|Year : 2018 | Volume
| Issue : 1 | Page : 6-9
Reduction of radiation exposure to patients and professionals by reducing the administered activity of 18f-fluorodeoxyglucose in a positron-emission tomography/computed tomography study
Sneha Mithun, Ashish Kumar Jha, Ameya D Puranik, Priya Monteiro, Sneha Shah, Archi Agarwal, Nilendu C Purandare, Venkatesh Rangarajan
Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||16-Jan-2018|
Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: With increased clinical indications for positron-emission tomography/computed tomography (PET/CT) and repeated PET/CT scans, there is a need to reduce the radiation burden to the patient, professionals as well as public. This requires a redefining of the workflow and the 18-F-fluorodeoxyglucose (18F-FDG) administered activity. The objective of our study is to observe the impact of strike out reduction of administered activity on the radiation exposure to personnel and public, as well as the absorbed dose to the patient with no compromise on image quality by increasing the image acquisition time. Materials and Methods: Nineteen patients evaluated in this study (11 males, 8 females) were put into two groups, namely, A and B. Patients in Group A (n = 10) were administered with 18F-FDG equivalent to the recommended dose (7–8 MBq/kg body weight) whereas patients in Group B (n = 9) were administered with 18F-FDG equivalent to half the recommended dose (3–4MBq/kg body weight). The exposure rates from the patients at the body surface and 100 cm distance were measured immediately and 1 h postinjection. Results: The average surface dose rate and 100 cm dose rate of the adult patients immediately postinjection for patients of Group A were 0.94 ± 0.19 mSv/h and 0.057 ± 0.007 mSv/h, and for Group B were 0.34 ± 0.24 mSv/h and 0.031 ± 0.01 mSv/h. Conclusion: This study suggests that reduction in injected 18F-FDG activity reduces the radiation exposure rate from the patient, absorbed dose to the patient with reportable image quality.
Keywords: 18-F-fluorodeoxyglucose, positron-emission tomography/computed tomography, radiation exposure
|How to cite this article:|
Mithun S, Jha AK, Puranik AD, Monteiro P, Shah S, Agarwal A, Purandare NC, Rangarajan V. Reduction of radiation exposure to patients and professionals by reducing the administered activity of 18f-fluorodeoxyglucose in a positron-emission tomography/computed tomography study. Indian J Nucl Med 2018;33:6-9
|How to cite this URL:|
Mithun S, Jha AK, Puranik AD, Monteiro P, Shah S, Agarwal A, Purandare NC, Rangarajan V. Reduction of radiation exposure to patients and professionals by reducing the administered activity of 18f-fluorodeoxyglucose in a positron-emission tomography/computed tomography study. Indian J Nucl Med [serial online] 2018 [cited 2018 Nov 13];33:6-9. Available from: http://www.ijnm.in/text.asp?2018/33/1/6/223235
| Introduction|| |
Positron emission tomography/computed tomography (PET/CT) provides functional information corroborating anatomic details. With increasing clinical indications for PET/CT scans in oncology, the patient undergoes PET/CT multiple times at various stages of the disease management, such as initial staging, interim response, treatment response, and follow-ups.,,, This has also increased the risk of radiation exposure to the patient, professional and public. Hence, judicious administration of radiopharmaceuticals and proper confinement of patient during the uptake period becomes important to reduce radiation burden to the patient and professionals. Over the years, since the advent of PET/CT scanners, there have been several advancements in instrumentation as well as image reconstruction algorithms. With increased use of time of flight (TOF) PET scanners, the increased sensitivity and better spatial resolution can result in a reduction of injected dose and at the same time maintain good image quality with comparable imaging time. The objective of our study, therefore, was to assess the reduction in radiation burden by reducing the injected dose, however, maintaining the image quality by increasing the acquisition time on non-TOF PET/CT system.
| Materials and Methods|| |
This study was approved by Institutional Ethics Committee. We evaluated 19 patients in this study (11 males, 8 females). All the patients except one weighed <80 kg. All patients' age, height, and weight were taken just before injection with relevant history including date of last menstrual cycle and breastfeeding, where relevant. All pregnant and diabetic patients were excluded from the study.
The patients were put into two groups, namely, A and B. Patients in Group A (n = 12) were administered with 18-F-fluorodeoxyglucose (18F-FDG) equivalent to the recommended dose (7–8 MBq/kg body weight) whereas patients in Group B (n = 10) were administered with 18F-FDG equivalent to half the recommended dose (3–4 MBq/kg body weight).
Positron-emission tomography/computed tomography facility
The typical layout of a PET/CT facility is as suggested by the atomic energy regulatory board (AERB) as described by Tandon  PET/CT facility in our hospital has provision for 3 postdose waiting areas as described by Jha et al.
Radioactive dose administration
The patients were made to change to hospital robe and given instruction on sitting quietly and calmly postinjection. 18F-FDG activity was dispensed with respect to the patient's weight and the Group allotted and measured using dose calibrator (CRC-15PET, Capintec Inc., USA). The administered dose and time were noted in the datasheet. These patients were seated in their respective postdose administration waiting areas. During the waiting period, the patients were advised to drink approximately a liter of water mixed with oral contrast and instructed to void in the radioactive toilet.
Exposure rate measurements
RAM GAM 1 ROTEM INDUSTRIES survey meter (Model no.: BAK-2070) used for this study has GM tube with an accuracy of ±15% and an energy response accuracy of ±20% between 50 keV and 1.3MeV. The measurement range of this detector was from 0.5 μSv/h to 9999 μSv/h. The average exposure rate of the patient, at the body surface and 100 cm was measured immediately postinjection and at 1 h postinjection by a technologist or the RSO.
Postadministration of 18F-FDG, the patient was monitored for exposure rate immediately and after 1 h from head to toe at the body surface as well as at 100 cm from the body surface anteriorly and posteriorly. Maximum exposure rate at body surface as well as at 100 cm from the body was recorded.
Whole body absorbed dose to the patient
The whole body absorbed dose to the patients was estimated using MIRD whole body dose equivalent by equation 1.
D wb = (D u × A) Equation 1
Dwb = Whole body absorbed dose (mGy)
Du = Absorbed dose per unit of administered activity (mGy/MBq)
A = Administered activity (MBq)
All these patients were asked to void their bladder before imaging. All patients were imaged at 45 min after injection on Discovery ST PET/CT scanner, GE Medical Systems, Milwaukee, USA. The patients in Group A were imaged at one and a half min per bed position, and those in Group B were imaged at 3 min per bed position.
All the images were transferred to the advantage workstation ADW4.3, GE Medical system, Milwaukee, USA. Identities of the scan were masked before reading. Two trained Nuclear Medicine Physicians with more than 12 years of experience reviewed the scan quality independently, and images were graded as reportable or not reportable on visual interpretation.
| Results|| |
Patient's weight in both groups and corresponding administered activity along with whole body absorbed dose to the patient are shown in the table [Table 1]. The average surface dose rate and 100 cm dose rate of the patients immediately and 1 h postinjection for both groups are shown in the table [Table 2]. Average whole body absorbed dose to the patients in Group A was 4.38 mGy, and that of Group B was 2.4 mGy [Table 2]. The average of total imaging time in Group A was 9.15 min and that of Group B was 15 min. The images acquired were assessed qualitatively on the basis of the diagnostic value of the scan independently by two experts [Figure 1]. All the scans from Group A as well as Group B were graded as reportable by both the Nuclear Medicine Physicians.
|Table 1: Patient weight and corresponding administered activity and whole body absorbed dose in both groups|
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|Table 2: Results of dose rate and whole body absorbed dose for Groups A and B|
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|Figure 1: Whole body 18-F-fluorodeoxyglucose positron-emission tomography images (a) shows maximum intensity projection image of a patient from Group A, (b) shows maximum intensity projection image of a patient from Group B, (c) shows transaxial image of a patient from Group A and (d) shows maximum intensity projection image of a patient from Group B|
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| Discussion|| |
The guidelines for tumor imaging using 18-F-FDG mentions an average injected activity in the range of 370–740 MBq., This, however, is the dose considering the use of non-TOF PET/CT. However, with the advent of scintillation detectors such as lutetium oxyorthosilicate which are used in TOF PET scanners, there is a clear advantage of shorter dead time which allows less random and yet provide a high counting rate with better spatial resolution. With such growth in technology, there was also a corresponding growth in clinical indications for PET/CT in several diseases, particularly in the field of oncological imaging.,,,,,,,, This has thrust the need to reduce the radiation dose to the patient, professional and public. Masuda et al. have demonstrated in their study that increasing dose with respect to increase in body weight does not result in improved image quality without increasing imaging time. de Groot et al. have developed linear as well as quadratic relation between the administered FDG activity, the patients' body weight, and acquisition time, and also suggested that the quadratic expression gives a better relation of the aforementioned parameters without compromising on image quality. FDG PET/CT: EANM procedure guidelines for tumor imaging: version 2.0 has also adapted the de Groot et al. quadratic expression. Wickham et al. have also recently suggested an expression for reduction of administered 18F-FDG activity to achieve a reduction in radiation exposure to the patient as well as professional. Considering these recommendation, we empirically decided to reduce the administered activity and accordingly increase the imaging time to compensate for the reduced administered activity without compromising on image quality. In our study, we found the average reduction in administered activity to patients in Group B with respect to Group A by 55% resulted in 56% reduction in whole-body patient absorbed dose as well as 40%–50% reduction in external exposure rate eventually resulting in reduced radiation exposure to the professional and general public. However, average imaging time per patient in Group B increased by 89% in comparison with that of Group A. 89% increment in average imaging time instead of 100% in Group B as compared to that of Group A may be attributed to the difference in the height of patients in respective groups.
This study identifies the reduction of external and absorbed radiation dose to patients and personnel which may be used as a reference for modification of layout plan of a PET/CT facility. The present regulatory framework in our country to plan a layout of a PET/CT facility is based on the assumption that around 370–555 MBq FDG is injected in a routine PET/CT imaging. According to regulatory norms, in a PET/CT patient waiting room, there should be at least 2 m distance along with a 230 mm RCC wall between any two 18F-FDG administered patients. However, certain modifications to this layout can be made by adhering to the regulatory norms as described by Jha et al. Based on the workload of the department, a PET/CT facility can be planned with appropriate alterations in the area, wall thickness, and material for construction.
Image quality assessment was made purely based on the assessment by an experienced nuclear medicine physician. Although qualitatively assessment parameters could have been be objectively based on Likert scale or similar, but, this was not performed and maybe considered as one of the limitations of the study.
| Conclusion|| |
Our study suggests that while reduced 18F-FDG injected activity can reduce the radiation exposure rate from the patient and absorbed dose to the patient, at the same time, reportable image quality can be produced by increasing the imaging time.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Avril NE, Weber WA. Monitoring response to treatment in patients utilizing PET. Radiol Clin North Am 2005;43:189-204.
Larson SM, Schwartz LH. 18F-FDG PET as a candidate for “qualified biomarker”: Functional assessment of treatment response in oncology. J Nucl Med 2006;47:901-3.
Weber WA. Use of PET for monitoring cancer therapy and for predicting outcome. J Nucl Med 2005;46:983-95.
Fletcher JW, Djulbegovic B, Soares HP, Siegel BA, Lowe VJ, Lyman GH, et al
. Recommendations on the use of 18F-FDG PET in oncology. J Nucl Med 2008;49:480-508.
Surti S, Karp JS, Popescu LM, Daube-Witherspoon ME, Werner M. Investigation of time-of-flight benefit for fully 3-D PET. IEEE Trans Med Imaging 2006;25:529-38.
Tandon P. Regulatory requirements for designing PET-CT facility in India. Indian J Nucl Med 2010;25:39-43.
] [Full text]
Jha AK, Singh AM, Mithun S, Shah S, Agrawal A, Purandare NC, et al.
Designing of high-volume PET/CT facility with optimal reduction of radiation exposure to the staff: Implementation and optimization in a tertiary health care facility in India. World J Nucl Med 2015;14:189-96.
] [Full text]
Hays MT, Watson EE, Thomas SR, Stabin M. MIRD dose estimate report no 19: Radiation absorbed dose estimates from (18)F-FDG. J Nucl Med 2002;43:210-4.
Delbeke D, Coleman RE, Guiberteau MJ, Brown ML, Royal HD, Siegel BA, et al.
Procedure guideline for tumor imaging with 18F-FDG PET/CT 1.0. J Nucl Med 2006;47:885-95.
Boellaard R, Delgado-Bolton R, Oyen WJ, Giammarile F, Tatsch K, Eschner W, et al.
FDG PET/CT: EANM procedure guidelines for tumour imaging: Version 2.0. Eur J Nucl Med Mol Imaging 2015;42:328-54.
Karp JS, Surti S, Daube-Witherspoon ME, Muehllehner G. Benefit of time-of-flight in PET: Experimental and clinical results. J Nucl Med 2008;49:462-70.
Surti S, Scheuermann J, El Fakhri G, Daube-Witherspoon ME, Lim R, Abi-Hatem N, et al.
Impact of time-of-flight PET on whole-body oncologic studies: A human observer lesion detection and localization study. J Nucl Med 2011;52:712-9.
Lee E, Werner ME, Karp JS, Surti S. Design optimization of a TOF, breast PET scanner. IEEE Trans Nucl Sci 2013;60:1645-52.
Conti M, Eriksson L, Rothfuss H, Melcher CL. Comparison of fast scintillators with TOF PET potential. IEEE Trans Nucl Sci 2009;56:926-33.
Slomka PJ, Pan T, Germano G. Recent advances and future progress in PET instrumentation. Semin Nucl Med 2016;46:5-19.
Masuda Y, Kondo C, Matsuo Y, Uetani M, Kusakabe K. Comparison of imaging protocols for 18F-FDG PET/CT in overweight patients: Optimizing scan duration versus administered dose. J Nucl Med 2009;50:844-8.
Wickham F, McMeekin H, Burniston M, McCool D, Pencharz D, Skillen A, et al.
Patient-specific optimisation of administered activity and acquisition times for 18F-FDG PET imaging. EJNMMI Res 2017;7:3.
de Groot EH, Post N, Boellaard R, Wagenaar NR, Willemsen AT, van Dalen JA, et al.
Optimized dose regimen for whole-body FDG-PET imaging. EJNMMI Res 2013;3:63.
Sjövall J, Bitzén U, Kjellén E, Nilsson P, Wahlberg P, Brun E, et al.
Qualitative interpretation of PET scans using a likert scale to assess neck node response to radiotherapy in head and neck cancer. Eur J Nucl Med Mol Imaging 2016;43:609-16.
[Table 1], [Table 2]