Radiation protection in
Nuclear Medicine - Best practice
Sigrid Leide-Svegborn, Assoc. prof., MPE, RPE
Radiation physics
Skåne University Hospital, Malmö
Lund University
SWEDEN
IAEA Webinar
15th March 2022
Disclosure:
I have nothing to disclose and
no conflict of interests with
respect to this presentation
Sigrid Leide Svegborn 2022
Nuclear Medicine
BENEFIT - an effect of radioactive substances emitting ionizing radiation
RISK - an effect of radioactive substances emitting ionizing radiation
Extravasation of 131I-MIBG
Bonta et al., J Nucl Med 2011
Tumour diagnostic using 18F
Sigrid Leide Svegborn 2022
Radiation Protection in NM – Exposure of whom?
Medical exposure
- Patients (adults, adolescents, children, infants)
- Carers and comforters
- Volunteers in medical and biomedical research Special groups
- Unborn children of pregnant women
Occupational exposure - Breastfed newborns and infants
- Workers, apprentices and students
Exposure of the public due to NM practice
- Exposure of individuals excluding any occupational or medical exposure
(other professionals at the hospital, language interpreters, taxi drivers, individuals in the society etc. )
Radiation protection in NM – The Principles
Justification Optimization Dose limitation
No dose limits for medical exposure, dose constraints for carers and comforters
Sigrid Leide Svegborn 2022
ICRP 103, Ann ICRP, 2007 and
ICRP 118, Ann ICRP, 2012
IAEA. General Safety Guide No. GSG-7
(2018), Occupational Radiation Protection
20 mSv
EU Basic Safety Directive
2013/59/Euratom
Please follow the recommendations as prescribed by your national authority.
Sigrid Leide Svegborn 2022
Radiation sources
Radiopharmaceuticals
Radiation Protection in NM – Exposure from what?
Unsealed radioactive sources
Radiopharmacuticals - liquid, gaseous or solid
- In vials, syringes, containers or if contamination on surfaces or in air
- Within the patient and in the excreta of the patient
Sealed radioactive sources
- Quality control and calibration of equipment or as markers
Radioactive waste (liquid, gaseous and solids)
Radionuclides
Characteristics of the radionuclide is of significant importance
- Decay mode and type of radiation emitted
- Energy emitted [keV – MeV]
- Physical half-life [sec – months]
etc
Sigrid Leide Svegborn 2022
Hybrid Imaging – includes CT
Design of a
Nuclear medicine
facility
Radiation protection starts already in the design of a Nuclear medicine facitlity
- Design of facilities
- Shielding
- Monitoring
- Recording
Workers designation
Monitoring Area designation
Sigrid Leide Svegborn 2022
The patient
Justification and optimization
Radiopharmaceuticals
Radiation protection of the patient - justification and optimization
Justification Optimization
R B E Q
Risk versus benefit Radiation exposure versus diagnostic
quality or therapeutic outcome
Sigrid Leide-Svegborn 2022
Optimization of a diagnostic procedure
• The relation between the activity and the diagnostic accuracy is dependent on the type
of examination. It is important to know whether the diagnosis is based on quantitative
information or on visual evaluation. Both for a simple uptake measurement and in
connection with imaging, the amount of activity needed will depend on the type of
equipment used, the body constitution of the individual patient, the patient’s
metabolic characteristics and clinical condition.
• Image quality is dependent on technical
factors and on patient related factors
• Equipment must be operated within the limits SPECT/CT
PET/CT
and conditions established in the technical
specifications and in the license requirements,
ensuring that it will operate satisfactorily at all
times. Thus, an extensive QA program is
needed.
https://www.iaea.org/resources/rpop/health-professionals/nuclear-medicine/ Sigrid Leide-Svegborn 2022
Diagnostic reference level, DRL in Nuclear medicine
DRL is a level used in nuclear medicine imaging to indicate whether, in routine
conditions, the amount of activity (MBq or MBq/kg) of radiopharmaceuticals
administered in a specified procedure for medical imaging is unusually high or
unusually low for that procedure.
DRLs is a practical tool to promote optimization.
DRLs are general guideline for clinical operations and do not apply
directly to individual patients and examinations.
Sigrid Leide Svegborn 2022
Examples of different radiopharmaceuticals for diagnostic use
99mTc-diphosphonates
99mTc-MIBI 123I-ioflupane
111In-octreotide
18F-FDG
Anterior Posterior 10 min p.i. 6 h p.i.
Anterior Posterior 15 min p.i. 24 h p.i.
Sigrid Leide Svegborn 2022
Internal dosimetry – The dose to the Nuclear medicine Patient
Table. Absorbed dose per unit A [mGy/MBq]
Sigrid Leide Svegborn 2022
ICRP, 2019..ICRP Publication 140. Ann. ICRP 48(1).
Optimization in radionuclide therapy
• In nuclear medicine therapy radiopharmaceuticals are used to
cure, mitigate or control a disease, such as a benign thyroid
condition or various malignant, such as lymphomas or bone
metastases. It can be used either on selective targets or
throughout the entire body.
• The goal of therapy with radiopharmaceuticals, is to optimise
the relationship between e.g., tumour control probability and
potential complications in normal organs and tissues.
• Treatment with radiopharmaceuticals requires
administration protocols that justify and optimise the
treatment. Individual absorbed dose estimates should be
performed for treatment planning and for post-
administration verification of doses to tumours and normal
tissues.
Sigrid Leide-Svegborn 2022
Optimization for paediatric patients
Renal scintigraphy
99mTc-DMSA
https://humanhealth.iaea.org/
Bone scintigraphy
99mTc-MDP
Neuroblastoma scan
123I-MIBG
Patient – benefit from the radiation is expected Children are more radiation sensitive
Justification and optimization Longer expected life time
Sigrid Leide Svegborn 2022
Breastfeeding patient
S.Leide Svegborn, Radiat Prot Dosim 2010
Sten Carlsson, Uddevalla
Thyroid scintigraphy
99mTc-pertechnetate, 200 MBq
In breast milk Lymphoma PET/CT
18F-FDG, 277 MBq
10-20 % of Amother
In breast milk
0.07 % of Amother
Sigrid Leide Svegborn 2022
Recommendation on breastfeeding interruption – IAEA cont’d (IAEA Safety Standards, 2018)
Radiopharmaceutical Most common Typical adm. activity Feeding interruption time
clinical use (MBq) (hours)
99mTc-pertechnetate Thyroid scan, Meckel’s diverticulum 100-400 12 h (2)
99mTc-MAA Lung perfusion imaging 40-150 12 h
99mTc-HMPAO WBC Infection imaging 180-400 12 h
99mTc-labelled RBC Radionuclide ventriculography 800 12 h
99mTc-mebrofenin and
Hepatobiliary imaging and function 300 4 h (1)
other iminodiacetic
acid derivatives
99mTc-human albumin Sentinel nodes 5-120 4 h (1)
nanocolloidal Liver scanning 120-200 4 h (1)
particles
111In-octreotide Neuroendocrine tumours 100-200 60 h (2.5 d)
Sigrid Leide Svegborn 2022
123I-MIBG Neuroblastoma imaging 400 > 3 weeks or complete
cessation (3)
123I-NaI Thyroid imaging and function 20 > 3 weeks or complete
cessation (3)
123I-ioflupane (FP-CIT) Dopaminergic neurotransmission (D1) 150-250 > 3 weeks or complete
in movement disorders cessation (3)
1) One meal discarded, if free pertechnetate + external exposure 2) > 400 MBq 24 h, 3) risk of iodine impurities, 4) normal renal function,
6) incl. external exposure
Cont’d
Pregnancy and medical radiation
Radiation related effects on fetus or embryo
• Early effects (failure to implant or miscarriage)
• Effects on embryo/fetus during growth
- Lethal effects ‒ threshold dose 100 mGy
- Malformation ‒ threshold dose 100-200 mGy or higher
Pregnancy and
- Mental retardation ‒ threshold dose 100 mGy Medical Radiation
• Higher risk 8-15 w post-conception
• Somewhat less risk16-25 w p.c. INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION ——————————————————————————————————————
ICRP publication 84
• Cancer (leukemia and solid tumours) ‒ No threshold dose
Sigrid Leide Svegborn 2022
Fetal exposure in Nuclear medicine
Irradiation of the embryo/fetus from radiopharmaceuticals
administered to the pregnant patient
▪ The embryo/fetus may be irradiated
externally from activity in the
mother
www.womenshealth.gov
▪ Some radiopharmaceuticals may cross
the placenta and concentrate in fetal
tissue i.e. internal exposure of the fetus
99mTc-pertechnetate
Berg G et al.,
Acta Oncol. 47, 145-149, 2008 Sigrid Leide Svegborn 2022
Assessmeent of the dose to the embryo/fetus
Sigrid Leide Svegborn 2022
Stabin MG. J Nucl Med 2018:1005-1006
An example of a pregnant female computational phantom
Rensselaer Polytechnic Institute pregnant female models for
3 mo (left), 6 mo (middle), and 9 mo (right) of gestation.
This was originally published in JNM. Michael G Stabin. New-Generation Fetal
Dose Estimates for Radiopharmaceuticals. J Nucl Med. 2018;59:1005-1006.
© SNMMI.
99mTc-X: 1-10 mGy
18F-FDG: 10 mGy
111In-pentetreotide: 20 mGy
131I-NaI: High doses to embryo/fetus Cont’ d
**Shaded rows indicate consideration of placental
crossover in the fetal dose estimates
Risk of significant fetal thyroid harm
Occupational exposure
Dose limitation
Monitoring
Radiation Protection in NM – Occupational exposure - When?
− Production of the radionuclide incl. QC
− Preparation of the radiopharmaceutical incl. QC
− Transportation (external and internal)
− Receiving and unpacking the radionuclide
− Quality and activity control of the delivered radionuclide
− Administration of the radiopharmaceutical to the patient or a phantom (QC of the equipment)
− Taking care of the patient during the NM procedure (e.g. imaging or treatment)
− Taking care of the radioactive waste (short-term and long-term)
− Storage of radiation sources
− Accidental and unintended exposure
− …….
Sigrid Leide Svegborn 2022
ICRP 103, Ann ICRP, 2007 and
ICRP 118, Ann ICRP, 2012
IAEA. General Safety Guide No. GSG-7
(2018), Occupational Radiation Protection
20 mSv
EU Basic Safety Directive
2013/59/Euratom
Please follow the recommendations as prescribed by your national authority.
Sigrid Leide Svegborn 2022
Detection of ionizing radiation - human inadequacy
Can easily detect it
✓ Can not see it with a radiation detector
✓ Can not hear it
✓ Can not feel it
✓ Can not smell it
✓ Can not taste it
ICRP, 2010. Conversion Coefficients for Radiological Protection Quantities
for External Radiation Exposures. ICRP Publication 116, Ann. ICRP 40(2-5).
Sigrid Leide-Svegborn 2022
Radiation Protection in NM – Monitoring
Sigrid Leide Svegborn 2022
Personal monitoring
Continuously and periodically
Whole body (PED, TLD), extremity dose
and eye lens dose (TLD)
Workplace monitoring
Source related and task related
Continuously or periodically
Monitoring for contamination
External contamination Internal contamination
Minimize the radiation dose - TDS
Minimize the
TIME of exposure
Use various SHIELDING
Use DISTANCE tools e.g. forceps
Sigrid Leide Svegborn 2022
Minimizing external exposure, by using SHIELDING
Sigrid Leide Svegborn 2022
Minimizing external exposure, especially finger doses by
using both SHIELDING AND DISTANCE
Anniqa Rastbäck, Malmö 2022
Automatic dispensing- and infusion
robots for PET-substances
Sigrid Leide Svegborn 2022
Avoid contamination
Do not eat, drink or
smoke in the lab.
Use laboratory
clothing
Use gloves Wash and
nitrile or vinyl measure
hands
Use protective paper
Sigrid Leide Svegborn 2022
Safety culture in NM
Accidental and unintended medical exposure
IAEA
QUANUM3.0
The Quality Management
The SAFRON Reporting system Audits in Nuclear Medicine
programme
also for Radionuclide therapy
Safety in Radiation Oncology (SAFRON)
Sigrid Leide Svegborn 2022
Radiation protection in Nuclear Medicine
Best practice
Thank you for your attention
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