1. How to estimate conceptus dose from radiographic, fluoroscopic and fluoroscopically guided interventional procedures Georgia Solomou, Medical Physicist MSc Department of Medical Physics, University Hospital of Heraklion, Crete http://medicalphysics.med.uoc.gr 8 th ECMP, 11-13 September 2014, Athens

2.  When a detailed dose assessment is needed  Available tools to estimate conceptus radiation dose  CONCERT Project  Conclusion Contents

3. Radiation and pregnancy Thousands of pregnant women are exposed to ionizing radiation Lack of knowledge may lead to unnecessary termination of pregnancies “No safe level” is a sweeping statement Radiation exposure should be medically appropriate

4. Is a detailed dose assessment always needed? No if: gestational age less than 2 weeks gestational age less than 2 weeks conceptus dose is low (conceptus is located out of the primary beam) conceptus dose is low (conceptus is located out of the primary beam)

5. Conceptus Dose(mGy) TERMINATION of pregnancy at conceptus doses of less than 100 mGy is not justified based upon radiation risk. ICRP publication 84: Conceptus dose estimation Dose > 10 mGy Dose > 10 mGy But when a detail assessment of conceptus radiation dose is needed? But when a detail assessment of conceptus radiation dose is needed? 10 mGy50 mGy100 mGy

6. When 10 mGy is exceeded? Examination “Typical estimate” conceptus dose (mGy) Reported range (mGy) Chest Radiography<0.010.0001-0.43 Abdomen1.41.4-4.2 Pelvis20.16-22 Lumbar Spine42-40 Hip fractures0.16- Cardiac Catheter Ablation0.6- Kyphoplasty T93- Therapeutic ERCP3.10.1-55.9

7. When 10 mGy is exceeded? Examination “Typical estimate” conceptus dose (mGy) Reported range (mGy) Chest Radiography<0.010.0001-0.43 Abdomen1.41.4-4.2 Pelvis20.16-22 Lumbar Spine42-40 Hip fractures0.16- Cardiac Catheter Ablation0.6- Kyphoplasty T93- Therapeutic ERCP3.10.1-55.9 Barium enema100.28-130 Uterine fibroid embolization42- Kyphoplasty L5105- Pedicle screw fixation L511.7- Transureteral stent44- Cholangiography100.05-16 Varicocele embolization15.8 Dauer et al, JVIR, 2012

8. Which are the available tools for a detailed dose assessment?

9. Dosimeters - Patient models TLD MOSFET

10. Monte Carlo Simulation  A general purpose, three-dimensional general geometry, time- dependent, coupled neutron-photon-electron code  It is supported, on a variety of platforms including personal computers.  It has been widely used for medical physics applications   Input file: energy spectra, geometry, mathematical phantoms, materials and tallies.  Mathematical anthropomorphic phantoms are generated using BODYBUILDER software (White Rock Science, White Rock, NM).

11. … Monte Carlo  Output: Normalized conceptus dose /reference dose

12. PCXMC- Dose Calculation  Only at the first postconception weeks PCXMC 2.0, STUK-TR 7, Radiation and Nuclear Safety authority, 2012

13. How can we estimate conceptus dose in every day clinical practice?

16. AP, PA Chest projections Dc= f (AP thickness) 1 st trimester 2 nd trimester 3 rd trimester Damilakis et al, Eur. Radiol, 2003

17. Limitations The existing studies do not include:  All performed projections  The depth of the conceptus at the first trimester,  All radiological examinations  Especially in fluoroscopically guided interventional procedures the existing studies are limited

18.  Conceptus Dose Estimation by radiological examinations  Risks for fatal childhood cancer estimation

19. RADIOGRAPHS ExaminationsProjectionsField Size (cm)TrimesterskVpFiltration Abdomen AP PA 36X43 1 ST, 2 ND, 3 RD 50-1202.5-5.0 Chest AP PA LAT 36X43 1 ST, 2 ND, 3 RD 50-1202.5-5.0 Kidneys AP PA 36X24 1 ST, 2 ND, 3 RD 50-1202.5-5.0 Lumbar Spine AP LAT LAT LSJ LPO RPO 36X43 18X24 24X30 1 ST, 2 ND, 3 RD 50-1202.5-5.0 Pelvis/Colon AP PA AP Hip Joint 36X43 24X35 1 ST, 2 ND, 3 RD 50-1202.5-5.0 Thoracic Spine AP LAT 24X43 20X49 1 ST, 2 ND, 3 RD 50-1202.5-5.0 Urinary BladderAP 24X21 24X18 1 ST, 2 ND, 3 RD 50-1202.5-5.0

20. Abdomen radiography Pregnant patient at the 1 st trimester of gestation  0.055mGy/mAs (FSD=100cm, 80kV)  Output =0.055mGy/mAs (FSD=100cm, 80kV) Examination ParametersAP Abdomen Tube potential (kV)80 Focus to skin Distance(cm)100 mAs33 Filtration (mm Al)3 Fetus Depth (cm)8 How conceptus dose was estimated?

21. kVpdepth(cm) filtration (mm) 2.53.03.54.04.55.0 5040.56570.61380.66700.69770.73970.7728 60.33770.38030.40840.45010.47840.4983 80.20520.22330.25810.28310.30020.3285 100.12230.14330.15360.16600.19150.2046 120.07100.09030.09680.11290.11860.1321 140.04960.05030.06540.06680.07390.0806 6040.62590.67840.72340.76200.79310.8263 60.39440.43240.47220.50340.53680.5627 80.26080.28630.30660.33870.35800.3771 100.16390.19010.20330.22090.23330.2456 120.10930.12710.13240.14260.15880.1618 140.07230.08660.09230.10230.10500.1127 7040.72100.77170.82700.85870.90200.9336 60.48300.52700.56180.59560.62780.6516 80.32130.36050.38480.41450.43220.4572 100.21730.24470.25970.28480.30050.3146 120.14440.16420.17400.19130.20620.2236 140.09830.10860.12930.13640.13890.1535 8040.81300.86680.90600.95050.98741.0299 60.55650.59810.64350.67790.71170.7409 80.38910.42420.45400.48160.51640.5322 100.27140.30340.31570.34470.35920.3781 120.19540.20880.22460.24640.25650.2747 140.13270.14370.15750.16630.18290.1883 9040.88450.94150.99151.02971.06751.1090 60.62690.67720.71410.75570.78320.8175 80.45470.48650.51480.55110.57400.6075 100.32460.35100.37560.39510.42200.4381 120.23070.24850.26970.28840.30140.3218 140.16080.17920.18770.20090.21340.2314 10040.95201.00691.05891.10251.13951.1684 60.69850.74600.77810.81610.85220.8869 80.51150.54920.57880.60590.63740.6568 100.36470.39350.42260.44840.46780.4832 120.26390.28970.31150.32270.33800.3537 140.19290.20410.22220.23550.24510.2589 11041.01331.06261.11621.15251.19051.2121 60.75800.80030.84550.87690.90030.9386 80.55570.59680.62240.64950.68660.7048 100.41100.43410.47050.48770.51320.5304 120.30120.32150.33790.36060.38270.3928 140.20920.22890.24710.26220.27740.2882 12041.10861.16061.20731.25351.29471.3150 60.84440.88990.92780.97561.00501.0237 80.63250.66420.69820.73100.75730.7862 100.46280.48970.52710.54660.57440.6015 120.33220.36620.38780.40740.42540.4492 140.24740.26300.28390.30170.31290.3311 D FETUS = Σ (ESD I *NFD I ) 0.454

22. FLUOROSCOPY ExaminationsProjectionsField Size (cm)TrimesterskVpFiltration Barium Enema AP Colon/Pelvis AP Rectum LAO Colon LAO Flexure LAT Rectum LPO Colon LPO Rectum PA Pelvis/Colon PA Rectum RAO Colon RAO Flexure RAO Rectum 24x30 15x15 35x35 28x35 17x17 35x35 19x19 40x40 15x15 35x35 28x35 19x19 1 ST 50-1202.5-5.0 Barium Follow Through AP Small Intestine PA Small Intestine 22x18 1 ST, 2 ND, 3 RD 50-1202.5-5.0 Barium Meal AP Duodenum AP Stomach AP Upper Stomach LAO Stomach LAT Stomach LPO Duodenum LPO Stomach PA Duodenum PA Stomach PA Upper Stomach RAO Duodenum RAO Stomach 15x15 18x22 15x15 21x21 19x24 19x19 21x21 15x15 18x21 15x15 19x19 21x21 1 ST 50-120 2.5-5.0 Barium Swallow LAO Oesophagus LAT Throat LPO Oesophagus RAO Oesophagus 13x47 18x24 13x47 1 ST, 2 ND, 3 RD 50-120 2.5-5.0 Cardiac CatheterizationAP Heart LAO Heart LAT Heart PA Heart RAO Heart 12.5x12.5 1 ST, 2 ND, 3 RD 50-1202.5-5.0 -

23. Barium Enema  0.055mGy/mAs (FSD=100cm, 80kV)  Output =0.055mGy/mAs (FSD=100cm, 80kV) How conceptus dose was estimated? Pregnant patient at the 1 st trimester of gestation Examination Parameters AP Colon /Pelvis AP Rectum RAO Colon RAO Rectum LAO Colon LPO Rectum Tube potential (kV) 10090 Focus to skin Distance(cm) 80 mA3.5 Fluoroscopy time(min) 2.40.81.2 Filtration (mmAl) 3.5 Contribution30%10%15% Total DAP (Gycm 2 )80

24. AP Pelvis/Colon kVp filtration(mm) 2.53.03.54.04.55.0 500.40440.43740.47400.51250.54360.5766 600.56830.61040.65740.70670.74640.7885 700.71690.76470.81830.87480.91980.9676 800.86160.91270.97041.03131.07921.1303 900.99201.04381.10261.16501.21311.2649 1001.10561.15621.21421.27591.32281.3734 1101.20411.25261.30851.36821.41291.4615 1201.29001.33591.38921.44611.48831.5342 AP Rectum kVp filtration(mm) 2.53.03.54.04.55.0 50 0.18130.19780.21580.23470.25030.2669 60 0.27280.29530.32000.34580.36720.3897 70 0.35920.38580.41520.44590.47120.4977 80 0.44550.47470.50720.54140.56880.5980 90 0.52570.55580.58980.62560.65390.6840 100 0.59580.62540.65970.69580.72350.7531 110 0.65560.68440.71750.75250.77940.8083 120 0.70710.73460.76610.79980.82510.8527 LAO Colon kVp filtration(mm) 2.533.544.5 5 50 0.16390.17860.19480.21160.2257 0.2404 60 0.24210.26160.28320.30580.3244 0.3439 70 0.31570.33860.36390.39060.4122 0.4351 80 0.39070.41590.44400.47370.4973 0.5226 90 0.46000.48610.51550.54640.5709 0.5969 1000.52180.54780.57720.60850.63270.6587 1100.57660.60180.63070.66140.68490.7102 1200.62460.64890.67670.70640.72880.7531 LPO Rectum kVpfiltration(mm) 2.53.03.54.0 4.55.0 50 0.05170.05710.06290.0689 0.07420.0796 60 0.08950.09810.10730.1169 0.12510.1337 70 0.13060.14180.15400.1666 0.17740.1886 80 0.17580.18920.20380.2190 0.23180.2452 90 0.21950.23420.25030.2672 0.28100.2958 100 0.25980.27500.29190.3095 0.32390.3390 110 0.29630.31160.32850.3466 0.36080.3761 120 0.33070.34410.36050.3787 0.39020.4036 RAO Colon kVpfiltration(mm) 2.53.03.5 4.04.55.0 500.15450.16850.1838 0.19970.21310.2270 600.23050.24940.2701 0.29180.30970.3285 700.30260.32490.3494 0.37530.39620.4185 800.37640.40100.4284 0.45720.48030.5049 900.44420.46960.4982 0.52840.55230.5777 1000.50340.52870.5573 0.58770.61130.6365 1100.55550.58010.6081 0.63780.66060.6851 1200.60130.62470.65160.68030.70200.7255 RAO Rectum kVpfiltration(mm) 2.5 3.03.54.04.5 5.0 50 60 70 0.1017 0.11170.12240.13360.1431 0.1530 0.1603 0.17430.18970.20560.2191 0.2331 0.2184 0.23560.25440.27410.2905 0.3077 800.2789 0.29840.31990.34240.3609 0.3804 900.3352 0.35560.37840.40240.4217 0.4421 1000.3851 0.40560.42880.45310.4725 0.4930 1100.4609 0.47850.48890.49550.5169 0.5344 1200.4663 0.48550.50750.53080.5487 0.5679 D fetus =5 cGy

25. Cardiac Procedures ExaminationsProjectionsField Size (cm)TrimesterskVpFiltration Pacemaker insertion LPO 30 Heart PA Heart RPO Heart 14x14 12.5x12.5 14x14 1 ST, 2 ND, 3 RD 50-1202.5-5.0 PCA/CALAO 40(±15) LAO 40-CAUDAL 30(±10) LAO45-CRANIAL 20(±10) LLAT(±10) PA(±15) PA(±15)-CAUDAL30(±5) PA-CRANIAL 30(±10) RAO20(±10)-CAU20(±5) RAO20(±10)-CRA20(±5) RAO 30 (±5) 12.5X12.5 1 ST, 2 ND, 3 RD 70-1003-5 Al +0-0.3 Cu Interventional Procedures ExaminationsProjections Field Size (cm) TrimesterskVpFiltration Ballons PA Abdomen both PA Abdomen right PA Abdomen left 27.14x21.74 1 ST, 2 ND, 3 RD 80-100 3-5 Al +0-0.3 Cu Vena CavaSubrenal placement Supernal placement Guidance iliac & jug 15x8 6.31x31.54 1 ST, 2 ND, 3 RD 80-100 70-100 3-5 Al +0-0.3 Cu

26. Vena Cava filter placement Pregnant patient at the 2 nd trimester of gestation Examination ParametersCatheteriasm jugular VenographyGuidance jugular Suprenal filter placement Venography Tube potential (kV)708070709080 Focus to skin Distance(cm) 86.78886.785.488 mA3.02.53.54.02.5 Fluoroscopy time(min)23242 Filtration (mmAl)5mm Al Contribution (%)14.918.617.439.89.3 Total DAP (Gy cm 2 )48 How conceptus dose was estimated?  11.412 mGy/(mAs×min) (FSD=100cm, 110kV)  Output =11.412 mGy/(mAs×min) (FSD=100cm, 110kV)

27. Catheterisation jugular FILTRATION3 mm AL 4 mm AL 5 mm AL + + + kVp mm Cu 0.00.10.20.30.00.10.20.30.00.10.20.3 70 0.0035420.0061650.0084160.010376 0.0043160.0068030.0089740.010863 0.0050400.0074210.0095220.011331 80 0.0062310.0101950.0134110.016069 0.0074210.0111350.0141600.016702 0.0085270.0120190.0148930.017315 90 0.0088990.0137370.0173800.020270 0.0103810.0148430.0182850.021043 0.0117680.0158580.0190840.021717 100 0.0113860.0167770.0206920.023711 0.0127580.0179580.0215760.024420 0.0190230.0190280.0223950.025088 Venography FILTRATION3 mm AL 4 mm AL 5mm Al + + + kVp mm Cu 0.00.10.20.30.00.10.20.30.00.10.20.3 80 0.0783170.1186580.1476080.1710830.0911000.1274420.1541080.1746330.1024080.1354580.1601500.179367 90 0.0991750.1441080.1749750.1976830.1136250.1535750.1817580.2032330.1262250.1621330.1877580.207600 100 0.1178170.1646750.1957080.2179670.1331000.1742830.2024080.2214330.1462500.1829080.2084670.227558 Guidance jugular FILTRATION3 mm AL 4 mm AL 5 mm AL + + + kVpmm Cu 0.00.10.20.30.00.10.20.30.00.10.20.3 70 0.0035420.0061650.0084160.010376 0.0043160.0068030.0089740.010863 0.0050400.0074210.0095220.011331 80 0.0062310.0101950.0134110.016069 0.0074210.0111350.0141600.016702 0.0085270.0120190.0148930.017315 90 0.0088990.0137370.0173800.020270 0.0103810.0148430.0182850.021043 0.0117680.0158580.0190840.021717 100 0.0113860.0167770.0206920.023711 0.0127580.0179580.0215760.024420 0.0190230.0190280.0223950.025088 Suprenal placement FILTRATION3 mm AL 4 mm AL 5mm Al + + + kVp mm Cu 0.00.10.20.30.00.10.20.30.00.10.20.3 80 0.0783170.1186580.1476080.1710830.0911000.1274420.1541080.1746330.1024080.1354580.1601500.179367 90 0.0991750.1441080.1749750.1976830.1136250.1535750.1817580.2032330.1262250.1621330.1877580.207600 100 0.1178170.1646750.1957080.2179670.1331000.1742830.2024080.2214330.1462500.1829080.2084670.227558 D fetus = 4 mGy

28. Conceptus Radiogenic Risk Dauer et al, JVIR, 2012, McCollough, Radiographics 2007 Barium Enema 0.49% 0.07% Vena Cava Filter Placement 0.12% 0 0.2 0.4 0.6 0.8 1 020406080100120 Conceptus Dose(mGy) Possibility of childhood cancer %

29. Conclusion  Conceptus doses from extra-abdominal procedures are low. Conceptus risk is negligible compared to the benefit for the mother.  A detailed dose assessment is needed in examinations where conceptus is irradiated primarily.  Each physicist has the tools to estimate conceptus radiation dose and the associated radiogenic risk.