newborn up to several months. The child was
7 years old; it was, however, slightly small for its
age and can be regarded as representative for the
ages between 5 and 7 years. The CT-based voxel
81

Table C.5. Organ doses DT/mGy for an 8-week-old BABY phantom for different x-ray procedures (as listed in Table C.4).
Type of examination
Body organs and tissues
Thorax AP
DT/mGy
Abdomen AP
DT/mGy
Pelvis AP
DT/mGy
Skull AP
DT/mGy
Skull LAT
DT/mGy
Bladder wall
Brain
Eye lenses
Heart
Lungs
Ovaries
Small intestine wall
Stomach wall
Testes
Thymus
Thyroid
Total skeleton
Active BM pelvis
Active BM ribs
Active BM skull
Total active BM
0.02
0.28
0.86
23.3
18.6
0.02
0.13
0.88
0.00
27.4
34.2
22.1
0.01
7.53
1.43
3.02
60.9
0.04
0.00
37.1
23.8
52.1
69.0
70.0
10.1
4.38
1.12
39.1
29.2
13.3
0.07
5.83
47.6
0.00
0.00
0.14
0.11
42.1
25.8
0.99
67.3
0.06
0.02
15.7
22.1
0.10
0.00
2.81
0.02
88.9
295
6.99
16.6
0.03
0.26
0.78
0.01
51.7
212
304
0.07
11.7
86.9
43.9
0.00
60.2
125
1.66
2.68
0.00
0.07
0.29
0.03
6.04
90.3
186
0.04
1.46
52.1
22.8
Table C.6. Exposure parameters used as input data for the dose calculation of the CHILD phantom, relevant for 57-yearold patients in Germany.
Type of examination
Voltage/kV
Field width/cm
Field height/cm
dFIDa/cm
dPIDa/cm
Skull AP
Skull LAT
Thorax AP
Thorax PA
Abdomen AP
Pelvis AP
70
70
60
60
70
70
26.5
26.5
25.7
26.7
25.6
26.2
31.0
30.5
19.0
19.7
39.4
22.7
110
110
100
150
110
110
10
10
0
10
10
10
dFID focus-to-image receptor distance; dPID: patient-to-image receptor distance.
Table C.7. Organ dose-conversion coefficients, i.e., DT/Ka,i for different types of examination (Table C.6) for the CHILD
phantom.
Type of examination
Body organs and tissues
Brain
Eye lenses
Lungs
Ovaries
Testes
Thymus
Thyroid
Uterus
Skeleton (hard bone)
Active BM
Total body
Skull AP
Skull LAT
Thorax AP
Thorax PA
0.285
1.30
0.047
0.351
0.563
0.020
0.003
0.006
0.466
0.003
0.003
0.002
0.479
0.001
0.173
0.417
0.060
0.585
0.238
0.163
0.694
0.078
0.123
0.691
0.066
0.122
0.616
0.799
0.001
0.351
0.042
0.126
0.502
0.061
0.136
Abdomen AP
Pelvis AP
0.002
0.200
0.569
0.124
0.036
0.012
0.627
0.449
0.075
0.235
0.001
0.505
0.184
a
a
0.636
0.309/0.303b
0.057
0.137/0.131b
Less than 0.01.

The pelvic AP examination results for skeleton and total body in slightly higher doses for girls (first value) than for boys because of field
reduction due to shielding of testes.
b
C.3.3
from that listed in Table C.4 can be easily

derived by normalizing them to the values given in
the table.
For CHILD, the quantity required to apply the
organ dose-conversion coefficients cT,Ka,i from
Application of the publications
For BABY, organ doses are presented for specific

exposure conditions and can be directly taken from
Table C.5. Organ doses for values of Ka,i different
82
APPENDIX C
Table C.8. Radiation qualities in CT for which organ doseconversion coefficients were calculated.
Table C.7 is Ka,i

DT cT,Ka,i Ka,i :
C:4
Radiation quality
C.3.4
Illustrative calculations
Total active BM dose DBM,tot for BABY from an

abdomen AP examination performed with the same
physical exposure parameters as given in
Table C.4, but a Ka,i (exposure at skin entrance)
value of only 43.0 mGy (5 mR)
DBM;tot 5:83 mGy 43:0/76:2 3:3 mGy,
Tube voltage/kV
Total filtration/mma
Mean photon energy/keV
HVL1/mm Al
80
50.5
5.38
The total filtration is the same for each of the spectra considered.
Table C.9. Organs and tissues for which CT organ doseconversion coefficients were calculated.
Adrenals
Bladder
Brain
Breasts
Colon
Eye lenses
Kidneys
Liver
Lungs
Ovaries
Pancreas
Total active bone marrow
Skin
Small Intestine
Skeleton
Spleen
Stomach
Testes
Thymus
Thyroid
Uterus
The bones for which the dose to the active bone marrow is listed
separately are the following.
C:6
Arm bones
Clavicles
Cranium
Facial skeleton
C.4 REPORT ON ORGAN DOSES FROM CT

EXAMINATIONS (ADULTS) GSF-BERICHT
30/91 (ZANKL ET AL., 1991)
Leg bones
Pelvis
Ribs
Scapulae
Cervical spine
Thoracic spine
Lumbar spine
listed in Table C.9 and as the mean dose to the

total active BM distributed in the body. The dose
to the skeleton is given as the mean dose to the
whole skeleton, including both mineral bone and
active BM.
Main features of the calculations
The Monte Carlo calculations and the phantoms

used (ADAM and EVA) are the same as those for
radiographic examinations of adults (Section C.2).
The irradiation conditions for the calculation of
organ dose-conversion coefficients were derived
from a field study in Germany (Panzer et al., 1989).
Most of the CT scanners at that time were of the
following type.
C.4.3
Application of the data
The organ dose-conversion coefficients c(organ, z)

presented in the Report express the organ dose
D(organ, z) resulting from a single axial 1 cm slice
with the axial co-ordinate z across the phantom per
unit of the CT kerma index CK. The z-axis has its
origin at the base of the trunk of each phantom. To
facilitate the positioning of a slice anatomical landmarks with their axial co-ordinates z in the phantoms are provided.
Rotate only systems

Tube rotation 360
No beam shaping devices between focus and patient
Focus to axis of rotation distance 7076 cm
The radiation qualities considered are listed in
Table C.8.
C.4.2
125
2.2 Al 0.2 Cu
64.4
7.98
C:5
where 0.061 is the organ dose-conversion coefficient

for active BM from Table C.7.
C.4.1
66.0
8.06
where 5.83 mGy is the total active BM dose from

Table C.5, 43.0 mGy (5.0 mR) the actual Ka,i (exposure at skin entrance) value and 76.2 mGy (8.684 mR)
the Ka,i (exposure at skin entrance) value from
Table C.4.
Total active BM dose DBM for CHILD from an
abdomen AP examination performed with the same
physical exposure parameters as listed in
Table C.6 and a Ka,i value of 0.7 mGy is given by
DBM 0:061 0:7 mGy 0:043 mGy,
137
D organ, z c organ, zCK :
C:7
The normalization quantity CK should be based on

measurements at the respective unit using dosimeters suitable for the measurement of CK and on
considerations of the influence of geometric effects
like overlapping of adjacent slices or spaces
between them. If measured dose values are not
available or if only rough estimates of organ doses
Scope of the report
Table C.9 contains the organs and tissues for

which organ dose-conversion coefficients were
calculated. The doses to the active BM are given
both as dose to the active BM in the single bones
83

Table C.10. Sample table from Zankl et al. (1991) showing mean pancreas dose-conversion coefficients c(pancreas, z) for
single 1 cm axial CT slices and the radiation qualities A, B, C from Table C.8. The z coordinate of the slice is given in the
first column. The volume ratios of the organ located within each slice and the average coefficients of variation from the
Monte Carlo calculation are also given.
Slicea
(cm)
4546
4445
4344
4243
4142
4041
3940
3839
3738
3637
3536
3435
3334
3233
3132
3031
2930
Volume
ratio
%
1.0
14.6
26.6
32.5
9.7
8.7
6.2
0.8
Male phantom ADAM
Coefficient of
variation
Conversion coefficients for

radiation qualities
A
0.0105
0.0114
0.0144
0.0195
0.0220
0.0301
0.0515
0.0695
0.0817
0.0465
0.0382
0.0327
0.0240
0.0188
0.0151
0.0129
0.0104
0.0104
0.0115
0.0148
0.0194
0.0222
0.0290
0.0487
0.0639
0.0816
0.0461
0.0390
0.0323
0.0230
0.0183
0.0158
0.0124
0.0106
0.0073
0.0077
0.0103
0.0134
0.0157
0.0221
0.0375
0.0479
0.0624
0.0335
0.0274
0.0235
0.0169
0.0129
0.0106
0.0085
0.0068
0.031
0.029
0.026
0.023
0.022
0.019
0.016
0.014
0.013
0.016
0.018
0.019
0.021
0.023
0.025
0.028
0.031
Volume
ratio
%
8.6
24.7
33.5
15.9
9.5
6.9
0.9
Female phantom EVA
Coefficient of
variation
Conversion coefficients for

radiation qualities
A
0.0074
0.0080
0.0100
0.0121
0.0131
0.0187
0.0221
0.0280
0.0471
0.0716
0.0921
0.0623
0.0433
0.0382
0.0268
0.0209
0.0163
0.0069
0.0080
0.0098
0.0122
0.0137
0.0179
0.0226
0.0288
0.0462
0.0697
0.0903
0.0611
0.0440
0.0385
0.0271
0.0202
0.0166
0.0048
0.0051
0.0067
0.0079
0.0097
0.0137
0.0161
0.0207
0.0341
0.0523
0.0691
0.0452
0.0311
0.0281
0.0192
0.0149
0.0120
0.04
0.038
0.034
0.031
0.029
0.024
0.023
0.02
0.017
0.014
0.013
0.015
0.018
0.018
0.021
0.023
0.026
In the Report doses are given in this case for slices 71 down to 24.
are intended, values from literature can be used for

CK. Seven typical values for CK normalized to a PIt of
100 mAs per slice or tube rotation are given in the
Report.
For each of the organs separate tables of organ
dose-conversion coefficients are given for ADAM
and EVA. A sample tabulation for the organ doseconversion coefficient for pancreas is given in
Table C.10. The first column indicates the z coordinate of the slice. Each of the gender-specific
datasets contains also the percentage organ volume
included in the single slice, i.e., the fractions of
the organs being directly irradiated during
scanning by the respective 1-cm-thick slice. The
last column for each phantom presents an average
value of the coefficient of variation of the organ doseconversion coefficients estimated from the Monte
Carlo calculation.
The mean organ dose DT resulting for a complete
CT-examination is calculated by summing up the
values of the conversion coefficients c(organ, z) as
listed in the tables between the lower (zl) and the
upper (zu) boundary of the scanned region
DT CK cT,CK CK
zu
X
c organ, z:
In the case where a CT-examination consists of various sections with different physical exposure parameters, the organ doses have to be calculated for
each section separately.
The method described above can also be applied
to examinations performed by spiral or multi-slice
CT, provided CK is correctly determined for these
techniques.
C.4.4
Pancreas dose DPancreas of the phantom EVA for an

abdomen-CT consisting of 40 serial 8 mm slices (360
rotation, couch increment 8 mm) from thoracic vertebra 12 (z co-ordinate in EVA: 41 cm) to the coccyx (z
co-ordinate: 9 cm). Radiation quality A from
Table C.8 and a PIt of 200 mAs per slice
DPancreas 35:2 mGy 0:562 19:8 mGy,
C:9
where the CK value of 35.2 mGy is either obtained

from either measurement, literature, or the table in
the Report, and the conversion coefficient of 0.562 is
the sum of the 32 c(organ, z) values listed in
Table C.10 from slice 9 to slice 41.
C:8
zl
84
APPENDIX C
Table C.11. Radiation qualities use for the calculation of
organ dose-conversion coefficients for paediatric CTexaminations.
Table C.12. Organs for which organ dose-conversion

coefficient was calculated for paediatric CT-examinations.
Radiation quality
Tube voltage/kV
Total filtration/mma
Mean photon energy/keV
HVL1 Al
80
Adrenals
Bladder
Brain
Breasts
Colon
Eye lenses
Oesophagus
Kidneys
125
2.2 Al 0.2 Cu
50.5
5.38
64.4
7.98
The total filtration is the same for each of the spectra considered.
Liver
Lungs
Ovaries
Pancreas
Active BM
Skeleton
Skin
Small intestine
Spleen
Stomach
Testes
Thymus
Thyroid
Tissue
Uterus
The bones for which the dose to the active BM is listed separately
are:
Arm bones
Clavicles
Cranium
Leg bones
C.5 REPORT ON ORGAN DOSES FROM CT

EXAMINATIONS (PAEDIATRIC) GSF-BERICHT
30/93 (ZANKL ET AL., 1993)
C.5.1
Cervical spine
Thoracic spine
Lumbar spine and sacrum
Sternum
The Monte Carlo program and the voxel phantoms

BABY and CHILD used to produce this catalogue of
organ dose-conversion coefficients were the same as
described in Section C.3.
The scanner types considered are rotate-only systems with a focus to axis of rotation distance
between 70 and 85 cm and angles of rotation of
360 or 180 , respectively. For 180 rotation, anterior
radiation incidence was modelled.
The use of beam-shaping devices between focus
and patient was rare at that time in Germany and
was, therefore, not modelled. Scans were, however,
often performed using an asymmetric beam, which
means that the beam width is reduced to 10 cm on
one side. Consequently, only a circle with a radius
of 10 cm around the axis of rotation is fully irradiated, the area outside is not. Because of their
small body size, this makes no difference for babies.
For heavier children, such beams lead to markedly
lower doses in the parts of their body outside the
10 cm field. For these tissues, additional tables for
scans using asymmetric beams are given in the
catalogue.
The radiation qualities considered in the Report
are shown in Table C.11. They cover a wide energy
range and allow interpolation or, to some extent,
extrapolation for beam qualities deviating from
those given.
C.5.2
Mandible
Pelvis
Ribs
Scapulae
entire skeleton, including both mineral bone

and BM.
C.5.3
Application of the data
The determination of organ doses follows the same

procedure as described in Section C.4.3 for adults
according to Eqs. (C.7) and (C.8). Also anatomical
landmarks within the phantoms and orientation values for CK normalized to a PIt value of 100 mAs per
slice or tube rotation are presented.
For each of the organs considered, separate tables
of organ dose-conversion coefficients are given for
the BABY and for the CHILD phantom. A sample
tabulation of the data for the brain in the BABY
phantom resulting from 1 cm slices with a symmetrical beam is given in Table C.13. The first column
describes the single slices with respect to their z-coordinate within the phantom. The next column
shows the percentage of the organ volume included
in the single slice, i.e., the ratio of the organ
being directly irradiated during scanning with a
1-cm-thick slice.
Two pairs of columns of conversion coefficients
follow, one pair for each of the two radiation qualities considered. Within each of these pairs, the first
column presents conversion coefficients for full 360
rotation of the fan beam, the second column those for
180 rotation around the anterior surface of the
body. The last column in each table presents an
average value of coefficient of variation of the
organ dose-conversion coefficients estimated from
the Monte Carlo calculation.
Scope of the report
The organs and tissues for which organ doseconversion coefficients were calculated are listed in
Table C.12. The doses to the active BM are
given both as dose to the active BM in the single
bones listed in Table C.12 and as the mean dose to
the total active BM distributed in the body. The dose
to the skeleton is given as the mean dose to the
C.5.4
Organ dose to brain of the BABY phantom from a

CT skull examination consisting of 12 contiguous
1-cm-thick slices from the top of the skull performed
85

Table C.13. Sample table from Zankl et al. (1993) showing mean brain dose coefficients (DT/CK for a series of transverse CT
slices of the BABY phantom and average coefficients of variation per single 1-cm-thick slice. The volume ratio of the organ
located within each single slice is also shown.
Slice (cm)
Volume ratio (%)
Conversion coefficients
80 kV
01
12
23
34
45
56
67
78
89
910
1011
1112
1213
1314
1415
1516
1617
1718
1819
1920
2021
2122
2223
2324
2425
2526
2627
2728
2829
2930
3031
2.4
8.1
13.7
16.9
18.1
17.1
12.4
7.5
3.3
0.4
Coefficient of variation
125 kV
360
180
360
180
0.0276
0.0685
0.102
0.119
0.124
0.116
0.0886
0.0593
0.0319
0.0140
0.0084
0.0054
0.0038
0.0027
0.0021
0.0016
0.0012
0.0009
0.0007
0.0005
0.0003
0.0003
0.0002
0.0002
0.0002
0.0001
0.0001
0.0001
0.0001
*
*
0.0287
0.0711
0.1028
0.120
0.125
0.115
0.0838
0.0550
0.0289
0.0128
0.0082
0.0052
0.0038
0.0027
0.0022
0.0017
0.0013
0.0010
0.0007
0.0005
0.0004
0.0314
0.0795
0.1178
0.140
0.146
0.1361
0.105
0.0709
0.0398
0.0181
0.0108
0.0071
0.0051
0.0037
0.0030
0.0024
0.0018
0.0014
0.0011
0.0008
0.0006
0.0005
0.0004
0.0003
0.0003
0.0002
0.0002
0.0001
0.0001
0.0001
0.0001
0.0322
0.0813
0.120
0.141
0.147
0.1361
0.101
0.0667
0.0369
0.0170
0.0108
0.0071
0.0052
0.0037
0.0030
0.0024
0.0019
0.0015
0.0011
0.0008
0.0006
0.0005
0.0004
0.0003
0.0003
0.0002
0.0002
0.0001
0.0001
0.0001
0.0001
0.0002
0.0002
0.0002
0.0001
0.0001
0.0001
0.0001
*
*
0.0034
0.0023
0.0019
0.0017
0.0017
0.0017
0.0020
0.0024
0.0031
0.0045
0.0057
0.0071
0.0084
0.0099
0.0109
0.0124
0.0141
0.0162
0.0185
0.0211
0.0254
0.0288
0.0308
0.0343
0.0383
0.0433
0.0490
0.0556
0.0634
0.0721
0.0835
An asterisk as table entry means that the organ dose-conversion coefficient is <0.00005.
with 125 kV tube voltage, 2.2 mm Al 0.2 mm Cu

filtration, a PIt of 100 mAs per slice, 360 tube rotation and symmetrical beam:
DBrain 14:4 mGy 0:902 13 mGy,
where CK is 14.4 mGy from measurement or

from literature values given in the Report and
0.902 the sum of the 12 c(organ, z) values listed in
Table C.13 from slice 0 cm to 1 cm until slice 11 cm to
12 cm.
C:10
86

APPENDIX D: REPORTS PRODUCED BY THE HEALTH

PROTECTION AGENCY (HPA) (FORMERLY NATIONAL
RADIOLOGICAL PROTECTION BOARD, NRPB)
D.1
GENERAL DESCRIPTION
NRPB has produced three sets of reports that

permit estimation of the mean absorbed doses to
25 different tissues and organs in reference adult
and paediatric patients from common radiographic,
fluoroscopic, and CT examinations.
The three sets of reports deal with the following.
1. Common Adult X-ray
Examinations
2. Common Paediatric
X-ray Examinations
3. Adult Computedtomography
Examinations
(NRPB-R262,
NRPB-SR262,
Hart et al., 1994a,b)
(NRPB-R279,
NRPB-SR279,
Hart et al., 1996a,b)
(NRPB-R250,
NRPB- SR250
Jones and Shrimpton,
1991, 1993)
Each set consists of a pair of NRPB reports, one

providing printed tabulations of conversion coefficients for a sample of the available data and the
other (the software report, denoted NRPB-SR . . .)
includes a computer disk containing a complete listing of all the available dose-conversion coefficients.
The listing is arranged in a large series of data files,
which can be incorporated into suitable computer
programs for processing the conversion coefficients
in a manner matched to the requirements of the
user. Such user-friendly software packages, which
calculate organ doses for any combination of x-ray
examination parameters specified by the user, are
available from the National Radiation Laboratory,
Christchurch, New Zealand, for each set of NRPB
reports.
The dose-conversion coefficients in the software
reports relate organ dose DT/mGy to entrance
surface air kerma, Ka,e/mGy and to air kermaarea
product, PKA/(Gy cm2) for radiographic and
fluoroscopic examinations and to CT kerma index
expressed in ICRU muscle tissue, CK,m/mGy for CT

examinations.
The same basic Monte Carlo code developed at
NRPB is used for all three sets of calculations and
both adult and paediatric patients are simulated by
hermaphrodite mathematical phantoms. The software reports include organ dose-conversion coefficients for a large number of diagnostic radiation
qualities or types of CT scanner.
D.2 REPORT NRPB-SR262 (HART ET AL.,

1994b): COMMON ADULT X-RAY
EXAMINATIONS
D.2.1
Details of the Monte Carlo code and the mathematical phantom developed at NRPB are described
by Jones and Wall (1985). Conversion coefficients
relating DT to Ka,e and to PKA were calculated
by simulating typical x-ray examination exposure
conditions on a hermaphrodite mathematical phantom representing a typical adult patient. Four million photon histories were followed for each x-ray
examination field simulated. The phantom was
based on Cristys adult hermaphrodite phantom
(Cristy, 1980) with Kramers modified neck region
(Kramer et al., 1982), a breast tissue composition of
50 % fat and 50 % water, and with an esophagus. The
arms of the phantom, which lie alongside the trunk,
were removed when lateral projections through the
trunk were simulated.
D.2.2
Scope of the report
Report NRPB-SR262 (Hart et al., 1994b) is a software report, which includes a computer disk containing files of conversion coefficients relating DT
to Ka,e and to PKA for the 68 radiographic projection
(e.g., Head) and view (e.g., AP) combinations listed
below.
Head AP, PA
Head LAT L and R
Cervical spine AP
Cervical spine LAT L and R
Throat LAT L and R
Shoulder AP L and R
Oesophagus RAO, LAO, LPO
Thoracic spine AP
Thoracic spine LAT L and R
Chest AP, PA
Chest LAT L and R
Heart AP, PA
Heart LAT L and R

Heart LAO, RAO
Upper stomach AP, PA
Stomach RAO, LPO, LAO
Stomach AP, PA,
Stomach LAT (L)
Kidneys AP, PA
Lumbar spine LPO, RPO
Lumbar spine AP
Lumbar spine LAT L and R
Left flexure LAO
Right flexure RAO
using the conversion coefficients listed in NRPBSR262 is Ka,e or PKA for each radiograph and the
corresponding tube voltage and total beam filtration.
Organ doses can be estimated for any combination
of the 68 radiographic projections and views, using a
software package called XDOSE developed at the
National Radiation Laboratory, Christchurch, New
Zealand. This software processes the data in NRPBSR262 according to the requirements of the user. An
example of part of the results produced by this software for a PA chest radiograph and an AP abdominal radiograph with specified exposure factors is
shown in Table D.1.
The focus-to-surface distance dFSD, the position of

the central axis of the x-ray beam in the phantom,
and the x-ray field size at the image receptor and at
the mid-plane of the phantom, for all the above
radiographic projections are described in the report.
The mid-plane field size is also shown diagrammatically on a drawing of the phantom so that the position of the x-ray field in relation to all the modelled
organs can be visualized.
For each radiographic projection and view, conversion coefficients are tabulated for 40 x-ray spectra,
specified by the peak tube voltage and the total beam
filtration. Tube voltages range from 50 to 120 kV, in
10 kV steps; and five total beam filtrations of 2, 2.5, 3,
4, and 5 mm Al are included for each tube voltage.
The source of the x-ray spectra data for these calculations is an updated (1991) version of the computer
program of Iles (1987). This program produces results
very similar to that published by the IPEM (1997).
In NRPB-SR262 (Hart et al., 1994b) conversion
coefficients are given for 26 organs for the 68 radiographic projection and view combinations and 40
x-ray spectra described above. These 26 organs are
the following.
Adrenals
Brain
Breasts
Eye Lens
Gall bladder
Heart
Kidneys
Liver
Lower large
intestine
D.2.3
Lungs
Oesophagus
Ovaries
Pancreas
Active BM
Residual tissues
(muscle)
Skeleton (bone
surfaces)
Skin
Small intestine
Duodenum AP, PA
Duodenum RAO, LPO
LSJ LAT L and R
Abdomen AP, PA
Small intestine AP, PA
Pelvis/colon AP, PA
Colon RAO, LPO, LAO
Urinary bladder AP
Hip AP L and R
Rectum AP, PA
Rectum LAT L and R
Rectum LPO, RAO
D.2.4
Organ doses DT for chest PA and abdomen AP

examinations were calculated using NRPB-SR262
Monte Carlo data (Hart et al., 1994b). The chest PA
examination is performed with a tube voltage of 120
kV, a filtration of 3.00 mm Al, and at the reference
dFSD. The entrance air kerma Ka,e for the chest examination is 0.16 mGy. The abdomen AP examination is
performed with a tube voltage of 85 kV, a filtration of
3.00 mm Al, and at the reference dFSD. The entrance
air kerma Ka,e for the abdomen examination is 5.60
mGy. The results of the organ dose calculation are
given in Table D.1.
Spleen
Stomach
Testes
Thymus
Thyroid
Upper large
intestine
Urinary
bladder
Uterus
D.3 REPORT NRPB-SR279 (HART ET AL.,

1996b): COMMON PAEDIATRIC X-RAY
EXAMINATIONS
D.3.1
Details of the Monte Carlo code developed at

NRPB are described by Jones and Wall (1985). Conversion coefficients relating DT to Ka,e and to PKA
were calculated by simulating typical x-ray examination exposure conditions on a series of five hermaphrodite mathematical phantoms representing
newborn, 1, 5, 10, and 15-year-old patients. Four
million photon histories were followed for each xray examination field that was simulated. The
The information required to estimate organ doses

from 68 adult radiographic projections and views
88
APPENDIX D
Table D.1. Organ doses DT/mGy calculated for chest PA
and abdomen AP examinations using NRPB-SR262 Monte
Carlo data and the software package XDOSE for the
examination conditions given in Section D.2.4.
Organ
D.3.2
Report NRPB-SR279 (Hart et al., 1996b) contains

files of conversion coefficients relating DT to Ka,e and
to PKA for the 18 radiographic projections and views
listed below.
DT/mGy
Adrenals
Brain
Breasts
Eye lens
Gall bladder
Stomach
Small intestine
Upper large intestine
Lower large intestine
Heart
Kidneys
Liver
Lungs
Ovaries
Pancreas
Skin
Spleen
Testes
Thymus
Thyroid
Urinary bladder
Uterus
Oesophagus
Muscle
Total bone
Active BM
Chest PA
Abdomen AP
0.0970
0.0006
0.0197
0.0003
0.0187
0.0238
0.0025
0.0032
0.0006
0.0362
0.0608
0.0419
0.0846
0.0005
0.0453
0.0163
0.0803
0.00
0.0184
0.0108
0.0001
0.0005
0.0490
0.0181
0.0485
0.0274
0.261
0.00
0.0199
0.00
1.95
1.95
1.64
1.98
1.32
0.0675
0.366
1.08
0.0474
1.28
0.872
0.387
0.507
0.243
0.0094
0.0003
2.61
1.67
0.0643
0.531
0.289
0.217
Head AP,
PA, LAT
Cervical spine
AP, PA, LAT
Chest AP,
PA, LAT
0
1
5
10
15
Weight/
kg
3.47
9.26
19.0
31.9
54.4
Height/
cm
51.5
75.0
109.0
138.6
164.0
Thickness
of head/cm
Thickness
of trunk/
cm
AP
LAT
AP
LAT
11.6
15.7
18.1
18.8
19.5
9.0
12.3
14.3
14.9
15.5
9.8
13.0
15.0
16.8
19.6
12.7
17.6
22.9
27.8
34.5
Lumbar spine
AP, PA, LAT
Abdomen AP, PA
Pelvis AP, PA
Urinary
bladder
AP, PA
The dFSD, the position of the central axis of the

x-ray beam in each phantom, and the x-ray field size
at the image receptor, for all the above radiographic
projections are described in the report. The field size
at the mid-plane of the phantom is also shown diagrammatically on a drawing of each phantom so that
the position of the x-ray field in relation to all the
modelled organs can be visualized.
For each radiographic projection and view, conversion coefficients are tabulated for 72 x-ray
spectra, specified by the peak tube voltage and
the total beam filtration. Tube voltage ranges from
50 to 120 kV, in 10 kV steps. For each tube
voltage nine total beam filtrations are included, the
same five as for the previous adult examinations
(i.e., 2, 2.5, 3, 4, and 5 mm Al) and a further four
involving additional copper filtration that has been
recommended for paediatric radiography (EC 1996d),
i.e., 2 mm Al 0.1 mm Cu; 2 mm Al 0.2 mm Cu;
3 mm Al 0.1 mm Cu and 3 mm Al 0.2 mm Cu.
The source of the x-ray spectra data for these calculations is an updated (1991) version of the computer
program of Iles (1987). This program produces very
similar results to that published by the IPEM (1997).
In NRPB-SR279 (Hart et al., 1996b) conversion
coefficients for 26 organs are given for the 18 radiographic projections and views and the 72 x-ray
spectra described above. These organs are the
following.
phantoms were based on Cristys hermaphrodite

phantoms (Cristy, 1980) and Kramers modified
neck region (Kramer et al., 1982) was applied to all
of them. An esophagus was added to each phantom.
A suitable volume of breast tissue was included in
each phantom and in the absence of specific information on the fat content of breast tissue in young
children, 50 % fat and 50 % water was used as the
breast tissue composition for all of the phantoms.
The arms of the phantom, which lie alongside the
trunk, were removed when lateral projections
through the trunk were simulated.
The weights and major dimensions of the five
paediatric phantoms are shown below.
Age/
years
Scope of the report
Adrenals
Brain
Breasts
Eye lens
Gall bladder
Heart
Kidneys
Liver
Lower large
intestine
89
Lungs
Oesophagus
Ovaries
Pancreas
Active BM
Residual
tissues (muscle)
Skeleton
(bone surfaces)
Skin
Small intestine
Spleen
Stomach
Testes
Thymus
Thyroid
Upper
large intestine
Urinary bladder
Uterus
D.3.3
D.3.4
Organ doses DT for chest PA and abdomen AP examinations were calculated using NRPB-SR279 Monte
Carlo data (Hart et al., 1996b) for child of 1 year.
The chest PA examination is performed with a tube
voltage of 90 kV, a filtration of 2.00 mm Al and of 0.10
mm Cu, and at the reference dFSD. The entrance air
kerma Ka,e for the chest examination is 0.05 mGy.
The abdomen AP examination is performed with a
tube voltage of 90 kV, a filtration of 2.00 mm Al and
0.10 mm Cu, and at the reference dFSD. The entrance
air kerma Ka,e for the abdomen examination is 0.40
mGy. The results of the organ dose calculation are
given in Table D.2.
The information required to estimate organ

doses from 18 paediatric radiographic examinations
using the conversion coefficients listed in NRPBSR279 is the Ka,e or the PKA for each radiograph
and the corresponding tube voltage and total beam
filtration.
Organ doses to any of the phantoms representing
a newborn, 1, 5, 10, or 15-year-old patient can be
estimated for any combination of the 18 radiographic
projections, using a software package called
CHILDOSE developed at the National Radiation
Laboratory, Christchurch, New Zealand. This software processes the data in NRPB-SR279 according
to the requirements of the user. An example of
part of the results produced by this software for an
examination comprising a PA chest radiograph and
an AP abdominal radiograph on a 1-year-old child
with the specified exposure factors is shown in
Table D.2.
D.4 REPORTS NRPB-R250, NRPB-SR250

(JONES AND SHRIMPTON, 1991, 1993): ADULT
CT EXAMINATIONS
D.4.1
Adrenals
Brain
Breasts
Eye lens
Gall bladder
Stomach
Small intestine
Upper large intestine
Lower large intestine
Heart
Kidneys
Liver
Lungs
Ovaries
Pancreas
Skin
Spleen
Testes
Thymus
Thyroid
Urinary bladder
Uterus
Oesophagus
Muscle
Total bone
Active BM
DT/mGy for child of 1 year

Chest PA
Abdomen AP
0.0215
0.0002
0.0105
0.0002
0.0026
0.0049
0.0008
0.0009
0.0002
0.0144
0.0029
0.0081
0.0311
0.0004
0.0079
0.0063
0.0107
0.00
0.0080
0.0060
0.0001
0.0003
0.0177
0.0068
0.0259
0.0060
0.0796
0.0001
0.0102
0.0002
0.252
0.271
0.211
0.242
0.152
0.0440
0.0796
0.226
0.0390
0.184
0.167
0.0468
0.118
0.0335
0.0065
0.0024
0.264
0.216
0.0508
0.0748
0.0860
0.0274
The same Monte Carlo code and adult hermaphrodite mathematical phantom were used as in the
calculations for conventional x-ray examinations
(see Appendix D.2.1). Only the esophagus was missing from the phantom described in Appendix D.2.1.
The arms of the phantom remained alongside the
trunk for all simulated CT examinations, as is the
usual practice with patients.
To simulate the distinct exposure conditions prevailing during CT examinations, the x-ray source
was rotated around the long axis of the phantom.
Organ doses were determined for the individual irradiation of 208 contiguous 5-mm-thick transverse
slabs of the phantom ranging from the top of the
head to the top of the legs. A line x-ray source of
the same length of each irradiated slab (5 mm) was
used, with the photons emitted normally from the
source into a fan-shaped beam spanning the width of
the phantom. An abrupt cut-off of the x-ray beam at
the edges and faces of the fan (i.e., perfect collimation) is a feature of this model. Conversion coefficients were calculated relating the organ doses to
the kerma on the axis of rotation of the scanner
free-in-air, i.e., with no phantom or patient present.
The imperfect collimation of the x-ray beam in the
axial direction, which occurs in practice, can lead to
a build-up of dose in adjacent scans. However, this is
taken account of by measuring the CT kerma index
free-in-air, CK, under the exposure conditions, i.e.,
slice thickness, tube voltage, and tube-current
exposure-time product, PIt. The value of CK
is then multiplied by the conversion coefficients
to estimate the organ doses for the degree of
beam collimation achieved by the CT scanner of
Table D.2. Organ doses DT/mGy for child of 1 year

calculated for chest PA and abdomen AP examinations
using NRPB-SR279 Monte Carlo data and CHILDOSE
software for the examination conditions given in
Section D.3.4.
Organ
90
APPENDIX D
distance, and total filtration), selected to cover 27
models of CT scanner from five different manufacturers, which were in common use in the UK in the
late 1980s (Table D.3). Shaped (bow-tie) filters
have been modelled where necessary. The exposure
conditions assumed for the 23 sets of calculations
and the appropriate CT scanner models are listed
below.
Report NRPB-R250 (Jones and Shrimpton, 1991)
contains tables of conversion coefficients relating
doses to 27 organs or regions of the phantom to the
CK,m for each of the 208 5 mm slabs and for four of
the datasets listed below. Report NRPB-SR250 is a
software report that contains a computer disk on
which the conversion coefficients for all the datasets
listed below are recorded.
The 27 organs and regions of the phantom for
which conversion coefficients have been calculated
are the following.
interest. In these early (pre-1990) calculations

kerma calculated on the axis of rotation of the scanner was expressed in terms of ICRU muscle tissue,
Km, not as air kerma Ka. Consequently the CK should
be converted into CT kerma index expressed in
terms of absorbed dose to ICRU muscle, CK,m, when
using these conversion coefficients to estimate organ
doses.
Conversion coefficients relating organ doses to
CK,m measured free-in-air on the scanner axis for
any complete CT examination of the head or trunk
can be obtained by suitable summation of the conversion coefficients for the irradiation of the individual 5-mm-thick slabs.
D.4.2
Scope of the reports
Calculations have been performed for 23 sets of

exposure conditions (i.e., tube voltage, focus-to-axis
Table D.3. Exposure conditions for calculation of normalized organ doses for CT using Monte Carlo techniques according
to Jones and Shrimpton (1991, 1993).
Monte Carlo
data set no.
1
2
3
4
5
6
7
8
9c
10
11
12
13
14
15
16
17
18
19
20c
21c
22c
23c
CT scanner models for which

data set is appropriate
Siemens
Somatom 2,DR1/2/3
Somatom DRG,DRG1
Somatom DRH,CR,CR512
Picker
1200SX
1200SX
GE
CT 8800,9000I/II/HP
CT 8800,9000I/II/HP
CT 9800,9800Quick
CT 9800,9800Quick
CT MAX
CT PACE
CGR
CE 10000,12000
Philipse
Tomoscan 305N,310,350 (GE No. 2, no Cu)
Tomoscan 305N,310,350 (GE No. 2, with Cu)
Tomoscan 310,350 (GE No.3, no Cu)
Tomoscan 310,350 (GE No. 3, with Cu)
Tomoscan TX
Tomoscan CX,CX/S
Tomoscan LX
Tomoscan TX
Tomoscan TX
Tomoscan LX
Tomoscan LX
Tube
voltage/kV
Focus to axis
distance/mm
Flat filter/
Shaped filter/
Al mm
Cu mm
Option
Type
125
125
125
760
700
700
2.2
2.2
2.2
0.25
0.4
0.2
130
130
640
640
0.7
0.7
HEAD
BODY
LEXANa
LEXANa
120
120
120
140
120
120
780
780
630
630
525
525
2.7
2.7
2.7
2.7
2.6
2.7
HEAD
BODY
PMMA
PMMA
PTFEb
PTFEb
PTFEb
PTFEb
130
750
1.0
0.3
PEEKd
120
120
120
120
120
120
120
100
130
100
130
487
487
608
608
606
606
606
606
606
606
606
3.5
3.5
3.5
3.5
1.4
1.4
1.4
1.4
1.4
1.4
1.4
0.25
0.25
0.1
0.1
0.1
0.1
0.1
0.1
0.1
Al
Al
Al
Al
Al
Al
Al
Al
Al
Al
Al
LEXAN is polycarbonate.
PTFE is polytetrafluoroethylene.
c
Datasets 9, 20, 21, 22, and 23 relate to alternative applied potential settings for selected scanners.
d
PEEK is polyetheretherketone.
e
Philips Tomoscan 300 series scanners have options for the variation of focus-to-axis distance (geometric enlargement setting) and for the
inclusion of additional copper filtration.
b
91
Adrenals
Brain
Breasts
Eye lens
Gall bladder
Heart
Kidneys
Liver
Lower large
intestine
D.4.3
Lungs
Ovaries
Pancreas
Active BM
Skeleton
(bone surfaces)
Skin
Small intestine
Spleen
Stomach
Table D.4. Organ doses DT/mGy for routine chest CT

examination, region 1, using NRPB-SR250 Monte Carlo
data and CTDOSE software for the examination conditions given in Section D.4.4.
Testes
Thymus
Thyroid
Upper large
intestine
Urinary bladder
Uterus
Head region
Trunk region
Leg region
Application of the reports
The information required to estimate organ doses

for CT examinations using the conversion coefficients tabulated in NRPB-R250 and listed in
NRPB-SR250 is CK,m for the particular scanning
parameters in clinical use (tube voltage, PIt, slice
thickness, focus-to-axis distance, and filtration).
Linearity of CK,m with PIt is assumed.
The conversion coefficients need to be summed for
all of the 5-mm-thick slabs that lie within the
scanned volume for a particular CT examination.
The value of DT to a given organ from the CT slices
imaged within a scanned volume is given by
zu
X
DT CK;m p cT,CK;m ,
D:1
zl
where p is the packing factor and the conversion

coefficients for the required organ are summed
between the lower (zl) and upper (zu) boundaries of
the scanned volume. The packing factor takes
account of the relationship between slice thickness
and table increment during a sequence of serial
slices (or the pitch during a helical scan).
For serial scans
wn
,
D:2
p
L
where w is the slice thickness, n the number of slices,
L the total length of the scan, and p 1 for contiguous slices, p > 1 for overlapping slices, and p < 1 for
gaps between slices.
For helical scans, p the pitch.
Organ doses can be estimated for any CT examination of the head or trunk, using a software package called CTDOSE developed at the National
Radiation Laboratory, Christchurch, New Zealand.
This software processes the data in NRPB-SR250
according to the requirements of the user. An
example of part of the results produced by this software for a CT examination of the chest on a Philips
Tomoscan LX scanner with just one series of scans
Organ
DT/mGy
Adrenals
Brain
Breasts
Eye lens
Gall bladder
Stomach
Small intestine
ULI
LLI
Oesophagus
Heart
Kidneys
Liver
Lungs
Ovaries
Pancreas
Skin
Spleen
Testes
Muscle
Thymus
Thyroid
Urinary bladder
Uterus
Head region
Trunk region
Leg region
Bone
ABM
2.97
0.08
17.50
0.07
0.76
1.55
0.10
0.14
0.02
31.90
23.10
0.61
2.37
20.60
0.02
2.30
3.24
1.75
0.0004
3.73
31.90
1.86
0.005
0.029
0.62
7.86
0.0002
9.76
5.05
(one region) and the specified scanning parameters

is shown in Section D4.4. CTDOSE allows up to four
series of scans (regions) involving the use of different slice thickness, PIt, and table increment combinations in any one CT examination. With no
esophagus modelled in the phantom, the dose to
the esophagus is taken to be the same as the dose
to the thymus.
D.4.4
Organ doses DT for routine chest CT examinations, region 1, according to NRPB-R250 combined
with CTDOSE. The scan was performed with a tube
voltage of 125 kV, PIt of 350 mAs, CK,m/PIt of
0.220 mGy (mAs)1, slice thickness of 10 mm,
table increment of 10 mm, number of slices 20,
start position of 430 mm, and end position of 650
mm. The resulting organ doses are given in
Table D.4.
92

APPENDIX E: REVIEW OF MONTE CARLO CALCULATIONS

FOR ASSESSMENT OF MEAN GLANDULAR DOSE IN
MAMMOGRAPHY
E.1
GENERAL
Among the quantities used for dose specification

in mammography the average absorbed dose in
glandular tissue DG is most appropriate for risk
assessments (NCRP, 1986). Generally, DG is derived
from incident air kerma Ka.i combined with conversion coefficients obtained from radiation transport
calculations in mathematical models of the breast.
For simplicity the notation cG Eq. (E.1) is used
instead of cG,Ka,i Eq. (3.3.8)
DG cG Ka;i :
E:1
Conversion coefficients cG have been published by

various authors (Stanton et al., 1984; Rosenstein
et al., 1985; Dance, 1990; Wu et al., 1991, 1994;
Alm Carlsson and Dance, 1992; Jansen et al., 1994;
Zoetelief and Jansen, 1995; Klein et al., 1997;
Dance et al., 2000). Values of cG are usually presented as a function of the HVL1 of the incident radiation. Commonly, cG values are calculated using
simple breast phantoms. These breast models contain a superficial layer of 0.4 or 0.5 cm thickness
representing the skin and underlying adipose tissue
and a central region consisting of a mixture of
adipose and glandular tissue (Figure E.1). Most of
the publications deal with firm compression of the
breast only, because it has been clearly demonstrated that this is mandatory in view of dose reduction and improvement of image quality (NCRP,
1986).
Concerning the elemental tissue composition it
should be noted that most authors employ data published by Hammerstein et al. (1979). The influence of
the variation in the fraction of glandular tissue in
the central region of the simulated female breast is
included in several publications (Rosenstein et al.,
1985; Wu et al., 1991a, 1994; Jansen et al., 1994;
Klein et al., 1997; Dance et al., 2000). Alm Carlsson
and Dance (1992) and Zoetelief and Jansen (1995)
studied the influence of variations in elemental composition of glandular and adipose tissues for the
range of values stated by Hammerstein et al. (1979)
and between Hammerstein et al. (1979) and ICRU

(1989) elemental compositions, respectively.
The calculations by different authors differ in
radiation transport codes, photon interaction data,
photon spectra, composition and thickness of superficial layer (representing skin and subcutaneous
adipose tissue), presence of a compression plate,
and focus-to-film distance dFFD. They are generally
not performed with the tissue compositions recommended by the ICRU (1989a). A study on the influence of these differences on cG (Table E.1) was made
by Zoetelief and Jansen (1995). It can be concluded
from the table that there are various sources of
Plan
16 cm
Elevation
variable
thickness
0.4 cm or 0.5 cm
Adipose tissue
50 : 50 Adipose and glandular tissue
Figure E.1. Mathematical model of the breast used in Monte
Carlo calculations of average glandular dose. Shown are the
superficial layer (either 0.4 cm of glandular tissue or 0.5 cm of
adipose tissue) and the central region consisting of 50 % adipose
and 50 % glandular tissue by mass (Reproduced from Dance,
1990, with permission from IOP, UK). The 50:50 breast model
was first suggested by Hammerstein et al. (1979).

Table E.1. Influence of difference in approach by various authors in the calculation of cG (Zoetelief and Jansen, 1995).
Parameter
Range of variation
Spectra at same HVL1 for same tube voltage and anode-filter combination
Photon interaction data: MCPLIB (1988) versus XCOM (Berger and Hubbell, 1987)
Presence or absence of compression plate
Composition and thickness of superficial layer Hammersteins tissue composition
ICRU tissue composition
Tissue composition Hammerstein versus ICRU
Fraction of glandular tissue in central region (HVL1: 0.4 mm Al, 6-cm-thick breast, 25 %
glandular tissue versus 50 % glandular tissue)
7 %
10 %
34 % (3 mm PMMA)
1119 % (breast thickness 8-2 cm)
310 % (breast thickness 8-2 cm)
1114 % (at breast thickness 8-2 cm)
1013 %
Table E.2. Conversion coefficient cG that relates Ka,i to DG for a 5-cm-thick breast having a central region of 50 % adipose
and 50 % glandular tissue by mass (tissue compositions according to Hammerstein et al., 1979).
HVL1
Rosenstein et al.
(1985)a
mm Al
0.30
0.35
0.40
0.45
0.50
0.55
0.60
0.65
(Mo/Mo)
0.171 (0.160)
0.217 (0.200)
0.314
Dance
(1990)b
Wu et al.
(1991)
Jansen et al. (1994)c
Wu et al. (1994)d
Dance et al.
(2000)e
0.164
0.187
0.209
0.232
0.258
0.287
0.310
0.332
0.146
0.172
0.195
0.168 (Mo/Mo)
0.1910.198 (W/MoMo/Mo)
0.2210.229 (Mo/RhRh/Rh)
0.257 (Rh/Rh)
0.273 (W/Rh)
0.294 (W/Rh)
0.1510.153
0.1740.180
0.1960.209
0.2200239
0.2420.260
0.164
0.1880.194
0.2160.224
0.2410.253
0.270
0.296
0.321
Conversion coefficients for tungsten targets; conversion coefficients given in brackets refer to Mo and Mo/W targets
HVL1 range: 0.250.45 mm Al: Mo/Mo; 0.450.70 mm Al: W/Mo; 0.500.80 mm Al: W/Rh; 0.550.90 mm Al: W/Pd; 0.502.00 mm Al: W/Al.
c
Anode/filter materials include Mo/Mo, W/Mo, Mo/Rh, Rh/Rh and W/Rh.
d
Lower values refer to Mo/Rh and higher values to Rh/Rh. Values can differ by 5 % depending on differences in tube voltage.
e
Anode filter combinations also include Mo/Mo, Mo/Rh, Rh/Al, Rh/Rh and W/Rh (Dance, 1990).
b
difference with values ranging from 3 to 19 %.

Consequently, differences in cG-values of the order
of 20 to 30 % could have occurred between results
published by different authors. However, in practice
maximum differences of 15 % are observed.
E.2
thickness. The method does not allow for corrections

due to variations in the fraction of glandular tissue
present in the breast. This method will be advantageous when the distribution of compressed breast
thickness cannot be reasonably represented by
standard breast thicknesses of 4.5 or 5 cm.
The third method (Appendix E.5) enables assessment of DG for variations in compressed breast
thickness and fraction of glandular tissue. This
method requires an assessment of the fraction of
glandular tissue.
SCOPE
Three approaches for dose assessment in mammography are presented in this appendix. The first
method (Appendix E.3) concerns determination of
DG for a 4.5 (ACR, 1992) or 5-cm-thick standard
breast (EC, 1996b). According to the American College of Radiology (ACR) protocol, Ka,i is measured
using a mammographic phantom equivalent to
4.5 cm compressed breast tissue. The EC recommends Ka,i measurements for 5-cm-thick breasts or
alternatively for a 4.5-cm-thick PMMA phantom
(used in practice to mimic a standard breast). DG
then results from measured Ka,i and application of
the appropriate conversion coefficient cG, selected
on the basis of HVL1.
The second method (Appendix E.4) also takes
into account the variation in compressed breast
E.3 CONVERSION COEFFICIENTS CG FOR A

4.5 OR 5-CM-THICK STANDARD BREAST
Table E.2 shows a summary of conversion coefficients cG calculated by various authors for a standard sized breast, i.e., having a total thickness of 5 cm
and a central region consisting of 50 % adipose and
50 % glandular tissue by mass, examined under firm
compression. At an HVL1 of 0.30 mm Al employing
a Mo/Mo anode-filter combination the largest difference is 12 %; at values of HVL1 of 0.35 and 0.4 mm
Al for the same anode/filter combination these
94
APPENDIX E
Table E.3. Differences in conversion coefficients cG due to differences in technical parameters in mammography.
Technical parameter
Variation
Tube voltage at same HVL1 and target material

Tube voltage at same HVL1 and anode/filter combination,
but different layers of Lexan filtration
Presence or absence of a compression plate
Difference in anode/filter combinations at same HVL1
Within 10 % from the average (Rosenstein, 1984)

Within 5 % from the average (Wu et al., 1991)
CONVERSION COEFFICIENT; CG
34 % (3 mm PMMA, Dance, 1990)

Few % from the average between W, MoW alloy and Mo targets
(Rosenstein, 1984)
3 % for a 4.5-cm-thick breast, for Mo/Mo, W/Mo, W/Rh, W/Pd and W/Al
combinations (Dance, 1990)
7 % difference between Mo/Rh and Rh/Rh (Wu et al., 1994)
Within 5 % for a 5-cm-thick standard breast for various anode/filter
combinations (Jansen, 1994)
Relative spectral correction factors are given by Dance et al. (2000).
They range up to 1.061 0.036 for Rh/Rh
HVL1 / mm Al
Figure E.2. Calculated conversion coefficients for mammary gland cG for a 5.0-cm-thick breast model with a central region consisting of
50 % adipose and 50 % glandular tissue as a function of the HVL1 for various anode/filter combinations (EC, 1996b). The anode the
anode material is indicated by the chemical symbol, the filter thickness is given in mm and the filter material by the trailing symbol.
differences are reduced to 9 and 7 %, respectively.

For larger values of HVL1 the differences remain
approximately constant at 7 %. These differences
are not large in view of those due to variations in
technical parameters (Table E.3).
Concerning the influence of tube voltage for the
same target type and HVL1 of the incident radiation,
the variations reported by Rosenstein et al. (1985)
are somewhat larger than those published by Wu
et al. (1991, 1994). Wu et al. varied tube voltage
and also included an additional layer of Lexan
(polycarbonate). This latter filtration will have an
effect similar to the introduction of a compression

plate.
The influence on cG of different anode/filter combinations producing the same HVL1 is dependent
on the compressed breast thickness (Dance, 1990).
Figure E.2 shows the conversion coefficients cG as a
function of HVL1 for a 5-cm-thick standard breast,
i.e., containing a central region consisting of 50 %
adipose tissue and 50 % glandular tissue by mass
using various anode/filter combinations. The difference for a specific anode/filter combination from the
average value amounts to 5 % at maximum. This is
95

Table E.4. Conversion coefficients cG for calculating DG for a 4.5-cm-thick breast (50 % adipose/50 % glandular tissue) from
Ka,i (after ACR, 1992. Reprinted with permission from the American College of Radiology).
HVL1b
23
0.23
0.24
0.25
0.26
0.27
0.28
0.29
0.30
0.31
0.32
0.33
0.34
0.35
0.36
0.37
0.38
0.39
0.40
0.41
0.42
0.43
0.44
0.45
W/Ala
Mo/30 mm Mo target-filter combination X-ray peak tube voltage/kV
0.124
0.129
0.133
0.138
0.144
0.148
0.154
0.159
0.164
0.169
0.174
0.179
24
0.132
0.137
0.141
0.146
0.151
0.156
0.161
0.166
0.171
0.176
0.181
0.186
25
0.139
0.144
0.148
0.153
0.158
0.163
0.168
0.172
0.177
0.182
0.187
0.192
26
0.146
0.151
0.155
0.161
0.165
0.170
0.174
0.179
0.184
0.189
0.194
0.198
27
0.153
0.157
0.162
0.166
0.171
0.176
0.180
0.185
0.190
0.195
0.200
0.204
28
0.158
0.163
0.168
0.172
0.177
0.181
0.186
0.192
0.196
0.201
0.205
0.210
29
0.164
0.169
0.173
0.178
0.182
0.187
0.193
0.197
0.202
0.206
0.211
0.216
30
31
0.170
0.174
0.180
0.185
0.189
0.194
0.198
0.203
0.208
0.212
0.217
0.221
0.176
0.181
0.186
0.190
0.195
0.200
0.203
0.208
0.212
0.218
0.222
32
0.182
0.187
0.192
0.196
0.201
0.204
0.209
0.213
0.219
0.223
0.228
33
0.182
0.187
0.192
0.196
0.201
0.205
0.210
0.214
0.219
0.223
0.228
0.233
0.194
0.200
0.205
0.211
0.217
0.221
0.227
0.233
0.237
0.243
0.247
0.252
0.257
0.262
0.267
0.271
W/Al target-filter combination, peak tube voltage 45 kV, filter thickness 1.6 mm.
HVL1 in mm Al.
in agreement with the findings by the other investigators (Table E.2).

In addition, Wu et al. (1991) report a dependence
of cG on tube voltage waveform amounting to 4 %
between one phase, two pulse, and constant potential generators. This finding is less relevant today as
modern mammography units are equipped with
high-frequency tube-voltage generators, which provide approximately constant potentials.
Alm Carlsson and Dance (1992) report variations
in dose up to 4 % across an 8-cm-thick breast for a
homogeneous x-ray field. This variation is due to a
lack of side scatter and does not include a heel effect.
It is concluded that the differences in results
obtained by various investigators are rather small,
i.e., <9 % for HVL1 in excess of 0.35 mm Al. The most
widely used conversion coefficients are those of
Wu et al. (1991) and Stanton et al. (1984) included
in the ACR Protocol (ACR, 1992) and of Dance
(1990) recommended in the European Protocol (EC,
1996b). The source of cG values employed should be
indicated.
According to the ACR protocol, Ka,i (or incident
exposure) is measured for a mammographic phantom (equivalent to 4.5 cm compressed breast tissue
with a composition of 50 % adipose tissue and 50 %
glandular tissue by weight; for example, Radiation
Measurement Inc. Model 156 Mammographic

Phantom or equivalent). The conversion coefficients,
cG for a 45-mm-thick breast containing a central
region (Figure E.1) consisting of 50 % adipose
tissue and 50 % glandular tissue are given in
Table E.4 (after ACR, 1992). The ACR conversion
coefficients have been converted to SI units.
In the European protocol on dosimetry for mammography, Ka,i is measured for 5-cm-thick breasts or
a 4.5-cm-thick PMMA reference phantom can be
used to assess DG for a 5-cm-thick standard breast
(EC, 1996b). The remaining dimensions of such a
reference phantom are either rectangular in excess
of 15 cm 10 cm or semicircular with a radius
>10 cm (EC, 1996b). The attenuation in a reference
PMMA phantom is somewhat smaller than that in
the corresponding 5-cm-thick standard breast model
used for numerical dosimetry. Therefore, the conversion coefficients from Ka,i to DG are somewhat larger
than those for the 5-cm-thick standard breast and
are given in Table E.5 (EC, 1996b).
E.4 CONVERSION COEFFICIENTS CG AS A
FUNCTION OF BREAST THICKNESS
Almost all authors provide cG as a function of
HVL1 and compressed breast thickness. As an
96
APPENDIX E
Table E.5. Conversion coefficients for calculating DG for a
5.0 cm standard breast from Ka,i for 4.5-cm-thick standard
PMMA phantom (EC, 1996b).
cG
0.30
0.35
0.40
0.45
0.50
0.55
0.60
0.65
0.177
0.202
0.223
0.248
0.276
0.304
0.326
0.349
Ratio of conversion factors
HVL1/mm Al
1.4
0% glandularity
1.2
1.0
0.8
100% glandularity
0.6
2
HVL1/ cG for breast thicknesses of

mm Al
2 cm 3 cm 4 cm 4.5 cm 5 cm
6 cm
7 cm
8 cm
0.30
0.35
0.40
0.45
0.50
0.55
0.60
0.65
0.135
0.154
0.172
0.192
0.214
0.236
0.261
0.282
0.114
0.130
0.145
0.163
0.177
0.202
0.224
0.244
0.098
0.112
0.126
0.140
0.154
0.175
0.195
0.212
0.390
0.433
0.473
0.509
0.543
0.573
0.587
0.622
0.274
0.309
0.342
0.374
0.406
0.437
0.466
0.491
0.207
0.235
0.261
0.289
0.318
0.346
0.374
0.399
0.183
0.208
0.232
0.258
0.285
0.311
0.399
0.363
0.164
0.187
0.209
0.232
0.258
0.287
0.310
0.332
Breast thickness (cm)
Table E.6. The conversion coefficient cG that relates Ka,i

to DG for standard breast phantoms (Reproduced from
Dance, 1990, with permission from IOP, UK).
Figure E.3. Ratios of conversion coefficients cG for breasts with

glandularities different from 50 % for a HVL1 of 0.35 mm Al. The
upper curve is the ratio for 050 % and the lower curve is the ratio
for 10050 %. In each case the solid line corresponds to the data of
[Dance et al. (2000), reproduced with permission from IOP, UK],
the open circles to the data of Wu et al. (1991), and the closed
circles to the data of Klein et al. (1997).
tube-current exposure-time product for radiographs

of phantoms of various thickness having central
regions with compositions of 0, 50, and 100 %
glandular tissue. By comparing the tube-current
exposure-time product measured for the phantoms
of different thickness and composition with that
determined during actual patient examinations at
known compressed breast thickness the fraction of
glandular tissue for a patient can be derived.
Klein et al. (1997) determined the fractions of
glandular tissue in German women. They found
that the average composition ranged from 75 % at a
compressed breast thickness of 25 mm through 40 %
at 50 mm breast thickness to an approximately constant level of 20 % for breast thicknesses in excess of
70 mm. Similar work has been done by Geise and
Palchevsky (1996) and by Young et al. (1998) with
excellent and reasonable agreement with the results
of Klein et al. (1997), respectively.
An alternative method to take the fraction of
glandular tissue into account for assessment of DG
has been presented by Dance et al. (2000). Dance
et al. (2000) propose to extend Eq. (E.1) to
example, Table E.6 shows cG values as a function of

thickness of standard breasts, i.e., mathematical
models having a superficial layer of 0.5 cm adipose
tissue and a central region of 50 % adipose tissue and
50 % glandular tissue by mass. Application of these
conversion coefficients implies that the fraction of
glandular tissue is independent of compressed
breast thickness. This, however, is not the case in
practice (Geise and Palchevsky, 1996; Klein et al.,
1997; Young et al., 1998).
E.5 CONVERSION COEFFICIENTS CG FOR

ASSESSMENT OF DG TAKING BREAST
COMPOSITION INTO ACCOUNT
Conversion coefficients cG for fractions of glandular tissue in the central region of the compressed
breast differing from 50 % have been presented by
various investigators (Rosenstein et al., 1985; Wu et
al., 1991, 1994; Jansen et al., 1994; Klein et al., 1997;
Dance et al., 2000). Figure E.3 shows ratios of conversion coefficients cG for breasts with glandularities different from 50 % for a HVL1 of 0.35 mm Al.
A method for the assessment of the fraction
of glandular tissue has been presented by Klein
et al. (1997). Measurements were made of the
DG Ka;i cG cs,
E:2
where c corrects for any difference in breast composition from 50 % glandular tissue, and the factor s for
any difference from the cG tabulation by Dance
(1990) due to the use of a different x-ray spectrum.
Correction factors c are tabulated against HVL1 and
breast thickness. They are available as a function of
glandularity and for breasts of typical glandularity
at a given breast thickness for women in the age
groups 4049 years and 5064 years.
97

APPENDIX F: PCXMCA PC-BASED MONTE CARLO

PROGRAM FOR CALCULATING PATIENT DOSES
IN MEDICAL X-RAY EXAMINATIONS
F.1
F.2
INTRODUCTION
PCXMC is a PC-based Monte Carlo program for

calculating organ doses for patients undergoing
medical x-ray examination (radiography and fluoroscopy). The program uses the mathematical phantoms of Cristy (1980) and computes organ doses for
patients of different ages and sizes in freely adjustable
x-ray projections and other examination conditions
used in radiology. The program has the unique feature of phantom scaling by changing weight or height.
The program runs on a PC operated under Windows 95/98/NT, for example. The Monte Carlo simulation time depends on the accuracy required and on
the speed of the PC. It takes typically from a few
seconds to a few minutes for a PC with a 200 MHz
Pentium processor. The same Monte Carlo data can
be used for calculating doses for any x-ray spectrum
of interest when the other conditions of the examination remain unchanged. In this case the calculation is fast because it does not involve any further
Monte Carlo simulation.
PCXMC has been developed by STUK, the
Radiation and Nuclear Safety Authority of Finland,
(Tapiovaara et al., 1997). A brief summary of the
program is given below. More information and a
free demonstration version of the program are available from the web page of STUK (http://www.stuk.fi/
pcxmc).
DOSE QUANTITIES IN PCXMC
All organ doses calculated by PCXMC are given in

proportion to the patient Ka,i. Data on Ka,i. (or,
alternatively, PKA) must be supplied by the user of
the program.
PCXMC calculates doses in the organs shown
below.
Ovaries
Testes
Active BM
Lungs
Colonb
Stomach
Liver
Thyroid
Oesophagus
Breasts
Urinary bladder
Bone surfacea
Skin
Adrenals
Brain
Kidneys
Pancreas
Small intestine
Spleen
Thymus
Uterus
Musclec
Gall bladder
Heart
PCXMC approximates the bone surface dose by using the dose to

the skeleton (excluding active BM).
b
The colon dose is calculated as Dcolon 0.57 Dupper large intestine
0.43 Dlower large intestine (see ICRP, 1995).
c
In PCXMC, this dose is calculated as the average dose to the
whole phantom, but excluding the other organs and tissues given
in this table.
All doses in PCXMC are expressed in mGy.
Table F.1. Principal dimensions of the mathematical phantoms (Cristy 1980). The arms of a phantom can be included at the
sides of the trunk or be removed.
Newborn
1 year old
5 years old
10 years old
15 years old
Adult
Weight/
kg
Total height/cm
Trunk height/cm
Trunk thickness/cm
Trunk widtha/cm
Trunk widthb/cm
Leg length/cm
3.51
9.36
19.1
32.1
54.5
71.1
51.5
75.0
109.0
138.6
164.0
174.0
21.6
30.7
40.8
50.8
63.1
70.0
9.8
13.0
15.0
16.8
19.6
20.0
10.9
15.1
19.6
23.8
29.7
34.4
12.7
17.6
22.9
27.8
34.5
40.0
16.8
26.5
48.0
66.0
78.0
80.0
Excluding arms.
Including arms.

Table F.2. Elemental composition of the phantom tissues as used in PCXMC (percent by weight).
Skeleton
Active BM
Breast tissue
Lung tissue
Other soft tissues
F.3
Density/g cm3
Ca
1.49
0.99
0.975
0.296
0.99
7.04
10.18
11.70
10.21
10.47
22.79
47.48
38.04
10.01
23.02
3.87
2.18
0.00
2.80
2.34
48.56
39.70
50.26
75.96
63.21
7.68
0.29
0.00
0.78
0.39
10.06
0.17
0.00
0.24
0.58
MATHEMATICAL PHANTOMS
PCXMC allows further modification of the phantoms by letting the user change their weight, M, or
height, h. Using these body size measurements, the
program calculates scaling factors
The phantoms used in PCXMC are computational hermaphrodite phantoms representing

humans of various ages, i.e., newborn, 1, 5, 10,
15-year-old, and adult patients. The phantoms
include mathematical expressions describing various organs and body parts. These phantoms have
been specified by Cristy (1980), but a few modifications, explained below, have been made. The principal body dimensions of the phantoms are given in
Table F.1.
The origin of the coordinate system is located at
the middle of the base of the trunk of each phantom. The z-axis points upwards, the x-axis to the
left-hand side of the phantom, and the phantom
looks in the negative y-direction.
Cristys phantom models have been developed for
calculating doses from internal radiation sources. To
simulate the conditions in radiology, the following
changes, closely following Jones and Wall (1985) and
Zankl et al. (1992), have been made to the Cristy
phantoms.
sz h=h0 ,
F:1
sxy ho M=hMo 0:5 ,
F:2
where sz is the scaling factor in the direction of

the z-axis (phantom height), sxy the scaling factor
in the directions of the x and y-axes (phantom
width and thickness, respectively), and ho and Mo
are the height and weight of the basic phantom
(Table F.1). All dimensions of the phantoms are
then multiplied by these scaling factors, and the
organ masses are changed accordingly. This operation allows the shape of the phantoms to be modified
to resemble that of the actual patient more closely. It
should be noted, however, that all measures in a
given direction (i.e., vertical or horizontal) are
multiplied by the same scaling factor and phantom
variability due to, for example, variability in the
amount of fat tissue cannot be simulated by this
method.
The elemental composition of the tissues of the
phantoms is shown in Table F.2. The number of
elements included in PCXMC is reduced compared
with that employed by the NRPB (Jones and Wall,
1985). The elements Na, Mg, P, S, and Cl are
grouped together and treated as phosphorus. All
elements of atomic numbers Z 19 are grouped
together and treated as calcium (Z 20).
The esophagus has been added. The dimensions

and location of the esophagus are modelled to
resemble those of the male phantom model of
Zankl et al. (1992) and are given for the phantoms
of various ages by Tapiovaara et al. (1997).
The anterior half of the neck of the phantom has
been modified from the Cristy phantom model,
which has no jaw (Kramer et al., 1982). This
modification makes the depths of the thyroid
and esophagus better resemble those in real
patients. The dimensions of the anterior neck
region are given by Tapiovaara et al. (1997).
The arms of the phantoms can be present or
removed. The latter geometry may simulate the
real situation better, e.g., for lateral projections.
The removal of the arms is accomplished by cutting the trunk region with two planes, which are
parallel to the yz plane, and located at the
maximum dimension of the rib cage in the direction of the x-axis, but increased by the thickness
of the skin.
The breast material is taken to be a 50:50 mixture of fat and water.
F.4 THE MONTE CARLO RADIATION

TRANSPORT METHOD
The Monte Carlo simulation has been formulated
in PCXMC in a standard manner. Photons are
assumed to be emitted from an isotropic point source
into the solid angle specified by the focus-to-surfacedistance and the x-ray field dimensions. The primary photons are followed while they interact with the
phantom according to the probability distributions of
the physical processes that they may undergo, i.e.,
photoelectric absorption, coherent scattering, or
100
APPENDIX F
Dose in active bone marrow
300
250
PCXMC
NRPB
mGy/Gy
200
150
100
50
15hp60
15ha60
10ha60
5ha60
15aa60
5cr60
1aa60
5aa60
10aa60
15hp120
5ca60
15ca60
15ha120
1ca60
10ca60
0pp60
10ha120
0ca60
15cp60
1ha60
0aa60
0ha60
5ha120
5cr120
15ca120
15aa120
5ca120
1aa120
1ca120
0pp120
10ca120
0ca120
10aa120
1ha120
0aa120
0ha120
15cp120
Examination condition
Figure F.1. A comparison of the conversion factors calculated by PCXMC with the data of Hart et al. (1996b) according to (Tapiovaara
et al., 1997). Conversion coefficient from air kerma to dose in the active BM. All doses correspond to a Ka,i value of 1 Gy. In the examination condition, the first digits show the patients age, the letters show the examination (a, abdomen; c, chest; h, head; p, pelvis) and
projection (a, AP; p, PA; r, right lateral), and the last digits show the x-ray spectrum (60, 60 kV, total filtration 3 mm Al; 120, 120 kV, total
filtration 3 mm Al and 0.2 mm Cu, 17 x-ray tube anode angle). The uncertainty bars shown correspond to two standard deviations of
the data.
various ages (Table F.2). However, the amount of

active BM is varied from one part of the skeleton to
another and is different for phantoms representing
different ages (Cristy, 1980). In reality, active BM is
located in small cavities in the trabecular bone, and
this must be taken into account when calculating the
dose to the active BM. PCXMC calculates the kerma
in both components of the skeleton, the active BM
and the rest of skeletal material, by dividing the
absorbed energy in the whole skeleton into two
parts, applying the method of Rosenstein (1976). In
PCXMC, however, the actual energy spectrum at the
interaction site is used instead of the incident photon
spectrum used by Rosenstein. The influence of the
small cavity size on the dose in the active BM is
considered by applying a photon energy dependent
kerma-to-dose-conversion coefficient (Kerr and Eckerman, 1985), which increases the active BM dose by
a few percentage compared with the kerma. The size
of the BM cavities may vary depending on the age or
the anatomical part of the skeleton (Kerr and Eckerman, 1985), but this has not been taken into
account in PCXMC.
PCXMC calculates the organ doses for monochromatic photons of 10150 keV in energy steps of
10 keV (or up to less than the maximum 150 keV,
if the user so specifies) in 10 batches at each
incoherent scattering. Other interactions are not

considered in PCXMC, because the maximum
photon energy is limited to 150 keV. The range of
secondary electrons in soft tissue is only a fraction of
a millimeter, and the energy of the secondary electrons is approximated to be absorbed at the site of
the photon interaction (except in calculating the BM
dose, see below). A large number of individual
photon histories are generated, and estimates of
the mean values of the energy depositions in the
various organs in the phantom are used for calculating the dose in these organs.
Pseudo-random numbers are used for sampling
the initial photon direction, distance between interactions, type of interacting atom, type of interaction,
scattering angle, and energy. The cross sections for
the photoelectric interaction, coherent scattering,
and incoherent scattering have been taken from
Storm and Israel (1970) and the atomic form factors
and incoherent scattering functions from Hubbell
et al. (1975).
The bones of the mathematical phantoms are modelled as a homogeneous mixture of mineral bone,
active BM, and other organic constituents of the
skeleton. The overall composition of the skeleton is
approximated as being constant over all bones in the
body and over all phantoms representing patients of
101
data using the conversion coefficients in ICRU

Report 46 (1992c).
energy. The final estimate of the absorption at each

energy is obtained as the average of these batches,
and the statistical uncertainty is estimated from
their standard deviation. The doses and their statistical uncertainties for a practical x-ray spectrum of
interest are calculated afterwards by another module included in the program. The same Monte Carlo
data can, therefore, be used for calculating doses for
any spectrum of interest. The calculation is fast
because it does not involve any further Monte Carlo
simulation.
The x-ray spectra are calculated according to the
theory of Birch and Marshall (1979) and specified in
terms of the x-ray tube voltage (kV), the angle of the
tungsten target of the x-ray tube, and filtration. In
the present version of the program, the user can
simultaneously define two filters of arbitrary atomic
numbers and thickness. The filter data are from the
compiled x-ray interaction data of McMaster et al.
(1969). Air kerma is calculated from photon fluence
F.5
COMPARISON WITH OTHER DATA
The data calculated by PCXMC are most directly

comparable with the organ dose-conversion coefficients calculated at the NRPB by Jones and Wall
(1985) and Hart et al. (1994b, 1996b), because they
are based on the same phantom models (Cristy,
1980). In general, the agreement between the results
of PCXMC and the NRPB data is good (e.g.,
Figure F.1). The differences typically fall within
the statistical uncertainty and are generally <10
%. The remaining deviations can be explained by
the differences in the phantoms. An exception to
the good agreement is the calculations for esophagus, where differences in the phantom model lead to
larger deviations (by up to a factor of 2, Tapiovaara
et al., 1997).
102

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PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING

Journal of the ICRU Vol 5 No 2 (2005) Report 74

THE INTERNATIONAL COMMISSION ON RADIATION UNITS

feels that action based on expediency is inadvisable

International Commission on Radiation Units and Measurements 2005

PATIENT DOSIMETRY FOR X-RAYS USED IN MEDICAL IMAGING

THE ICRUS RELATIONSHIP WITH OTHER

The Commission has found its relationship with

benefit to the ICRU program. Relations with these

Journal of the ICRU Vol 5 No 2 (2005) Report 74

PATIENT DOSIMETRY FOR X RAYS USED IN

Evolution of radiation dosimetry in medical x-ray imaging . . . . . . . . . .

PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING

SPECIFICATION OF X-RAY BEAMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

QUANTITIES AND UNITS FOR MEASUREMENT AND CALCULATION IN MEDICAL

Basic dosimetric quantities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Quality assurance of dosimeters . . . . . . . . . . . . . . . . . . . . . . . . .

Skin dose determination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5 METHODS FOR DETERMINING ORGAN AND TISSUE DOSES . . . . . . . . . . . . . . . . . . . . . . . 55

Dose measurements in physical phantoms . . . . . . . . . . . . . . . . . . .

HANDBOOKS PRODUCED BY THE CENTER FOR DEVICES

REPORTS PRODUCED BY THE GERMAN NATIONAL RESEARCH

REPORTS PRODUCED BY THE HEALTH PROTECTION AGENCY (HPA) (FORMERLY

REVIEW OF MONTE CARLO CALCULATIONS FOR ASSESSMENT OF MEAN

PCXMC ------ A PC-BASED MONTE CARLO PROGRAM FOR CALCULATING

Journal of the ICRU Vol 5 No 2 (2005) Report 74

The ICRP has recently proposed (2005) to replace the

International Commission on Radiation Units and Measurements 2005

PATIENT DOSIMETRY FOR X RAYS USED IN MEDIUM IMAGING

clearly identified. The relevant quantities to be

Journal of the ICRU Vol 5 No 2 (2005) Report 74

automatic exposure control

International Commission on Radiation Units and Measurements 2005

Journal of the ICRU Vol 5 No 2 (2005) Report 74

on dose-conversion coefficients for x-ray imaging

International Commission on Radiation Units and Measurements 2005

Journal of the ICRU Vol 5 No 2 (2005) Report 74

quantity are discussed in Section 4. Quantities are

International Commission on Radiation Units and Measurements 2005

PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING

data based on similarities in exposure conditions

reflect the differences in medical imaging using x

Journal of the ICRU Vol 5 No 2 (2005) Report 74

1.1 EVOLUTION OF RADIATION DOSIMETRY

International Commission on Radiation Units and Measurements 2005

PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING

(GSD) (UNSCEAR, 1972; NAS/NRC, 1980) and the

Figure 1.1. Acute dermatitis 3 weeks after excessive skin

Figure 1.2. Chronic dermatitis on the skin of the same patient as

Better information on the relative radiosensitivities

1.2 RISKS FOR THE PATIENT IN

PATIENT DOSIMETRY FOR X RAYS USED IN MEDICAL IMAGING

Acute deterministic effects1

weighting factors could probably be selected taking

Late effects in normal tissues

An increasing number of data indicates that some

Cancer induction is generally considered to be the

Impairment of mental development

Evidence has been reported that doses such as

For some radiological procedures involving the

The ICRP has recently proposed (2005) to replace the

relevant dosimetric quantities and dosimetric procedures can be derived.

Skin, because the skin is the most heavily

Doses at reference points, for example, entrance