Gonad shielding in pelvic radiography: modern optimised X-ray systems might allow its discontinuation

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Abstract

Objective

As gonad shielding is currently under debate, this study evaluates the practice, from its introduction in about 1905 until today.

Methods

The literature was searched for developments in shielding and insights into the effects of ionising radiation on gonads. Based on own pre-1927 dose reconstructions, reported doses after 1927, a 2015-report from the European Union and recent own measurements, the effects of technological evolution and optimisation on radiation dose and hereditary risk were assessed.

Results

In the 1900s, gonad shielding was first applied to prevent male sterility, but was discontinued when instrumental developments led to reduced radiation doses. In the 1950s, concerns about hereditary risks intensified and gonad shielding was recommended again, becoming routine worldwide. Imaging-chain improvements over time were considerable: in 2018, the absorbed dose was 0.5% of its 1905 value for the testes and 2% for the ovaries, our optimised effective dose a factor five lower than the value corresponding to the current EU diagnostic reference level, and the reduction in detriment-adjusted risk by shielding less than 1 × 10 ⁻⁶ for women and 5 × 10 ⁻⁶ for men.

Conclusions

Assessment of pelvic doses revealed a large reduction in radiation risks facilitated by technological developments. Optimisation likewise contributed, but unfortunately, its potential was never adequately exploited. Today, using a modern and optimised X-ray system, gonad shielding can be safely discontinued for women. For men, there might be a marginal benefit, but potential negative side-effects may well dominate. Discontinuation of gonad shielding seems therefore justifiable.

Related collections

Most cited references 48

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ICRP Publication 135: Diagnostic Reference Levels in Medical Imaging

E Vano, D.L. Miller, C.J. Martin … (2017)

The International Commission on Radiological Protection (ICRP) first introduced the term ‘diagnostic reference level’ (DRL) in 1996 in Publication 73. The concept was subsequently developed further, and practical guidance was provided in 2001. The DRL has been proven to be an effective tool that aids in optimisation of protection in the medical exposure of patients for diagnostic and interventional procedures. However, with time, it has become evident that additional advice is needed. There are issues related to definitions of the terms used in previous guidance, determination of the values for DRLs, the appropriate interval for re-evaluating and updating these values, appropriate use of DRLs in clinical practice, methods for practical application of DRLs, and application of the DRL concept to newer imaging technologies. This publication is intended as a further source of information and guidance on these issues. Some terminology has been clarified. In addition, this publication recommends quantities for use as DRLs for various imaging modalities, and provides information on the use of DRLs for interventional procedures and in paediatric imaging. It suggests modifications in the conduct of DRL surveys that take advantage of automated reporting of radiation-dose-related quantities, and highlights the importance of including information on DRLs in training programmes for healthcare workers. The target audience for this publication is national, regional, and local authorities; professional societies; and facilities that use ionising radiation for medical purposes, and responsible staff within these facilities. A full set of the Commission’s recommendations is provided.

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ICRP publication 121: radiological protection in paediatric diagnostic and interventional radiology.

P L Khong, S Ringertz, V Donoghue … (2013)

Paediatric patients have a higher average risk of developing cancer compared with adults receiving the same dose. The longer life expectancy in children allows more time for any harmful effects of radiation to manifest, and developing organs and tissues are more sensitive to the effects of radiation. This publication aims to provide guiding principles of radiological protection for referring clinicians and clinical staff performing diagnostic imaging and interventional procedures for paediatric patients. It begins with a brief description of the basic concepts of radiological protection, followed by the general aspects of radiological protection, including principles of justification and optimisation. Guidelines and suggestions for radiological protection in specific modalities - radiography and fluoroscopy, interventional radiology, and computed tomography - are subsequently covered in depth. The report concludes with a summary and recommendations. The importance of rigorous justification of radiological procedures is emphasised for every procedure involving ionising radiation, and the use of imaging modalities that are non-ionising should always be considered. The basic aim of optimisation of radiological protection is to adjust imaging parameters and institute protective measures such that the required image is obtained with the lowest possible dose of radiation, and that net benefit is maximised to maintain sufficient quality for diagnostic interpretation. Special consideration should be given to the availability of dose reduction measures when purchasing new imaging equipment for paediatric use. One of the unique aspects of paediatric imaging is with regards to the wide range in patient size (and weight), therefore requiring special attention to optimisation and modification of equipment, technique, and imaging parameters. Examples of good radiographic and fluoroscopic technique include attention to patient positioning, field size and adequate collimation, use of protective shielding, optimisation of exposure factors, use of pulsed fluoroscopy, limiting fluoroscopy time, etc. Major paediatric interventional procedures should be performed by experienced paediatric interventional operators, and a second, specific level of training in radiological protection is desirable (in some countries, this is mandatory). For computed tomography, dose reduction should be optimised by the adjustment of scan parameters (such as mA, kVp, and pitch) according to patient weight or age, region scanned, and study indication (e.g. images with greater noise should be accepted if they are of sufficient diagnostic quality). Other strategies include restricting multiphase examination protocols, avoiding overlapping of scan regions, and only scanning the area in question. Up-to-date dose reduction technology such as tube current modulation, organ-based dose modulation, auto kV technology, and iterative reconstruction should be utilised when appropriate. It is anticipated that this publication will assist institutions in encouraging the standardisation of procedures, and that it may help increase awareness and ultimately improve practices for the benefit of patients.

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Diagnostic Reference Levels for Diagnostic and Interventional X-Ray Procedures in Germany: Update and Handling

Alexander Schegerer, Reinhard Loose, Lothar J. Heuser … (2019)

Purpose Recent developments in medical technology have broadened the spectrum of X-ray procedures and changed exposure practice in X-ray facilities. For this reason, diagnostic reference levels (DRLs) for diagnostic and interventional X-ray procedures were updated in 2016 and 2018, respectively. It is the aim of this paper to present the procedure for the update of the DRLs and to give advice on their practical application. Materials and Methods For the determination of DRLs, data from different independent sources that collect dose-relevant data from different facilities in Germany were considered. Seven different weight intervals were specified for classifying pediatric X-ray procedures. For each X-ray procedure considered, the 25th, 50th, and 75th percentile of the respective national distribution of the dose-relevant parameters were determined. Additionally, effective doses that correspond to the DRLs were estimated. Results In procedures with already existing DRLs before 2016, the values were lowered by circa 20 % on average. Numerous DRLs were established for the first time (9 for interventional procedures, 10 for CT examinations). Conclusion For dose optimizations even below the new national DRLs, the BfS recommends establishing local reference levels, using dose management software (particularly in CT and interventional radiology), adapting dose-relevant parameters of X-ray protocols to the individual patient size, and establishing internal radiation protection teams responsible for optimizing X-ray procedures in clinical practice. When applying good medical practice and using modern equipment, the median dose values of the nationwide dose distributions can not only be easily achieved but can even be undercut. Key Points: Citation Format Ziel Die Entwicklungen der Medizintechnik in den letzten Jahren haben das Spektrum medizinischer Röntgenanwendungen erweitert und die Untersuchungspraxis in Röntgeneinrichtungen verändert. Infolgedessen wurden 2016 und 2018 die diagnostischen Referenzwerte (DRW) für diagnostische bzw. interventionelle Röntgenanwendungen aktualisiert. Ziel dieser Arbeit ist es, das Prozedere der Aktualisierung und die aktualisierten DRW vorzustellen sowie Hinweise zu ihrer praktischen Anwendung zu geben. Material und Methoden Für die Aktualisierung der DRW wurden verschiedene, voneinander unabhängige Datenquellen berücksichtigt, die Dosis-relevante Untersuchungsparameter von verschiedenen Einrichtungen aus dem gesamten Bundesgebiet registrieren. Röntgenanwendungen an Kindern wurden in 7 verschiedene Gewichtsklassen eingeteilt. Für jede erfasste Röntgenanwendung wurde die 25., 50. und 75. Perzentile der entsprechenden nationalen Verteilung der Dosis-relevanten Untersuchungsparameter bestimmt. Für die aktualisierten und neu festgelegten DRW wurden die zugehörigen effektiven Dosiswerte abgeschätzt. Ergebnisse Die DRW für Röntgenanwendungen, die schon vor 2016 existierten, konnten im Mittel um circa 20 % gesenkt werden. Für zahlreiche Röntgenanwendungen wurden neue DRW festgelegt (für die interventionelle Radiologie 9, für die Computertomografie 10). Schlussfolgerungen Um Röntgenanwendungen auch unterhalb der neuen nationalen DRW zu optimieren, empfiehlt das BfS, lokale Referenzwerte festzulegen und anzuwenden, Dosismanagementsoftware (v. a. für den Bereich der CT und interventionellen Radiologie) einzusetzen, Dosis-relevante Protokollparameter der Röntgenuntersuchung bzw. des interventionell-radiologischen Eingriffs systematisch an die Patientenstatur anzupassen und einrichtungsinterne Strahlenschutzteams zu etablieren. Bei guter Praxis und Einsatz moderner Geräte-Technologien können die durch die 50. Perzentile der nationalen Verteilungen vorgegebenen Expositionsniveaus erreicht und sogar unterschritten werden. Kernaussagen: Zitierweise

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Author and article information

Contributors

Cécile R. L. P. N. Jeukens:

ORCID: http://orcid.org/0000-0003-1403-8301

cecile.jeukens@mumc.nl

Journal

Journal ID (nlm-ta): Insights Imaging

Journal ID (iso-abbrev): Insights Imaging

Title: Insights into Imaging

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Electronic): 1869-4101

Publication date (Electronic): 7 February 2020

Publication date PMC-release: 7 February 2020

Publication date Collection: December 2020

Volume: 11

Electronic Location Identifier: 15

Affiliations

GRID grid.412966.e, ISNI 0000 0004 0480 1382, Department of Radiology and Nuclear Medicine, , Maastricht University Medical Center, ; P. Debijelaan 25, 6229 HX Maastricht, The Netherlands

Author information

Cécile R. L. P. N. Jeukens http://orcid.org/0000-0003-1403-8301

Article

Publisher ID: 828

DOI: 10.1186/s13244-019-0828-1

PMC ID: 7005227

PubMed ID: 32030539

SO-VID: 32d960f8-0b92-4811-a345-8f1157b06462

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 13 October 2019

Date accepted : 10 December 2019

Custom metadata

ScienceOpen disciplines: Radiology & Imaging

Keywords: gonad shielding,pelvic radiography,gonad radiation dose,hereditary radiation risk,optimisation

Data availability:

ScienceOpen disciplines: Radiology & Imaging

Keywords: gonad shielding, pelvic radiography, gonad radiation dose, hereditary radiation risk, optimisation