-d

United Nations Scientific Committee
on the Effects of Atomic Radiation

1977 report to the General Assembly, with annexes

NOTE
The report of the Committee without its annexes appears as Official Records of the General
Assembly, Thirty-second Session, Supplement No. 40 (A/32/40).
In the text of each annex, Arabic numbers in parentheses are references listed at the end.
The designations employed and the presentation of material in this publication do not imply theexpression of any opinion whatsoever on the part of the Secretariat of the United Nations concerning
the legal status of any country, territory, city or area, or of its authorities, or concerning thedelimitation of its frontiers or boundaries.

UNITED NATIONS PUBLICATION
Sales No. E.77.IX.1
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Produced by UNIDO, Vienna

--

ANNEXF

Medical irradiation

CONTENTSParagraphs

INTRODUCTION • . . . . . . . . . . • . . . . . . .

1-9

I. BASIC INFORMATION • • . . • . . . . . . .

10-31
10
11-14
15-30
15-17

A.

B.
C.

D.
II.

Method of data presentation . . . . . .
Individual dose per unit procedure .. .
Collective dose per type of procedure
1.
Purpose of assessment . . . • . • .
2.
Limitations in the use of thecollective dose as a measure of
detriment from medical exposures
3. Weighting for relevance . . . • . .
4.
Assessment of collective dose .. .
5. Accuracy of assessments . . . . . .
Groups of potential epidemiologicalinterest . • . . . . . . . . . . . . . . . . .

DIAGNOSTIC USES OF RADIATION
A. X-ray diagnostic radiology . . . . . . . •1. Trends in frequency and technique
2.
Individual dose per unit procedure(a) Accuracy of dose estimatesand reasons for variation .. .
(b) Doses to various organs .. .
(c) Embryo and foetal exposures(d) Comparison of procedures
3.
Collective dose to various organs
from different types of procedures(a) Accuracy of assessment .•.
(b) Collective dose to variousorgans • . • . . . . . . . . . .
{c) Annual genetically significant
dose . . . • . . • . . . • . . .
4.
Groups of epidemiological interest
5.
Potential means of dose reduction

Paragraphs

B.

Diagnostic uses of radiopharmaceuticals
1.
Trendsinfrequencies
andtechniques •.••..••••.•••
2.
Individual dose per unit procedure{a) Administered activity . • . . .
{b) Dose per examination . . . .

117-130
117-122123-130
123-125
126-130

47-51
52-75
76-77
78-80

III. THERAPEUTIC USES OF RADIATION
A. Treatment with e.xternal beams andsealed sources • . . . . . • . • • • . . • .
1.
General . . . . • . • • • . . . . • .
2. Trends in radiotherapy practice3.
Dose data in radiotherapy . . • . .
4.
Information of epidemiologicalinterest . . . . . . . . . . . . . . .
5. Genetically significant dose . . . .
B. Therapeutic
uses of radiopharma·
ceuticals . . . . . . . . • • • • • . . . . . .
1.
lodine-131 therapy for hyperthyroidism and heart disease2.
Jodine-131 therapy for cancer of
the thyroid . . . . . . . . • • . . .
3.
Polycythemia vera patients treatedwith l2p • • • • • • • • • • • • • • •81-10882

IV. WASTE DISPOSAL OF MEDICALLY USEDRADIOPHARMACEUTICALS • . . • . . . •154-156

V. CONCLUSIONS

157-161

18
19-20
21-26
27-30
31
32-12632-116
32-46
47-80

83-92
93-108109-110111-116

IntroductionI.
The Committee has previously presented data on
the medical irradiation of patients in its reports of 1958
(242), 1962 (243) and 1972 (244). Medical exposures131-153
131-145131-132
133-135
136-137
138-142
143-145
146-153
147-148
149-150
151-153

Page

References . . . . . . . . . . . . . . . . . . . . • . .

349

are of particular interest since they contribute thehighest man-made per caput doses in the population, aregiven with high instantaneous dose rates and cause thehighest individual organ doses short of accidental
exposures. From the radiation protection point of view,301they also offer the largest scope for implementing
methods of dose reduction without loss of theinformation required. They differ from many othertypes of exposure in that they usually involve irradiationof limited regions of the body. They also differ in thatthe individuals who are irradiated are those who may
expect to benefit directly from the particular treatment
or examination.
2.
A particularly difficult problem, however, arises
when risk of medical irradiation is compared with therisk from other sources of man-made exposure or fromnatural background radiation. The organ doses received
in diagnostic radiology may range over four orders ofmagnitude (from a few millirads to a few tens of rads)
and will usually be given at high dose rates, comparedwith other man-made and natural sources. The various
effects of radiation depend in a complex manner on thedose, the part of the body exposed, the dose rate andthe length of time during which the total dose wasreceived (described in Annexes H, I and J). Therefore,
the detailed estimation of the risk from medical
exposure is very complex; however, it is possible, by
making simple assumptions about the relationshipbetween dose and effect (as has been described in
Annex A), to use the product of the number of persons
in a subgroup and the dose received by a particular organ
as a measure of the relative radiation detriment. The
Committee has used this concept of collective dose forthe estimation of the relative risk in diagnostic
radiology.
3.
However. since in radiotherapeutic practice, ascompared with diagnostic practice, considerably higher
doses are given to smaller groups of patients, and since
the dose-effect relationship is likely to be different, theCommittee has followed the practice of quoting, forradiotherapy the average organ dose together with thenumber of patients in the treated group. In this way it ishoped that there will be a clear indication that there
may well be differences between the relative risk
estimates from a given collective dose from diagnostic
radiology and those from an equivalent numerical
product for a radiotherapeutic practice. For this reason,
it is important that the risks from the two practices
should not be compounded or summed.
4.
A vast amount of information on medical
exposures was summarized in the 1958, 1962 and 1972
reports. Nevertheless, since the variation in practice andperformance is large, not only from one country toanother, but also between different hospitals anddifferent radiologists, it is difficult to give a comprehen·sive presentation of the situation. Some of thesevariations arise from the differing needs of the individual
patients. e.g., in the extent or duration of a particularexamination; other variations occur because of the typeof equipment available and the standard of theperformance. The Committee has found no reason tocompile data merely for recording purposes. but has
tried to present information which might be useful forrisk assessment, trend consideration and radiationprotection evaluation.
5.
In the previous reports special emphasis was put
on assessments of the annual genetically significant dose(GSD). The presentation of such data has encouraged
302

further studies, so that it is now relatively clear to what
extent medical exposures contribute to the total genetic
dose in both developing and developed countries. In thedeveloping countries the level of the GSD will usuallyreflect the availability of x-ray facilities. In order tomeet the medical need, such services may need to be
expanded. This is likely to increase the genetic dose inthese countries in spite of any recommendations forgood practice that are aimed at decreasing GSD.
6.
The emphasis on the GSD may have detracted
attention from exposure of organs other than the gonads
and may therefore have led to an under-estimation of
the overall risk from certain types of examination thatusually cause very low gonad doses. One-example is thechest examination, which involves irradiation of such
radiosensitive tissues as lung, breast, marrow andsometimes also thyroid. The 1972 report, accordingly,
gave more information on the dose in the active marrow.
A number of groups of patients were also reported who
had been identified as receiving high doses, and somehad been shown to have a higher incidence of certain
diseases than comparable but non-irradiated groups. In
this report, further attention is given to identifying
examinations in which particular organs may receive
high doses. An attempt is also made to give a fuller
picture of the patient's dose distribution, including dataon doses in radiosensitive tissues such as bone marrow.
thyroid, lung and breast.
7.
In presenting data on dose levels in medical
procedures, the Committee has three different purposesin mind. Firstly, it is of interest to know, for individuals,
the doses to. particular organs from the various types of
medical irradiation and, particularly, the extent of thevariation of such doses for any one type of investigation,
as a basis for any attempt to weigh the radiation risks
against the expectation of benefit to the individual
patient and for differential cost-benefit analyses ofprotective measures (100). Secondly, it may be ofinterest to know both the individual and the collective
organ doses from various medical practices as part of thepresentation of man's total radiation exposure. Thirdly,
the identification of some highly exposed groups may beof interest in epidemiological studies; for this purpose,the collective dose would be of interest.

8.
As has been stated in paragraph 1, medical
exposure is unique in the sense that the benefit is usuallylimited to the individuals who are irradiated. Assessments of individual doses in relation to the expected
benefit are therefore usually sufficient for justificationand optimization purposes. Only in special cases, e.g.,
public health examinations (267). or medico-legal
examinations, is there an expected benefit to society inaddition to that measured by the benefit to theindividual. In such cases there may also be a need toassess the collective dose from a given practice as awhole.
9.
The information sought for any individual is thedose to those particular organs which are considered to
be at risk (see Annex G). Only then would it be possible
to make a complete assessment of the radiation risk
from that irradiation. Such complete information has
only rarely been presented, principally for a few

therapeutic procedures, e.g. a survey of the radiation
treatment of ankylosing spondylitis (see Annex G).
However, the general awareness of the problem has
resulted in further studies.

I. BASIC INFORMATION
A. METHOD OF DATA PRESENTATION
10. Medical irradiation comprises irradiation for both
diagnostic and therapeutic purposes, and these will betreated separately in chapters II and III of this Annex. In
each chapter, individual dose per unit procedure and thecollective dose to various organs from different
diagnostic procedures will be reported and discussed inseparate sections. The individual dose will be influenced
by the differences in techniques. In addition, thecontributions to the collective dose will be proportional
to the number of individual irradiations at a given doselevel.

14. The difficulties in assessing the true organ doses
will introduce systematic errors but will also to someextent increase the apparent spread of doses in each typeof irradiation. For example, the gonad dose will varydependent on the position of the stomach during
radiological investigations of the gastro-intestinal tract(127). The doses actually received by individual patients,
however, will also differ. depending upon the clinicalrequirements, the standards of the equipment and theskill of the operators. It has been claimed that spread ofindividual organ doses in each type of examination withx rays may fit a log-normal distribution (120). However,it has also been shown that. with some limitations
measured doses in x-ray examinations will fit a normal
distribution (17). This will be discussed in more detail inchapter II. It seems reasonable to assume, however, that
there is no a priori reason to expect a log-normal
distribution of patient doses. Since each type of medical
irradiation has a special objective (e.g., to destroy atumour or produce an x-ray image) and is subject tooptimization, it could rather be expected that theresulting doses would follow a normal distribution
around the optimum value. Even this assumption,
however, is usually an over-simplification.

B. INDNIDUAL DOSE PER UNIT PROCEDURE
11. The determination of the dose to a particularorgan for a given examination, investigation or treatment
may be direct: a dosimeter can be placed at
representative sites in the organ of interest. Morefrequently, however, the method of dose determination
has to be indirect: the organ may be inaccessible andmeasurements must be made elsewhere; calculations orfurther measurements are needed to determine the organ
dose.
12. Measurements are normally made on the skinsurface, although for the estimation of ovary dose
measurements have been made in the vagina and rectum.
The skin measurements combined with measurements on
man-like phantoms have been used to estimate the doseto the bone marrow. The detenrtination of the radiation
doses to other organs has principally been undertaken byMonte Carlo methods (171) or by using skinmeasurements in conjunction with phantom measurements, percentage-depth dose data or isodose curves(239). For organs outside the main beam, scatterfunction curves are used (47, 86, Ill, 137, 222).
Alternatively, in the case of the administration ofradiopharmaceuticals. calculations based on the distribution of the radiopharmaceuticals and on the physicalproperties of the nuclides need to be undertaken (140).
Monte Carlo type calculations have also been made tofacilitate such estimates (212). Considerable errors may
arise in the determination of dose, but in general the
direct method of measurement is expected to be subject
to the least error.
13. Studies involving measurements on man-like
phantoms require that such phantoms be sufficiently
like Reference Man or normal patients in relevantcharacteristics to keep errors within reasonable limits(147). Reports such as that of the ICRP on Reference
Man (101) enable anthropometric considerations as well
as physiological variations to be taken into account in
the choice of models or design of phantoms.

C. COLLECTNE DOSE PER TYPE OF PROCEDURE
1. Purpose of assessment
15. Ideally. the detriment from a unit procedure (e.g.,a treatment course or a particular type of diagnostic
examination) should be assessed by the weighted sum of
all significant organ and tissue doses, but in practice thenecessary weighting factors are not known. Lacking thisinformation, it is still of interest to know the variousorgan doses, e.g., for relative risk assessments andoptimization evaluations on the basis of various assumed
risk factors.
16. As indicated in paragraphs 7 and 8, there is usuallyno need to assess· collective doses from various medical
practices for the purpose of justification and optimization considerations; instead, the individual doses may be
used for the same purpose, because the risks and benefits
relate to the same individuals. However, certain
protection measures are of an administrative nature andmay involve considerations of a practice as a whole. For
example, in planning education and information, it may
be of value to know where efforts might yield the best
results. The doses to patients in dental examinations
requiring two or three pictures are in general low andwould not justify much attention in the individual case,but because of the very large number of examinations
improved education might result in a larger reduction in
the collective dose with higher individual doses but
fewer individuals exposed. For this reason, national
authorities may wish to have information not only onhigh individual doses but also on practices causing highcollective doses. Also, the total collective dose from all
medical practices would be of interest in the assessmentof man's overall radiation exposure.
17. There is also an obvious interest in knowing thecollective dose to various organs in those irradiatedpopulation groups which could be subject to epidemiological studies. The requirements are discussed inparagraph 31.
303

2. Limitations in the use of the collective dose as ameasure of detriment from medical exposures
18. It has been shown in Annex A that for a given
radiation the collective dose may be used as a relative
measure of detriment if doses are so low that effects areproportional to dose and independent of dose rate.
Doses are considered in this report to be sufficiently
small in most diagnostic examinations so that thecollective dose concept is applicable, and the relatively
high dose rates utilized in these examinations are of little
significance as far as the validity of the collective doseconcept is concerned. However, this concept should not
be extended to the case of therapeutic exposures where
there is a risk of acute effects and where cell killing may
reduce the risk of late- deleterious effects. A further
limitation arises from the fact that for some late effectsof radiation it is not yet known which particular cell or
tissue is at risk and therefore what tissue dose should be
calculated.

23. In practice it is not often possible to ascertain thedose Dp,x,i for each individual in the total number ofpatients involved Nx. As data can usually be obtained
only for a sample nx of individuals within the relevant
patient population, some simplifying approximations tothe summation over all individuals have to be made. If
sampling is unbiased and can be considered representative, then the collective dose to the organ p fromprocedure x can be estimated by

Sp,x = (Nx/nx/ Sp,x,nx
where SP • x • n X is the collective dose in the sample.

(3)

24. A further approximation is required when
information about doses delivered by a given procedureis only available for a different group of patients who
have undergone a similar procedure but do not form partof the patient population under study. The collective
dose can be estimated by(4)

3. Weighting for relevance

where Dl,x is the average individual dose in the outsidegroup for which information is available.

19. Neither collective doses nor per caput doses willreflect the detriment in a population if a substantial
fraction of the per caput dose is contributed by the
exposure of individuals who, for biological reasons, are
not at risk. This would be the case with regard to genetic
risks and carcinogenic effects when doses are received byindividuals who would not be expected to be able to
make the possible biological effect manifest because
they are not expected to have children or to live longenough.

25. The approximation given by equation 4 isobviously not as reliable as that of equation 3, because
there may be unspecified factors in the outside groupthat may be different in the patient population understudy. This approximation would be used, for example,
when the relevant average dose is available in one
country and an estimate of the collective dose isrequired for a patient population in another country
where no direct information on the individual doses isavailable.

20. In such cases weighting procedures are called for.
Weighting for the individual's child expectancy is part ofthe calculation of the GSD. A weighting for life
expectancy could properly be an element in thederivation of a weighted per caput dose for the
production of a particular somatic effect if sufficient
data were available (see paragraph 86).

26. An alternative way of presenting info_!lllation on
population exposures is the per caput dose Dp.x, which
is simply the collective dose divided by the total
population size N:(5)

5. Accuracy of assessments
4. Assessment of collective dose
21. As was shown in Annex A, the radiation detrimentfrom a given source k can be assessed, at least on arelative basis, by means of collective dose Sk (measured
in man rad), which can be derived from the weighted
product of the individual dose and the number ofindividuals:(I)
sk = ioDNv(D)dD
where Nv(D)dD is the number of individuals receiving adose in a specified organ or tissue in the range
D to D + dD. The collective dose can apply to the world
population, to a subpopulation or to one person. The
defined group may comprise individuals who live at
different times or individuals living in a given year,
depending upon the purpose of the assessment.
22. In the context of medical irradiation, thecollective dose to a certain organ, p, in the patients
receiving a given type of examination or treatment, x,
can be formulated as

Sp,x = K "f,;Dp,x,i(2)where K = I man since each group i is composed of one
person.

304

27. The accuracy of any estimate of collective dose
obviously depends on the accuracy of the determinationof the two main factors, i.e., the individual dose and thenumber of irradiated individuals. The accuracy would
depend on which of the above equations is used for the
calculations.
28. In the case of studies which use equation 3, i.e.,
when measurement data are obtained from only asample of the patient population, it is important thatsuch a sample group should be large enough (37). In
practice it has been found that, to obtain a reliable
distribution of the doses received in a particular medical
practice, it is necessary to have at least 200-300
measurements (23). Obviously, it is also essential thatthe individuals in the sample should be selected so as tobe representative of the patient population being
studied.
29. In some collective dose surveys, the number of
exposed individuals will be obvious, e.g., wheninvestigating a group of individuals who have all had aparticular investigation or treatment during a definedtime at a limited number of centres, such as theradium-224 patients surveyed in reference 215. However, more generally, for an estimate of the collective
dose to individuals who undergo x-ray examinations incurrent practice, e.g., in the .examination of the stomach
in Japan, it is necessary to obtain data on the frequencyof these examinations in the country concerned. Thisrequires a sample to be taken over a period of time froma selected sample of the hospitals in the country. Suchfrequency surveys have fanned part of most of thestudies undertaken for the estimation of the GSD, andsamples of frequency data have usually covered about
1-4 per cent of the year's radiological examinations.
Some surveys have shown that fluctuations in thefrequency of particular examinations throughout theyear also need to be taken into account (36).

II. DIAGNOSTIC USES OF RADIATION
A. X-RAY DIAGNOSTIC RADIOLOGY
1. Trends in frequency and technique

32. In most countries the distribution of x-ray
apparatus is non-uniform and the number of installedmachines increases with population density. A study ofthis in Japan (115) showed a good correlation between
population and number of units. The study also showedthat in some areas non-trained or unlicensed staff wereused to take up to 60 per cent of the radiographs madein practitioners' offices.

30. In the determination of the collective dose, theleast error is involved if the organ doses for all theirradiated individuals are known. In this case the overall
error is in the determination of the doses to theparticular organ concerned. When direct measurementsof the skin dose or the male gonad dose are being madeduring x-ray examinations, modern techniques should
enable the measurement errors to be of the order of
5 per cent. In other cases the' errors hi the measurement
or estimation of the organ dose may be considerably
greater. The bigger the contribution from a particular
practice to the total collective dose. the more effort
should be applied to improve the pr~cision of the dose
determination. In those surveys in which only a sampleof the individuals are measured, there will be, in addition
to the measurement error, sampling errors for both themeasurement sample selection and the frequency sample
used.

33. In the 1972 report of the Committee, the overall
rate of increase in the number of radiologicalexaminations reported for the 1960s by a number ofcountries with technically advanced medical services wasreported to be between 2 and 6 per cent per year. Whencorrected for the increased population the growth wasestimated to be about 3 per cent per year. However amore recent report from the Netherlands (175) for thesam~ period has shown an annual growth rate of 8 .5 percent. Reports quoted by Puijlaert (176) indicate that fora number of countries the annual growth rate per caput
for the late 1960s and early 1970s was between 5 and
15 per cent.

D. GROUPS OF POTENTIALEPIDEMIOLOGICAL INTERESTTABLE 2. CHANGES IN DATA PERTAINING TO DIAGNOSTIC X-RAY PROCEDURES IN A SIX-YEAR
PERIOD
United States of America, 1964 and 1970

31. When a group is being studied to determine theincidence of a deleterious effect caused by radiation, it isessential that an estimate be made of the incidence in acontrol group. The appropriate size of an exposed
population for this.purpose has been studied recently by
Goss (65). Table 1 gives the size of collective doseneeded to have a 95% chance of detecting an increased
risk at the 5% level of significance. It is obvious that at
low doses very large groups of patients are required, but
at therapeutic dose levels it is possible to observe therequired number of patients with relative ease.
TABLE 1. SIZE OF COLLECTIVE DOSE NEEDED TO GIV'E
A 95% PROBABILITY OF DETECTING AN IN·
CREASED RISKAge group andinvestigated risk

Collectivedose(10 3 man rad)Observation
period

310
700
310

10
10
10

100
420a

20
20
20
20

Children
Leukaemia
Thyroid cancer (incidence)
Other cancers
Adults
Leukaemia
Breast cancer (females)
Lung cancer
Other cancers

4 OOO
12 OOO

Source: Reference 65.
a Corrected by the Committee.

(y)34. Further analysis of surveys made in the UnitedStates of America in 1964 and 1970 (27, 250, 251)
indicates a number of interesting trends in frequency,
technique and dose (table 2). As can be seen from thetable, the trend pattern is rather complex.

1964

Number of persons
having x-ray
108 106
examinations
Number of x-ray
procedures
173 10 6
506 10•
Number of films exposed
Average number of films
per examination
2.2
Fraction of thoracic
examinations with two
or more films
31 %Mean ratio of beam area
to film area
(in hospitals)
1.9
Estimated mean skin
exposures forposterior-anterior andanterior-posterior viewsof the abdomen
480mR
Mean skin exposure
per dental film
1140 mR

1970

Increasea(percent)

130 1Q6+ 20

212 10•661 10•

+ 22
+ 30

2.4

+ 9

47%

+ 52

1.2

-37

620 mR+ 29b

910 mR-2oc

Sources: References 27, 250, 251.
The population of the United States increased by 7 percent over the six.year period.
bThis'mcrease may be due to the increased frequency ofhigh-exposure examinations, the increase in the use of grids, andthe use of higher tube potentials and currents without acorresponding increase in filtration.
cThis decrease is due to the increased use of faster film.
0305

TABLE 3. ESTIMATED ANNUAL NUMBER AND DISTRIBUTION OF MEDICAL X-RAY PROCEDURESBY TYPE OF FACILITY AND SUPERVISION
United States, 1964 and 1970
Number of medical
x-ray procedures(thousands)

Per cent ofprocedures
supervised byradiologists

Number ofprocedures supervisedby radiologists(thousa11ds)

Per cent of medical
x-ray procedures

1964

1970

1964

1970

1964

1970

1964

1970

118 919144 355

100,0

100.0

72 346100 530

60.8

69.6

Hospital

68 49057.6

64.l

63 08091 356

92.1

98.8

Private officeRadiologist
Other

24 1955 335
18 86092 48927 136
4 223
22 913

20.3
4.5
15.8

18.8
2.9
15.9

5 335

4 223

100.0

100.0

Private group

7 861

9 903

6.6

6.9

3 931

4 951

50.0

50.0

14 826

15.5

10.3

Type of facility

All types

Health agencies and others

18 374

Note: Table reproduced from reference 2 S 1.

35. The estimated number and distribution ofdiagnostic x-ray procedures in the United States in 1964
and in 1970 (251 ), by type of facility and supervision,
are shown in table 3. There was a 6.5 per cent increase in
the use of hospital radiological facilities. and an increase
from 92.l per cent to 98.8 per cent in the proportion offilms taken in hospitals under the supervision ofradiologists.
36. An analysis of the trend in the number of medical
x-ray visits by age group for the years 1960, 1964 and1970 is shown in table 4 (250). The major increases
occurred in the age groups <IS, ~5 and, particularly,>65 years. According to this information, the fractional
number of patients under 30 decreased from 223 percent in 1960 to 20.5 per cent in 1970.

TABLE 4. ANAL YSlS OF THE INCREASING FREQUENCYOF MEDICAL X·RA Y VISITS BY AGE AND SEX
United States, 1960-1970(Visits per 100 persons per year)
July 1960June 1961

Apn1.June

AprilSeptember

1964

1970

15-29
30-44
;>45
45-64
;;,, 65

16.4
57.1
63.0
66.5
71.2
55.4

20.9
55.2
61.1
69.8
73.6
61.5

24.4
55.4
65.9
81.5
82.3
79.9

Sex
Male
Female

49.7
46.2

50.6
49.0

56.6
55.3

47.9

49.8

55.9

CategoryAge (y)< 15Overall

37. The United States surveys (255) showed nosignificant change in the annual GSD between 1964 and1970, in spite of the increased number of examinations
and the indication of higher abdominal doses. (Seeparagraph 107 .) An analysis of the increase in frequency
of abdomen and thoracic examinations shows, however,Source: Reference 2 SO.

that these examinations increased principally in the agegroups above 30, which might be one explanation forthe lack of significant change in GSD. Additional patient
protection was used in 10 per cent and 8.5 per cent of
TABLE 6. NUMBER OF X-RAY EXAMINATIONS IN MASS
Breakdown,10• J

Sex

Age ('Y)(a) Mass chest

Male
FemaleTotal.;;.10

11-15

16-18

19-24

25-29

30-34

35.39

655
622

634
606

2 278
2 296

3 340
2 201

2 426
1 849

2 053
1565

1 830
1432

1 277

1 240

4 574

5 541

4 275

3 618

3 262

(b)

Mass stomach

Male
Female
Total

<; 19

20-24

25,29

30-34

35.39

4.7
2.3

22.2
11.1

70.9
30.1

136.1
94.9

310.1
216.5

7.0

33.3

101.0

231.0

526.6
(c)

Male and female

6-10

11-14

15-19

2()..24

25-29

30-34

35.39

1 261

2 495

2 595

5 061

9 731

11 36011 51012 762

Sources: Chest screening, reference 84; stomach screening, 83; dental radiography, 138.

306

Dental0-5

-TABLE 5. ANALYSIS OF THE INCREASING FREQUENCYOF DIAGNOSTIC X·RAY EXAMINATIONS BY TYPE
Japan, 1958-1975
Number of examinations
per 1 OOO persons

Type of examination

Ratio

a. Radiography
1959
(A)

1969
(B)

1974
(C)

8.8
Head, cervical spine
22
Shoulder
144
Chest
19.4
Barium meal
1.5
Abdomen
5.9
Barium enema
3.3
Dorsal spine
7.1
Lumbar or sacral spine
5.1
Urography, cystography
8.5
Hip and joint
15.8
Lower leg
Tomography
Pelvimetry, obstetrical
1.6(abdomen)
13.9
Other

58
33
277
86
14
6.2
7.0
37
7.7
14
44
5.0

60
48
289

2.8
54
641

259

Total

B/A

C/B

6.6
1.5
1.92
4.4
9.3
1.05
2.1
5.2
1.51
1.65
2.8

1.03
1.45
1.02

1.9
63

1.75
3.9

0.68
1.16

729

2.5

1.14

108
23
6.5
5.0
41
9.6
19
56
7.3

1.25

1.64
1.04
0.71
1.11
1.24

1.35
1.27
1.46

b. Dental radiography

Dental x-ray
examinations

1958
(AJ

1974
(CJ

C/A

13

833

64

c. Photofluorography

Chest
Barium meal

1963
(AJ

1968
(BJ

1973 1975
(CJ
(DJ

434

641
18

486
31

313
40

B/A

C/B

D/B

1.47

0.76
1.72

0.49
2.22

Sources: References 74, 79,146,181.

the diagnostic x-ray examinations in 1964 and 1970,
respectively, whereas in dental radiography the use ofadditional patient protection increased from 18.8 percent to 27 .2 per cent (251 ).

38. A survey by Bederke et al (202) in 1974 in the
Kopenick ward of Berlin (GDR) of out-patient radio·
logical examinations showed that. of the 29 OOO patients
examined, 30 per cent were under 30 years of age. On
the average, the patients had 2.5 exposures per
examination; in the case of barium meals and enemas,
the average was 5.0. Fluoroscopy was used in 17 percent of the examinations, and 49 per cent of the patients
had radiographs of the abdomen or pelvis with relatively
high gonad doses. The total number of examinations per
year was 40 OOO for out-patients and about the same
number for in-patients. With a total population of
131 OOO, that would indicate an examination rate of
67 per 100 persons per year.
39. In Ja pan, nation-wide radiological surveys weremade in 1959, 1969 and 1974 (74, 78, 80, 81, 181). The
frequency data from these surveys are summarized intable 5. There was a considerable increase in the numberof x-ray examinations between 1959 and 1969; theincreases according to type were by factors that ranged
from 1.05 to 9 .3. with an overall factor of 2.5. However,during the five years 1969-1974, the rate of increase wasmuch reduced for many of the examination types, andthe overall rate of increase in the number of
examinations was assessed at about 3 per cent per year.
The most important increases from the collective dose
aspect are those for barium-meal examinations and for
abdomen, lumbar spine and sacral spine examinations.
There was also a very significant rise in the number ofdental x-ray examinations (see paragraph 44).
40. Table 6 gives the frequency of mass chest andstomach screening and dental radiography by age groupin Japan. The mass chest screening during school age iscarried out only at the time of admission into theprimary school (age 5-6) and at the second class of thejunior high school (age 13-14). The largest numbers areradiographed in the 19-24 y group for chest examinations and in the 40-44 and 4549 y groups for thestomach examinations.

SCREENING AND DENTAL RADIOGRAPHY IN JAPAN, 1974 AND 1975
by age ana sex
Total
screening, 1975
40-44

45-49

50-54

55.59

;;. 60

1 762
1407

1 559
1 273

1109
1 094

469
345

537
438

18 65215 128

3 169

2 832

2 203

814

975

33 780screening, 1975
40-44

45-49

50-54

55.59

60-69

;;. 70

492.6
331.3

496.8
331.3

369.2
279.1

224.0
193.2

205.6
207.5

51.8
39.7

2 384

823.9

828.1

648.3

417.2

413.1

91.5

4 121

1 737

radiography, 1974
40-49

50-59

16 66810 055..

;;. 606 423

89 921307

41. A comparison between the 1974 Swedish survey
by Bengtsson et al (17) and·the 1955 survey by Larsson(128) shows that x-ray examinations (excluding dental)
increased by 51 per cent between ·1955 and 1974.
During this period the Swedish population increased by
11 per cent, which means that the net increase was
36 per cent, or less than 2 per cent per year. The
disappearance of tuberculosis as a significant problem isreflected in decreased frequencies of mass photofluoroscopy, but this trend may not be representative ofother countries. There is a remarkable increase in thenumber of dental exposures, almost by a factor of five.
The frequency data are summarized in table 7.
TABLE 7. ANALYSIS OF THE INCREASING FREQUENCYOF DIAGNOSTIC X-RAY EXAMINATIONS BY TYPE

Sweden, 1955 and 1974
Number of
examinations per1000 persona
Type ofexamination

Ratio
1955
1974
1974/1955(Population (Population (Population
66
8.1 10 )ratio 1.11)
7.3 10 )Hip and femur
9.6
Pelvis8.2
Pelvimetry
0.5
Lumbosacral region
16.1
Urography, retrograde
pyelography
9.1
Urethrocystography
1.2
Stomach, small intestine
30.0
Colon
9.0
Abdomen
5.0
Obstetrical abdomen
0.6
Hysterosalpingography
1.2
Cholecystography,
cholangiography
12.0
Dorsal spine
5.8
Lung, ribs, heart
79.4
Lung (photofluorography) 139
DenW (single exposures) 307
Other
103
Total (excluding
denW)

430

25.0

2.0
1.9
2.6
1.6

23.9
2.7
33.0
16.0
12.9
1.4
0.8

2.6
2.3
1.1
1.8
2.6
2.3
0.7

18.4
13.3
161.6
110
1500
195

1.5
2.3
2.0
0.8
4.9
1.9

650

1.51

18.9
15.4
1.3

Sources: References I 7, 12 8.

42. An interesting study reported by Berry and Oliver(20) shows that in the United Kingdom of Great Britain
and Northern Ireland, 18 per cent of the x-rayedpatients had spoilt films, principally because of exposure
or positioning faults.
43. The annual number of dental exposures per 1000of population in Sweden increased from about 300 in
1955 to 570 in 1969 (151), i.e., by about 6 per cent per
year. The subsequent increase to 1500 in 1974 (table 7)
corresponds to about 20 per cent per year over that last
five-year period. Of the 13 million dental films exposed
in Sweden in 1974, about 3 million were exposed inbite-wing examinations of school children. Of theremaining 10 million films, about 50 per cent have been
estimated to have been used in bite-wing examinations.
The increasing number of bite-wing examinations ispartly explained by deliberate efforts to makefull-mouth examinations irrespective of whether thedentist knows beforehand that the film will be needed.
308

This practice is defended on the basis of claimed earlier
detection of small cavities. Such dental examinations are
therefore health investigations rather than diagnostic
examinations. The yield has been estimated to be about
10 per cent in those examinations for which there wereno clinical indications, but this number is uncertain. No
estimate has been made on how many of the bite-wing
exposures were made without clinical indication.
44. Similar observations have been made in othercountries. For example, in the 1970 United Statessurvey (251) it was reported that there were an
estimated 68 million dental x-ray visits, corresponding to
an average of 340 x-ray examinations per 1OOO of
population. As each examination consisted of, on the
average, 4.1 films, the to.ta! numbef was approximately
1400 films per 1000 of population, in line with thepractice in Sweden. The annual number of dental
exposures per 1000 of the population in Japan increased
from 13 in 1958 to 855 in 1974 (146). The age
distribution of the population in Japan having dental
examinations during 1974 is given in table 6. The study(138) also includes information on the numbers in eachage group for the different types of intra-oral
examination.
45. In contrast, it has been estimated that 4 million
x-ray films were used in the United Kingdom in 1973(52), an average of only 73 per 1000 of population. This
compares with an estimated 2 million films used in
1957.
46. Interesting sociological variations in the UnitedStates in the frequency of x-ray visits for dental
examinations are shown by the fact that the rate of
x-ray visits per 100 of population were 11.2, 29.2 and50.3 for those people having under 9, 9-12 and 13 ormore years of education, respectively (250). This finding
agrees with the findings of the 1964 survey for dental
examinations, but not with those shown by the analysisof x-ray visits for medical examinations.

2. Individual dose per unit procedure(a) Accuracy of dose estimatesand reasons for variation
47. Previous reports of the Committee have shownthat individual organ doses in each type of examinationvary considerably from one clinic or individual radiologist to another. Some of this variation arises fromdifferences in the actual extent and needs of theexamination itself and some from differences in theselection of field sizes and localization of the beam.
However, there is also a large variation in the skin
exposures, both because of differences in the technicaloperation of the equipment (89), including the use ofgrids, and in the dimensions of the patients.
Additionally, the sensitivity of the recording medium
influences the results.
48. The use of equipment that measures the productof the exposure and area at the beam collimator issometimes used as an indication of the total energy
emerging from the x-ray tube towards the patient. Theseper cent

99.9

99

z

0

;:: 90
:,

."'"'
ii:

0

> 50
;::
<(

.J

:,
::;;

JO

<J

20

:,

10

5

0.1

10

100

10000

1 OOO

100000 mr•d

GONADAL DOSE(a)Intravenous pyelography;D = 1300 mrad; s = 2600 mrad; median= 370 mrad; 102 patients

99.9

99

I

z

'

0

;:: 90

:,

."'"'
ii:

0
w
>
;::

I

I

.....

50

<(

.J

:,
~

:,
<J

,'

I

JO
20
10

I

I

I

I

I
I

0.1

10

100

10000

1 OOO

100000 mrad

GONADAL DOSE(b)
Lumbosacral region examination; 15 = 1048 mrad; s = 855 mrad; median= 1079 mrad; 93 patients.
This examination type forms the unique exception to the log-normal distnoutions found in all othertypes (120)
Figure I. Cumulative distribution of male gonadal doses from intravenous pyelography and lumbosacral
region examinations; D = mean dose; s = standard deviation

instruments are useful as comparative instruments
between one operator and another, but do not give atrue value of skin exposure. When the beam size is large
and misses the patient, the recorded value obviously
shows a larger variation than the skin exposure. A
United States study (the NEXT program) has shownsuch a variation for lumbar spine and chest examinations(30,., 31 ). A correction also has to be applied for theenergy transmitted completely through the patient. A
comparison undertaken for the British Committee onRadiological Units showed that there was poor
agreement between exposure-area product and bone-marrow dose ( 48). Stieve (226) reports that the error inestimating dose using the exposure-area product may be
200 per cent.
49. The spread of individual doses in any given type of
x-ray examination may be quite large even within one
and the same hospital. The distribution is usuallyskewed, with a preponderance of doses lower than themean. It has been suggested by Koen and Weber (120)that the distribution is sometimes log-normal, and they
have illustrated this with distribution diagrams for the
male gonadal dose (fig. I). For some examinations, e.g.,309

of the lumbosacral region in male patients, the gonadal
dose will increase by an order of magnitude when the
direct beam falls on the gonads. This will be equivalent
to two distinct groups of patients and hence will, when
the data are plotted on probability paper, provide two
distinctive but overlapping populations. Subsequently,
more detailed information from the same survey ( 121)

showed that various distributions were obtained when all
the doses for a particular examination from all the
hospitals surveyed were included.
50. Bengtsson et al (17) have analyzed the skewed
distribution in further detail. Figure II gives an exampleof the distribution of mean whole body absorbed dose in

per cent

99

0

. 0

0

0

0

90

>u
z

70

:::>
0
w
a:
u.
w

50

w

>
i=
~

:::>

~

:::>

u

30

10

0

10

20

30

40

50

60

70

80

90

100 mradMEAN WHOLE BODY DOSE

Figure II. Distribution of mean whole body dose from chest examinations at one Swedish hospital. The deviation from normal
distribution results mainly from the taking of an additional film (17)chest examinations at one Swedish hospital. The figure
shows a significant deviation from the normal
distribution at high patient doses. A closer review
revealed that with some patients three exposures wererequired whereas with most patients two were sufficient.
If the three-exposure cases were excluded, a good fit to anormal distribution was obtained. This illustrates (as inparagraph 49) that basically there may be a normal
distribution when the number of parameters is limited,
310

but· as further parameters are introduced, the distribution may become quite complex.
51. In this Swedish study, neither chest nor stomach
examinations fitted a log-normal distribution. The mean
whole body dose in stomach examinations was found tofollow closely a normal distribution whereas the
distribution of the energy imparted to the whole body
showed some deviation from a normal distribution.

-(b) Doses to various organs(i)52. There is an increasing number of publications on
measurements carried out during radiological pro·cedures. Even though they may reflect particularconditions in the clinics and hospitals concerned, they
are nevertheless useful in illustrating the levels ofradiation dose to patients. Typical publications onpatient dose are referred to in each of the following
sections and in references 7, 58, 71, 116, 207 and 234.
A number of reports referring to technical advances arereferred to, such as those on the improved sensitivity ofimage recording (10, 11, 12, 55, 196). It is particularly
useful if patient studies are directed at measuring thetotal absorbed dose ·to each of the organs of interest thatis accumulated from all radiological studies during aparticular patient's period of ill health. Examples of thisare given by Trott et al (238).

Incident skin dose

53. As has been described in paragraph 12, thedose to organs in the primary x-ray beam may bederived inter alia from knowledge of the incident
skin dose. A summary of typical skin doses forthree broad groups of examinations giving rise tohigh, medium and low skin doses was given in the1972 report (244) and is reproduced here as table 8
except for the entry for mammography examinations, for which new techniques requiring lower
doses are now available (see paragraph 71). New
data on skin exposure in diagnostic procedures wereobtained during the 1970 United States survey forradiographic examinations (251) and also by studies
in the Federal Republic of Germany (25). The
doses are in general similar to those shown intable 8.

TABLE 8. TYPICAL SKIN DOSE IN THE PRIMARY BEAM
IN DIAGNOSTIC X-RAY EXAMINATIONS(rad)
Per exposure

Dose group
High skin dose
Barium swallow R
Barium swallow F
Barium mealR
Barium mealF
Barium enema R
Barium enema F
Whole chest
R
Whole chest
F
Mammography
Pelvimetry
Lumbosacral spine
Lumbar spine
Cardiac catheterization
Medium skin dose
Head
Cervical spine
Clavicle and shoulder
Dorsal spine
ThoraxCholecystography
Abdomen
Abdomen (obstetric)
Urography (descending)
Urography (retrograde)
Salpingography R
Salpingography F
Placentography
Cystography
PelvisHip and upper femur
DentalAngiography (head)
Angiography (abdomen)
Tomography (chest)
Mass survey chest
Low skin dose
Arm and hand
Chest
Femur (lower two thirds)
Leg and footMedianvalue

Range ofaverage
val1Jes

6.4a

0.9
4.4a
0.7
4,ga
0.02
2.oa

0.9-2.2
0.4-1.0
0.006-0.09

2
2.7
1.5

0.8-3.8
0.5-2.9
0.7-2.9

0.4
0.3
0.9
1.8
0.4
0.8
0.2
2.0
1.2

0.3-1.5
0.03.Q.8

0.2
1.4
1.1
0.4

0.2-1.2
0.15·1.3
0.4-3.9

0.4-1.7
0.4-1.7

0.9
0.1
0.02
0.03
0.1

0.006-0.09

Per examination
Medianval1JeRange ofaveragevalues

1.4
8.5
1.7
2.1

6-25

1.5
20
0.14
12
6b
8
5
4.5
47

5-26
0.07.Q.15
3-22
o.2.1.8b
6-10
5-6

1.5

1.4-1.9
0.6-1.9
0.3-0.4
2.0-4.7
0.6.Q.9
1.5-2.8
1.0-1.4
2.7-3.8
1.7-5.0
1.4-2.4

1.5
0.3
2.8
0.8
2.2
1.2
3.2
3.2
2.9
1.2
3.4
3.0
3.1
3.3
1.4
2.5
1.0
3.3
1.1
1.0
0.3
0.14
0.4
0.4

2.1-4.S
1.1-3.0
1.6-3.4
0.8-1.4
0.6-1.4
0.1-1.7
O.Q7·0.15
0.3.Q.4

Source: Reference 244.
Note: R = radiography; F = fluoroscopy.
aR min·•.
bNew data (see paragraph 71).

311

55. High skin doses have been reported for such typesof examinations as cardiac catheterization, pace-makerinsertions and cine investigations in voiding urethrocystography. Gough, Davis and Stacey (66) indicate
mean skin doses of 47 rad in a group of 85 patients
undergoing cardiac catheterization, with a maximum
value of 140 rad. The frequency of undertaking thisexamination is not accurately known. Other surveys also
indicate high doses (8, 10, 46, 153, 192). A comparisonof the skin doses received in different techniques ofinvestigations of the heart and large vessels are given intable 9 (235).

Final line of scan of x•rav bumI

56. Recent detailed measurements (52) during 24
cardiac catheterization studies have shown a reasonable
correlation between dose and exposure expressed as thecurrent-time product. Typically, for ·a study involving an
x-ray tube operating for 104 mAs a posterior skin dose of
8-20 rad was received, the anterior skin dose being
1-2 rad. The mean marrow dose, deduced from the skindose, was 0.5-1.2 rad and the gonad dose 5-100 mrad.
Figure III. lsodose curves in a water phantom for single
complete scan (165)

54. The new technique of computerized tomography(CT) scanning utilizes a narrow beam of x rays either in a
pencil or a fan shape. The skin dose to the patient percomplete scan is increased as the matrix element size ofthe display is decreased. Typical skin doses have beenmeasured by Perry and Bridges (165) and are shown infigure III for a single complete scan of the head. The
increase in dose for subsequent consecutive scans will
depend on the amount of overlap. The width of thebeam is about 1 cm and the overlap may be between one
third and one half of the width of the beam. The
radiation dose will therefore be of the same order as incomparable x-ray examinations of the head or the trunk.

57. Pace-maker insertions are controlled by x-ray
fluoroscopy. Gough et al (66) have reported an averageskin dose of 132 rad per insertion for a group of six
patients. This dose is likely to be repeated a number oftimes for each patient. The high skin-dose rates in cineinvestigations have been mentioned by several authorsand may be of the order of 50 rad_min- 1 (192. 258).

(ii)

Dose to the head and thyroid, particularly fromdental x-ray examinations

58. The considerable increase in the frequency ofdental x-ray examinations reported in paragraphs 41-44
merits the inclusion of recent measurements of the dose

TABLE 9. MEAN ENERGY IMPARTED TO PATIENTS DURING RADIOLOGICAL INVESTIGATIONS
OF THE HEART AND LARGER VESSELS
Dose
Typical conditions

Merhod of investigation

Fluoroscopy
Radiography
DirectLateral
Tele
Photofluorography
Tomography
Kymography
DirectLateralElectrokymography
Angiocardiography
Heart catheterization
Heart catheterization with image
intensifier
Cine with image intensifier
Source: Reference 235.

312

Skin-focus
distance
Vo/rage Area
(cm')
(cm)
(kV)

Per procedure
1Tme
(min)

Filrer(mm Al)1.5

0.5

7.5-10(R)(kg rad)

60

200

80
60
150
80
70

70
80
90
70
70

1 200
BOO
1200
800
1 200

0.5
0.5
0.5
0.5
0.5

0.25-0.5
0.5-1
0.3
0.5-1
1-2

1.64-3.3
2.3-4.7
2.0
2.3-4.6
6.8-12.6

80
70
60
70
40

90
90
60
llO
70

720
720

1
1
1

32.9
51

1200
100

22

1

8
12
25
0.5
3().232

40
60

60
70

400
400

22
22

3
3

21
12.5

10

(kg rQd)

8.5-11.35

60

so

Per
examination

3.6

4.6-9.2
20.4-37.8

7
55
145
58.4
32

r
I

1000

-•-

-•-

I

•

•

• 90 kVp, 9 mAs

-•-

•

800

I 70 kVp, 15 mAs

••
-•-

~

!

600

w

~

u.

~

w

a:
:J

(I)

~w 400200-·090 kVp, 1.5 mAs

2

4

6

8

10

12

14

16

18

20

CURRENT-TIME PRODUCT (mAs)
Figure IV. Dependence of exposure at the face on cunent·tirne product in dental x-ray examinations (187)

distribution from various dental x-ray techniques. The
relationship between the radiation exposure and thecurrent-time product of the x-ray tube has been
investigated by Roessler and his co-workers (187), and isgiven in figure IV. In order to give information on the
distribution of radiation over the head and neck fromdental exposure, Alcox (5) measured the exposure at theskin surface over sites of interest and the reported values
are given in tables 10 and 11. The exposure to the lensof the eye may be estimated from those to theinfraorbital, supraorbital and nasion regions, which
represent the maximum, minimum and most probable
exposure to the lens. The maximum values reported are
84 mR for the two-film technique and up to 1.66 R for
the whole-mouth examination. The exposure to thethyroid was between 2.4 and 9.0 mR for the two-film,
and between 35 and 70 mR for the full-mouth,

examination. Similar studies have been carried out forchildren (260). These measurements are similar to thosereported in Finland by Altonen et al. (6), in Sweden by
Bengtsson et al. (17), in the Union of Soviet Socialist
Republics (235), and in the United States survey (251 ).
59. In the 1974 Japanese survey of dental practice,
Maruyama et al. (I 38) made measurements on a
man-like phantom of the doses received by the eyes,
thyroid and gonads for a variety of dental examinations
and tube voltages. The measurements, given in table 12,
show the large variations in doses received caused by thedifferent beam directions, for a current-time product of
10 mAs.
60. Measurements of the dose in the head duringorthopantomography have been made in Norway by
313

TABLE 10. INTRA· AND EXTRA-ORAL EXPOSURES IN A lWO-FILM POSTERIOR BITE-WING
EXAMINATION
Mean measured exposure (mR)
Long-cone technique

Shorr-cone technique
Anatomic
location

50 kVp4-inch TFD

70kVp
8-inch TFD

90kVp
50 kVp8-inch TFD 8-inch TFD

70kVp
90kVp
16-inch TFD 16-inch TFD

152.0
140.0
31.0
18.0
7.0

204.6
198.3
54.9
28.8
7.6

258.0
250.0
93.0
47.8
23.2

252.0
240.0
46.0
26.2
6.4

156.6
153.1
46.5
24.3
9.5

141.6
137.3
52.0
31.0
11.3

4.0
6.0
50.0
5.0
311.0
61.0
116.0
9.0

4.5
3.8
35.9
8.0
415.4
11.7
10.4
2.4

5.1
24.7
84.3
9.4
390.0
28.5
52.9
5.0

2.7
2.6
19.3
3.4
425.0
23.0
51.4
2.6

2.5
2.4
11.6
13.5
310.8
4.6
5.0
2.4

2.4
1.7
9.4
71.7
189.2
5.9
65.1
4.0

Intra-oral
Upper molar
Lower molar
PalateFront of film
Back of ftlm
Extra-oral
Supra-orbital
Nasionlnfraorbital
TMJ area
Molar area
Philtnn11
Lower lip
Thyroid
Total beam

839.0

868.0

919.0

I 139.0

659.0

525.0

Exposure per film

416.0

434.0

460.0

570.0

330.0

263.0

Number of patients

18

12

12

15

16

12

Source: Reference S.
Note: TFD = tooth-focus distance.

TABLE 11. INTRA· AND EXTRA-ORAL EXPOSURES IN AN 18-FILM FULL·MOUTii
EXAMINATION
Mean measured exposure (mR)
Right-angle techniqueBisecting-angle technique
Anatomic
location

70kVp
50kVp
8-inch TFD 8-inch TFD

90kVp
90kVp
50 kVp70kVp8-inch TFD 8-inch TVD 16-inch TFD 16-inch TFDIntra-oral
1 329.0
1 503.0443.0

I 462.0
1 414.0
538.0

944.0
932.0
368.0

1 085.0
1 198.0339.0l.103.4
1 070.6
435.3

704.6
657.4
311.3

76.0
163.0
1 660.0
24.6
1 726.0
2 095.0
1 820.0
67.0

65.0
156.0
1 547.0
39.4
1 386.0
2 084.0
1 465.0
43.0

46.9
190.0
835.0
29.3
983.0
1 329.0
1 042.0
70.0

49.0
90.0
1 187 .0
21.0
1 149.0
2 04,1.0
1 427.0
59.0

42.2
57.7
1 003.3
44.3
995.6
I 387 .1
1 053.0
39.2

29.5
35.6
507.3
48.3
417.6
831.8
539.0
35.4

9 905.0

6 727.0

4 885.0

7 949.0

4 657.0

3 130.0

Exposure per ftlm

550.0

374.0

271.0

442.0

259.0

174.0

Number of patients

15

13

12

14

13

12

Upper molar
Lower molar
PalateExtra-oral
Supra-orbital
NasionInfraorbital
TMJ area
Molar area
PhiltrumLower lip
Thyroid
Total beam

Source: Reference s.
Note: TFD = tooth-focus distance.

TABLE 12. ABSORBED DOSES IN CRITICAL ORGANS DURING INTRA-ORAL DENTAL EXAMINATIONS(mrad)

Location of examination
Upper jaw
Organ

Eye

314

Lower jaw

Tubevoltage(kV)

Molar andpremolarCanineIncisor

Molar andpremolarCanineIncisor

50
60
70

85
118
156

6.25
8.25
10.S

2.00
2.75
3.75

2.00
3.00
4.50

25.0
47.7
86.S

2.75
4.25
6.00

Location of examination
Upper jaw
Tubevoltage

Lower jaw

Organ

(kV)

Molar andpremolarCanineIncisor

Molar andpremolarCanineIncisorThyroid

50
60
70

2.75
3.50
4.25

20.2
26.7
33.7

6.25
8.00
9.75

23.0
33.2
45.5

3.0
5.5
9.5

5.25
9.50
15.2

Testis

50
60
70

0.12
0.21
0.34

0.08
0.17
0.29

0.18
0.28
0.35

0.10
0.18
0.30

0.12
0.20
0.31

0.10
0.22
0.45

Ovary

50
60
70

0.00000.00070.00150.00000.00000.00000.00260.00550.01050.00000.00000.00000.00000.00000.00000.00000.00000.0000Source: Reference I 38.

the State Institute of Radiation Hygiene (221) and by
Casebow {32) in the United Kingdom. Figure V shows
the cross-section dose distribution and the skin exposure
from the Norwegian study. There are high-dose regions(700 mrad) around the rotational axes.
61. The Norwegian report gives the dose to the bonemarrow as 1.0, 7 and 2 mrad for molar bite-wing,
10-exposure whole-mouth and orthopantomography
examinations, respectively. The dose to the gonads fromone exposure has been estimated as 5 µrad for adults and25 µrad for children.
(iii)

Gonad doses

62. Data on gonad doses in different types of
examinations are presented in the review of the annual
GSD in paragraphs 93 to 108.
(iv)
(a)

Dose distribution in cross-section of the head through thelower jaw. The figures are absorbed doses (mrad) in soft
tissue. The rotational axes are shown as black spots

63. In addition to thyroid doses from the direct
radiation incident during cervical spine and barium
swallow examinations, thyroid doses of the order of
1 mrad may also be received in examinations of thehead, sinus and dorsal spine ( 17), and somewhat higher
doses during dental examinations (see paragraph 58).
(v)

(b}

Skin exposure (mR)

Figure V. Distribution of head dose and skin exposure fromorthopantomography (221)Thyroid doses

Bone-marrow doses

64. In the 1972 report (244). the bone-marrow doses
per examination for three major national surveys were
published, and these data are reproduced here astable 13, together with data obtained in new studies inJapan, Sweden and the United States. From the data
given in the previous report, the maximum values ofbone-marrow dose observed for any one examination
type were about two orders of magnitude greater thanthe mean value when the examination included
fluoroscopy. When it did not involve fluoroscopy, themaximum values were about one order of magnitude
greater than the mean. These effects also reflect theextent of the examination both in beam area and skindose, i.e., the number of films and the exposure per film,
which is dependent on the film-screen combination.
315

TABLE 13. BONE-MARROW DOSE PER EXAMINATIONCountry surveys(mrad)

Japan

Gennany,
Federal
Republic of

Nether-(73)

Type of examination

(25)

1969

1974

Head
Cervical spine
Barium swallow
Arm and hand
Clavicle and shoulder
Dorsal spine
Whole chest
Thorax (ribs and sternum)
Barium meal
Cholecystography
Abdomen
Abdomen (obstetric)
Descending urography
Retrograde urography
Salpingography
Placentography
Pelvimetry
Cystography
Barium enema
PelvisLumbar spine
Lumbosacral joint
Hip and upper femur (upper third)
Rest of femur
Leg and footDentalAngiography (head)
Angiography (abdomen)
Tomography (chest)
Cardiac catheterization
Bronchogram
Mass survey chest
Mass survey stomach

12-90
8-51
359-1 180

29
43
140

44
37
747

18
140
9
34
210
73
59
72
110

370
25
40
705
237
202
70
262

50

212

170
37
210
70
150
92
43
8

98
116
1114

67-2087-40
6-106
359-1 180
36-59039-12556-206200-1160
257-386
21-300168-1 160
50-94039-13856-27061-651
21-58
4-50

248
140
169

lands
(259)

United Kingdom

United States

(37)

(208)

Sweden(17)

MaleFemale

1964

1970

120
38
420

32
54
1 300

39
49
590

65
31

78
52

60
105
470
0
10, 40b 29
6
54
80
350
36
150
93
300
56
220
433
240
257
300
282
170

38
200
12
180
510
150
120

81
220

232

13

10

37
800
150
130

124
624
183
183

247
10
143
535
168
147

450
330
210

453

420

280'1
940
1 060
140
270
220
60

288
183
624
116
336
418
97

595
147
875
93
347
450
72
21

1.8
130
380
390
190
31
101

13.2

9.4

65

44

90
8

so

168
359
138
140
651
47

680
940
190
410
100
250

210C
580
440

170
530
130
270
· 290
57

0.3
1

35
60

47

90

1.8
130C
380C
360
190C
31
61

a Radiography.
bf1uoroscopy.
cFoetal contribution, SOO mrad.
dFoetal contribution, 1100 mrad.
e Assuming equal frequencies of male and female examinations.

65. The basic data used in the 1957 United Kingdom
survey have recently been published by Ellis, Healy,
Shleien and Tucker (50). These include the conversion
factors for the bone marrow site-to-skin exposure forsquare fields, the appropriate conversion factors forrectangular and circular fields and the computer
programme for the calculation of mean bone-marrowdose. The measurement data are for 16 marrow sites
irradiated at seven qualities, half-value layers {HVL)
from 1.0 mm Al to 20.0 mm Al, for source-to-skindistances of 20, 40, 60 and 80 cm and for fivesquare-field sizes from 16 to 900 cm 2 •66. An analysis of the variation of the bone-marrowdose with HVL, source-to-skin distance and beam area
were also undertaken and the results are shown for anumber of examinations in figures VI, VII and VIII.
Reasonable agreement exists between the studies of Elliset al (50) and Epp et al (54) for examinations not
involving the passage of the beam through the lungs,
from the anterior projection. For examinations involving
this passage, the differences probably result from thefact that the mean lung densities used in the twophantoms were 0.2 and 0.3 g cm- 3 , respectively.
316

67. An extensive Monte Carlo type computational
study has been undertaken by Rosenstein and his
co-workers (190) for the estimation of organ doses fromdiagnostic radiological procedures. The method involves
the simulation and recording of the energy deposited by
x-ray photons as they undergo physical interactions in amathematically described heterogeneous anthropom:>rphic
phantom. The general techniques have been developed
by Snyder et al. (211, 212) for use in determining
doses from internal radiation. Tissue-air ratios have been
generated for the testes, ovaries, active bone marrow,thyroid and embryo (uterus) of a reference adult patient
for several photon energies from 20 to 100 keV. Fromthese ratios a compilation of the five organ doses perunit entrance exposure free in air (mrad R -I) has beendeveloped as a function of six beam qualities from 1.5 to
4.0 mm Al HVL for 34 projections common in diagnostic radiology. An example of the data for one ofthese projections is given in table 14. Similar studies
using the Monte Carlo system and the Snyder phantom
have been published by Kramer et al {123).
68. A comparison of the Monte Carlo system {190)with that using direct ionization measurements of thenvlddose to the bone marrow (50) shows that there is generalagreement between the two methods. The tissue•air
ratios for six AP projections, when compared for thetwo methods, lie between ·0.4 and 0.7 of each other; forthree PA projections the ratios between I and 2.4; andfor two lateral projections they are both about 0.7 ofthe direct measurement values (50). These differences
occur because of the differences between the measure·

r·-.,

120

480 cm

1

:

'

0

110

100

!lO

80

10
mr1d

,sol

60

,eoi

50

170i

40

1601

JI)

20

150

10

140

0

130

40

20

mi

80 ''"SOURCE TO SKIN DtSTANCE

w

120

~
IC

110

"'g

Figwe VII. Dependence of active bone-marrow dose on beam
area and source-to-skin distance (SSD) in thoracic spine andlumbosacral joint x-ray examinations (208). HVL constant at
2mmAI

IC

< 100
:l

w
z

0

CSE = central skin exposure

90

m

w

>
,:::
~

-

80
70

70

Thoracic spine (lateral protfction)

CSE: 980 mR; bum 388 an 2
SSO: 73cm

Ill)

961Cffl 1,..- -- -,

II)

I

•

I

~

0

50

I

O

I

50

C

-·~

3:

C

.
!

40

30

1.0

2.0
2.5
10
HVLlmmAII

1.5

3.5

4.0

4.5

40

z

JI)

rSJ8
_

•

CSE: l70mA''

I

j,I' _:"'>;:~r•• J.....---

2Jlcml / L - -

20

I

0

5.0

Hip and femt1 (an1aricw projllcUon)

CSE:560rrilO'""~'o~--J..,...,
-""~·
r--.

10

.

AbdotNn lport1r1« proiec:tion1Ig:i~~~.
0.S

"'"'

:

I

~

• _., 120c:m1 '---'270cm'

~

~

m

m ~

SOURCE TO SK1" 01ST ANCE

Figure VI. Dependence of active bone-marrow dose on thehalf-value layer (HVL) in various x-ray examinations (208)

CSE = central skin exposure

Figure VIII. Dependence of active bone-marrow dose on beam
area and source-'to-skin distance (SSD) in abdominal and hip andfemur x-ray examinations (208). HVL constant at 2 mm Al
CSE = central skin exposure

SSD = source-to-skin distance

TABLE 14. DOSES TO ORGANS DURING LUMBAR SPINE EXAMINATIONS(Dose in millirads per 1000 mR entrance skin exposure free in air)Beam quality (HYL i11 mm Al)
Organ

Projection

TestisAP
Lateral

LI
0.2

Ovary

AP
Lateral91
15

ThyroidAP
Lateral

0.05

0.2

0.3

0.5

0.8

LI

Active bone marrow

AP
Lateral

13
8.2

21
13

32
19

46
27

62
37

81
48

AP
Lateral

128
9.4

189
17

250
27

309
39

366
53

419
68

Embryo (uterus)

1.5

2.0
2.2
0.4
139
27

2.5
3.7
0.7
188
41

3.0
5.6

1.1
238
58

3.5
7.8
1.6
288
76

4.0
10
2.3
336
96

Notes: (a) Conditions: Source to image-detector distance, 102 cm; film size (= field size),
35.6 cm X 43.2 cm.
(b) A dash (-) signifies a value of less than 0.01 mrad.

317

ment phantom and the mathematical phantom, theeffect of the amount of compact bone overlying any
specific dosimeter and the thickness of the homogeneous
mixture of bone and marrow assumed in the skeleton of
the mathematical phantom. The comparisons reported
made corrections for the differences in the x-ray spectra
and the assumed volume and density of the lung thatwere used in the two studies.
(vi)

Breast doses

69. The breasts are exposed to radiation in a numberof common x-ray examinations. The highest doses to thebreast are caused during urography examinations.
photofluorography of the lung, examinations of thedorsal spine and stomach examinations, in the ordermentioned, with doses between 100 and 540 rnrad (17).
Photofluorography of the lung is of special interest
because of the high frequency of examinations.
70. In addition to these common examinations, special
examinations may cause higher doses. Direct radiography of the female breast, i.e., mammography, is ofparticular interest because the technique is also being
used in health investigations. The organization of anumber of large population mass-screening surveys
caused concern when high-dose techniques were in use
and when regular re-examinations were carried out on
young women. The justification for such examinations
was questioned because of the increase of breast cancer
that might be induced by radiation (13, 49, 182).
71. In the 1972 report the radiation dose in the breast
per mammography examination was reported to be in
the range 10-35 rad. However, since then considerable
progress has occurred in techniques for reduction of theradiation dose. The use of the low-dose technique (verysensitive films with high-efficiency intensifying screensin vacuum packing) has enabled radiographs to be takenwith a maximum skin dose to the breast of 0.1 rad ( 13,173, 229, 268). With two-film techniques being accepted
for screening examinations, surveys can be undertakenwith a breast dose of less than 200-300 mrad. The use of
xeroradiography leads to doses which are an order ofmagnitude higher, i.e., 1-5 rad per examination (22, 56,
191 ), while the use of industrial film leads to doses
between 1.8 and 18 rad (13, 60, 229).

(viii) Doses in other organs

73. Eye. Surveys (102, 103) have shown that theradiation dose to the cornea during extensive neurological x-ray examinations may be in the range
20-80 rad. Patients who have repeated examinations may
have a considerably increased risk of a radiation-induced
cataract. The introduction of new x-ray units using
computerized axial tomography will tend to change
the mode of examination of patients with head lesions.
Dose distributions in the head have been reported by
Perry and Bridges (165). Doses to various parts of thehead in dental examinations have been calculated or
measured by several authors (5, 187, 251, 260).
Casebow (32) has reported the dose to the head duringorthopantomographic dental examinations.
74. Bone. The frequent radiography of young children
with orthopaedic handicaps may cause damage to thedevelopment of bone and, in particular, produce stunted
growth when the epiphysis has received a high dose (67).
It is not uncommon to observe that particular patients
have had over 100 radiographs of one particular joint
during childhood. Estimates of dose distributions are not
yet available.
75. The application of nuclear-powered pace-makers
introduces problems associated with the dose to theconnective tissue surrounding the pace-maker itself(108). The dose rates vary from type to type, but
Kowalewsky (122) has reported that the surface doseover 10 years may vary from 385 to 1150 rad of gamma
rays and from O to 85 rad of neutrons. Smith andMunson (209) report a first-year dose of 70 rad at thesurface of a generator with a beta cell containing 14 7 Pm
and a similar dose with a 2 3 8 Pu power source. The rateof irradiation of a bystander in close proximity to aperson with a nuclear-powered pace-maker has been
estimated by Cross (41) to be about 1 mrad h -i at thesurface of the body. Data from Stieve (226) show thatthe average length of implantation has been between 3
and 4 y and that the dose rate at the surface of thegenerator evolves as shown in figure IX (122). In

20( vii) Lung doses
72. The density of the lungs at full inspiration is about
0.1-0.15 g cm- 3 , while an average value of 0.25 g cm- 3
is more appropriate when the main vessels are included.
These changes make accurate assessment of the lungdose difficult. In typical x-ray examinations thetransmission through the chest is about 10 per cent.
Lung doses may therefore be estimated as a function of
the direction of the beam from the incident skin dose.
For full-size radiographs, the skin dose per exposure isabout 20 mrad: for photofluorography using 70- or
100-mm cameras, the skin dose is usually about
200-300 mrad; for photofluorography using 35-mm
cameras, the skin dose is usually in the range
600-1000 rnrad. In the Swedish study by Bengtsson etal. (17), the highest dose to the lung, 800 mrad, wasfound in examinations of the dorsal spine. Special
examinations such as cardiac catheterization cause muchhigher lung doses (see paragraph 56).
318

Medtronic (138 Pu)

w

I-

<
a:
w

"'00

w 10

u

<
u.
a:

::>

"'

o.___ _ _..------,----..------,
5

10
TIME

15

20 years

Figure IX. Dose rate at the surface of three brands ofradioisotope-powered cardiac pace-makers (122)rinterpreting the effect of the absorbed dose rate infigure IX, account should be taken of the relevant
biological effectiveness of the neutron contribution.
( c) Embryo and foetal exposures
76. The surveys of pre-natally exposed children ( 134,228) were summarized in the 1972 report. The practiceof x-ray pelvimetry and obstetric abdomen examination
has declined in frequency in a number of countries, eventhough recent statistical information on this is notreadily available (see table 7, however). The introductionof ultrasonic scanning is probably reducing the need for
x-ray and radionuclide investigations to localize theplacenta {172). From the data given in the 1972 report,
it can be deduced that the foetal whole-body dose isusually about 300 mrad in obstetric abdomen examinations and 620 mrad in pelvimetry examinations. The
frequencies reported for the two examinations wereabout 2 and 1 per 1000 of population, respectively.
These data give an annual collective dose to the foetus of
about 1.2 man rad per 1000 of population from these
two types of examination. A recent survey in Japan{1974) from Kitabatake et al. (119) reports, however,frequencies of 69 and 92 per I OOO pregnancies,
respectively, for the two examinations.
77. Several reviews have been published (42, 150, 155,
223, 225) dealing with the levels of dose to women
having child-bearing capacity at which subsequent action
might be considered desirable, including termination ofpregnancy. In the state of available human informationon the risks of radiation during various stages ofpregnancy (see Annex J. paragraphs 169-173). as well ason the normal incidence of congenital defects, it does
not seem appropriate to make any absolute recommendation regarding the line of action following such
medical radiation exposures. In any case. such
recommendations could serve only as a guide that would
have to be modified in specific instances according to
the judgement of the patient's physician and consulting
radiation experts and, of course according to the desiresof the patient herself. The radiation dose itself,
particularly from diagnostic radiologic procedures, isunlikely to be the sole determining factor in advisingabortion. Decisions based on the generally small risks
involved must require very careful consideration of theconditions applyin~ in each indi'tidual case.
( d) Comparison of procedures
78. Tables showing mean organ doses from the various
types of diagnostic x-ray procedures have frequently
been published for gonad doses and mean marrow doses
and for incident skin exposure (see tables 8 and 13).
There has been less information on the overall exposure,including doses to a number of the most radiosensitive
organs. In the Swedish survey by Bengtsson et al {17),however, information is given on the doses in gonads,
thyroid, active marrow, breast and lung, as well as on theenergy imparted. This information is summarized intable 15.

TABLE 15. AVERAGE ORGAN DOSES IN VARIOUS DIAGNOSTIC X-RAY EXAMINATIONS IN
SWEDEN{mrad)

Whole
bodya

Ovary

Testis

170
125
440
1sob
590
730
1 ooob
600b
440
300
860
300b
zoob
130

310b
190
460
18ob
620
880
8oob
1 soob
56
180
700
200b
1sob
590

1 soob

Dorsal spine
Lung, n'bs
Lung (photofluorography)
Lung plus heart
Cervical spine
Shoulder, clavicle, sternum

130
300
30
105
57
26
60b

24
< 100
< 3b
< lob

Head, sinus
Cerebral angiography
Femur Oower two thirds)
Lower leg, knee
Arm

97
970
10b
30b
7b

Examination

Hip and femur
PelvisPelvimetry
Lumbosacral region
Lumbar spine
Urography
Retrograde pyelography
Urethrocystography
Stomach, upper GI tract
Small intestine
Colon
AbdomenObstetrical abdomen
Hysterosalpingography
Cholecystography,
cholangiography

Dental (single exposure)

Activema"owThyroid

Breast

Lung

100b
410
240
300b
300b
420
250
940
300b
220b
170

< 1b
< 1b
< 10b
< 1b
16
38
sob
5b
29
3
10
3b
2b
< 1b

< 5b
< 5b
< lob
< 5b

< lob
< lob
< sob
< 10b
< 100
<100
< 100b
20b
< 50
< 20
< 20
< 20b
< 15b
< 10

150
470
29
90
54
38
60b

3
1 300
17
100
24
140
sob

15
170
55
200
61
< 10
< sob

122
1 500
sob
400b
<1
<1
< 1
< 1
<1
< 1
< 1
1
0.01
2.9
0.01

790
300
< 1b
< 1

< 1

< lob
< 10b
< 1b
< l
< 1

3

0.5

< 5b
< 1
< lb
< 1
< 10

310
100b
180
330
1 300b
2 ooob
16
100
530
200b

6
< 20
< 3b
< 10b
< 5b

< l
< 1b
< 1
< 10

250
190
680b

120
540
soob
20b
100
11
27
11b
8b
< 5b

< 10
800

80
350
120
< 10b
< 10b
< 10b
< 10b
< 1b

<
<

1

1
0.1

Source: Reference I 7.
a Assuming same mass as Reference Man {70 kg); not averaged over actual weight.
berude estimate.

319

79. The Swedish study involved measurements on
about 1000 patients in 13 Swedish hospitals. The
techniques employed at these hospitals were believed tobe representative for the whole of Sweden sincediagnostic techniques are quite uniform throughout thecountry. Image-intensifier television was generally used,
the older fluoroscopic screen, rarely. Chest examinations
were normally made without fluoroscopy. Automatic
exposure control was generally used. The dominant
screen-film combination would under optimum condi·
tions require an exposure of 0.4-1 mR to give anadequate density. Examinations of gall bladder, stomach
and colon, and special examinations were performed bydoctors. Most other examinations were performed by
specially trained nurses or x-ray technicians. The
exposures were measured at various points on thepatients using thermoluminescent lithium fluoride
dosimeters. These were placed at the laryngeal
prominence (to estimate the thyroid dose), the breast,
the male gonad and the rectum (to estimate the ovarydose). For the other organs an estimate of the dose wasmade from the recorded exposure area product (seeparagraph 48). The overall accuracy of the mean
absorbed dose for a particular organ was± 50 per cent.
80. It is seen from table 15 that the imparted energy(expressed in the table as mean whole body dose inReference Man in mrad, but in the Swedish study
reported in mJ is usually a good indicator of thesignificance of an exposure as regards high doses inradiosensitive organs. None of the examinations having
an imparted energy of less than 200 mJ (280 mrad
whole-body dose) caused an absorbed dose of more than
800 mrad in any of the organs listed, with the exceptionof a testis dose of 1500 rnrad in examinations of hip andfemur. However, some examinations simultaneously
exposed several of the listed organs to the extent thatthe exposures might be considered more significant than
indicated by the imparted energy alone. These
examinations were the examinations of the lung and thedorsal spine. As can be expected, examinations of thepelvic region. e.g. pelvimetry, urethrocystography andexamination of the hip and femur gave high gonad
exposures in relation to the energy imparted.

3. Collective dose to various organs fromdifferent types of procedures
81. In this section,. the population exposures fromvarious procedures are reported in terms of the per caputdose, which, as explained in paragraph 26, is thecollective dose to the population divided by the numberof individuals in the population.

(a) Accuracy of assessment
82. Estimates of the overall error in the determinationof the collective dose for a given organ may be
exemplified by the case of the annual GSD. The overall
error comprises the statistical error of the observations
and the systematic errors incorporated in the organization of the inquiry. Statistical error estimates areavailable for three major studies: the 1958 United
Kingdom survey (36), and the 1964 and 1970 UnitedStates surveys (27. 255). The estimated standard error in
the United States surveys decreased from 37 per cent in1964 to 15 per cent in 1970. For the United Kingdom
study the error was estimated at 8 per cent. However,there have been no estimates of the systematic errors,
which are difficult to assess.

(b) Collective dose to various organs
83. Bengtsson et al (17) have calculated the per caput
doses from the various types of diagnostic x-ray
examinations in Sweden. Their data are shown intable 16. The per caput doses in the six listed organs are

TABLE 16. ANNUAL PER CAPUT DOSES TO ORGANS IN VARlOUS
DIAGNOSTIC X-RAY EXAMINATIONS IN SWEDEN(man rad per 1000 of population, or mrad per caput)

320

Examination

Whole
body'

Ovary

Tents

Hip and femur
PelvisPelvimetry
Lumbosacral region
Lumbar spine

3.2
1.9
0.7
0.4b
13.2

1.0b
2.9
0.7
0.5b
14.0

28.0b
4.8

Urography
Retrograde pyelography
Urethrocystography
Stoma~h, upper GI tract
Small intestine

17.2
0.3b
1.6b
13.0
1.0

21.0
0.2b
4.lb
1.7
0.6

7.8
0.4b
5.5b
0.5
0.3

Colon
AbdomenObstetrical abdomen
Hysterosalpingography
Ololecystography,
cholangiography
Dorsal spine
Lung, ribs
Lung (photofluorography)
Lung plus heart
Cervical spine
Shoulder, clavicle, sternum

13.8
3.9b
0.3b
0.1

11.0
2.6b
0.2b
0.5

8.5
2.6b

2.4
4.0
3.5
11.6
2.7
0.3
I.Ob

0.4
< 1.3
<0.3b
< I.lb
< 0.2b
0.0
0.0

0.1
<0.3
<0.3b
< I.lb
< 0.2b
0.0
0.0

0.3b
4.0

Activemarrow

Thyroid

Breast

Lung

4.7
2.9
l.lb
0.3b
9.1

0.0
0.0
0.0
0.0
0.4

< O.lb< O.lb
0.0
0.0
2.6

<0.2b
< 0.2b< O.lb
0.0
<2.2

5.6
O.lb
0.8b
12.0
1.2
15.0
3.9b
0.3b
0.1

0.9
0.0
0,0
0.9
0.0

13.0
0.2b
O.lb
3.1
0.0

< 2.4
0.0
O.lb
< 1.5
<0.1

0.2
0.0
0.0
0.0

0.4
O.lb
0.0
0.0

<0.3
< 0.3

2.8
6.2
3.2
9.9
2.5
0.5
1.0b

0.1
18.0
2.0
11.0
1.1
1.8
0.8b

0.3
2.3
6.3
22.0
2.8
< 0.1
<0.8b

<0.2
11.0
9.2
39.0
5.6
<0.lb
<0.2b

o.o

0.0

pa

Examination

Whole
bodya

Ovary

TestisActivema"owThyroid

BreastLung

Head, sinus
Cerebral angiography
Femur Oower two thirds)
Lower leg, knee
Arm

4.2
1.2
0.4b
1.9b
0.4

0.0
0.0
0.3b
< 0.1
0.0

0.0
0.0
2.4b
< 0.1
0.0

5.3
1.8
0.0
0.0
0.0

34.0
0.4
0.0
< 0.1
0.0

<0.4b
0.0
0.0
< 0.1
0.0

< 0.4b
0.0
0.0
<0.1
0.0

Dental (single exposure)

4.4

0.0

0.0

1.5

4.5

0.8

0.2

110

70c

65c

90

75

55

65

Total (rounded)

Source: Reference 1 7.
aThe authors estimated the per caput mean whole-body dose at about 100 mrad, based on
actual patient weights instead of the 70 kg assumed in this table.
bcrude estimates.
cNot including foetal exposures.

between 55 and 90 mrad y- 1 , whereas the annual per
caput mean whole-body dose was estimated by theauthors to be about 100 mrad.

(i)

189 mrad y- 1 for the Netherlands (259), United
Kingdom (37) and Japanese (73) surveys, respectively.
They were undertaken in 1960, 1957 and 1969,
respectively. The recent Swedish survey (see table 16)
gave 90 mrad for Sweden in 1974 and a repeat of theJapanese survey gave 132 mrad for the same year. A
recent assessment (208) gives the CMD for the UnitedStates as 83 mrad for the 1964 survey and 103 mrad forthe 1970 survey. In table 17, the examinations making

Marrow collective doses

84. The annual per caput mean marrow dose (CMD) as
derived in three national surveys was reported in the1972 report. The CMD totalled 30, 32 andTABLE 17. ANNUAL PER C4PUTD0SE TO BONE MARROW(mrad)
Japan(73, 79, 80,
81, 84,138)

Type of examination

SwedenUnitedKingdom

(17)

(37)

1969

1974

(259)

o.s

1.1
0.5

0.2
0.9
2.2
1.1
3.7
0.1
2.5

Hip and femur
Pelvis0.3
Lumbosacral joint
0.8
Lumbar spine
4.4
Urography
1.2
Stomach, upper GI tract
115
Small intestine
Barium meal (photofluorography) Colon
10.3
Abdomen
0.8
Obstetrical abdomen
0.2
Cholecystography
7.0
Dorsal spine
1.0
Lung
10.1
Lung (photofluorography)
20.2
Head
0.7
Other
16.3
Total

United States
Netherlands

189

5.1
2.1
73.2
16.5
7.3
4.4
0.2
2.1
0.8
6.1
9.7
3.3
132

the greatest contributions to the CMD in the sevennational surveys are listed. The large contribution fromstomach examinations in Japan is striking; it is caused by
the very large frequency of these examinations. A recent
survey by Hashizume et al (83) gives the -number ofphotofluorographic examinations of the stomach in1975 as 2.38 10 6 and 1.74 10 6 in males and females,
respectively. The mean marrow dose was 453 mrad and392 mrad, respectively, and the CMD from thisexamination 16.5 mrad. A similar survey of mass chest
screening in Japan (84) during 1975 gave a CMD of
9.7 mrad.

4.7
2.9
9.1
5.6
12.0

(208)
1964

1970

0.3
0.3
0.7
1.5
2.3
1.2
6.0

0.7
1.4
4.0
6.7
9.9
17.9
0.7

0.7
1.1
5.7
8.1
10.1
24.3
1.0

13.7
3.6

21.2
2.9

3.2
2.0
2.0
7.8
1.0

3.7
2.5
3.2
3.2
1.6

3.1
0.6

15.0
3.9

0.5
0.3
8.1
3.8
1.1

2.8
6.2
9.9
5.3

2.2
0.8
1.1
0.5
0.6
1.8
7.8
0.5

1.8

12.6

4.7

8.4

13.7

30

90

32.3

83

103

85. The 1970 United States survey (208) analysed theC.MD for six different age groups; whereas the CMD for
the whole population was 103 mrad, the CMD for the
specific age groups were:
Age group

CMD (mrad)

15-24
25-34
35-44
45.54
55-64
~ 65

52
81
107
120
143
151
321

per cent(al Head and thorax(b) Abdomen and pelvis

30

z

0
j::
:::::>
ID

a:

/

20

1-

I

z
u

0

,

Lumbar and lumbosacral spine
IVP

10, __ 1_
Hip and pelvis-- --O '------,-----,H,....e.;..;;a..;.d..;;.a_nd_n_eck..-------.-----.---'---r------..-----,,----r------..-----,

15-24

25-34

35-44

45-54

55-64

>SS

15-24

25-34

35-44

45-54

55-64

>65

AGE (years)

Figure X. Contribution of certain x-ray examinations to the age-specific per caput mean marrow dose (CMD) in the United States (208)
IVP a intravenous pyelography

The contributions made by the various examinations tothese specific CMD are given in figure X. This
demonstrates the variation in frequency with age ofsome of the major contributors to the CMD of the total
population.

10 rad per examination. With 0.1 rad per examination,
however, the individual breast doses would be about thesame as the breast doses in photofluorographic
examination of the lung (see table 15).

86. In the 1969 Japanese survey an attempt was also
made to calculate a weighted mean marrow dose("leukaemia significant dose") with weighting for
reduced risk of leukaemia as a function of the age of
exposure. considering the latency period for manifestation of the disease. This reduced the CMD from 189
to 169 mrad. The CMD for photofluorographic examinations of the stomach was reduced from 16.5 to
14.5 mrad by a similar weighting in the 1975 survey, andthe mass chest screening CMD was reduced from 9.7 to
9.3 mrad (83).

(iii) Lung collective doses

87. An estimate of the CMD in Romania was made in1970. The value derived was 382 mrad y- 1 , but it would
appear from the report that this value represents thedose to the marrow in the direct x-ray beam rather thanthe mean value in the whole active marrow.

(ii)

Breast collective doses

88.

As indicated in paragraph 71, health investigations

with mammography may be expected to result in quite

high breast collective doses if carried out at the level of322

89. Mass photofluorographic surveys of the chest. The
incidence of tuberculosis throughout the world is high;therefore, most countries have either mobile or fixedinstallations for taking 35-, 70- or 100-mm films of. thechest as a screening or follow-up study. The radiation
exposure incident on the back of patients is related
the size of the film and the optical system, and the skin
exposure is usually in the range 0.5-2.0 R for
35-mm film and about 0.2-0.5 R for 70- or
100-mm film. Photofluorographic lung examinations
give the highest contribution to the per caput lung dosein most countries (e.g., 60 per cent in Sweden). The
median frequency of mass chest surveys among thecountries for which data were reported to theCommittee for the 1962 report was 130 per year and1000 of population. Of the additional data presented in
the 1972 report the median value was 267 examinations
per year and 1OOO of population. The frequency in
Sweden in 1974 was 110 examinations per year and1000 of population, a relatively low frequency.
Nevertheless, the Swedish per caput annual lung dosefrom photofluorography of the lung was found to beabout 40 mrad ( table 16).

to

examination (113). During 2.2 10 6 fluoroscopic mass
surveys, 2423 persons were found to have gastriccancers; 1042 of them were expected to survive morethan five years. An estimate of the radiation-induced
cancers indicated 30 Jeukaemias and 15 abdominal
cancers during the following 25 years.

90. An assessment of the benefits and risks of mass
chest radiography has been made by Kitabatake and his
co-workers (I 14). In the 40 l 0 6 chest fluorographies
carried out in 1968, about 44 500 cases of pulmonary
tuberculosis were detected. Estimatc:s were made of thenumber of lung cancers that might be detected and of
how many of them were likely to benefit from earlyradical resection. An estimate of the deleterious effects
produced by the irradiation was made for the next
25 years on the basis of current risk estimates. These
included 46 leukaemias and 7 incurable lung cancers.

(iv)

(v)

Foetal collective doses

92. From the 1974 survey in Japan, Hashizume (82)has estimated an annual collective dose to the foetus of
0.86 man rad per 1000 of population from obstetricabdomen and pelvimetry examinations.

Stomach collective doses

91. An estimate of the collective dose to the stomach
from the Japanese examinations may be deduced on thebasis of the mean dose in the stomach of 4 rad per
examination. This leads to an annual collective dose of
10 8 man rad. Such assessments have been made inattempts to estimate the risk of inducing cancer by the(c) Annual genetically significant dose
93. The details of the many GSD surveys have been
given in the previous reports of the Committee. They aresummarized in table 18.

TABLE 18. ANNUAL FREQUENCY OF X-RAY EXAMINATIONS AND GSD BY COUNTRY
Annual number of x-ray examinations
per 1 OOO of total population
Mass surveys

Diagnostic
Country or area

Population
106

PeriodRadiography

Fluoroscopy

Radiograph}'

Fluoroscopy

GSD (mrad)
Diagnostic
exami·
nationssurveysMass

Ref·erence(a) Surveys reviewed in the 1962 report
Argentina
Buenos Aires
Denmark
Egypt
Alexandria
CairoFranceGermany, Federal Republic ofHamburg
Italy
Rome
Japan
Netherlands
LeidenNorwaySwedenSwitzerland
United Kingdom

16670

1950-1959
1956-1958

6
4.5

270
260

80
140

37.0
27.5

1.90
0.05

1956-1960
1955-1961
1957-1958

1.4
.2.6
42

36
40
150

4
5

40

7.0
7.0
58.2°

0.09 1360.07
1350.02b 178-180

1957-1958

1.8

560

130

17.7

0.05

94

1957
1958-1960

1.9
90

500
410

80
320

43.4
39.0

0.93
0.08

21
181

1959-1960
1958
1955-1957
1957
1957-1958

0.1
3.5
7.3
5.2
50

350
390
290
310
280

130
210
140
130
95

6.8
10.0
37.8
22.3
14.1

0.02
0.08
0.40
0.12
0.01

15
57
128
269
37

331
266

37.0
16.8

0.44

126
104,105267

13.7(15.l)d
25.7
20.0
13.1
13.7

0.05

203-206

0.8

74
16,174
266
152

200

330

570

60

(b) Surveys reviewed in the 1972 report

Czechoslovakia
Bohemia
FinlandGermany, Federal Republic of
BavariaJapan
Netherlands
New ZealandPuerto Rico
Southern region
Western region
ThailandUnion of Soviet Socialist Republics
Russian SFSR
United Kingdom
Sheffield

1965-1966
1963-1964

4.3
4.5

517
334

1956-1958

9.6

601c

1969
1967
1963
1969

105
12.6
2.5
2.8

610
810
366
400

1968
1968
1970

0.5
0.4
34.7

414
512
39

1964

82

171

1964

4.5

310

79

191

628
113
113

439

183

36.4
48.6
5.2-1.3

158
157
142,143

27.of

125

8.6

139

323

TABLE 18 (continued)
Annual number of x-ray examinations
per 1 OOO of total population
Diagnostic
Country or area

United States
National surveys
Local surveys
New York CityNew Orleans
Johns Hopkins University
Texas
Yugoslavia
Slovenia

Mass surveys

PeriodPopulation
10 6

Radiography

Fluoro:scopy

Radiography

1964
1970

187
200

475
580

56
65

87
45

Fluoro:scopy

GSD (mrad)
Diagnostic
examination.s

Masssurveys

Reference

16.Qt
20.oe

63,164247,249, 28

1962
1962-1963
1965
1963

8
0.9

630
825

100

50.0
75.3
20.3
16.0

161
106
148
38

1960-1963

1.5

594

436

9.1

141

a From radiographic mass survey.

blncluding fluoroscopic mass survey.
cln this case, one examination equals one radiograph.
dThe figure in parentheses is a later figure that includes special children's clinics.
e Revised estimates (27, 2 5 5).
/Mean gonad dose per year rather than GSO.

94. Since the 1972 report a few further reports ofinvestigations on the GSD in various countries and areas
have become available. These may be usefully considered
in two groups: countries or areas where there is anadvanced technical medical service and those that only
have these facilities in the largest towns and cities. A
summary of these recent surveys is given in table 19 andbelow.

TABLE 19. ANNUAL FREQUENCY OF X-RAY EXAMINATIONS AND GSD BY COUNTRY
Recent surveys
Annual number of x-ray examinations
per 1000 of total population
DiaifllOStiCCountry or area

PeriodPopulation(JO')

Germany, Fed. Rep. of(Hamburg)
India
Iraq
Japan
Netherlands
Puerto Rico
Romania
SwedenSwitzerland
Island of Taiwan (urban areas)
United States

1974
1967-72
1972
1974
1972
1973
1970
1974-76
1971
1972
1970

1.8
550
10
105
12.6
3.0
20.5
8.1
6.3
5
195

Radiography

1 530
35
1500
676
1 186
502
238
540
1 350
43a
669

Fluoroscopy

Mass survey
Radiography

128
88a
134
40
322
100

56
452
110

Fluoroscopy

GSD (mrad)
Diagnostic
examination.s

41
1.1
52
16.5
28
46
28.5
46
42.9
3-4
20

Mass
surveys

Reference

129
168
1
74, 79, 80
120
61
177
17
170
261
27

aEstimate from data received.

(i)France. 197695.

An estimate of the GSD in France, made by Reboul

et aL (178-180) in 1959, was 58 mrad. Since then alarge-scale study (163) was conducted in 1976 on thebasis of I 0 6 radiological examinations for the purpose ofproviding an estimate of the mean gonad dose received
by the members of the public. The per caput gonad dose324

found in the study is about iestimated GSD of about 3
measures taken by the nation::suppression of obsolete fac
quality of the examination
authorized facilities, a decreaof the exposure received .
achieved.

Cf'.

I!:! .rose
iPto be;'-(ii)(iii) India, 1967-1972

Federal Republic of Gennany, 1972-1973

97. Surveys in four representative areas of India wereused to obtain data on the frequency of examination,dose per examination and child expectancy factors(228). From these data the GSD was calculated for each
district in each area. The four GSDs derived were 1.89,
0.77, 0.88 and 0.93 mrad for the state of Maharashtra(1967-1968). the state of Tamil Nadu (1969-1970), thenorthern region ( 1970-1971) and the eastern region{1971-1972). respectively. In those districts where thelarger x-ray facilities existed, considerably higher GSDs
were obtained (table 20). The GSD was weighted

96. An assessment of the GSD in the Federal Republicof Germany has been made by Stieve for 1972-1973 on
the basis of reported average values of the doses fromvarious procedures. The GSD has been estimated as
50 mrad from medical sources (25. 224). Surveys wereconducted in the Hamburg region in 1958, 1972 and1974 (94, 129). The GSD increased from 17.7 to 37 to
41 mrad, respectively while the average annual numberof examinations per person increased from 0.61 to 1.16
to 1.33.

TABLE 20. CONTRIBUTION TO TIIE ANNUAL GSD DUE TO DIAGNOSTIC RADIOLOGY
India, 1967-1972(mrad)

Fluoro•scopy

Radiography

Fluoroscopy

Foetaldose

AnnualGSD

Districtcontrib·
ution tostate orregionannual
GSD

0.447
0.043
0.001
0.006
0.004
0.014
0.013
0.003
0.147

1.308
0.158
1.259
0.083
0.157
0.032
0.018
0.001
0.036

2.592
0.743
0.482
0.009
0.041
0.081
0.081
0.001
2.619

0.240
0.201
0.435
0.037
0.007
0.023
0.006
0.002
0.014

10.646
1.870
4.052
0.957
0.490
0.362
0.141
0.021
2.9]6

1.118
0.117
0.155
0.152
0.015
0.043
0.016
0.003
0.138

Male
State orregion anddistrict

Radiography

FemaleMaharashtra (1967-1968)

BombayPoona
Nagpur
Nasik
SangliNandedRatnagiri
Buldhana
Sholapur

6.059
0.725
1.875
0.822
0.281
0.212
0.023
0.014
0.110

Overall

1.894

Tami1 Nadu (1969-1970)

MadrasMadurai
Coirnbatore
Thanjavur
Kanyakumari

4.14690.30640.62090.14030.00480.00030.00050.00041.43910.45020.2171
0.05340.1646
0.04180.07140.00220.26050.08650.04750.00746.01590.88520.95740.20370.30980.08450.10100.0196

0.11370.00230.12150.21850.07800.53400.01580.7664Overall
Northern region (1970.1971)

Delhi
Arnritsar
PatialaChandigarh
Himachal
PradeshHissarHoshiarpur
Jullundar

1.97510.75001.04747.13320.64570.01530.00310.01560.70600.00171.01660.20000.59993.08940.22400.17850.00371.07068.56050.01140.25900.04170.3271
3.52310.03593.44450.99853.060623.01220.91870.32570.04260.08680.13770.07390.05330.00640.43070.00080.00090.02240.04260.00030.13370.00040.00180.00170.00770.00030.02730.10480.00970.61580.87720.00520.00020.02030.00890.00800.01610.00380.00780.00080.0004neg

3.4016
0.54300.42030.07850.01010.15310.41680.01030.62930.11840.02980.00180.0454neg
0.0012neg

0.19080.00980.02570.0065
neg
neg
neg
neg

9.67181.9562
1.22840.38690.08870.93711.63880.01090.24780.06110.03560.00820.00280.01750.02460.0002Overall
Eastern region (19 71-19 72)

I

Calcutta
Cuttack
Patna
RanchiShahabadGanjamSambalpur
Saharsha
Overall

5.4412
1.27700.73650.29630.02540.78321.22040.0006

0.9337

Source: Reference 168.

325

according to the population. and an average of 1.11 mrad
was obtained as representative of the country as a whole.
The frequency of radiographic examinations (excluding
dental and screening examinations) in India as a wholewas estimated to be 35 per 1OOO of population and in
the four areas, 14, 25, 24 and 51. respectively. The
numbers of males and females in various age groups andtheir child expectancy factors are given in table 21.

TABLE 21. AGE AND SEX DISTRIBUTION AND CHILD EXPECTANCY FACTORSOF THE POPULATION SURVEYED IN TABLE 20
Maharashrra

Tamil Nadu

Northern region

Eastern region

Male

FemaleMale

Female

3 161
3 280
2 561
I 694
1 686
1 555
1 236
1 009
926
655
591
286
914

9 311
10 582
7 460
4 934
5 016
5 482
4 688
3 928
3 220
2 608
2 225
1 323
2 702

9 166
10 218
6 392
4 644
5 239
4 969
4 094
3 341
2 973
2 224
1 917
1 133
2 940

4.825
5.362
5.417
5.390
4.795
3.50
2.134
1.056
0.368
0.062
0.0
0.0
0.0

4.24654.92745.01185.06534.9127
4.13912.91551.76300.88010.35170.09030.0
0.0

4.10264.88684.99354.8535
4.11562.9236
1.78440.89900.35930.0913
0.0
0.0
0.0

Age
(y)

Male

Female

,;;4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
;;, 60

2 994
2 890
2 328
1 679
1 718
1 774
1511
1 298
1 067
897
744
505
1 023

2 943
2 845
2 084
1 533
1 781
1 690
1 332
1 097
931
764
649
415
1 061

..;4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
4549
50-54
55-59
;;, 60

4.577
4.836
4.958
4.926
4.745
3.815
2.625
1.613
0.874
0.342
0.05790.0075
0.00

4.116
4.368
4.486
4.214
3.396
2.651
1.660
0.90160.08740.05940.0082
0.00
0.000

Male

Female(a) Population by age and sex ( 1 O')

2 623
2 622
2 212
1 589
1 589
1 576
1 329
1 260
1 055
888
740
411
918

2 510
2 624
2 126
I 538
1 710
1 652
1 313
1 222
1 009
802
674
411
878

3 506
3 729
2 949
2 071
1 930
1 840
1 522
1 217
1130
866
873
436
1 377

(b) 0,i/d expectancy factor

3.27854.08374.29674.45394.17973.25482.04871.351
0.37440.06270.00280.00110.000

3.3937
4.18444.31304.05073.13491.9872
1.03250.38050.06390.00290.00110.0000
0.000

4.96
5.316
5.376
5.417
5.384
4.777
3.482
2.116
1.048
0.365
0.062
0.0
0.0

Source: Reference 168.

(iv)

Iraq, 1972

98. A survey in Iraq during 1972 reported a total of407 x-ray units and 146 dental x-ray units serving the
population of 10 7 (1). The total radiographic exposures
reported were 4.2 10 6 along with 15 10 5 dental x-ray
exposures. The term "examination" is used in thereference to indicate exposures; thus, 2.2 "examinations"were reported per visit. A measurement survey using film
badges determined the gonad dose per examination in agroup of 70 patients. The age distribution and frequencyof examination were derived from an analysis of 1000
patients. The GSD for 1972 was estimated to be
52 mrad, with a probable accuracy of 60 per cent. A
dental survey estimated the GSD from dental radiography to be 0.3 mrad.

(v)

Japan, 1974

99. Pr~lirninary results are available for the GSD
survey in Japan during 1974 (74, 79, 80). The GSD wasestimated to be 16.5 mrad. compared with 25.7 mrad in
the 1969 survey. The frequencies of the examinations
were obtained from a sample of 8.5 per cent of thehospitals with > 300 beds. with somewhat lower
sampling fractions for the smaller hospitals. The
326

frequency of examination for the major contributors
and the resulting contributions to the GSD are given intable 22. The distribution of the GSD with age and thedivision between radiography and fluoroscopy are given
in table 23. The values in parentheses indicate thecontributions in the 1969 survey. The contribution fromphotofluorography for mass stomach screening was
0.15 mrad (83), and that from photofluorography formass chest screening was 0.03 mrad (84).

(vi)

Netherlands, 1972

l 00. New data on the male gonad dose per examination, the frequency of examination and child expectancy
factors were used in conjunction with data from the1967 survey to recalculate the GSD ( 120). It was
assumed that the frequency of all examinations had
increased by 10 per cent per year for each of the four
years 1968-1971. The 1972 value of GSD obtained was
28 mrad. which was not significantly different from the1967 estimate of 19-40 mrad. The measurement survey
was extended and by mid-1974, 6600 measurements had
been made on patients. The GSD for 1974 was estimatedto be about 20 mrad (121). Further studies have also
been reported on the contributions to the GSD due tovarious x-ray diagnostic examinations.

f
TABLE 22. FREQUENCY OF X-RAY EXAMINATIONS AND GSD BY SEX AND TYPE OF EXAMINATION
Japan, 1974
(Units: frequency, number of examinations per 1 OOO of population group; GSD, mrad)
Radiography
Male
GSD

Chest
StomachAbdomenIntestine
Lumbar, lumbosacral
PelvisUrography
BladderHysteroObstetric
Hip joint
Lower leg

145
59
12
3
23
2
3
2

0.2
0.3
1.5
0.7
0.4
0.1
0.4

Other

75.1

9
34

2.2
0.5

Frequency

136
46
10
3
17
3
3
0.9
0.7
1.9
10
20

Frequency

GSD

6.4

309.4

Total
Female

GSD

7
56
2
2
0.5
0.1
0.7
0.3

1.1
0.3
0.3
0.8
0.2
0.4

0.3
0.2
0.5
0.1
0.1

0.1

Frequency

GSD

6
43
2
2
0.3
0.1
0.5
0.2
0.1

2.0
0.5
0.5
0.2
0.2
0.1
0.1

0.5

0.1
0.5

0.9

0.1

5.6

57.9

367.l

Total

Male

FemaleFrequency

Type of examination

Fluoroscopy

4.7

0.1
0.3

0.2

4.4

74.8

1.5

59

3.9

Fractionof total
GSD

Frequency

GSD

294
204
26
10
41
5.2
7.2
3.4
0.8
1.9
18
55

0.1
3.6
1.3
2.8
1.7
0.7
0.8
0.6
0.2
0.5
3.4
0.6

0.6
22
7.9
17
10
4.3
4.9
3.7
1.2
3.0
21
3.7

143

0.1

0.6

809.5

16.4

{%)

100

Sources: References 74, 79, 80.
Note: A dash(-) signifies that the GSD was less than 0.05 mrad.

TABLE 23. GSD FROM X-RAY EXAMINATIONS BY AGE AND SEX
Japan,1974(mrad)
30-44 y15-29 y0-14yType ofexamination

>4Sy

Male

FemaleMale

FemaleMale

FemaleMale

FemaleTotal

Radiography

1.51(1.32)

1.16(0.61)

4.22(7 .23)3.24(4.31)

0.63(1.45)

0.32(0.30)

0.02(0.02)

0.0

11.1(15.2)

Auoroscopy

0.20(0.41)

0.53(0.64)

1.04(2.64)

3.00(5.62)

0.22(0.54)

0.39(0.61)

0.01(0.01)

0.002

5.4(10.5)

Total

1.71(1.73)

1.69(1.25)

5.26(9.87)

6.24(9.93)

0.85{1.99)

0.71(0.91)

0.03(0.03)

0.002

16.5(25.7)

Sources: References 74, 80
Note: Values in parentheses are the 1969 dose values (74).

( vii) Puerto Ricol O1. In Puerto Rico a repeat in 1973 on the same basis
as the 1968 survey included new frequency data derived
from questionnaires about one week's work in all the
hospitals (61). The new gonad doses per examinationthat are reported show apparent decreases comparedwith those in the 1968 survey. but these recent values
would appear to be based on very few measurements.
The frequency of lumbar spine and abdominal
examinations, particularly in females, has increased thecontribution to the GSD from these examinations byfactors of three and two respectively. There was however
no significant change in the overall GSD, which wasestimated to be 46 mrad, compared with 43 mrad in the1968 survey.

(viii) Romania, 1970
102. The frequency of the use of x rays in Romania
during the period 1953 to 1970 increased from 429 toI O12 examinations per I OOO of population. This
increase has predominantly been in radiography (37 to238) and photofluorography (54 to 452). with a slightdecrease in fluoroscopic examinations (338 to 322). A
measurement survey has been conducted in which direct
patient measurements using thermoluminescent detectors have been made during 5370 radiological, 8750
fluoroscopic and 9370 photofluorography examinations:
The GSD. has been estimated for the first time and avalue of28.5 mrad obtained {177).

(ix)

Sweden, 1974

103. From preliminary data reported by Bengtsson etal. {17), it is possible to analyze the changes that hav.e·. hoccurred .m the factors from whi ch th e GSD in Sweden
was derived in the 1962 report by the Committee:~!

results of this analysis are shown in table 24.

· ·
327

TABLE 24. ANALYSIS OF THE INCREASE IN THE GSD
Sweden, 1955-1974

Type ofexamination
Lumbosacral region
Pelvimetry
Urography
PelvisAbdomenColon
Hip and femur
Urethrocystography
FemurbObstetrical abdomen

Ratio ofRatio ofexamination
gonad doses
frequency
1974/1955
1974/
Female
1955
Male

Male

FemaleFoetusMale

FemaleFoetus

0.18

6.30

1.36
0.28
1.17
0.40
0.93
2.03
0.25
0.14
0.02
0.06

0.14
6.40
.0.16
0.03
0.11
0.21
0.01
0.02
0.01
1.20

1.75
2.43
1.80
0.70
1.68
8.16
1.90

2.44
0.33
4.36
0.71
0.42
1.64
0.96
0.24

0.25
1.35
0.39
0.05
0.05
0.17
0.04
0.03

0.08

1.59

1.55
2.59
2.59
1.86
2.63
1.76
2.70
2.25

0.27
0.36
0.15
1.71
1.38
0.54

GSD (mrad)
1955

1.16
0.46a
0.95
0.95
0.17
0.46
1.42
0.77

2.33

0.57

1.42

(No change assumed)

3.48
2.70
1.78
0.56
2.19
1.57
1.40

Subtotal
Other
Total

1974

20.0

7.2

8.3

18.4

11.2

3.9

0.3

1.8

0.2

0.4

2.6

0.3

9.0

8.5

18.8

13.8

4.2

20.3

Total of male, female and foetus totals for the year

37.8

Enhanced 1974 totals due to an assumed shift in age distribution

36.8
24.4

Total of enhanced totals

16.5

5.0

46

Source: Reference 131.
a For the mother; the ratio for the foetus is 0.03.
bNot included in comparison; no data for 1974.

104. It can be seen from table 7 that the totalfrequency of examinations (excluding dental exposures)increased by 50 per cent from 1955 to 1974. Table 24
shows that the increase in the types of examination
which give the highest contributions to the GSD has
been higher, nearly 100 per cent. The mean gonad dosesin the various types of examinations have sometimes,
but not always, been substantially reduced. The result isthat the male contribution to the GSD has not changed
despite the increased number of examinations. The
female contribution, however, has increased approximately in proportion to the higher number of
examinations, since there has been no apparent dose
reduction in the types of examinations which give thehighest contributions (e.g., urography and examinationsof the lumbar spine). Due to improved techniques, thefoetal contribution has decreased despite an increase in
the number of pelvimetries. In total, the annual
genetically significant dose from x-ray diagnostic
procedures in Sweden has not changed significantly fromthe value of 38 mrad assessed for 1956, assuming noshift in the age distribution within the types of
examinations giving the highest contributions. Bengtsson
et al (17), however, take into account an enhancement
due to shift towards younger patients, corresponding toa factor of 1.2 for females and 1.3 for males. If thiscorrection is made on the results in table 24, the annual
GSD will be assessed at about 46 mrad.

films used in 1971 was estimated to be 15 10 6 ,compared with 5 10 6 in 1957. The total number of
examinations in 1971 was estimated to be 8.55 10 6 •increasing annually at the rate of 34 per cent. The
number of examinations per caput of the population
increased from 0.96 in 1957 to 1.35 in 1971. The GSD
for 197 I was estimated to be 42.9 mrad; the breakdownby type of examination is given in table 25. A
calculation shows that by using suitable gonad shielding
the GSD could be reduced by 20 per cent to 34.9 mrad.
TABLE 25. BREAKDOWN OF GSD
BY TYPE OF EXAMINATION
Switzerland, 1971

Contribution to GSD
Type of examination(mrad)(%)

Pelvis without pregnancies
Descending urography
Hip and femur
Lumbar vertebrae
Barium meal
Barium enema
Urography
Obstetric abdomen
Abdomen without pregnancies
Pclvimetry
Other

9.24
8.74
6.24
3.81
2.19
1.91
1.29
1.06
1.01
0.52
6.89

21.5
20.4
14.5
8.9
5.1
4.5
3.0
2.5
2.3
1.2
16.1

42.90

100

Total

Source: Reference I 70.

(x)

Switzerland, 1971

105. A radiological survey of the frequency of 60 typesof x-ray examinations was carried out during two weeks
of September 1971 and information recorded on 60 OOO
patients in 1567 hospitals (170). The total number of328(xi) Island of Taiwan, 1972
I 06. A survey was conducted over eight months of
I 972 in five hospitals in the city of Hsineku, consideredF
to be representative of the five major cities on the i'slandof Taiwan, where the urban population is 5 10 6 (261).
about one half of the total population. The method of
estimating the frequency of: examination and the gonaddose per examination was simplified. It would appear
from the reference that the radiation dose incident to
the gonad region was integrated, using a thermoJuminescent detector, for all patients examined radiographically over a period of one month on five x-ray
units at the five chosen hospitals. A separate detector
was used for those patients having fluoroscopic
examinations. A mean gonad dose was used for all
examination types, and the age distribution of thoseexamined was used in the calculation of the GSD for
1972, which was found to be 3-4 mrad.

WHO staff report (64) describes the present status ofradiological services in several countries of the eastern
Mediterranean area. The report compared the average of
one diagnostic x-ray unit per 72 OOO people with theUnited States situation of one unit per 1000 people, andthe film consumption of 0.063 film per person-year with
the United States value of 2.46 films per person-year.

4. Groups of epidemiological interest
109. Collective doses to special patient groups are ofparticular interest when they can be used for
epidemiological studies. Annex G describes in detail theuse of such information, from past medical practices, forthe assessment of carcinogenesis risks.

(xii) United States surveys in 1964 and 1970
107. The dosimetry of the United States surveys in 1964
and I 970 has been revised, and the new national
estimates of the GSD in those years from radiographic
examinations only are 16 and 20 mrad, respectively(25 I, 255). The contribution from screening examinations was not included. The main examinations and theircontributions (per cent) to the 1970 total were as
follows: lumbar spine, 18; urography, 16; pelvis, 12:
abdomen KUB and flat plate, 10; other abdominal
examinations, 20; barium enema, 10; hip, 5. The
frequency of x-ray examinations is given in table 26.
TABLE 26. FREQUENCY OF X-RAY EXAMINATIONSBY TYPE OF EXAMINATION

110. The organs of special interest in these investigations, for which dose information are required, are:Public health investigations:
DentalSkin, thyroid, hypothalamus,
lens of the eye: particularly forpatients having regular wholemouth x-ray examinations

Mass surveysof the chest

Lung, heart, thyroid, bonemarrow;
particularlyforpatients with a history ofchronic chest disease

Mammography

Breast; particularly for groupsof high breast-cancer risk

United States, 1970

Type of examination

Head and neck
Oiest
Radiography
Photofluorography
Not categorized
Oiolecystography, andcholangiography
Lumbar and dorso-lumbar spine
Upper GI tract
Upper abdomen not categorized
Abdomen KUB and flat plate
Urography
Barium enema
Pelvis, lumbo-pelvis
Lower abdomen not categorizedUpper extremities
Lower extremities
Two-area examinations
Total

Frequency(number of examinations
per 1 OOO of population)

Ginical investigations:
Barium meal

Stomach, bone marrow, small
intestine, pancreas; particularly
for patients having multiple
fluoroscopic examinations

Barium enema

Large intestine, particularly forpatients with chronic diseases
such as ulcerative colitis

Orography

Kidney, particularly in patientswith chronic disease or kidney
failureChildren withorthopaedic
handicaps

Epiphyses of bones, gonads,
bone marrow

49.8
251.7
53.7
32.5
20.7
18.7
29.1
8.0
17.5
20.7
17.8
10.6
22.7
50.9
62.6
1.8

668.8

Source: Reference 2 51.

(xiii) Projections of GSD for other countries
108. Three new estimates of GSD {India, Iraq andTaiwan) have been reported for populations that have
limited radiological facilities. Low frequencies of radiological examinations correlate in principle with small
GSD. unless very high individual doses are involved. A

Foetal irradiation Whole body of foetus
Cardiaccatheterization

Heart, lung, bone marrow;particularly in children

Pace-makerinsertions

Heart. lung. bone marrow andconnective tissues in vicinity of
nuclear-powered pace-makers;
particularly in patients under
40 years of age

Dynamic
investigations

Organs in the chest for cardiac
investigations and the kidneys,
large intestine, bladder andgonads for pelvic examinations

Neurologicalexaminations

Eye, thyroid, hypothalamus329

5. Potential means of dose reduction

Ill. ICRP publications 15, 16 and 21 (97, 98) andcertain WHO publications (I 12, 216) indicate generalways in which the patient dose in diagnostic radiology
may be reduced without loss of useful information. In
addition to these, there are a number of national
publications giving general guidance on procedures likely
to reduce patient doses. These may be summarized asfollows: implementation of the "ten-day rule'' in the
United Kingdom (193), guidelines on use of gonad
shielding in the United States (252, 253), radiologicalprotection in dental practice in France, the United
Kingdom and United States (162, 241, 149, respectively), and general radiation dose reductions (26, 40,
144,154,201,218,233,256).
112. Useful surveys have been carried out on aspects ofdose reduction, such as the rate of retakes of x-ray
examinations in hospitals in Ja pan ( 117) and in twolarge hospitals in the United States (29).
113. Investigations have been made on the effect ofpositioning for radiographic examinations and theresulting gonad dose (62), and on the design andeffectiveness of gonad shields (33). Absorbed dose
measurements of male gonad doses have been made inphantoms representing various age groups by Warner(257). Studies of the range of gonad doses for particularexaminations in the German Democratic Republic
indicate that the maximum tends to be about twice themean value (202). The reduction in gonad dose duringmass chest screening by appropriate use of shields,
particularly when examining children. has been demonstrated by Hashizume in the Japanese 1975 survey
report (84).

114. Comparisons of the radiation exposure of patientsusing various types of apparatus have also been studied,e.g., on the exposure reduction obtained by using image
intensifiers instead of fluoroscopy (87).
115. Questionnaires aimed at determining how muchthe public knows about radiation-dose reduction haveproduced answers that indicate that further education,
not only of radiological personnel, but also of thegeneral public is required (195. 240). General descrip·
tions of examination techniques, such as those producedin the German Democratic Republic (200, 217}, may
help.
116. The introduction of new techniques, such as
pulsed fluoroscopy and electronic retention of theresultant image, should reduce the radiation dose by afactor of five in the case of stomach examinations ( 156).
However, Gustafsson (69) has reported that, in acomparison of 1974 techniques with those used in 1960,
the mean energy imparted (integral dose) for stomach
examinations has remained the same despite theadvances in techniques (figure XI). In barium enema
examinations, the mean energy imparted has increased
by 50 per cent from 1960 to 1974 (69).

en
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1960

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1974

Figure XL Comparison of mean energy imparted in stomach examinations by various techniques, 1960-1974

330

F
B. DL\.GNOSTIC USES OF
RADIOPHARMACEUTICALSTABLE 28. SURVEY OF THE DEVELOPMENT OF NUCLEAR MEDICINE IN THE GERMAN DEMOCRATIC
REPUBLIC, 1965-1974

1. Trends in frequencies and techniques(1974 population approximately 17 10 6 )117. In the 1972 report attention was drawn to the factthat in certain countries the number of diagnostic
examinations using radiopharrnaceuticals was doubling
approximately every three years. This trend iscontinuing, and therefore it is important that more data
should be presented so that estimates of organ dose and
GSD may be calculated. Most examinations using
radiopharmaceuticals give organ doses of about the sameorder as or less than complementary x-ray examinations(99, 238). Examination of the thyroid using 1 31 I is themain exception, but with the introduction of alternativein vitro techniques, the number of in vivo tests using131
I is likely to decline (172). The growth ofradioisotope uses in developing countries is being
monitored by lAEA (96); from their data it may bepossible to assess the effect of the introduction andgeneral availability of short-lived radiopharrnaceuticals
and the changes in demand resulting from new x-ray
facilities, such as computerized axial tomography.
118. The annual frequency of radionuclide examinations was given in the 1972 report for a number ofcountries for the late 1960s as 2-10 per 1000 of
population. With a doubling time of three years, it isnow, in several places, approaching and even exceeding
10 per 1000 of population as can be seen in figure XII
arid in table 27 (93). which show the increase in the30000

I 99fflr,

"'

~
::;

t

<

i

~
~

/
I

10000

/
.," 13tl(Hipp$anl}~.,,,,

:::,

z

,"j

~

......• 198Au

57

o k::::;::::::::=......,.......ql!.:l:<~,~.:.,~;;:;·;~;~~~;,··~.:;:.:,.:~·;~;;::;~:..f::'.·~:.:··.·=:.:.::_:..:·;.-_..:;eo.::_51co::_

~

11155

~

1~

=

Figure XII. Trend in the annual number of applications ofcertain radionuclides in West Berlin, 1953-1975 (93)

TABLE 27. SURVEY OF THE DEVELOPMENT OF
NUCLEAR MEDICINE IN WEST BERLIN, 1955-1975(1975 population approximately 2.2 10 6 )

1955
1960
1965
1970
1975

25 91331 89542 46171 37877 172131 021137 128
167 483

1.5
1.9
2.5
4.2
4.5
7.7
8.0
9.9

96.96
97.06
97.67
98.79
98.75
99.20
98.94
99.16

3.04
2.94
2.33
1.21
1.25
0.80
1.06
0.84

Source: Reference 202.

TABLE 29. TRENDS IN THE 1 3 ' I-UPTAKE TESTS IN THE
GERMAN DEMOCRATIC REPUBLIC, 1958-1974(Administered activity 25-30 µCi)

Year

Numberof tests

1958
1960
1965
1970
1971
1972
1973
1974

729
2 818
10 19220 09221 90226 32625 17024 969Fraction of
all radionuclide
diagnostic
examinations (%)

40.6
28.5
27.8
21.6
18.5
15.0

Frequencyof test(per l(J()()of
population)

Number of
performing
facilities

1.47

2
6
11
14
15
16
16
17

Source: Reference 202.

ll 1111ododol

/

Year

1965
1966
1967
1970
1971
1972
1973
1974

/

~ 20000;

Year

NumberDistribution by purposeof allFrequencyof application (%)
radionuclide (per 1000 of
applications population) Diagnostic
Therapeutic

Number
FreDistribution by purposeof allquencyof application (%)
radionuclide (per I (}Q() ofapplications population) Diagnostic
Therapeutic

729
4 220
15 22830 23664 720

0.32
1.92
6.92
13.87
32.29

Source: Reference 93.

90.5
91.0
97,1
98.1
99.2

9.5
9.0
2.9
1.9
0.8

annual number and frequency of application of radiopharmaceuticals in West Berlin (91, 92, 93 186), and in
table 28, which show similar data for the German
Democratic Republic (202). Table 29 shows the
reduction in the frequency of 131 I-uptake tests in theGerman Democratic Republic in the last few years dueto the introduction of in vitro techniques.
119. The introduction of new nuclides in radiophannaceuticals giving lower doses for some types of
examinations has to some extent minimized the increasein dose that would be expected from the rapid increasein the number of radiopharmaceutical examinations.
This is illustrated in figure XIII, which shows how thechange froin 198 Au to 9 9 m Tc in liver scans has reduced
the gonad dose per examination by a factor of three sothat the collective dose has increased but little, eventhough the total number of examinations has increased
substantially (151 ). Roedler et al (186) have calculated
the achievable dose reduction for examined or criticalorgans and gonads by selection of suitable radiopharmaceuticals (see table 30). The most promising dose
reductions have been made possible by the introductionin the mid 1960s of 9 9 m Tc, which is now in increasing
use all over the world.
331

15000

Total

en

z

~

'/ '/99tnr C

0~ 10000

i<(
X

w

...0
a:

w
5000

z

/

/

/

/

/

/

/

/

j
C:

1w
"'0

/'/'/

z

;
:,

7

;,
/'/

500

0
0

/

Total .,,."'
/

<(

z

0

/

C)

w

>

/

~

·········•..

(.)

w

.J
.J

0

(.)

·········

/
1968

1969

1970

_ _ ..-

1971

1972

1973

1974

1975

/

/99mT

C

//

.......

/-~/'"······)~:..
O ...__.,..,,,_ _~1_1_3m.,.,1,::n:..·::~_··:..:·:_==·..,,........._···_··_·..~··-":..:··:..:·"::;":;:··:.:.·~8:.:.•~:.:.•'::.;·~--~/.,,.......
113mln···... ...

'•,,,198Au

0 L....-,--~---,o..::.:·:=-=:-;::.:·-=-~-·-·~··-=··.:.:"=-=··;:.··c.e·.?.,"'!.''!.;'--

1968

1969

1970

1971

1972

1973

1974

1975

Figure XIII. Trend in the annual number of examinations and collective gonad dose for liver scans in Sweden 1968-1975 (15 I)

TABLE 30. DOSE REDUCTION FOR EXAMINED OR CRITICAL ORGAN AND GONADSBY REPLACEMENT OF CONVENTIONAL RADIOPHARMACEUTICALSDose reduction coefficientRadiopharmaceuticafl
Conventional

Replacement

Diagnostic method Examined or critical organ"'I
iodide (43)"mTc
pertechnetate(1000)

Thyroidscanning

Thyroid'" I
iodide (25)Functiontest (30%)

Thyroid19'Au
colloid (240)

99

58

"Co

Co
vitamin B12 (0.9)

1311

MAA (220)

}

0.013

2.6

mTc
Liver scanning
S-colloid (1 500)

Liver

0.063

0.13

Schilling test

Liver

0.12

0.11

nmTc
MAA(3 000)

Lung scanning
(66%)

Lung

1.1

0.071

'"Xe

Lung scanning
(34%)

Lung

vitamin B12 (0.5)(15 OOO)}"'IHSA (10')99mTc
HSA (100)

Blood volume

Total body

0.088

0.1

"' I

nmTc
HSA (500)""

Placental
localization

Total body

0.44

0.5

••mTc
HSA (1500)

Myelography

Total bod}

0.13

0.15

'"Hg
BMHP (360)t9mTc
S-colloid (1 SOO)

Spleenscanning

Spleen

0.15

0.069

15

Sr
nitrate (330)nmTc
polyphosphate(10 OOO)

Bonescanning

Skeleton

0.11

0.2

1o•Hg
BMHP (400)9tmTc
DTPA (3 OOO)

Kidney scanning

Kidney0.00090.0096

l03Hg

t9mTc
DTPA (3 OOO)

Kidney scanning

Kidney

0.017

0.053

HSA (10"')1311

HSA (100"')

chlormerodrine(180)

Source: Reference 186.
The mean administered activity in microcuries is given in parentheses.

0332

Gonads140

Rectilinear scanners

120

Static scans

I

100

.I

0

w

I

..J

..J

<
!;;
z

100 OOO

,~

u.

I

a:
w

i

80

en

t::

z

:,
u.

0

a:

i

~ 60
~

:,

z

i

i

i

/

/

0

CX)

:::,

z

')'-cameras/,,,.. .....

z
<
u
en

:E

I

40

en

/

/

/

50 OOO.,.../

/

~/

/

20

----- --

0
1963

1964

1965

1966

1967

1968

/

/

1969

/

/

Dynamic studies············-"--7>
1970

1971

1972

1973

Figure XIV. Number of scanners and r-cameras installed in the United Kingdom. 1963-1973. and total number of static scans anddynamic studies carried out, 1971-1973 (I 72, 188, 189)

120. Part of the increase in frequency of examinationsin the United Kingdom is due to the increased
availability of imaging equipment; the increase inscanners and cameras in England and Wales is shown forthe period 1963-1973 in figure XIV (172, 188, 189). Ina population of 50 10 6 , the number of scans, also shownin figure XIV, doubled every two years and by 1973
amounted to 2 per 1000 of population.

121. The most common single type of radionuclide
examination is the thyroid function (uptake) test with
13 1
I. In many countries it accounts for about one thirdof all radionuclide examinations, while in technologically advanced countries this proportion has declined
to about 10 per cent of the total, as can be seen from
Table 31 (96). The use of in vitro T3 and T4 tests to
replace in vivo uptake studies is significantly reducing
333

TABLE 31. RELATIVE PROPORTION OF IODINE-131
THYROID UPTAKE STUDIES IN VARIOUS COUNTRIESFraction of all radionuclide
investigations (%)

Country

Argentina
BrazilDenmark (1973/74)
Hungary
India
IsraelMexicoPolandSweden (1968)
Sweden (1974)
United State~
Yugoslavia

40
47
9
27
38
18
23
30
19
12
8
22

the radiation dose to this group of patients in the United
Kingdom (I 72). The introduction of the use of 123 I forthyroid imaging would reduce the dose by a factor of<1bout 10 compared with 131 I (254).
122. It is possible to complete the picture of the use of
I by presenting some data compiled by IAEA (96)on the us!l of r:idionuclides in 11 countries for periods
around 1970. Tables 32 and 33 give the frequencies, theaverage administered activities and the range of activities
in these countries for thyroid uptake studies and thyroid
scans with 1 3 1 I. It has already been shown ( table 31)that thyroid uptake studies dominate the number ofradionuclide examinations in many countries. It can beseen from table 32 that, with the exception of India,
there is relatively little variation in the frequency of
uptake studies, the range being 0.12-2.29 per 1000 of
population. Table 33 shows that there is. on the averageone 1 3 1 I thyroid scan for every two uptake tests. The
administered activities range between 9 and 44 µCi forthe uptake studies and between 31 and 116 µCi for thescans. It is important to obtain more recent informationon these aspects, as the situation is likely to havechanged significantly in the last eight years.
131

Source: Reference 96.
aData from 65 academic divisions of nuclear medicine(231).

TABLE 32. FREQUENCY OF 1 3 1 1-UPTAKE STUDIES AND
THE ACTIVITY ADMINISTERED IN VARIOUS COUNTRIES
Administered activity(,sCi)

Population
Country(10 6)

Frequency(per lOOOof
population) Range

Argentina
24.0
Brazil91.3
Denmark(1973)
5.06
Hungary
10.3
India
537.0
Israel2.82
Sweden7.9
Mexico48.9
Poland32.5
UnitedStates (1966) 195.0
Yugoslavia
20.4

Mean
(population
weighted)

0.66
0.18

5-100
20-70

44
41

0.89
1.40
0.013
2.29
1.14
0.12
0.46

0.5-50740
6-35
2.5-35
5-50
5-60

20
16
16
21
9
14
13

1.54
0.66

2.5-100
5-100

37
31

Source: Reference 96.

TABLE 33. FREQU.,ENCY OF 1 31 I THYROID SCANS AND
THE ACTIVITY ADMINISTERED IN VARIOUS COUNTRIES
Administered activity(,sCi)

Population
Country(10 6 )

Frequency(perlOOOof
population) Range

Argentina
24.0
Brazil91.3
Denmark
5.06
Hungary
10.3
India
537.0
Israel2.82
Sweden7.9
Mexico48.9
Poland32.5
UnitedStates (1966) 195.0
Yugoslavia
20.4
Source: Reference 96.

334

Mean
(population
weighted)

0.23
0.093
0.23
0.36
0.003
1.38
1.53
0.077
0.14

50-10015-30015-50
20-10010-50
4-100
50-18010-100

78
32
41
31
41
116
50

0.78
0.63

10-15020-10057
45

2. Individual dose per unit procedure(a) Administered activity
123. As with x-ray examinations, the doses received
during radiopharmaceutical examinations vary from
hospital to hospital. In this case, however. comparisonsare somewhat easier because the choice of nuclide,chemical substance. mode of administration andadministered activity define the dose for any particularinvestigation of disease. Interesting comparisons may
therefore be made on the basis of the administeredactivity, once the other factors are kept constant, which
is usually the case within each type of examination andfor each nuclide.
124. Data are available from Sweden on the average
activity used in each type of examination and on thelowest and highest average activities used in particularclinics. On the basis of the reported average activity, thehighest organ dose (in the average procedure) has been
calculated, together with the gonad dose. The results areshown in tables 34 and 35 for 1968 and 1974 (151). The
doses have been calculated using data from Swedishcompilations (59).

8071125. Tables 34 and 35 may be compared with tables 36
and 37. where similar information is presented forDenmark (1973-1974) and the United States (1966)(219, 248). There is a great degree of similarity in thepractices for the corresponding years. These recent data
give a relatively clear picture of the magnitude ofradionuclide examinations in technologically developed
countries for the year I 974. The variation inadministered activities in three of the most common
types of examinations is shown in table 38.

TABLE 34. DATA ON THE USE OF RADIONUCLIDES FOR DIAGNOSTIC PURPOSES
Sweden, 1968

Radionuclide

Type ofexami11atio11

Thyroid scan{ rn 1,'"I
vvmTc

Thyroida"' I{ ,,. I

Brain scan

tvmTc

Lung scan
Skeleton scan

"'I

85

Sr
{ ,v"Au

9911\Tc

Liver scan

131

I

,nAu

RIIISA
Pertechnetate

MAA
Chloride
Colloid
S-Colloid
Rose Bengal
Colloid
Methionine

l'O
PO
PO
PO

IV
IV
IV
IV

IV
IV
IV
IV
IV

75

Profile sc:1n"'I

IodidePO

Thyroid function{ "' I'"I

IodideIodidePO

Brain circulation
Circulation test
Lung function

1311

RII-ISAIAIM
IV

Potassium determination
Iron metabolism
Schilling test

12SJ

•2K
s9Fe

r·eo
58

{

Renography

Se

'"Xe
111
Xe
{ "'I

57

Co
Co

I
"' I
1ai

'"I
Other
Total
Source: Reference I SI •aconcer patients.

w
w

IodideIodidePertechnetatc
IodideAdmlnistration
metltod

Marrow scan
Pancreas scan

Blood volume

Vo

Cltemical fonn

Sol
Sol

RIHSA
RIHSA
Chloride
CitrateVitamin B11
Vitamin B12
Vitamin B12
IodideHippurate
Hippurate

PO

IV
IV
PO
PO
PO
PO

PO
IV

IV
IV

Administered activity
per examination (µ.Cl)
Average

41
42
I 700
980

Lowest

4
30
1 OOO
750

353

94

10 OOO
235
53

3 720
130
30
100
600
100
300
200
50
2.5
6
50
20
500
I
I

182
2 800

128
921
210
220
9
16
156
109
I 720
II
3
ISO
5
0.4
0.4
0.4

so
23
14

so

3
0.24
0.05
0.16
50
10
I

Higllest

100
50
2 100
1 OOO
500
14 OOO
325
200
300
3 OOO
300
2 OOO
250
241
35
127

263
300
4 900
115
8
107

40
0.5
0.7
0.75
50
200
100

C,-it/calorgan
dose perexamination(mrad)

Criticalorgan

73 OOO
31 OOO
430

ThyroidThyroidThyroid

12 OOO
I 700
I 200
1 500
7 800
800
240
39 OOO
12 OOO430 OOO
16 OOO
12 OOO
5 300
2 800
34
380
8
950
760
730
ISO
35
120
40
3

Thyroid
Lower intestine
Lung
Skeleton
SpleenLiver
Liver
SpleenKidneyThyroidThyroidThyroidThyroid
Adipose tissue
Trachea
Thyroid
Blood
GI tract
Spleen
Liver
Liver
Liver
GonadsBladder
KidneyNumberofexaminations

12 091
766
610
89
40
I 033
391
545
2 894

590
96

Gonad dose
Frequency(per 1000
Per 1000 of
Perexamlnof
ation
population
population) (mrad)(man rad)

1.53
0.097
0.077
0.011
0.005
0.130
0.049
0.069
0.365
0.075
0.012
0.024
0.005
0.017
1.14
0.032
0.013

193
38
138
9 002
251
99
I 231
811
954
818
292
377
523
I 430
I 436
121
5 176
2 849
2 728

0.102
0.120
0.103
0.037
0.048
0.066
0.181
0.181
0.015
0.654
0.360
0.345

47 616

6.02

0.155

96
16
14
2 300
I 600
170
ISO
400
90

(50)

0.147
0.002
0.001
0.026
0.008
0.022
0.007
0.028
0.033
0.005
0.001
0.011
0.011
0.009
0.024
0.000
0.009
0.016
0.000
0.006
0.000
0.007
0.003
0.017
0.010
0.000
0.002
0.000
0.000
0.017

70

0.422

64
92
450
2 200
510
21
6
720
(100)
I
50
2
200
72
260
57
2
120
I
I

TABLE 35. DATA ON TIIE USE OF RADIONUCLIDES FOR DIAGNOSTIC PURPOSES
Sweden, 1974

Type ofexamination

Thyroid scan
Brain scan
Lung scan
Skeleton scan

Chemical
form

u1 1
'"I
,,mTc
,,mTc
umTc
"'I
"mTc

IodideIodidePcrtechnctatc
Pertechnctate
DTPA

PO

MAA
MAA

"Sr

01loridc
Phosphate
Colloid
S-colloid
Culluid
Metionine
8-colloid
IodideIodideIodide
Sol
Sol
RIHSA

IV
IV
IV
IV
IV
IV

umTc
98
'
Au
,,mTc
19
"Au

Liver scan
Marrow scan{'5Se
99111Tc

Pancreas scan
Profile scan
Thyroid function
Thyroid 0
Circulation test
Lung function
Blood volume
Iron metabolism

Administration
methodRadionuclide

"'J
"' I
1>1 I
'"Xe
"'Xe
{ "'I
125 (

Schilling test

"Fe
{ "Co
51
Co

Renography

{'"
'"JI
I SI I

Other
Total
Source: Reference IS I.
acancer patients.

PO
IV

IV
IV

IV
IV

IV
PO
PO
PO

IM
IV
IV

RIHSA

IV

Chloride
Vitamin B12
Vitamin B12
Hippurate
Hippuratc

PO
PO
PO
IV

RIHSA

IV

IV

Administered activity
per examination (µCi)

Average

Lowest

4
II
600
5 OOO
14 OOO
300
I OOO
40
4 OOO
120
500
833
500
240
200
2 OOO
2 OOO
100
479
12
2
279
200
319
8
2 517
263
4.4
1.5
4.6
0.7
6.9
0.6
0.57
0.05
0.44
0.05
32
6
17
6
10
10

86
25
1 810
10 95014 360
767
I 780
66
8 670
138
2 050

Highest

1 OOO
40
5 OOO
15 OOO
14 700
1 500
3 OOO
100
15 OOO
175
5 OOO
1 aoo
250
2 OOO
950
30
357
1400
10 500
6
10

20
0.8
0.5
200
40
10

Criticalorga,1
dose perexamination(mrad)

Criticalorgan

153 OOO
18 500
920
1 860
5 600
3 900
90
1 900
1 765
5 900
585
35 OOO
13 500570
936 OOO
21 OOO

ThyroidThyroidThyroid
Lower intestine
BladderLung
Blood
Skeleton
Bladder
SpleenLiver
SpleenKidneyLiver
ThyroidThyroid

8 200
50
150
12
I 050
210
38
56
4
340

Adipose tissues
Trachea
Thyroid
Blood
SpleenLiver
Liver
Bladder
KidneyThyroid

Numberofexaminations

Gonad dose
Frequen,•y(per 1000
Per 1000 of
Per exaof
population
minatio,1
population) (mrad)(man rad)10 101265
3 647
10 894
I 382
200
2 084
831
3 926
162
10 600
97
328
236
155
11 796
346
259
2 652
I 546
695
484
727
I 682
11 4758 311
110
10 774

1.22
0.032
0.439
1.31
0.166
0.024
0.251
0.100
0.473
0.020
1.28
0.012
0.039
0.028
0.019
1.42
0.042
0.031
0.319
0.186
0.084
0.058
0.088
0.203
1.38
1.00
0.013
1.30

95 765

11.5

202
10
30
185
280
490
20
500
135
68
47
410
2 500
46
I 100
28
640
(300)
I
20
3
JOO
80
2
I
I
(50)

0.246
0.000
0.013
0.242
0.047
0.012
0.005
0.050
0.064
0.001
0.060
0.005
0.098
0.001
0.021
0.040
0.027
0.009
0.000
0.004
0.000
0.006
0.007
0.000
0.001
0.001
0.001
0.065

80

0.922

45

,

.

TABLE 36. DATA ON 'fHE USE OF RADIONUCLIDES FOR DIAGNOSTIC PURPOSES
Denmark, 1973/74
Go11addo:seType of examination

Thyroid scan
Brain scan{Radio·,wclfdeCllemlcal
fonn

Ill I
umTc
nmTc

IodidePertechnetate
Pertechnetate{ umTc"'lLung scan
Skeleton scan
Liver scan
Pnncroos scan

Thyroid function
Circulation test
Lung function
Iron metabolism
Schilling test
Rcnography
Kidney clearance
Other
Total
Source: Reference 219.

nmTc
"mTc
75

Sc

{ ,,, I
••mTc

•nxe

"'Xe
"Fe
51
{
Co
"Co
{ ISI I
"'I
51
Cr

MAA

Microspheres
Phosphate
S.Colloid
Methionine
IodidePertechnetate
Sol
Sol
CitrateVitamin B12
Vitamin B 12
Hippuran
Hippuran
EDTA

Number ofaaminat/ons

Frequency(per 1000of populatfon)

Administeredactivity per
examination
(µCl)

1 187
2 605
8 624
334
714
1 409
2463
46
4 525
447
2 112
123
140
1 101
932
7 539
2 638
1 019
10 741

0.235
0.515
1.70
0.066
0.141
0.278
0.487
0.009
0.894
0.088
0.417
0.024
0.028
0.218
0.184
1.49
0.521
0.201
2.12

78
1 493
11 890293
I 467
10 250
1 689
263
20
1 OOO
90
2 852
10
0.54
0.44
36
26
82

48 6999.62

Perexaminat/011(mrad)Per 1000 of
poplllation(ma11 rad)

183
25
200
187
19
154
56
2 740
47
17
(100)
I
145
80
2
I
1
1
(50)

0.043
0.013
0.340
0.012
0.003
0.043
0.027
0.025
0.042
0.001
0.042
0.000
0.004
0.017
0.000
0.001
0.000
0.000
0.106

75

0.719

TABLE37_ DATAONTHEUSEOF
UnitedType ofexamination

Radio-

Thyroid scan
Brain scan

u1 I
99mTc
1
"Au
131 I

nuclide{Liver scan

1,1 I
Lung scan
assr
Skeleton scan
131 I
Thyroid function
u1 I
Blood volume
Vitamin Bu absorption 6•coChemicalform
IodidePertechnetate
Colloid
Rose Bengal
Albumin
Chloride
Iodide
RIHSA
Vitamin B 11

Adminisrered activity
per examination (µCi)

Administrotion
methodAverage

PO
IV

7 937

57
175
158
260
105
37

IV
IV
IV

IV
PO

LowestHighest

10
600
60
SS
100

150
15 OOO
500
400
350
300
100
22.5
1.4

so

IV

5.5

PO

0.5

2.5
0.5
0.1

Source: Reference 248.
w
U)
0
C
2

50

99"'Tc pertechnetate thyroid scan

w

>
<.?

1311 thyroid scan

40

u.

0

>- 30
zw
(.)

::::,

0
w

a:

20

u.

w

> 10 -___.,.
i\----_.,,.. \.--·--·,

j::
c(
...J

w

a:

.....

0

.........

0.1

"'

10

1.0

100

200

rad

THYROID DOSE PER EXAMINATION

w

U)

60

)(

0

I\

C

zw
50
>

I \

I

i,
u.
0

>z

I

40

(.)

w

::::,
0

Liver dose

30

/

I

/

99mTc sulphur colloid liver scan

\
\

\

\
\

Thyroid and liver dose
99 mTc pertechnetate brain scan

w

a:

u.

w

.";·\

20

~
I-

c(
...J

w

10

a:

I

I

.~·----.lt::::.-><---;)(- -x-;
0

-x

2

\

\

\

x------x3

radDOSE PER EXAMINATION

Figure XV. Frequency distribution of doses to thyroid and liver in radiopharmaceutical examinations given in England and Wales (172)(b) Dose per examination

126. A number of publications give estimates of organ
doses per unit of administered activity {18, 24. 43. 44,
59, 85, 90, 95, 99. J 10, 124. 125, 132, 133, 140, 183,
184, 185, 211. 213, 245,246). The estimates are given
for normal individuals as well as for patients who,
because of metabolic changes caused by the disease, may
receive somewhat different organ doses. In a number of338

examinations with 131 I or with other radionuclides.
such as 99 mTc, which are readily taken up by the
thyroid, it is customary to reduce the thyroid dose byblocking the thyroid (51). The dose estimates thencritically depend upon the assumptions about thyroid
blocking. The biokinetic data compiled by Kaul et al{I 09) are particularly useful in calculating the absorbed
doses from various radiopharmaceuticals when differences from the normal have to be taken into account.

...
RADIONUCLIDES FOR DIAGNOSTIC PURPOSESStates, 1966

0-iticalorgan dose(mrad)

101 500
l 350
7 500
296
1 330
2 970
65 OOO
190
913

Gonad dose

Criticalorgan

Numberofexaminations

Frequency(per 1000
ofpopulation)

Perexamination(mrad)Per 1000 of
population(man rad)Thyroidlower intestine
Spleen
Liver
Lung
Bone
ThyroidThyroidLiver

153 089
63 07841 85519 72122 8406 232
301 052
101 994
16 486

0.78
0.32
0.21
0.10
0.120
0.032
1.54
0.52
0.085

133
135
87
114
166
792
86
25
325

0.104
0.043
0.018
0.012
0.020
0.025
0.132
0.013
0.028

TABLE 38. ADMINISTERED ACTIVITY IN THREE COMMON RADIOPHARMACEUTICAL EXAMINATIONS(µCi per examination}
Examination
Thyroid scanCountry

Denmark(1973/74)
West Berlin(1975)
Sweden (1968)
Sweden (1975)
United Kingdom(1973)
United States(1966)

Thyroidur.rake
II

Brain
scan
••mrc

1311

9•mrc

78

1490

20

11 890

41
57

1 035
1 700
1 840

9
9

9 380
10 OOO
10 990

41

900

I

9 500

57

37

7 940

Sources: References 93, 151, l 72, 219, 248.

127. Typical radiation doses received from radio-pharmaceutical examinations are given in the eighth
column of table 34 for the organs listed in the ninth
column. The distribution of typical doses in all thecentres in England and Wales have been reported byPotter (172), and are given in figure XV. It is important
to note that the dose to the thyroid is two orders ofmagnitude lower when 9 9mrc pertechnetate is usedinstead of 1 3 1 L
128. Roedler et al (186) have made a critical review ofthe dose factors reported in the literature. Because of
the high frequency of thyroid examinations with 131 I,
the dose factors for this nuclide are of particularinterest. A number of authors have assessed the gonadal
dose per unit administered activity of 1 3 1 I at more than
2 mrad µCi- 1 • Roedler et al. suggest that the dose factor
is only 0.2 mrad µCi- 1 . A comparison of some current
estimates of the dose factor to organs for a number of
examinations is made in table 39 and the corresponding
dose per examination given in table 40.

TABLE 39. RANGE AND NOMINAL VALUE OF ABSORBED DOSE PER UNIT ADMINISTEREDACTIVITY IN THE MOST FREQUENTLY PERFORMED RADIOPHARMACEUTICAL
EXMUNATIONS{mrad µCi"')
Range

i

Recalculated

Nominalvalue

68-3 400
0.024-8.5
0.3-1.4

840-3 700
0.10-0.33
0.20-0.59

2 OOO
0.2
0.4

Thyroid
GonadsSkeleton

0.1-0.6
0.01-0.04

0.56
0.019
0.018

0.6
0.02
0.02

Thyroic
GonadsSkeleton

0.37-50
0.18-0.20

4-90
0.061-0.14
0.068-0.11

30
0.1
0.1

I

Kidneyo-Iodohippurate Gonads
Skeleton

0.07-10.016-0.25

0.22-0.65
0.0053-0.0087
0.0057-0.0076

0.5
0.01
0.007

Sr

Nitrate/chloride

GonadsSkeleton

2.9-402.9-52

2.8-3.3
113
10!7·msrNitrate/chloride

GonadsSkeleton

0.071-0.6

0.02
0.05

0.02
0.05

0.02
0.04

0.02
0.04

Type ofexamination

Radionuclide

Chemicalform

Thyroid scanor function

131

I

Thyroid scan
Brain scan
Thyroidfunction

Organ

From
literature

IodideThyroid
GonadsSkeleton••mTc

Pertechnetate

132

I

IodideKidneyfunction

131

Bone scan

85

••mTc

PolyGonads
phosphate Skeleton:,,339·

.,

-

:

'

.-

;¥1i, .. .
•J

TABLE 39 (continued)
Range

Type ofexamination

Radionuclide

Chemicalform

Kidney scan

203Hg

BMHP

KidneyGonadsSkeleton

690-760

203Hg

ChlorKidney
merodrine Gonads
Skeleton

0.66-580
0.02-1.9

••mTc

DTPA

KidneyGonadsSkeleton

0.042
0.01-0.02(0.04)(0.02)(0.02)

1nHg

BMHP

SpleenGonadsSkeleton

0.17-30
0.05-0.4

(10)
(0.5}

••mTc

S-colloid

SpleenGonadsSkeleton

0.02-0.45
0.012-0.023
0.026-0.034

0.053
0.0021-0.0061
0.011

0.1
0.005
0.01

•'"Au

Colloid

Liver
GonadsSkeleton

20-1 OOO
0.11-1.4
2.7-5030-39
0.035-0.38

0.28-0.49

40
0.3
0.5

••mTc

S-colloid

Liver
GonadsSkeleton

0.002-0.53
0.012-0.023
0.02-0.14

0.35
0.002-0.006
0.011

0.4
0.005
0.01

1um1n

Colloid

Liver
GonadsSkeleton

0.05-0.6

0.44

0.02-0.5

0.007

0.5
0.002
0.01

Methionine

Pancreas
GonadsSkeleton

0.24-12
1-11

13
10

15
10

8.3

10

HSA

Total body
GonadsSkeleton

0.25-12.3
1.7-4

1.7
2.0
1.7

2
2
2

••mTc

HSA

Total body
GonadsSkele~on

0.002-0.02
0.005-0.08

0.014-0.016
0.019-0.022
0.018-0.021

0.02
0.02
0.02

Erythrocyte
volume orsurvival time

51 Cr

Chromate

Total body
GonadsSkeleton

0.25-30.03-3
2

0.34
0.43
0.35

0.4
0.4
0.4

Lung scan

131 I

MAA

Lung
GonadsSkeleton

0.67-9.8
0.074-2

4.0
0.29

0.28

4
0.3
0.3

••mTc

MAA

Lung
GonadsSkeleton

0.047-0.4

0.2-0.36
0.012-0.057
0.01-0.012

0.3
0.002
0.01

s•pe

atrateSpleenGonadsSkeleton

14-2303-350
1.3-18Spleen scan

Liver scan"Se

Pancreas scan

Blood (plasma) u, I
volumeIron kinetics

Organ

From
literature

Recalculated

Nominal
value

(500)
(10)
(10)
87
1. 7-1.9
1.7

90
2
2

(0.5}

0.001-0.003

150
50

130

50
16

15

Source: Reference 185.

TABLE 40. ABSORBED DOSE PER EXAMINATION IN THE MOST FREQUENTLY PERFORMED RADIOPHARMACEUTICAL
EXAM INA TI ONSType of examination

Thyroid scan orfunctionRadionuclide

Chemical
form

u, 1

IodideAverageadministeredactivity(µ.Ci)

Absorbed dose per examination (mrad)

Examined and/or
critical organSO OOO

s

10

1 OOO

Thyroid

600

20

20

25

Thyroid

750

2.5

2.5

10

0.2

0.14

1 OOO

.. mTcPertechnetate

Thyroid function

'"l
u, I

Iodideo-Iodohippurate

20

Kidney

"Sr
nmsr
••mTc

Nitrate/chloride
Nitrate/chloride
Polyphosphate

100
1 OOO
10 OOO

Skeleton
Skeleton
Skeleton

Bone scan

340

SkeletonThyroid25

Thyroid scan
Kidney function

Gonads

so

400

300
20
400

1 OOO
50
200

Radio·nuclideChemicalfonn

Averageadministeredactivity
(µCi)

,nHg
203Hg
"mTc

BMHP
Chlormerodrine
DTPA

100
150
3 OOO

KidneyKidneyKidneyBrain scan••mTc

Pertechnetate

10 OOO

Spleen scan

1•1Hg
••mTc

BMHP
S-colloid

Liver scan

191
Au
"mTc
1um1n

Colloid$-colloid
Colloid

1 500

1 OOO

75Se
1,1 I
••mTc

Methionine
HSA
HSA
Chromate

Type of examination
Kidney scan

Pancreas scan
Blood (plasma)
volume51

Erythrocyte volume
or sunival time
Lung scan

Cr

Iron kinetics

Absorbed dose per examination (mrad)
Examined and/or
critical organ

GonadsSkeleton

50 OOO
13 SOO
120

l OOO
300
60

l OOO

Thyroid

6 OOO

300
1 500

SpleenSpleen

3 OOO
lSO

150

Liver
Liver
Liver

6 OOO
600
SOO

200

Pancreas

3 OOO

200
!SO
7.5
4S
7.5
2
2 OOO

10
100

Total body
Total body

20
2

20
2

20

100

Total body

40

40

40

300
60
200
150
15
75
15
10
2 OOO
2

MAA
MAA

200
3 OOO

Lung
Lung

800
900

60
6

60
30

Citrate15

Spleen

2 250

750

225

Source: Reference 185.

129. To calculate an approximate value for the annual
collective dose, the data from England and Wales(population 50 10 6 ) for 1973 may be averaged andcombined with the number of examinations carried out.
The collective doses for five examinations are given intable 41.

TABLE 41. COLLECTIVE DOSE FROM RADIOPHARMACEUTICAL EXAMINATIONSIN ENGLAND AND WALES
Averageadministeredactivity
(µCi)

Organ

Collectfl.e
dose (I 0 3
man rad)Pertechnetate

9 500

StomachThyroid101
101

44 OOO
44 OOO"mTc

5-colloid

2 OOO

Liver

14

20000

Thyroid scan••mTc

Pertechnetate

900{ Thyroid
Stomach2
2

10 OOO
10 OOO

Lung scan••mTc
11,mln4600
8 600

Type ofexamination

Radionuclide

Chemicalform

Brain scan

nmTc

Liver scan

131

Placental
localization

J

41

Thyroid

467

MAA

1 800

Lung

4

Chloride

700

Foetus.040

Annualnumber of
examinations

2 900

Source: Reference 172.

130. Only very little new information is available sincethe 1972 report on the GSD from radionuclide
examinations. The survey in West Berlin has been
updated (186) and the GSD in 1970 was estimated to be
0.2 mrad, compared with 0.1 mrad in 1968. The change
is primarily due to the increased number of examinations. This is in line with the GSDs reported in 1972 by
the Committee, which were in the range 0.01-0.4 mrad.

III. THERAPEUTIC USES OF RADIATION
A. TREATMENT WITH EXTERNAL BEAMSAND SEALED SOURCES
1. General131. High radiation doses have been used in radiotherapy for the treatment of two major classes of

disease, the first being skin and other non-neoplastic
diseases, for which radiation doses of up to
l000-2000 rad have been given. The majority of thesetreatments are for skin diseases, for which a low-energy,
fairly non-penetrating radiation has been used.
132. The second class of disease treated by irradiation
has been neoplastic disease, which includes all thevarious forms of cancer and other invasive and malignant
diseases. For the treatment of these diseases. radiation
doses of up to 6000-7000 rad are given to localized
tumours: in the ease of more generalized neoplastic
diseases, such as leukaemia, extra corporeal irradiation
may be given. These high doses are necessary to cause a
destructive effect on the tumour cells. It is inevitable inthese treatments thatlarge radiation doses will also bereceived by some of the healthy tissues lying within thetreatment volume or in the path of any of the treatment
beams. The seriousness of the primary disease, however,necessitates that little consideration be given to any

341

deleterious late effects of radiation that might occur
many years after a successful treatment. Nevertheless, it
is important to obtain estimates of the radiation dose
within healthy organs and tissues irradiated in thetreatment regime, so that estimates of the frequency ofsuch late effects may be made.

2. Trends in radiotherapy practice133. In the 1972 report of the Committee it wasestimated that in many industrialized countries about
one half of the new cancer cases arising each year are
treated with radiotherapy and that this proportion does
not seem to change appreciably even with the increased
use of chemotherapy. Elsewhere, the treatment ofcancer will rise in importance as other causes of deathsuch as malnutrition, malaria and tuberculosis aregradually eliminated by the improvement of living
conditions and the availability of medical care. Theseestimates seem to remain valid.
134. For the treatment of non-neoplastic disease,alternative treatment forms not involving radiation havebeen recommended, and a drastic decrease in thenumber of such treatments took place in the 1960s(118, 232), which is illustrated by table 42. X rays wereregularly used for the treatment of skin lesions,particularly dermatological conditions, in the years 1930
to 1960. Since that time a great reduction in the numberof patients treated has occurred and lower tube voltages
have been used, meaning less penetration of the beam.
TABLE 42. PERCENTAGE OF THERAPEUTIC IRRADIA·TIONS PERFORMED IN CONNECTION WITH NONNEOPLASTIC DISEASE IN JAPAN AND SWEDEN,
1956-1972
Country

1956

1965

1970

1972

Japan (118)
Sweden (171)

72
88

22
49

12°

10
10

14

aRepresenting 1722 patients.

135. The technological development in radiotherapy
equipment over the last 25 years has been aimed atproviding radiation beams capable of penetrating

adequately to deep-seated tumours and of producing
higher dose rates. Thus, orthovoltage x-ray units
operating at 250 kV and 2 2 6 Ra sources used inbrachytherapy have been replaced by electron accelerators (4-20 MeV) and telecurie units containing gammaray emitting sources such as 6 Co with activities of up
to 10 kCi. This trend is illustrated by the installation in
Sweden of cancer therapy machines (table 43).

°

TABLE 43. CHANGE IN USE OF RADIOTHERAPHY EQUIPMENT AT ONE LARGE SWEDISH CANCER CLINIC,
1956-1970
Annual number of trearments

Year

Using 250-kVand shorr-disrance226
Ra and 60 Co unirs

Using accelerators
andtelecurie units

1956
1965
1970

49 58230 145
11 2810
21 63346 941

Source: Reference 15 I,

3. Dose data in radiotherapy
136. Radiotherapy of non-neoplastic diseases has beenreasonably well controlled and recorded. The radiation
doses received by the skin of such patients are therefore
reliably known. Information about the filters and tube
voltages employed is less likely to be available. This isexactly the information required for deducing the penetration of the beam and hence the dose fo organs below theirradiated skin surface. These doses will usually be Jess
well known than the dose to the irradiated skin surface.
Calculations of doses to an organ outside the direct
beam will be Jess accurate, particularly if there is apossibility that the organ might on occasions be justoutside or just inside the main beam. These variations
may occur due to slightly different positions of thepatient when the treatment is undertaken; for example,
irradiation of children for thymic enlargement may havebeen carried out with the thyroid just in or just out of
the beam (88) (see Annex G).

137. The complexity of the treatments and thegenerally somewhat higher doses delivered for neoplastic
disease make careful dosimetric control a necessity, and,TABLE 44. RADIOTHERAPY OF NON-NEOPLASTIC DISEASE:
Head and trunk onlyChildren
Males
Num-

Condition rreated
Skin conditions
Growths
Allergic and inflammatory
Ringworm
Other
Glandular enlargements
Ankylosing spondylitis
Arthritic and rheumatic
Artificial menopause
Deafness
Other non-neoplastic

ber

27
10

5
I

5
I

AdultsFemales

Mean
dose
(rad)
14.6
10.8
92.0
49.0

9.4
2.6

Num•
ber

Mean
dose
(rad)

21
13
1
1
2

10.0
23.3
62.5
5.6
6.2

2
2

8.6
282.0

FemalesMales

Number

Mean
dose
(rad)
4.8
10.4
36.0
6.9

52
201
2
38
7
70
23

83.6
27.1

7
15

3.5
20.9

5.5

Number

Mean
dose
(rad)

80
230

7.6
7.9

38
1
14
29
74
10
35

4.3
5.9
59.5
22.0
51.5
3.7
27.6

Source: Reference 37.
Note:The data in this table were produced by a computer programme that was adapted to make anapproximate estimate of the bone-marrow dose from small treatment areas which receive high doses.

342because of the need to provide a follow-up service, therecords of such patients are generally well kept. It is,therefore, reasonably easy to determine the radiation
doses to particular organs retrospectively. The potential
groups of interest would be composed of patients withlong survival after treatment.

2 3 4

I

I

I

2

"I =-

3

4

(

6

138. The following determinations of dose to given
organs have been carried out for epidemiologicalsurveys:Bone-marrow dose and whole-body integral dosein the treatment of ankylosing spondylitis (39,
107,269)
Dose to the stomach and pancreas in the treatmentof ankylosing spondylitis ( 14)Dose to the kidney in patients treated for stomach
ulcers (35, 236)
Dose distribution through the head and neck forchildren treated for tinea capitis (2, 3, 4, 72, 159,
160,199,263,264)
Thyroid dose for children treated for thymic
enlargement (88)Skin dose in patients treated for skin disease andneoplastic disease with rodent ulcers and basal cell
carcinoma occurring in the treatment area (9, 237)
Bone-marrow dose in the treatment of metropathia haemorrhagica (45, 210).
139. As leukaemia has been associated with theirradiation of the bone marrow and a number of surveys
of patients treated for non-neoplastic disease havereported an increase in the incidence of leukaemia,
considerable effort has been made to derive bonemarrow doses. In its 1972 report, the Committee
reproduced data from the British survey (37) on
bone-marrow doses from treatment of non-neoplastic
disease in the years 1957-1958, assessed by measurements and a computer programme (50). Since further
information is lacking, these data are again presented intable 44 to illustrate the fact that the mean marrow

L

r

~

.,....l--:' -- >--. . . .

. .

-

5
4. Information of epidemiological interest

5 6 7/8 9 IC II 12 13 14 15 16
I
I / - 'I...i...
\i' ~ .J I

i\.

(

'

.... _

• I

' I'

\

'

I/

''

···1

j

\

I

A

7

8

' I

1/

i

-- - J

\-

·-

~

--

)

I

9

-

. ,'

I.,

"
I

I,.....

,,..i...,...,(

I"-.... ' /

,.

.~

I

I
I

)

Figure XVI. Grid reference system for defining irradiation
position (see tables 45 and 48) (76)doses may range from less than I to nearly 300 rad per
treatment course, with values of about 10 rad not being
infrequent. Recent measurements and calculations basedon depth-dose studies published by Hashizume (76)provide tabular information from which the bonemarrow dose may be calculated for any particularradiotherapeutic treatment. Figure XVI shows the gridreference system used to indicate the particular part ofthe body that is irradiated. By selecting a particular pairof grid reference numbers in the first two columns oftable 45 one can find, for the particular types ofradiation given in the other column headings the valuesof direct plus scatter radiation M + S and of the marrowdose T from the generalized leakage radiation from thesource per unit of dose at the skin. These data are usefulin that they give the values for 250-kV x rays, 6 Co
gamma rays, 6-MV x rays and 15-MeV electrons. As
predicted in earlier United Kingdom work, the marrowdose per treatment course calculated for 250-kV x rays
tends to exceed the bone-marrow dose from any otherenergy source.

°

MEA.lll BONE-MARROW DOSE PER TREATMENT COURSEAll cases
AdultsChildren
Males

Number

Mean
dose
(rad)

91
26
6
1

5
I

Females

Males

Females

ber

Mean
dose
(rad)

4.3
4.2
76.0
49.0

125
18
2
1
2

1.7
16.8
31.3
5.6
6.2

110
600
4
65
7
70
33

2.3
3.5
18.0
4.0
5.5
83.6
18.9

9.4

2
2

8.6
282.0

7
23

3.5
13.6

2.6

Num-

Number

Mean
dose
(rad)

Number

185
578
3
115
1
14
42
74
10
37

Mean
dose
(rad)

3.3
3.2
18.oa
1.4
5.9
59.5
15.1
51.5

3.7
26.2

a Assumed male value in absence of data

343

TABLE 45. ACTIVE BONE-MARROW DOSE IN ADULTS IN DIFFERENT IRRADIATION CONDITIONS(mrad per rad at the skin)J"adiation posltiona
Verticalnumber

1

2

3

4

s

6

7
8
9

Xrays

,oco
gamma raysConi•entional

6-MV

I 5-Me V electrons

Lateral number

M+S

T

M+S

T

M+S

T

M+S

T

2,4
13, 1514
3, 7, 102,4
13, 15
3
7,10,143, 7, 10, 14
1, 5, 12, 16,
13, 15
2,4
2, 4
13,15
3
14
12, 15, 16
6, 7, 10, 11
6, 7, 10, ll
14
3
13, 152,4l, 5, 12, 16
6,7,10,11
14
3
13, 152,4l, s, 12, 16
3, 14
2, 4, 7, 10, 13, 15
2, 4, 7, 10, 13, 15
2, 4, 7, 10, 13, 15

290
300
320
295
70
70
140
180
120
25
45
40
230
250
500
750
120
200
260
830
480
60
65

250
370
360
240
265
380
305
360
385
340
450
380
505
560
475
530
380
300
285
345
425
340
415
385
345
595
475
680
440
385
395
290
235
40

280
350
370
360
95

30
35
35
30
30
40
45
45
40
30
45
35
40

295
305
330
320
75
75
150
175
125
30
50
45
235

150
250
250
170
180
260
300
340
260
235
300
265
340
380
315
350
255
210
195
380
285
365
285
260
235
400
320
320
160
300
195
160
26
0

200
200
230
230
25
25
0
30
0
0
25
25
100
100
200
650
20
220
0
105
0
0
0
0
230
95
0
300
30
0
0
30
0
0

175
180
180
135
130
195
105
220
195
175
220
190
260
300
250
285
200
170
145
290
220
265
210
190
175
300
230
340
220
170
210
150
115
26

so

330
7..;0

370
340
160
50
70
70
1
0

95

180
220
170
35
70
55

315
320
710
1 200
170
240
380
l 350
700
85
90
70
430
1 150
520
490
220
70
95
95

so
so

55
40
30
30
55

40

so

40
40
30
60
45
60
40
35
40
30
25
10

s

0

iss

510
760
120
205
270
840
485
60
70
SS
335
730
375
345
165

so

70
70
1
0

Source: Reference 76.
Note: See paragraph 139 for an explanation of the use of this table.
a As defined by the grid reference system in figure XVI.

140. The per caput marrow dose (CMD) and doseweighted for the incidence of leukaemia (LSD) in theremainder of the patient's life were 206 and 37 mrad,respectively, for the practice in Japan during 1971.
Table 46 shows that the contributions to the CMD wereabout 60 per cent from 6 °Co units, 30 per cent fromaccelerators and 10 per cent from conventional x-ray
machines. The skin treatment of non-neoplastic disease
gives only 1.3 per cent of the total CMD (table 46). The
use of the product of the average dose and the numberof patients treated is a better measure of the possible
detriment to the irradiated group than the per caput
dose to the whole population. The average bone-marrowdose was 120 rad to the 177 OOO patients treated forneoplastic disease and 0.15 rad to the I 965 OOO patientstreated for non-neoplastic disease. This latter dose may
be compared with the average dose from the treatmentof non-neoplastic disease in the United Kingdom in
1957-1958 of 103 rad to the 6000 persons treated (37).

142. The average doses and the sizes of the patient
populations studied in some epidemiological surveys areto be found in Annex G.

141. The number of patients treated by brachytherapy
in Japan (78) in 1974 was 21 650 (table 47a). The
population doses are given in table 47b, the CMD and
LSD being 43 and 7. 7 mrad, respectively.

144. The GSD in Japan for 1971 from the treatment of
non-neoplastic disease was 0.7 rnrad; of neoplastic
disease. suitably corrected for the expected number ofchildren in these ill patients, 0.26 rnrad. The GSD

344

5. Genetically significant dose
143. The gonad dose and GSD received fromradiotherapeutic practice was given in the 1962 and1972 reports for a few countries. The GSD from thetreatment of non-neoplastic disease ranged from 0.9 to
12.1 mrad; of neoplastic disease, from 0.5 to 2.5 rnrad.
Recent data by Hashizume (75, 77) are in the form of atabulation of the gonad dose for different kinds ofradiotherapeutic irradiation (table 48). The doses are
given in terms of the leakage radiation L and thescattered radiation S per field area of 100 cm 2 , and insome cases in terms of the primary beam.

TABLE 46. PER CAPUT MARROW DOSE (CMD) AND LEUKAEMIASIGNIFICANT DOSE (LSD) IN JAPAN, 1971
(mrad)
Male
SourceAge (y)CMD'°Co gamma rays

< 14
15-29
30-44
;;,. 45

1.5
1.1
4.2
20

Subtotal< 14

Conventional x rays
(HVL Cu 0.5-2 mm)

Superficial x rays
(HVL Al < 2 mm)

High-energy x rays
(4-30 MV)

High-energy electrons(8-35 MeV)

Female
CMD

LSD

0.71
0.33
0.87
2.0

0.93
3.2
28
70

0.30
0.80
5.0
11.5

27

3.9

102

18

15-29
30-44
:>45

0
0.42
0.26
1.6

0
0.10
0.04
0.12

0.12
0.30
0.86
5.2

0.03
0.09
0.17
0.91

Subtotal

2.3

0.26

6.5

1.2

< 14
15-29
30-44
;;,. 45

0.37
0.19
0.03
0.019

0.37
0.19
0.03
0

0.59
0.98
0.34
0.15

0.59
0.97
0.23
0.04

Subtotal

0.61

0.59

2.1

1.8

< 14
15-29
30-44
:>45

0.74
0.37
1.2
7.0

0.36
0.13
0.25
0.62

0.72
4.0
8.0
35.6

0.19
0.83
1.6
5.9

Subtotal

9.3

1.36

48.4

8.5

< 14
15-29
30-44
:> 45

0.33
0.007
0.26
5.5

0.29
0.004
0.051
0.14

0.10
0.21
0.60
1.5

0.04
0.13
0.19
0.38

Subtotal

6.0

0.48

2.4

0.74

45

6.6

Total

LSD

161

30

Source: Reference 76.

TABLE 47a. POPULATION DOSE FROM BRACHYTHERAPY IN JAPAN, 1974
Number of patients by sex, age, radiation source and source position
Male

Female

Total

400
180
560
1 720

1 320
460
3 240
13 770

1 720
640
3800
15 490

1 120
280
160
260
1 040

9 780
210
1 400
5 910
1 490

10 900
490
1 560
6 170
2 530

1 590
70
70
40
40
1 050

1 OOO
270
70
110
13 OOO
0
4 340

2 590
340
140
150
13 OOO
40
5 390

2 860

18 79021 650Age (y)

< 14
15-29
3~
:>45
Radiation source
11•Ra
222Rn
137Cs

•oco
9osr
Source position
Mouth

MaxillaNeck
BreastCervix
Femur
Other
Total
Source: Reference 78.

contributions from treatments by various types ofapparatus and by age group are given in table 49, and the
distributions by age for neoplastic and non-neoplastic
diseases are given in table 50. The GSD frombrachytherapy in 1974 was estimated to be 0.012 mrad
(table 47) (78).

145. The GSD from the treatment of non-neoplastic
disease in the region of Munich (Federal Republic of
Germany) has been estimated. One report (198)
estimates that the contribution to the GSD in clinics is
0.4 rnrad, and the other (197) estimates that thecontribution in private practice is 0.2 mrad. These
345

TABLE 47b. POPULATION DOSE FROM BRACHYTHERAPY IN JAPAN, 1974
GSD, CMD and LSD by sex and age
CMD(mrad)

GSD(10- 3 mrad)

LSD(mrad)

Age (Y)

FemaleMale

FemaleMale

Female

Male

< 14

10.7
0.003
0.465
0

l.033
0.155
0.001
0.001

0.077
0.415
6.390
33.280

0.120
0.144
0.100
2.724

0.075
0.088
1.327
5.469

0.119
0.081
0.031
0.493

11.178l.l 9040.149

3.088

6.959

15-29
30-44
;;. 45
Subtotal
Total

43.2

12.4

0.724
7.7

Source: Reference 78.

TABLE 48. GONAD DOSE IN ADULTS IN(mrad per rad
Xrays
60

Co
gamma rays

Irradiation
positiona
(V-L)

HVL
1.5 mm Cu

HVL
1.0 mm Al

Sex

L

s

L

4-2

M
F

0.75
0.55

0
0.01

0.08
0.04

0
0

0.04
0.01

0
0

6-2

M

1.2
420

0.06
1.3

O.Q7
125

0.13
2.4

0.05
12

O.Q7

960
1.0

0.03
0.11

820
0.03

0.25
0.25

800
0.05

0.2
0.14

Fb
Mb

7-3

F

s

Source: Reference 75.
Note: L = leakage radiation; S = scattered radiation.

asee figure XVI.
bThe values in this line are the gonad doses due to the primary beam (of zero area).

TABLE 49. GENETICALLY SIGNIFICANT DOSE
IN JAPAN, 1971
Breakdown by source, age and sex(mrad)
SourceAge (y)Male

Female

60

<: 14
15-29
30-44
;;,.45

0.047
0.088
0.030
0.000

0.046
0.018
0.011
0.000

Subtotal

0.17

0.075

<: 14
15-29
30-44
;;., 45

0.000
0.013
0.002
0.000

0.010
0.000
0.000
0.000

Subtotal

0.015

0.010

0.030
0.002
0.001
0.000

0.31
0.34
0.002
0.000

0.033

0.65

Co gamma-ray
units

Conventional x-ray
units(HVL 1.5 mm Cu)

Superficial x-ray
< 14
units
15-29
(HVL 1.5 mm Cu) 30-44;;,,45
Subtotal
High-energy x-ray
units(4-30MV)

346

<: 14
15-29
30-44
;;., 45

0.003
0.011
0.000
0.000

0.007
0.004
0.000
0.000

Subtotal

0.014

0.011

SourceAge (y)High-energy electron
accelerators(8-35 MeV)

< 14

Total

Male

Female15-29
30-44;;. 45

0.000
0.000
0.000
0.000

0.000
0.000
0.000
0.000

Subtotal

0.000

0.000

Total

0.23

0.75

Total

0.98

Source: Reference 75.

0.245

TABLE 50. GENETICALLY SIGNIFICANT DOSE
IN JAPAN, 1971
Breakdown by type of disease, age and sex
0.025(mrad)
FemaleMale

Nonneoplastic

Neoplastic

Non·neoplastic

Neoplastic

15-29
30-44
;;. 45

0.041
0.006
0.001
0.000

0.039
0.097
0.029
0.000

0.31
0.34
0.002
0.000

0.061
0.022
0.011
0.000

Total

0.048

0.17

0.65

0.094

Age (y)

0.683

0.025

< 14

Source: Reference 75.

s

L

0.25

estimates may be compared with the 1961 estimate by
Holthusen et al (94), which was 2.2 mrad from bothclinic and private practice.

prognosis. However, the use of this form of treatment
has mainly been discontinued. The frequencies oftreatments reported in West Berlin in I 970 and 1975(93), in Sweden in 1974 and 1969 (151) and in the
United States in 1966 (248) are given in table 51.

B. THERAPEUTIC USES OF
RADIOPHARMACEUTICALS

I. Iodine-131 therapy for hyperthyroidism

146. The therapeutic use of radiopharmaceuticals is
mainly restricted to the use of 1 31 I for the treatment ofhyperthyroidism, heart disease and thyroid cancer andthe use of 32 P for the treatment of polycythemia vera.
In the 1950s and early 1960s, colloidal solutions of
198
Au were used for serious pleural and peritoneal
effusions and the patients concerned usually had limited

and heart disease147. The main use of 131 l therapy is for the treatmentof hyperthyroidism; in the United States in 1966 (248),
about three quarters of all patients treated with 1 3 1 1
were in this category. The administered activity is
usually in the range 2-10 mCi and sometimes repeated

DIFFERENT IRRADIATION CONDITIONS
at the skin)
Electrons
20-MV

8-MV

s

L

0.3
0.2

0
0

0.4
750
780
0.3

0
0.02
0
0.03

s

L

0.15
0.1
0.2
650
720
0.2

15-MeV

25-MeV

0
0
0
0.04
0.03
0

L

s

L

s

0.05
0.03

0
0

0.04
0.02

0
0

0
0.24

0.04
0.04

0
0
0
0

0.1
400
l OOO
0.1

1 OOO
0.06

0
0

administrations are given. A thyroid dose of about
4000 rad is often used as the treatment objective. The
bone-marrow dose per unit of administered activity
received has been estimated as I.7 rad mCi- 1 (68) andthe gonad dose as 0.45-0.6 rad mCi- 1 (19). For thetreatment of heart disease, the activities are usually
about 25 mCL with similar bone-marrow and gonad
doses per unit of administered activity.
148. Surveys were made by Pochin (167), Saenger(194) and Werner et al. (262) in populations of 59 OOO,
36 OOO and 32 OOO patients, respectively, who hadreceived 1 3 1 I for the treatment of thyrotoxiosis. Typicalmean bone-marrow doses of 7 -15 rad had been received.
The approximate total collective dose to the bonemarrow in these three series would therefore be
1.4 10 6 man rad, assuming a mean dose to the bonemarrow of 11 rad.

2. Iodine-131 therapy for cancer of the thyroid
149. For the treatment of cancer of the thyroid, a very
high initial activity. often about 200 mCi, is administered. Subsequently. in order to suppress any further
thyroid activity or to destroy any metastatic spread of
the cancer, further administrations are given, often of
the order of 100 mCi. Because these subsequent centres
have very little uptake, most of the administered activity
is excreted in the urine. The initial dose to the bone

TABLE 51. RECENT SURVEYS OF TIIE FREQUENCY OF
TIIERAPY WITH RAD10PHARMACEUTICALS(Number of treatments per 1000 of population)
West BerlinRadio·
pharma-ceutical Disease treated
131

32

I
P

Other

1970

1975

SwedenUnited----Stares
1969 1974 1966

Thyroid diseases 0.172 0.132 0.235 0.294 0.127
Polycythemia vera 0.011 0.015 0.031 0.038 0.017
0.097 0.113 0.011 0.012 0.028
Total

0.28

0.26

0.28

0.34

0.17

Sources: References 93, 151, 248.

marrow per unit of administered activity is
1.7 rad mCi- 1 ( 130), but subsequent administrations
will give lower doses {169).
150. Pochin {168) has reviewed a group of 215 patients
who had been treated for inoperable thyroid carcinoma
during the period 1949-1967. The group was studied inrelation to the subsequent cancer risk. The collective
dose to the bone marrow in the group was 27 OOO man
rad. It should be noted that cancer of the thyroid can betreated successfully, and patients often survive many
years after the first treatment.
3. Polycythemia vera patients treated with 32 P
151. The treatment of polycythernia vera consists ofrepeated administrations of 32 P over a period of years at347

activities of 4-8 mCi. The bone-marrow dose is
30 rad mCi- 1 for intravenous administration. The gonaddose is in the range 2.6-7.0 rad mCi- 1 {133). High meanbone-marrow doses of the order of 600 rad per
treatment may be received (34,214).

greatest risk, and they would also receive a radiationdose directly from the activity remaining in the patient.
Estimates of this dose have been made by Stieve andKaul (227).

V. CONCLUSIONS
152. Modan and Lilienfeld (145) show that thecollective dose for such patients treated by 3 2 P issufficiently high to make epidemiological studies
interesting. Of an original series of 1222 cases, 228 weretreated by 3 2 P. The collective dose to the bone marrow
for the group of 228 cases was 132 750 man rad.
153. Details
Annex G.

of further studies are contained in

IV. WASTE DISPOSAL OF MEDICALLYUSED RADIOPHARMACEUTICALS
154. Much of the short-lived activity incorporated inradiopharmaceuticals l!Sed in a diagnostic investigation
decays either before or during the investigation, andonly a small fraction of the total activity is eventuallydisposed of as waste. The principal route of disposal is asliquid waste. However, therapeutically used radiopharmaceuticals do provide a substantial source of waste
activity, particularly in the treatments using 1 3 1 I. In thecase of treatments for hyperthyroidism, some 30 per
cent of the activity may be released in the ·urine.
Following the first treatment of a cancer of the thyroid,some 50-60 per cent of the administered activity (about
100 mCi) will be excreted in the urine. Further
treatments, particularly of metastases, lead to theexcretion of about 90 per cent or more of theadministered radioactive iodine. In some countries theurine from such patients is not stored but is released asliquid waste into the sewers.
155. Few countries have complete records of theactivity released to the sewers from medical establishments. The total activity administered to the patients
may be used as an upper estimate. In Denmark, the total
use of radionuclides has risen from 181 Ci in 1970 to
298 Ci, in 1974 (220), the total activity remaining after
one year being 48 Ci and 15 Ci, respectively. The total
use of 13 1 I has remained steady at about 20 Ci per year.
By using the frequency data in the Danish report (53)and assuming that on the average 5 mCi of 3 1 I wasused in each hyperthyroid treatment and 200 mCi ineach cancer patient, one can account for about 13 Ci of
1 31
I, of which about 8 Ci would probably be excreted
as urine into the sewers.
156. It is difficult to estimate the radiation doses
received by the public from such releases. However, thefamilies of the patients would be those who would be at348

157. Diagnostic radiology in many technically developed countries has been growing at a rate between 5
and 15 per cent per year. Because of increasing medical
requirements. the growth rate in developing countries islikely to be greater. The use of radiopharmaceuticals fordiagnostic purposes has been expanding rapidly over thelast decade, and many countries are reporting a doublingof the number of tests every three to five years.
Radiotherapeutic practice indicates that less treatment isbeing carried out for non-malignant conditions using
radiation, while treatment for malignant conditions is
now primarily carried out using high-energy radiationfrom accelerators or teletherapy units.
158. Considerable information is now available onradiation doses to the skin and the gonads received inindividual x-ray examinations. while the knowledge
about doses to bone marrow and some other organs iscurrently expanding. Further information is stillrequired, however, particularly in the case of specialized
examinations. With this further knowledge it will bepossible to assess the detriment that may be associatedwith such examinations. Consideration would then haveto be given to the basis for the comparison of thebenefits that are received by a patient with the estimateddetriment.

159. A satisfactory amount of information is now
available regarding the radiation doses to organs received
during investigations involving the use of radiopharmaceuticals. In general, these doses to particular organs areof the same order or smaller than those incurred during
x-ray examinations of the same region or function.
160. Published recommendations of a number ofnational and international bodies have made available
useful information about methods of reducing radiation
doses to patients, but the implementation of theserecommendations is not yet universal. There is a need toencourage the estimation of the radiation doses received
by organs during medical radiological procedures as ameans of identifying those practices likely to give rise tohigh patient doses.
161. Studies of the frequency of examinations should
be combined with studies of organ doses to provide
collective dose estimates for each technique andinvestigation. Collective doses may then be used to assess
relative detriments, with some limitations due to therange of individual doses, the age group and the effects
under consideration. Suggestions as to possible groups ofpatients that may be at greater risk have been made on
the basis of the known radiation doses, and further
studies of this type would be of particular interest for
epidemiological research.

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