1994, The British Journal of Radiology, 67, 860-863

Entrance surface and ovarian doses in hysterosalpingography

1

I A J FIFE, BSc MSc, 2 D J WILSON, BSc and 1 C A LEWIS, BSc, PhD

department of Medical Engineering and Physics, King's College Hospital, London SE5 9RS, and department of Medical Physics, Leeds General Infirmary, Leeds LS1 3EX, UK Abstract A survey of entrance surface doses on 40 patients undergoing hysterosalpingography (HSG) has been undertaken. HSG is performed on women primarily of child-bearing age, with the dose to the gonads of these patients being of significant interest. Four lithium fluoride thermoluminescent dosimeters (TLDs) were attached to anatomical landmarks on the patient's skin to measure entrance surface doses. The results ranged from 0.5 mGy to 38.6 mGy with an average entrance surface dose of 13.3 mGy measured at the symphysis pubis. A correlation was observed between the entrance surface dose and imaging technique. Higher doses were measured when 24 x 30 cm film-screen radiography was used as opposed to fluoroscopy using 100 mm

cut film for hard copy. Estimated of the organ *to to ths mriss TO to$ M
2.8 mGy for 24 x 30 cm film-screen radiography and 1.7 mGy for 100 mm cut film.

$}&

With the rise in concern about doses received by patients over recent years, there has been a growing requirement for information on typical doses and the range of dose received during various radiographic and fluoroscopic examinations [1]. Information on current national normal doses for hysterosalpingography (HSG) or guideline dose levels was not found to be abundant in a search of the literature. A single reference quotes a gonadal dose of 5 mGy from HSG [2], estimated from foreign data (Sweden, 1978; Japan, 1974 and Turkey, 1979) and from the Adrian report [3]. This study was performed following guidance from the Royal College of Radiologists (RCR) and the National Radiological Protection Board (NRPB) regarding measurement of patient entrance surface doses [4, 5]. The aims were to obtain typical dose values for HSG at King's College Hospital and to see how these doses varied with different techniques. HSG is a common procedure requested by fertility clinics. It is a fluoroscopic examination performed on women for the investigation of infertility (primary or secondary). Other indications for HSG include tubal surgery, post-sterilization, and to check the patency of the tubes following reversal of sterilization. Many patients undergoing HSG are between 20-40 years old and desire pregnancy (the average age according to Rajah et al [6] was 31 years and according to Tyrell et al [7], 30 years). It is obvious that such studies require Received 28 October 1993 and infinalform 2 March 1994, accepted 11 March 1994. 860

rigorous optimization of radiation protection in the balance of dose reduction and image quality required for the diagnosis. There is a variation in HSG technique used at King's College Hospital encompassing different numbers of exposures taken and different hardcopy formats used. The choice of hardcopy relates to the clinical preference of the radiologists, and the availability and function of X-ray equipment as opposed to the requirements of individual patients. Control radiographs are not routinely taken, except when the reason for the request is "reversal of sterilization" or the patient has surgical clips or devices within the pelvis. However, control radiographs are taken at some other hospitals [6]. A modern fluoroscopy room with overcouch tube is used for the procedure at King's College Hospital, with a resolving capability permitting visualization of the fine fallopian tubes, and image intensification to reduce the radiation dose. Patients are screened with the automatic exposure control selected. On this unit both the kVp and the mA are controlled automatically following operating algorithms programmed into the X-ray generator. The contrast medium used is "Omnipaque 240". A successful examination shows uterine filling, fallopian tube filling and spillage of contrast into the peritoneum. Radiographic exposures are made either on 24 x 30 cm film-screen combination cassettes, industry standard system speed of 300 (Kodak Lanex "Medium" screens, in a Kodax X-Omatic cassette with Kodak T-Mat G film), sometimes with two or more exposures on a single cassette, or with a 100 mm cut film (Kodak X-Omat GR film) camera. Both types of exposure involve a similar
The British Journal of Radiology, September 1994

Entrance surface and ovarian doses in hysterosalpingography Table I. Average entrance surface doses in mGy with TLD position Technique Average of left and right ASISs min 100 mm 24 x 30 cm 0.1 0.1 mean 0.6 0.8 max 4.2 3.2 Midway between the ASISs min 0.2 0.6 mean 8.3 16.7 max 40.5 39.0 Symphysis pubis min 1.0 0.5 mean 11.8 15.1 max 36.7 32.9

field size dictated by patient anatomy as opposed to hardcopy format. The patient remains still and supine with the radiation field from the overcouch tube confined to the uterine area. In these circumstances, without a dose-areaproduct meter, TLDs provide a meaningful method of entrance surface dose measurement. The ovarian radiation doses were obtained using a computer program for tissue doses in diagnostic radiology. The program was used to estimate the absorbed doses to the ovarian tissues of a reference patient for a specified X-ray projection, using tissue-air ratios generated previously by a Monte Carlo technique [8].
Method

TLD calibration Lithium fluoride TLD pellets were used. These were calibrated and read out locally. Calibration procedures involved irradiating the TLD chips placed on tissue substitute material blocks with a diagnostic X-ray source (from a mobile X-ray unit) of similar peak energy and spectral shape to that used during the HSG patient procedure. The pellets were read out and their sensitivities examined. These procedures were repeated until reliable chips were recognized and selected with sensitivities the standard deviation of which was less than 5%. Calibration doses were traceable to a secondary standard ionization chamber and electrometer. The absorbed doses are quoted as absorbed doses in air in units of mGy. Measurement geometry A self explanatory form was issued to the X-ray department. This requested the radiologist and radiogra-

pher to position the TLD chips and record various pertinent information on the examination. Preceding each examination, four TLD pellets were placed on the following surface anatomical landmarks: one each on the left and right anterior superior iliac spines (ASISs), one midway between the ASISs and one on the symphysis pubis. This arrangement enabled information to be inferred about the extent of the X-ray field and also rendered information on the entrance surface doses above the ovaries. The radiologist/radiographer was also requested to provide details of the examination such as the screening time, the generator kilovoltage and tube current for radiography and fluoroscopy, the tube mAs values, and the number and type of radiographic exposures taken. There was also an allowance made for other relevant comments to be noted. The relative position of the TLDs were noted on the back of the form, and at the end of the examination were returned for reading.
Ovarian tissue doses

The computer program required skin entrance exposures (free-in-air) to output various tissue absorbed doses. The measured entrance surface doses were adjusted for backscatter [9] and used as input to the computer program to derive ovarian tissue doses. The X-ray field was assumed to be centred on the midline at a level of 84 cm below the vertex of the mathematical model representing an hermaphrodite reference patient. This corresponded to the X-ray field being centred on the body of the uterus, collimated to include the fallopian tubes, the top of the uterus and the speculum at the bottom. The positions of the iliac crests were at 72 cm from the vertex of the reference patient, the ovaries at 79 cm and the symphysis pubis at 88 cm.

12

16

20

24

28

Entrance surface dose in mGy (axis is labelled with lower interval values) I 100 mm film technique 24 x 30 cm film technique

Figure 1. Histogram of averaged values of entrance surface dose at symphysis pubis and midway between the ASISs, for 100 mm and 24 x 30 cm film hard copy techniques.

Vol. 67, No. 801

861

I A J Fife, D J Wilson and C A Lewis

IUUIIIMI

Entrance dose (mGyl 20.0

24 x 30c mfilm

" ^ ^ 24 x 3 0 c

Figure 2. Entrance doses with screening time for 100 mm film and 24 x 30 cm film hard copy techniques.

Screening time (s)

Depths from skin surface of the ovarian and uterine tissues were taken as 10 cm from the front and from the rear for the ovarian tissue, and 8 cm from the front and 12 cm from the rear for the uterine tissues.

Results The TLDs placed on the left and right ASISs of each patient indicated similar values for the entrance surface dose at the lateral borders of the field. The readings revealed that these pellets had been exposed to much lower doses than the TLD chips placed on the symphysis pubis and midway between the ASISs. TLDs placed on the midline were assumed to be within the primary X-ray beam while those placed laterally were symmetrically positioned outside of the primary beam, excluded by the rigorous collimation used during HSG. The data show that examinations using a 24 x 30 cm film-screen combination result in a higher entrance surface dose. Table I shows the average entrance surface doses in mGy with TLD position. The doses received by chips placed on the symphysis pubis and midway between the ASISs have been averaged and the distribution of these entrance surface doses is shown in the histogram of Figure 1. This average value of entrance surface dose was taken as a dose index and is shown graphically with screening time in Figure 2. Linear regression fit lines have also been included in the figure with correlation coefficients ("R squared" values)

of 0.40 and 0.29 for the 100 mm cut film and 24 x 30 cm film-screen combination technique data, respectively. The entrance surface doses and ovarian tissue doses are summarized in tabulated form, along with the screening times in Table II for 100 mm cut film examinations from 22 patients, and for 24 x 30 cm film-screen combination examinations from 18 patients. Confidence limits at the 95% probability level for the mean entrance surface dose derived from the regression line were 9.9 2 mGy and 15.9 2 mGy for 100 mm and 24 x 30 cm techniques, respectively (using the /-distribution table with n-2 degrees of freedom). The range of screening kilovoltages was relatively small with a mean screening kilovoltage of 82 kV (standard deviation 8.8 kV; minimum 70 kV and maximum 100 kV). The associated mean screening current was 1.8 mA (standard deviation 0.4 mA; minimum 1 mA and maximum 2.5 mA). The X-ray staff expressed a difficulty in reading radiographic exposure parameters during the examinations as the kilovoltage and mA displays were behind the protective panel, some distance from the patient and film carriage mechanism where the staff are normally positioned. To record this information implied an increase in patient examination time and discomfort, so this information was rarely recorded and is not shown here. The grid was left in place for all the patient studies (the image intensifier (approximately 20 cm in size) entrance exposure rate with grid in place at 70 kVp and 1 mA with 1 mm of Copper in the beam was measured 1 as490nGys-'

Table II. Mean number of exposures and ovarian doses from entrance surface doses with screening times for 100 mm and 24 x 30 cm techniques Number of exposures 100 mm Min Mean Max 1 3.55 5 2 4 x 3 0 cm 2 3.56 6 Screening time (s) 100 mm 6.0 42.0 110.0 24 x 30 cm 11.0 40.4 91.0 Entrance : surface dose (mGy) 100 mm 3.1 9.9 22.8 24 x 30 cm 11.0 15.9 24.2 Ovarian organ dose (mGy) 100 mm 0.5 1.7 3.9 24 x 30 cm 1.9 2.8 4.2

The data are taken from 18 patients for 24 x 30 cm technique and 22 patients for 100 mm technique.

862

The British Journal of Radiology, September 1994

Entrance surface and ovarian doses in hysterosalpingography Discussion and conclusions Acknowledgments

There were no patient related criteria involved in choosing different hard copy techniques with different patients. Approximately half the patients were examined with each hard copy format. Patient weight and height were not measured in this study, and particularly difficult studies were excluded from the data presented here. Figure 2 shows that the entrance surface dose with screening time is delivered at similar rates for different hard copy formats used. In addition, the 24 x 30 cm film-screen combination technique delivers a higher dose (16 mGy compared with 10 mGy entrance skin dose for cut film technique). These doses result in lower ovarian tissue dose for the 100 mm film (1.7 mGy compared with 2.8 mGy). As the mean screening time for the two techniques is similar it is reasonable to assume that the average dose from fluoroscopy is similar. This leads to the conclusion that the difference in dose derives from the hard copy chosen, with a 24 x 30 cm film-screen combination leading to significantly higher doses than 100 mm cut film. It must be emphasized that no consideration was given to image quality in the study. It was merely assumed that the studies achieved their diagnostic purpose. Whilst these results are strictly applicable only to the unit at King's College Hospital, they provide useful guidance on dose levels and strategies for dose optimization appropriate elsewhere. The study has indicated that the use of a film-screen technique in this procedure requires particular justification and has led to the X-ray department at King's College Hospital aiming to perform HSG with 100 mm cut film as the desired hard copy format. The study has also shown that TLDs remain useful for fluoroscopy entrance surface dose measurement in fixed geometry examinations. This type of measurement is a useful complement to dose-area product information for certain radiology examinations.

The authors would like to thank the radiologists and radiographers of the X-ray Department of King's College Hospital for their valuable contribution to this study.

References

1. SHRIMPTON, P C, WALL, B F, JONES, D G E T AL, A

National Survey of Doses to Patients Undergoing a Selection of Routine X-ray Examinations in English Hospitals (NRPB-R200) (HMSO, London) (1986). DARBY, S C, KENDALL, G M, RAE, S and WALL, B F, The Genetically Significant Dose from Diagnostic Radiology in Great Britain in 1977 (NRPB-R106) (HMSO, London) (1980). LORD ADRIAN, Biological Hazards to Patients; Second Report of the Committee Under Lord Adrian (HMSO, London) (1960). NATIONAL RADIOLOGICAL PROTECTION BOARD, Patient Dose Reduction in Diagnostic Radiology (Documents of NRPB) (HMSO, London), Vol. 1, No. 3 (1990). INSTITUTE OF PHYSICAL SCIENCES IN MEDICINE DOSIMETRY WORKING PARTY, National Protocol for Patient Dose Measurements in Diagnostic Radiology (National Radiological Protection Board, Chilton) (1992). RAJAH, R, McHUGO, J M and OBHRAI, M, The role of hysterosalpingography in modern gynaecological practice, Br. J. RadioL, 65, 849 851 (1992). TYRELL, P N M, McHUGO, J M and HALE, M, Patients' perception of the hysterosalpingogram: the initial stages of the audit cycle, Br. J. RadioL, 66, 103-107 (1993). PETERSON, L E and ROSENSTEIN, M, Computer Program for Tissue Doses in Diagnostic Radiology (Food and Drug Administration, Centre for Devices and Radiological Health, Rockville, Maryland, USA) (1989). WALL, B F, HARRISON, R M and SPIERS, F W, Patient Dosimetry Techniques in Diagnostic Radiology (IPSM Report No. 53) (National Radiological Protection Board, Chilton), pp. 5 6 ^ 2 (1988).

2.

3.

4.

5.

6.

7.

8.

9.

Vol. 67, No. 801

863