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Risks of Medical Radiation

By Hakan Ilaslan, MD

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Patient Education

Ionizing radiation (see also Radiation Exposure and Contamination) includes

  • High-energy electromagnetic waves (x-rays, gamma rays)

  • Particles (alpha particles, beta particles, neutrons)

Ionizing radiation is emitted by radioactive elements and by equipment such as x-ray and radiation therapy machines.

Most diagnostic tests that use ionizing radiation (eg, x-rays, CT, radionuclide scanning) expose patients to relatively low doses of radiation that are generally considered safe. However, all ionizing radiation is potentially harmful, and there is no threshold below which no harmful effect occurs, so every effort is made to minimize radiation exposure.

There are various ways to measure radiation exposure:

  • The absorbed dose is the amount of radiation absorbed per unit mass. It is expressed in special units of gray (Gy) and milligray (mGy). It was previously expressed as radiation-absorbed dose (rad); 1 mGy = 0.1 rad.

  • The equivalent dose is the absorbed dose multiplied by a radiation weighting factor that adjusts for tissue effects based on the type of radiation delivered (eg, x-rays, gamma rays, electrons). It is expressed in sieverts (Sv) and millisieverts (mSv). It was previously expressed in roentgen equivalents in man (rem; 1 mSv = 0.1 rem). For x-rays, including CT, the radiation weighting factor is 1.

  • The effective dose is a measure of cancer risk; it adjusts the equivalent dose based on the susceptibility of the tissue exposed to radiation (eg, gonads are most susceptible). It is expressed in Sv and mSv. The effective dose is higher in young people.

Medical imaging is only one source of exposure to ionizing radiation (see Table: Typical Radiation Doses*). Another source is environmental background exposure (from cosmic radiation and natural isotopes), which can be significant, particularly at high altitudes; airplane flights result in increased exposure to environmental radiation as follows:

  • From a single coast-to-coast airplane flight: 0.01 to .03 mSv

  • From average yearly background radiation exposure in the US: About 3 mSv

  • From yearly exposure at high altitudes (eg, Denver, Colorado): Possibly > 10 mSv

Typical Radiation Doses*

Imaging Test

Average Effective Radiation Dose (mSv)

X-ray, chest (posteroanterior view)

0.02

X-ray, chest (2 views: posteroanterior and lateral)

0.1

X-ray, lumbar spine series

1.5

X-ray, extremity

0.001–0.01

X-ray, abdomen

0.7

Barium enema

8

Mammogram

0.4

CT, head

2

CT, body (chest, abdomen, or pelvis)

6–8

Coronary angiogram

7

Coronary angiogram with interventions

15

Lung perfusion scan

2.0

PET scan (without whole-body CT)

7

Bone scan

6.3

Hepatobiliary scan

2.1–3.1

Technetium sestimibi heart scan

9.4–12.8

*Doses may vary.

Data from Mettler FA, Huda W, Yoshizumi TT, Mahesh M: Effective doses in radiology and diagnostic nuclear medicine: A catalog. Radiology 248:254-263, 2008.

Radiation may be harmful if the total accumulated dose for a person is high, as when multiple CT scans are done, because CT scans require a higher doses than most other imaging studies.

Radiation exposure is also a concern in certain high-risk situations, as during the following:

  • Pregnancy

  • Infancy

  • Early childhood

  • Young adulthood for women who require mammography

In the US, CT accounts for about 15% of all imaging tests but for up to 70% of total radiation delivered during diagnostic imaging. Multidetector CT scanners, which are the type most commonly used in the US, deliver about 40 to 70% more radiation per scan than do older single detector CT scanners. However, recent advances (eg, automated exposure control, iterative reconstruction algorithms, 3rd-generation CT detectors), are likely to significantly lower radiation doses used for CT scans. The American College of Radiology has initiated programs— Image Gently (for children) and Image Wisely (for adults)—to respond to concerns about the surge in exposure to ionizing radiation used in medical imaging. These programs provide resources and information about minimizing radiation exposure to radiologists, medical physicists, other imaging practitioners, and patients.

Radiation and cancer

Estimated risk of cancer due to radiation exposure in diagnostic imaging has been extrapolated from studies of people exposed to very high radiation doses (eg, survivors of the atomic bomb explosions at Hiroshima and Nagasaki). This analysis suggests a small but real risk of cancer if radiation doses are in the tens of mGy (as used in CT). A CT pulmonary angiogram, routinely done to detect pulmonary embolism, delivers about as much radiation to the breasts as about 10 to 25 two-view mammograms.

Risk is higher in young patients because

  • They live longer, giving cancers more time to develop.

  • More cellular growth (and thus susceptibility to DNA damage) occurs in the young.

For a 1-yr-old who has a CT scan of the abdomen, estimated lifetime risk of developing cancer is increased by 0.18%. If an elderly patient has this test, risk is lower.

Risk also depends on the tissue being irradiated. Lymphoid tissue, bone marrow, blood, and the testes, ovaries, and intestines are considered very radiosensitve; in adults the CNS and musculoskeletal system are relatively radioresistant.

Radiation during pregnancy

Risks of radiation depend on

  • Dose

  • Type of test

  • Area being examined

The fetus may be exposed to much less radiation than the mother; exposure to the fetus is negligible during x-rays of the following:

  • Head

  • Cervical spine

  • Extremities

  • Breasts (mammography) when the uterus is shielded

The extent of uterine exposure depends on gestational age and thus uterine size. The effects of radiation depend on the age of the conceptus (the time from conception).

Recommendations

Diagnostic imaging using ionizing radiation, especially CT, should be done only when clearly required. Alternatives should be considered. For example, in young children, minor head injury can often be diagnosed and treated based on clinical findings, and appendicitis can often be diagnosed by ultrasonography. However, necessary tests should not be withheld, even if the radiation dose is high (eg, as with CT scans), as long as the benefit outweighs the potential risk.

Pearls & Pitfalls

  • During imaging tests that use radiation, shield the uterus in all women of child-bearing age when possible because radiation risks are highest during early (often unrecognized) pregnancy.

Before diagnostic tests are done in women of child-bearing age, pregnancy should be considered, particularly because risks of radiation exposure are highest during early, often unrecognized pregnancy during the 1st trimester. The uterus should be shielded in such women when possible.

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* This is the Professional Version. *