DIGITAL FLUOROSCOPY VERSUS CONVENTIONAL FLUOROSCOPY:

INFLUENCE ON PATIENT DOSE

P. Gmez, P. Collado, C. Martn, C. Montes, C.J. Sanz, A. Garca-Miguel

Servicio de Radiofsica y Proteccin Radiolgica. Hospital Universitario de Salamanca.

P San Vicente, 58-182. 37007. Salamanca (Spain).
Phone: +34 923 291 180. e-mail: mfbordes@usal.es

Abstract. The introduction of digital equipment into radiology departments presents large advantages with
respect to organisation aspects and makes better use of working time, but the topics related to the image quality
and dose received by patients must be carefully considered. In this paper, radiation dose received by patients
who underwent examinations by means of fluoroscopy procedures, in which digital equipment has been used,
were assessed. Measurements using as reference gastrointestinal and urographic exams were made. These studies
were made in two diagnostic radiology departments: Clnico Universitario de Salamanca and Nuestra Seora de
Sonsoles (vila) hospitals, over the last 5 years. The digital equipment was set up during this period. The dose
survey was made according to the procedures specified in the current legislation. Results have been compared to
those obtained with a previously used conventional fluoroscopy system. The measurements of the dose - area
product as dosimetric magnitude were made using transmission chambers as measurement system. Conditions of
exploration, sanitary staff and radiologists have been the same before and after the installation of the new digital
equipment in most cases, although in one of them we had to consider the influence of the change of one
radiologist in the obtained results. From the measurements made in the present study it is possible to conclude
that the doses received by the patients have been reduced as much as 60% with the use of the digital equipment.
The aim of this paper is not to compare the parameters related to the image quality in both digital and
conventional systems.

1. Introduction

Introduction of digital radiology equipment into a radiology department leads to numerous important
benefits, mainly related to image information processing as well as work flow and organization
optimization.

Picture Archiving and Communication Systems ( P.A.C.S.) are more flexible and user friendly image
archiving systems, compared to using conventional radiographic films. Furthermore, digital images
can be electronically transmitted as digital information through communication networks, providing
remote diagnostics virtually from any location. Identical duplicates of digital images can be made
without image information loss, even after many copies performed. Using P.A.C.S., together with
digital radiology equipment, allows an immediate and easy integration of the diagnostic image
information into archiving and management systems currently in use in a hospital [1-2].

There are many different detector systems that can be used to acquire and convert X-ray images into
electronic signals to be recorded as digital information, ready to be used as described before. These
systems can be grouped into two different categories: Direct conversion systems and Indirect
conversion systems [1-2].

Among direct conversion detectors, amorphous selenium-based flat-panel detectors are one of the
most technologic advanced today. In this kind of detectors, electron-hole pairs are released after X-ray
interaction with the semiconductor. These charges are collected and stored. Finally, the reading is
performed through a large matrix of thin film transistors (T.F.T.). Unlike indirect systems, conversion
from X-rays to charge is performed avoiding any intermediate step, which may cause scattering of
photons within the detection layer, that would produce additional sources of noise and image blurring
[2].

Indirect detection systems are based on phosphor screens, which convert X-rays into light photons.
These light photons are subsequently detected either by a photodiode matrix, (amorphous silicon flat
panel detectors) either by the photocathode of a common Image Intensifier Tube, which feeds a CCD
camera or a video camera. This video signal is recorded and digitized. The main drawback of a

1
indirect system is the additional scattering produced on the phosphor layer. Also noise is introduced by
the quantum nature interaction processes within that layer [2].

Those examinations requiring fluoroscopy were among the first to benefit from Digital Image
Processing, such as Digital Subtraction Angiography (D.S.A.) [1]. These examinations are performed
using digital detectors based on CCD or video cameras coupled to image intensifier tubes. This kind of
detector system is used in gastrointestinal examinations as well, being the obtained image quality
satisfactory and, in some cases, better than those images obtained with conventional systems [3].

Thus we can conclude that, as far as examination procedures optimization and diagnostic capabilities
of the acquired images is concerned, radiology systems based on digital detectors show evident
advantages over conventional systems [3-6].

Another important question to be discussed is whether digital equipment may offer advantages in
terms of radiation protection of patients. Many published works suggest that patient dose can be
reduced usin digital equipment [4-6].

The aim of this paper is to determine the influence on received dose in patients undergoing urographic
and gastrointestinal examinations, when conventional equipment is replaced by digital equipment. The
study group are patients in the hospitals controlled by our Radiation Protection Department.

2. Materials and methods

The following summarizes the material we have used to determine the impact of replacing
conventional equipment with digital equipment:

- Transmission chamber PTW, model Diamentor and its Diamentor M electrometer.

- Three conventional fluoroscopy equipments have been removed and replaced.
- Three digital-detector based fluoroscopy equipment, all of them with Image Intensifier Tube
which have been set up to replace the old conventional equipment.

These studies were carried out in three rooms sited in two different hospitals: Hospital Clnico
Universitario (Salamanca) and Nuestra Seora de Sonsoles (vila). In two of these rooms
gastrointestinal examinations are performed whereas in the remaining one urography examinations are
made. The replacement of the conventional equipment with digital equipment, in both centres, took
place during the dose evaluation survey. We followed the methodology required by current regulation
in imparted dose to patient verification [7].

We choose the dose-area product (D.A.P.) as reference dosimetric magnitude, because this is the best
dosimetric quantity from which it is possible to calculate the effective dose in these kind of
examinations [4]. We should bear in mind that the effective dose gives us a real estimation of the risks
involved in radiological examinations.

In order to measure the DAP we have used the above mentioned transmission chamber for those
equipment which does not have an integrated dosimeter. At least two of the digital equipment under
study have an integrated dose-area product measurement and archiving system, which clearly eases the
task of register patients dose, and shows one of the multiple advantages of the use of digital
equipment. The remaining digital equipment does not have any integrated measurement system at all.
Patient dose is estimated in this last case through calculations made by the equipment software, based
on tube performance and exposure parameters. During this survey we concluded that this calculation
system was unaffordable, by the lack of accuracy of its algorithm, and so we decided to use our
transmission chamber to measure doses in this diagnostic equipment as well.

Previous to the dose survey, quality controls of the equipment under study were performed in
accordance with the quality assurance program. The assessed technical characteristics of these
equipment are summarized in table I.

2
 Table I. Main technical features of the conventional equipment and the new digital equipment.
Hospital Clnico
Universitario
(Salamanca) Conventional equipment Digital Equipment.
Room 4 Total filtration (mmAl) 2.37 mmAl 2.9 mmAl

Input phosphor dose rate 0.91 uGy/s 0.27 uGy/s

Room 6 Total filtration (mmAl) 2.5 mmAl 3.1 mmAl

Input phosphor dose rate 1.8 uGy/s 0.18 uGy/s

Hospital Ntra. Sra.

Sonsoles
(vila) Conventional equipment Digital Equipment.
Room 5 Total filtration (mmAl) 2.5 mmAl 3.2 mmAl

Input phosphor dose rate 1.22 uGy/s 0.22 uGy/s

3. Results and conclusions

Tables II, III and IV show a compilation of measured dose-area product obtained over the last years.
Other important data such as fluoroscopy time are also shown.

A drop in fluoroscopy time can be seen in the first room (see table II) after the set up of digital
equipment. However, this fluoroscopy time improved only after past a period of time following the set
up. The dose-area product magnitude behaves in a similar manner. This transitory period before
fluoroscopy time optimization is achieved, may be due to personnel staff adaptation to this new
technology. The average number of acquired images increases after the digital equipment was set up,
although the dose contribution of digital imaging can be less than the dose contribution due to
conventional film imaging [4].

Table II. Room 4, Hospital Clnico Universitario de Salamanca.

2003 2002 2001
Equipment Digital Conventional
Examination Barium Meal Barium Enema Barium Enema Barium Meal Barium Enema
No. patients 5 5 10 12 5
Average age 52.4 58.2 63.4 60.7 70.2
Average
number of 12.5 10.8 11.7 11.7 7.2
images
Average
number of 12.5 10.8 11.7 11.7 5.8
radiographs
Average
fluoroscopy 3:32 3:19 4:11 4:35 4:25
time
DOSE AREA
PRODUCT 1089.33 1650.34 1658.96 3617.9 3438.6
(cGycm2)

3
Fluoroscopy time follows a similar trend in the second room (see table III), that is, it improved only
after a short period needed for personnel adaptation. In this second case under study, the measured
values of dose-area product improved just after the set up of the digital equipment. The average
number of acquired images increased, but this again seems to have no effect in increasing total patient
dose.

Table III. Room 6, Hospital Clnico Universitario de Salamanca.

2003 2002 2001
Equipment Digital Conventional
Examination Urography Urography Urography
No. patients 8 12 5
Average age 59.3 54.4 64.8
Average
number of 10.5 13.33
images
Average
number of 10.5 13.33 7.6
radiographs
Average
fluoroscopy 1:31 2:07 1:14
time
DOSE AREA
PRODUCT 1187.5 1666.17 2633.8
(cGycm2)

Table IV. 3. Room 5, Hospital Ntra. Sra. de Sonsoles de vila.

2003 1998
Equipment Digital Conventional
Examination Barium Enema Barium Enema
No. patients 7 7
Average age - -
Average
number of 12.3 8.1
images
Average
number of 12.3 5.4
radiographs
Average
fluoroscopy 3:56 1:11
time
DOSE AREA
PRODUCT 2268.9 1789
(cGycm2)

In the third room it is possible to notice that there is an increase in the dose area product as well as in
the fluoroscopy time following the set up of the new digital equipment. This is in some cases, the
effect of the digital radiology equipment, which can increase substantially the number of images taken

4
for exploration, due to the capacity of these systems to manage high quantity of information. Although
the increase in radiation doses is not proportional to the increase in fluoroscopy time and number of
images. This is due to the fact that the dose contribution from digital imaging can be less than that
from conventional imaging.

We can conclude that the image quality offered by these digital equipment fit the requirements
established for these kinds of examinations, as the obtained diagnostic results have been widely
accepted by radiologists in the institutions where this dose survey was made. Furthermore, selection of
the adequate technical parameters of the exposures may lead to better diagnostic results [3].

Correct operation of this kind of equipment may lead to a significant reduction of patients dose as well
[4-6]. That is because there is no lower limit for the exposure to reach a certain level of brightness
when digital detectors are used. That threshold of exposure is given only by the noise that can be
assumed [5-6].

Patient dose is also influenced by the correct operation of the Automatic Brightness Control (ABC).
The input phosphor dose rate is largely determined by the performance of the ABC and this is directly
related to the patient entrance dose rate [8]. It can be seen from the quality controls of the digital
equipment that the input phosphor dose rate is reduced after the set up of this new equipment.

Flexibility and integration into a digital environment are obvious advantages of setting up digital
equipment in a Radiology Department. Benefits can also be obtained from the point of view of the
protection of patients. Indeed, reduction of patient dose can be accomplished when digital equipment
operation is optimized, reducing the risks involved in these examinations.

4. References

1. S. Lpez Bravo. Introduccin a la Radiografa Digital. Revista de Fsica Mdica; 2(2): 99-110,
(2001).
2. M J Yaffe and J A Rowlands. X-ray detectors for digital radiography. Phys. Med. Biol. 42 139,
(1997).
3. Gen Iinuma, Kyosuke Ushio, Tsutomu Ishikawa, Shigeru Nawano, Ryuzou Sekiguchi and Mituo
Satake. Diagnosis of Gastric Cancers: Comparison of Conventional Radiography and Digital
Radiography with a 4 Million Pixel Charged coupled Device. Radiology; 214:497 502,
(2000).
4. J. Geleijns, J. J. Broerse, M. P. Chandie Shaw, F. W. Schultz, W. Teeuwisse, J. G. Van Unnik and
J. Zoetelief. A comparison of patient dose for examinations of the upper gastrointestinal tract at 11
conventional and digital X-ray units in The Netherlands. The British Journal of Radiology, 71,
745-753, (1998).
5. Jan Persliden, K.-W. Beckman, H. Geijer, and T. Andersson. Dose-image optimisation in digital
radiology with a direct digital detector: an example applied to pelvic examinations. Eur Radiol
12:15841588, (2002).
6. E. Vao, P. Morn, M. Chevalier, and J. M. Fernndez. Evaluacin de la calidad de imagen de un
sistema de mamografa digital. Revista de Fsica Mdica; 2(1): 35-39, (2001).
7. REAL DECRETO 1976/1999, de 23 de diciembre, por el que se establecen los criterios de calidad
en radiodiagnstico. BOE n 311, 29 de Diciembre (1999).
8. B. Capuz, E. Cabello, M. Sez, A. M Cuesta, F. Sierra, and M P. Olivares. Funcionamiento de los
Sistemas de Control Automtico de Brillo en Intensificadores de Imagen y Relacin con
Parmetros Dosimtricos. Radioproteccin. Extraordinary Number. Sociedad Espaola de
Proteccin Radiolgica, September (2000).