Version 20 April 2004

In press 2004

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Guest Editorial (F. Mettler, Guest Editorial (F. Mettler,

H. Ringertz and E. Vano) H. Ringertz and E. Vano)

Digital radiology An appropriate analogy that is What then is the problem and why did ICRP Committee
easy for most people to understand is the 3 request a Task Group to write this document?.
replacement of typical film cameras with digital
cameras: Images can be taken, immediately
examined, deleted, corrected, and cropped, and While digital techniques have the
subsequently sent to a network of computers. potential to reduce patient doses,
Digital technology has the potential to reduce
patient doses.
they also have the potential to
significantly increase them.
ADV
A NT A
G ES
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Guest Editorial (F. Mettler,

H. Ringertz and E. Vano) ICRP 93 CONTENTS
Introduction and purpose.
This is a technology that is
Patient dose and image quality in digital radiology.
advancing rapidly and which will
soon affect hundreds of millions of Regulatory aspects and quality management.
patients. ICRP recommendations.
If careful attention is not paid to the Appendices:
radiation protection issues of digital Fundamentals of digital radiology.
radiology, medical exposure of Patient dosimetry: quantities and units.
patients will increase significantly
Training outline.
and without concurrent benefit.
Glossary and acronyms.
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Main points (introduction) Main points (introduction)

The diagnostic information provided by modern
digital detectors can be equal or superior to
conventional film-screen systems, with
comparable patient doses.
Digital imaging has practical technical
advantages compared with film techniques, e.g.
wide contrast dynamic range, postprocessing
functionality, multiple image viewing options,
and electronic transfer and archiving
possibilities.
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With digital systems, an overexposure can occur
without an adverse impact on image quality.
Overexposure may not be recognised by the
radiologist or radiographer. In conventional
radiography, excessive exposure produces a
black film and inadequate exposure produces a
white film, both with reduced contrast. In
digital systems, image brightness can be
adjusted post processing independent of
exposure level.

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CLINICAL IMAGE COMMENT

PROBLEM QUALITY
Main points (chapter 2) CLASS

Primary bone High Image may characterise the lesion.

Different medical imaging tasks tumour
Chronic back pain Medium Degenerative changes are common
require different levels of image with no pointers to and non-specific. Mainly used for
younger patients (e.g. less than 20
quality. The objective is to avoid infection or years of age, spondylolisthesis etc.) or
neoplasm older patients e.g. greater than 55
unnecessary patient doses; doses years of age.

which have no additional benefit

Pneumonia adults: Low To confirm clearing, etc. Also, not
for the clinical purpose intended. follow-up useful to re-examine patient at less
than 10-day intervals as clearing can
be slow (especially in the elderly).

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Present and desired situation for the different digital

technologies for data on patient doses
Digital Technology Available now Desired in the future
CR Dose or exposure index Link with radiographic
technique, patient dose
estimation and patient
data. Archive in the RIS
DR Radiographic technique, Automatic extraction of the
Patient data and patient information from the
dose estimation DICOM header. Archive in
the RIS
Fluoroscopy Radiographic technique, Fluoroscopy information.
Digital image of lumbar spine. Fluoroscopy system: 10% dose (left); radiation field geometry On-line skin dose maps
100% dose (right) (relative values of dose). Courtesy of R. Loose. and dose parameters per and automatic extraction of
series information from DICOM
header. Archive in the RIS

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Main points (chapter 2) Main points (chapter 2)

Image quality can be compromised by With digital fluoroscopy systems it

inappropriate levels of data is very easy to obtain (and delete)
compression and/or post-processing images.
techniques. There may be a tendency to obtain
Data compression and post-processing more images than necessary.
requirements should be defined by This would irradiate the patient
modality and the medical imaging task. more than is clinically necessary.
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With digital fluoroscopy systems may be a

tendency to obtain more images than necessary Examples of dose reduction

Axelsson et al. have demonstrated that in Portable flat-panel evaluated for neonatal
upper gastrointestinal examinations, imaging requiring one quarter of the
some centres with digital fluoroscopy patient dose compared with conventional
use a mean number of 68 exposures per radiography. Samei et al. Med Phys 2003;30(4):601-7

examination in comparison with 16 A dose reduction of 33-50% in chest

exposures used in other centres with radiography using a flat-panel detector
conventional systems. Strotzer et al. AJR 2002;178(1):169-71; Fink et al. AJR 2002;178:481-6;
Herrmann et al. Eur Radiol 2002;12(2):385-90.
Axelsson et al. Eur Radiol 2000;10(8):1351-4.

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Actions that affect patient doses Influence Influence on image

on patient quality or diagnostic Main points (chapter 3)
dose information
Reduction of noise perception Increase Improvement
in the image (i.e. the perception Commissioning of digital
of the signal-to-noise ratio)
systems, or introduction of new
Lost of images in the network or Increase Retakes
in the PACS due to improper techniques, should ensure that
identification or other reasons imaging capability and radiation
(Smith et al, AJR 2001;176:1381-4).
Deletion of image files at the Increase Loss of (perhaps) dose management are integrated
viewing or workstation of some useful to achieve acceptable clinical
apparently non useful images information. Difficult
to control repeated
image production using
exposures appropriate patient doses.
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Increase in the number of examinations

Main points (chapter 3) with digital
In several U.S. hospitals the number of
Justification criteria should be one of the examinations per in - patient day increased
key components considered in the update by 82% after a transition to film-less
of a quality assurance programme when a operation.
facility converts to digital imaging. Outpatient utilization (i.e. the number of
Increases in the number of examinations examinations per visit) increased by 21%
could occur because of the relative ease compared with a net decrease of 19%
of obtaining and archiving images with nationally at film-based hospitals.
digital Reiner et al. Radiology. 2000 Apr;215(1):163-7.
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ICRP-93
Main points (chapter 3) RECOMMENDATIONS

1. Appropriate training, particularly in the

Once digital systems are in use,
aspects of patient dose management, should
comprehensive quality control programmes
be undertaken by radiologists, medical
are required to ensure image quality and
physicists and radiographers before the
patient dose management are maintained.
clinical use of digital techniques.
Quality control programmes should detect
any significant changes in image quality or 2. Local diagnostic reference levels should be
patient dose management and therefore reviewed when new digital systems are
prevent upward drift in doses, without introduced in an operational facility.
additional clinical benefit.
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Chest image.
Only a
printing
mistake
but exposure
was
repeated .
lack of
training?

Phosphor plate misused. Impossible to clean. Lack of training?

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ICRP-93 Chest PA
obtained as
RECOMMENDATIONS chest LL (flat
panel detector);
3. Frequent patient dose audits should occur 125 kV; 6.2
mAs; 0.54 mGy
when digital techniques are introduced in an (entrance
operational facility. patient dose 4
times higher
4. The original image data should be made than
necessary);
available to the user not only for objective AEC center cell
testing in a rigorous quality assurance program used. Saturated
but also for other types of independent tests of image at the
lung area.
the performance of digital-imaging systems. (Courtesy of E. Vano
and J.M. Fernandez)
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Same
Same image.
image. Isocontour 99%
Inverted of pixel
gray scale. content. Some
lung areas are
saturated
without any
diagnostic
information.
The image was
repeated.

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ICRP-93
RECOMMENDATIONS

5. When a new digital system or new post-

processing software is introduced, an
optimisation programme and continuing
training should be conducted in parallel.

6. Quality control in digital radiology requires

new procedures and protocols. Acceptance and
Two postprocessings of a patient after pneumonectomy from raw
constancy tests should include aspects
(original) image: Postprocessing for lung tissue (left) postprocessing for concerning visualization, transmission and
mediastinum (right). Courtesy of R. Loose.
archiving of the images.
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ICRP-93
RECOMMENDATIONS

7. As digital-radiology images are

easier to obtain and to transmit in
modern communication networks,
referring physicians should be fully
conversant with the justification
Relative exposure index 1.15 Relative exposure index 1.87
criteria for requesting medical x-ray
Image too noisy Image with enough quality
imaging procedures.
From the Glossary. Exposure Index = Term usually used in relation to the
absorbed dose to the phosphor plate (courtesy of E. Vano and J.M. Fernandez).
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ICRP-93
RECOMMENDATIONS Glossary (examples)
Raw image (read-out signal of flat-panel
8. Industry should promote tools to detector or storage-phosphor system);
inform radiologists, radiographers and
Original image (after all device-specific
medical physicists about the exposure corrections);
parameters and the resultant patient
Processed image (for display).
doses. The exposure parameters and
the resultant patient doses should be Image conditioning consists of all
standardized, displayed and recorded. processing steps necessary to transform
the raw image into the original image.
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ANNEX 1: Digital
ANNEX 1: Digital systems.
systems. Fundamentals
(examples) Fundamentals (examples)

Illustration of Comparison of high contrast

overshoot artefacts at and low contrast phantom.
high-contrast implant
borders:
Upper row: relative dose 100%
a) Without edge
enhancement (upper Lower row: relative dose 400%
left), (theoretical improvement of S/N
b) Kernel size 7x7 by a factor of two)
pixels (upper right), Significant change of low-
c) Kernel size 15x15
contrast resolution can be
pixels (lower left),
d) Zoomed display of observed, which would also be
critical border showing expected in clinical practice.
black and white halos
for sample c). (Courtesy of B. Geiger)
(Courtesy of B. Geiger)

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