Radiation Protection Dosimetry

Vol. 85, Nos. 1–4, pp. 333–340 (1999)

Nuclear Technology Publishing

APPLICATIONS OF THERMOLUMINESCENCE DOSIMETRY

IN MEDICINE
T. Kron
Newcastle Mater Misericordiae Hospital
Department of Radiation Oncology
Waratah, NSW 2298, Australia
and
University of Newcastle, Department of Physics
Callaghan, NSW 2308, Australia

INVITED PAPER

Abstract — Thermoluminescence dosimetry (TLD) features many advantages such as small detector size and close tissue equival-
ence that make it useful for a variety of applications in medicine. In medical imaging the high sensitivity of TLD materials such
as LiF:Mg,Cu,P and Al2O3:C enables risk assessment even for low dose procedures. In radiotherapy, the fact that no cables are
required during the measurement allows the use of TLDs inside tissue-equivalent phantoms to verify radiation doses delivered
in new treatment techniques. These features make TLD also the most versatile in vivo dosimetry tool allowing dose assessments
directly on patients during diagnostic or therapeutic procedures. In addition to these clinical uses, TLD is widely employed for
quality assurance in medicine. Dosimetric intercomparisons between different centres and spot checks of dose delivered in diag-
nostic procedures have found their way into many national and international guidelines for best practice.

INTRODUCTION Smith et al (5) who investigated treatment planning in the

The history of thermoluminescence dosimetry (TLD)
commences in the same year as the discovery of X rays
by C. W. Roentgen in 1895 (1). E. Wiedemann and G.
Schmidt described the use of TL for the detection of
‘cathode rays’ (2), the term used for the electron beams
before the electron as such was discovered. However,
the developments which form the basis of the present
use of TLD in medicine are centred around the work F.
Daniels at the University of Wisconsin. He proposed
geological dating and described what appears to be the
first clinical application of LiF: ‘The crystals were swal-
lowed by the patient (who had received an injection
containing radioactive isotopes), recovered one or two
days later, and the accumulated doseage in roentgens
was measured by matching thermoluminescence inten-
sity with that produced in crystals by a known roent-
gen dosage’ (3).
Twelve years later F. Daniels reported at the first
International Conference on Solid State Dosimetry (then
still termed International Conference on Luminescence
Dosimetry) that nothing much had changed: ‘I am sure
that still better thermoluminescence radiation dosemet-
ers will be developed. I refuse to believe that the LiF
available in 1950 with its accidental impurity is the best
possible material and that annealing for 1 h at 400°C
(quickly established 12 years ago) is still the best poss-
ible pretreatment’ (4). This sentence appears to be still
relevant for clinical TLD in 1998. However, the tech-
nique has matured and plays an important role in routine
clinical dosimetry. Its importance is illustrated for
example in a ‘radiotherapy patterns of care’ study by
United States. It was found that 90% of all academic
institutions and 50% of other hospitals used TLD for in
vivo dosimetry. Semiconductor diodes were the second
most common detector with about half the abundance
of TLD.
It is clear that TLD has unique features that make it
useful for clinical dosimetry. It is the aim of the present
review to illustrate these advantageous characteristics
by describing selected clinical applications that make
use of a particular feature. However, it cannot be a com-
plete summary of all applications and the discussion is
limited to the radiation types currently used routinely in
clinical applications: photons and electrons. There are
many applications of TLD in medicine when other types
of radiation such as neutrons and charged particles are
used. They will only be mentioned in passing and the
reader is referred to References 6–8 for more infor-
mation.
OBJECTIVES OF DOSIMETRY IN MEDICINE
Ionising radiation is used for diagnostic and thera-
peutic purposes in medicine. This encompasses a wide
range of different radiation doses and most applications
make use of photons either in the form of X rays
(diagnostic radiology, radiotherapy) or gamma rays
(nuclear medicine, radiotherapy). This is followed by
beta rays or electrons produced by linear accelerators or
betatrons. Other types of radiation are typically more
complicated to produce, and their use is restricted to a
few large centres, often in an experimental setting.
Common applications in this field include neutrons for

333
 T. KRON
body composition analysis and protons or neutrons for
radiotherapy (9).
The two main objectives of dosimetry in a clinical
environment are typically radiation protection and qual-
ity assurance. The former applies to the design of medi-
cal facilities and exposure of medical staff, many of
whom are required to wear personnel dosemeters. While
no limit values can be applied to restrict the dose to
patients, radiation safety considerations still apply in the
context of optimisation of procedures (10). It is essential
to assess radiation doses to patients in medical pro-
cedures to estimate the risk associated with the
exposure. This is particularly important for screening
procedures such as mammography where mostly heal-
thy people are exposed to radiation in order to detect
the few with severe diseases.
In radiotherapy the aim of dosimetry is to make sure
that the dose to the target volume is as prescribed while
minimising the dose to the surrounding normal tissue.
Here dosimetry is predominantly a tool for quality
assurance (QA), which is an essential part of modern
medicine. QA ranges from a check of equipment per-
formance to the investigation of new procedures. Dosi-
metric intercomparisons between different radiotherapy
centres and spot checks of dose delivered in diagnostic
procedures have found their way into many national and
international guidelines for best practice. A QA pro-
cedure, which has been associated with TLD for many
years, is in vivo dosimetry directly on patients during a
diagnostic or therapeutic procedure. Since each patient
is different, this is the ultimate verification of radiation
dose delivered to a tumour or to normal structures at
risk of radiation damage (11).
Table 1. Advantages and disadvantages of TLD for medical applications. Please note that this is a generalisation and
different TL materials may exhibit different characteristics. The topics indicated by an asterisk (*) are discussed in more
detail in the text.
Advantages
*Small physical size (‘point detector’)
*Tissue equivalence (at least for some materials)
*Integrative dose measurement
*No cables required during measurement
*High sensitivity — wide dosimetric range
Re-usable and cheap — multiple measurements can be made at
the same time
*Many physical forms available — different sizes, isotopes,
physical forms
*Many different materials to choose from
Mostly independent of environmental conditions such as tem-
perature and pressure
Glow curve provides additional information which could be
useful to improve accuracy or obtain information on radi-
ation quality
334
In addition to radiation protection and quality assur-
ance, TLD is commonly used in the context of medical
research. Dose assessment in novel applications and
radiobiological studies are examples of this approach.
ADVANTAGES OF TLD FOR MEDICAL
APPLICATIONS
Table 1 lists advantages and disadvantages that
characterise TLD in the context of clinical applications.
The advantages make TLD well suited for a variety of
medical applications. While it is often the combination
of features that render a particular technique suitable for
a certain purpose, the following summary aims at illus-
trating the usefulness of individual features for parti-
cular medical applications.
Small physical size
A small active volume is a typical feature of solid
state dosemeters. Consequently, they are often
employed for dose determination in small radiotherapy
fields, such as the ones used for radiosurgery (12–14). As
megavoltage photons are delivered in field sizes of 1
cm2 and less, lateral electron equilibrium is not achieved
and strong dose gradients exist even in the centre of the
field. In these applications small cubic TLDs of
1 ⫻ 1 ⫻ 1 mm3 are often the detector of choice which
allows the determination of output factors for small
radiation collimators and the verification of dose in
anthropomorphic phantoms (13). A particularly challeng-
ing field is the introduction of miniature multileaf colli-
Disadvantages
Small physical size (‘difficult handling’)
Does not allow absolute dosimetry
Delayed readout
Concerns regarding reliability (‘black art’)
Concerns regarding accuracy
Expensive readout equipment required
Many forms and materials available (‘confusing and difficult
to find appropriate technique for a particular application’)
No permanent dose record in detector
 TLD IN MEDICINE
mators that allow the delivery of small fields in virtually
any shape (15).
The small physical size of TLDs is also important for
intracavitary dose assessment directly on patients (16,17).
While measurements have been performed in the oral
cavity, in oesophagus and blood vessels and even
directly in tissues using a syringe needle (18), by far the
most common application is the determination of dose
to the rectum in intracavitary brachytherapy for gynae-
cological malignancies (19–21). Here, the rectum is the
most critical organ for the development of compli-
cations and dosimetry is a means to estimate the likeli-
hood of acute reactions and debilitating late effects.
Treatment approaches may be altered due to an early
dosimetric assessment or side effects can be targeted for
remedial action before they even occur.
Tissue equivalence
Tissue equivalence describes the property of
materials to interact with radiation in the same way as
human tissues. For dosimetric applications, tissue equiv-
alence is often replaced by water equivalence, which
can be better defined. In photon beams this is mainly
linked to effective atomic number and many formulae
have been proposed to estimate the effective atomic
number of materials from their elemental
compositions (22). Tissue equivalence is particularly
important for diagnostic X rays with accelerating poten-
tial between 30 and 150 keV. In these beams photoeffect
with its strong dependence on atomic number is a sig-
nificant interaction process. As the spectral composition
of X ray beams is often not known and scattered radi-
ation contributes significantly to dose, tissue equival-
ence is essential to determine a biologically meaningful
dose. A typical example is the assessment of skin
entrance dose in prolonged fluoroscopic procedures
such as cardiac catheterisation (23,24). The need for tissue
equivalence is also reflected in the wide use of lithium
borate, one of the most tissue-equivalent TLD detectors
in clinical dosimetry in kilovoltage X rays (25–28).
However, tissue equivalence is also of importance
when measurements are made under radiation con-
ditions where the effective energy of the photon radi-
ation field is difficult to assess. Examples are the deter-
mination of dose to critical organs outside the radiation
field in external beam radiotherapy. As can be seen in
Figure 1, the dose depends on high energy photons
transmitted through the collimators and radiation scat-
tered from within the patient. The resultant effective
energy is difficult to determine and varies from one
patient to the next. Therefore TLDs (typically LiF) are
the detector of choice for the assessment of scrotal (29,30)
or fetal doses (31).
It should be noted, however, that despite their tissue
equivalence TLDs usually have an electron density dif-
ferent from water. This may in itself lead to perturbation
335
of the radiation field and may alter the dose recorded
by the detector (32).
Integrative dose recording
This feature deserves a mention, as many medical
applications do not use static radiation beams. This is
evident in interventional radiology using fluoroscopy as
well as in dynamic radiotherapy. As can be seen in Fig-
ure 1, gantry, couch and collimator of linear accelerators
rotate around axes, which intersect at the isocentre. If
the target is positioned at the isocentre a dynamic arc
treatment (e.g. gantry rotation) can be utilised to main-
tain the tumour in the focus whilst spreading the dose
to the surrounding normal tissues. This approach is
often taken in stereotactic radiosurgery (15). Alterna-
tively, the patient may be moved to deliver electron
radiation uniformly to wide areas of the skin (33). There
is therefore an advantage in utilising the integrating
capability of TLDs to record doses accumulated during
the dynamic radiotherapy sequence.
No cables or high voltage required
This is one of the most important features of TLD as
a passive detector type. It is useful for environmental
and personnel dosimetry, however it is essential for a
variety of applications in medicine. The three most
important applications are:
(a) measurements in anthropomorphic phantoms,
(b) in vivo dosimetry,
(c) mailed dosimetry/intercomparisons.
Anthropomorphic phantoms
In diagnostic procedures, anthropomorphic phantoms
can be used to relate operational quantities such as
exposure or dose–area product to absorbed dose in
organs (34). This is essential to obtain a realistic risk
estimation for a certain radiological procedure.
Axis of collimator
and couch rotation Collimated
primary beam
Gantry
Transmission
Isocentre of primary
Axis of beam
gantry Critical
rotation organ
Gantry Internal
stand Patient scatter Treatment
couch
Base plate Floor
Figure 1. Dose contributions to critical organs in megavoltage
radiotherapy using linear accelerators. The features of the
accelerator are also indicated.

Examples are phantom measurements for spinal bone
mineral densitometry (35,36), CT scanning (37) or
dentistry (38,39). In radiotherapy anthropomorphic phan-
toms are widely used for verification of computerised
treatment planning (40–42), the check of new treatment
techniques (43) and the examination of dose in compli-
cated treatment situations (44–47). In addition to this TLDs
have been used for the determination of the dose to criti-
cal organs, such as the lens of the eye (48,49), the
scrotum (50) or the foetus during pregnancy (51). In these
applications it is advantageous that phantoms can be
moulded from wax to match the particular geometry of
an individual patient.
In vivo dosimetry
There are numerous applications of TLD for in vivo
dosimetry (16,52–54). In addition to the small size and the
fact that no cables are required during measurement, it
is advantageous that TLD readings are mostly inde-
pendent of environmental conditions such as (body)
temperature and air pressure. In the diagnostic field
important applications range from quality assurance in
mammography (55) to the dose assessment in procedures
with relatively high exposures such as CT scanning (56)
and prolonged fluoroscopic procedures (23). In radio-
therapy, in vivo dosimetry may be used as a means to
verify the entrance dose on all (or a randomly selected
sub-group of) patients for general quality assurance (52).
In these applications, semiconductor diodes have
replaced TLDs in most departments due to their
immediate readout (57,58). Also metal
semiconductors — field effect transistors (MOSFETs)
have recently been introduced (59). However, TLDs are
still the method of choice for a variety of applications
where there is a need for a small, free-standing detector.
Examples are the record of dose to critical organs such
as lens (53,60,61) and scrotal dose (29,62). In addition to this,
TLDs are a valuable tool for in vivo dose verification
in brachytherapy (16,17,20,63).
Intercomparisons
One of the most powerful quality assurance tools in
dosimetry are intercomparisons between different
centres. TLDs are ideally suited for this purpose as can
be seen by the multitude of applications ranging from
diagnostic surveys (55,64,65) to calibration checks in
radiotherapy (66–69). In addition to these simple dose
checks TLDs can be used to verify the total dose deliv-
ery chain in radiotherapy by sending an anthropo-
morphic phantom loaded with TLDs to different
centres (70). This can be planned and treated in exactly
the same way as a patient.
High sensitivity/wide dosimetric range
High sensitivity is of importance for personnel and
T. KRON
environmental monitoring. Environmental TLD allows
verification that correct use and workload factors have
been used in shielding calculations. Here new TLD
materials such as LiF:Mg,Cu,P (71,72) and Al2O3:C (73)
play an important role. Similarly, in low dose diagnostic
procedures such as dual X ray bone densitometry (36,74)
and exposures of children and neonates (36,75,76) these
new detectors have a great potential.
The wide dosimetric range is useful in applications
where the dose is difficult to predict. Lens dose
measurements in radiotherapy of head and neck or brain
lesions are a typical example (49,60). Here radiation fields
are very close to the lens of the eye. Due to the steep
penumbra of X ray beams produced by modern linear
accelerators the dose gradient is steep and the detector
may or may not be in the direct radiation beam.
Many physical forms and materials are available
The fact that many different materials and forms are
available is sometimes seen as confusing. However, it
also allows choosing the best detector for each medical
application. An example for this is the assessment of
skin dose, which is often difficult to predict. Carbon
loaded, black TLDs were designed for beta skin
dosimetry (77) and can also be employed in
radiotherapy (78,79). TLD extrapolation (80,81) makes use of
three different size of TLD chips to interpolate and
extrapolate the dose between readings from different
virtual depths. This technique has been used for in vivo
dosimetry (82) as well as for phantom measurements (46,83).
oxide
Application of different TLD materials in the same
radiation quality includes the use of different isotopes
(e.g. 6Li and 7Li) with different neutron cross sections to
determine selectively neutron and photon dose in mixed
radiation beams (84) and the assessment of radiation qual-
ity in orthovoltage radiation beams (85,86). In the latter
the difference in cross section for photo-effect between
materials with different effective atomic number reveals
an effective energy of the photon radiation.
Other advantages
TLDs are re-usable and individual detectors are
cheap. Therefore, multiple measurements can be made
at the same time to assess not only the dose at one speci-
fied point but also the distribution of dose. This is very
useful in radiotherapy where both the high dose in the
tumour and the low dose in surrounding normal tissues
contribute to a successful outcome.
It should also be noted that TLDs can yield more than
just dose information. Glow curve analysis (87) is not
only useful in the development and characterisation of
materials but can also give clues about radiation quality.
This is exemplified in the case of CaF (TLD-300) where
different glow peaks have highly different yields for
neutrons and photons (8,88,89). This allows the selective
336
 TLD IN MEDICINE
determination of photon and neutron dose in composite
radiation beams.
DISADVANTAGES
There is no ideal dosemeter for clinical dosimetry and
also TLD has its disadvantages. TLD is a relative dosi-
metric technique that does not allow absolute dose
assessment. In addition to this TL readout is delayed
which can cause problems, e.g. for in vivo dosimetry
for total body irradiations (TBI), when one wants to ter-
minate the radiation after a certain dose is delivered to
the patient. While direct readout of TLDs has been
shown to be feasible using lasers and fibre-optic
cables (90), other solid state dosemeters such as diodes
may prove to be more advantageous for immediate
results from in vivo measurements (57,91,92).
TLDs are sometimes characterised as unreliable and
not very accurate. On close inspection many of these
problems can be overcome if proper attention is paid to
thermal treatments of TLDs. Reproducibilites better
than 0.5% have been demonstrated for LiF:Mg,Ti (93)
and a reproducibility of ⫾2% (1 SD) can be achieved
routinely in radiotherapy using individually calibrated
detectors. As usually more than one detector is used for
each measurement point (53,94), an accuracy of 5% can
be easily obtained in most radiotherapy applications.
OUTLOOK AND CONCLUSIONS
With ion chambers and film, TLD is one of the three
most important detectors in clinical dosimetry. While
some already well established materials such as
LiF:Mg,Cu,P (71,72,95) have still to be widely
implemented into medical practice, old materials can
still be optimised (96) and new TLD materials have the
potential to broaden the application base of TLD even
further. Similarly, a better understanding of the TL pro-
cess has helped to manufacture better equipment and
improve the reliability of TLD results. Automatic glow
curve analysis provides additional information and a
powerful quality assurance tool that could reduce the
number of ‘spurious’ readings, which are often of con-
cern for clinical dosimetry. All this will help to develop
a variety of new applications and establishing TLD as
the dosemeter of choice for many additional appli-
cations in medicine.

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