Download pdf - Radiation Effects from Fluoroscopic X RaysRecognizing radiation injury and effects Characteristics of radiation injury 33 Fluoroscopically Guided Interventional Procedures: A Review

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Louis K. Wagner, Ph.D.

Department of Diagnostic and Interventional Imaging

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Radiation Effects from Fluoroscopic X Rays

Louis K. Wagner, Ph.D.

Department of Diagnostic and Interventional Imaging

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Louis K. Wagner, PhD is President and a principal partner of Partners in Radiation Management LTD, Co., a publishing and radiation management consultant company. The company markets the credentialing and CME program: “Minimizing Risks from Fluoroscopic X Rays”.

Radiation Effects from Fluoroscopic X Rays

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Radiation Effects Fluoroscopy

What we will do in this presentation (objectives):1. Review the history of radiation effects in medicine with emphasis on fluoroscopy

2. Review the dose‐response effects from fluoroscopic radiation.

3. Develop perspectives regarding our professional responsibilities in light of this information

2011

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Established Facts

1. Fluoroscopy has induced cancer in patients

2. Fluoroscopy has seriously injured patients

3. Fluoroscopy has caused cancer in medical staff

4. Fluoroscopy has caused skin injury in medical staff

5. Fluoroscopy has caused cataracts in medical staff

6. Medical staff have died from disease induced by medical fluoroscopy

7. Medical practitioners as a group are not well versed in the risks and exposures to patients from medical radiations

Reference: Vañó E et al, BJR 1998; 71, 728-733

How not to use a fluoroscope!

In workers, effects commonly due to long-term accumulation (chronic build-up) of radiation dose.

Effects from inappropriate use of fluoroscopy

Figure withheld

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In patients, effects typically due to accumulation of high radiation doses in a short time period, except for…….

Figure withheld Figure withheld …potential hypothetical stochastic effects ‐‐

Induced neoplasmHeritable genetic effects

‐‐which are hypothesized as possible at any dose.

Priority of concerns for fluoroscopy :

1. Short‐term (weeks to months) debilitating deterministic effects (e.g., radiation injury)

2. Long‐term (years to decades) debilitating deterministic risks (e.g., cataract, osteonecrosis)

3. Long‐term stochastic risks (e.g., cancer) [Typically this is primary concern in abdominothoracic procedures in small children]

4. Short‐term cosmetic risks (e.g., epilation)

Special concern:

1. Pregnancy (pregnancy test required for many procedures that potentially deliver high doses to uterus – e.g., hysterosalpingogram)

Radiation Risk to Pediatric Patients is a Special Problem!

“Children are not small adults” ---Keith Strauss

What do these injuries have in common?

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Figures withheld

Diagnosis of Radiation Injury• Skin absorbed dose must be high (beam

mostly fixed on same skin site)

• Must be located at entrance beam site

• Temporal patterns must fit with progression of injury

• Pattern must match collimation in size and shape (with consideration to movement of beam during procedure)

• Biopsy generally unnecessary and to be avoided if possible

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Why do we not feel the effects of X rays that cause such

effects?

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TissueHEAT

Why do we not feel the effects of X rays that cause such

effects?

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Tissue

Beam of X rays

Erster Nobelpreis fuer Physik 190115

Dudley Field, Vanderbilt University

William Dudley, president of the Vanderbilt Athletic

Association & Dean of the Vanderbilt University Medical

School from 1885 until his death in 1914

“Dr. Wm. L. Dudley and I decided to make a preliminary test of photographing through the head… 21 days after the experiment all of the hair came out over the space under the x ray discharge.” Professor John Daniel - Science: April 10 1896 16

Who are these guys?

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Developed fluoroscopy with CaWO4 fluorescent material in 1896

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Mihran Krikor Kassabian 1870 - 1910

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“The following facts are presented to substantiate the possibility that, in certain circumstances, it [ionizing radiation] may play a part in the development of mammary carcinoma.”

Patients were treated for TB by fluoroscopically guided artificial pneumothorax

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Figure withheld

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Figure withheld

Irradiation contributed to development of mammary cancers based on:

•Correlation between cancer site and site of radiation delivery

•Correlation with delivery of high radiation dose

•Unusual younger age of onset and

•Support from animal studies.

Conclusion

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What Effect Did Federal Regulations Have on Safety during the 1960’s to 1980’s?

• Regulated Manufacturing of Medical Radiation Producing Devices• Put limits on fluoroscopy output• Established the five-minute timer• Placed requirements on self-shielding of X-ray tubes• Placed requirements on collimation• Placed Requirements on distance of X-ray source from patient• Placed requirements on radiation penetration through image receptor• Required that the beam not extend outside the useful imaged area

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Result:

• Culture of safety gradually improved • Injury to personnel diminished to very small numbers• Radiation disease no longer evident in workers

But:

• Use of medical fluoroscopy was primarily diagnostic • Physicians generally left the room during acquisitions (cine or film changer series)

And:

Radiation outputs were self limited by early X-ray tube technology, slow film processing and time-consuming image management.

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This led to:

A FALSE SENSE OF SECURITY

ABOUT THE SAFETY OF FLUOROSCOPY

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Figure withheld

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Today:

• Medical fluoroscopy extensively used to guide therapeutic procedures• Physicians often at patient side during digital acquisitions

And:

Radiation outputs are virtually limitless with immediate image processing

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Renal angioplastyDandurand et al, Ann

Derm Vener 1999; 126: 413-417

Uterine embolizationCourtesy: Shope, FDA

TIPS placementNahass et al, Am J Gastroent

1998; 93: 1546-9

Radiofrequency AblationVañó, Br J Radiol 1998;

71, 510 - 516

Coronary AngioplastyCourtesy F Mettler MD

Radiation injury associated with wide range of complex procedures

Granel et al, Ann Dermatol Venereol 1998; 125; 405 -407Provided with

permission

From: Wagner and Archer. Minimizing Risks..

From: Koenig et al. AJR

From: D Wolf. Hautnah Derm

Injuries have occurred in a wide variety of anatomical locations

From: Pezzano M. Archives des Maladies du Coeur et des Vaisseaux 1992; 92: 1197 -1204.France

From: T Koenig, D Wolf et al. AJRGermany

From: Vano et al. BJRSpain Courtesy: Fred Mettler

Texas

Sovik E, Klow N-E. Acta Radiologica 1996; 37: 305-306.Scandanavia

Injuries have occurred around the world

Japan32

Courtesy of Kent Ogden, PhD

Figures withheld

Figures withheld

Figures withheld

Recognizing radiation injury and effectsCharacteristics of radiation injury

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Fluoroscopically Guided Interventional Procedures: A Review of Radiation Effects on Patients’ Skin and HairStephen Balter, PhD, John W. Hopewell, DSc, Donald L. Miller, MD, Louis K. Wagner, PhD and Michael J. Zelefsky, MD

February 2010 Radiology, 254, 326-341.

Recognizing radiation injury and effectsCharacteristics of radiation injury

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Not Scalp!!

• Coexisting diseases or conditions•Scleroderma; systemic lupus erythematosus; possibly rheumatoid arthritis; Hyperthyroidism; poor nutritional status; compromised skin integrity (diabetes mellitus – thought to negatively impact recovery from raidationdamage)

• Genetic factors• heterozygous for the ATM gene; Fanconi anemia; Bloom syndrome; xeroderma pigmentosum; Familial polyposis; Gardner syndrome; hereditary malignant melanoma; dysplastic nevus syndrome; Neurofibromatosis; Li-Fraumeni syndrome; Hereditary retinoblastoma

• Medication use• actinomycin D; doxorubicin; bleomycin; 5-fl uorouracil; methotrexate; when given in conjunction with radiation therapy: paclitaxel, docetaxel, and possibly tamoxifen can result in cutaneous toxicity

• Radiation history

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Some aggravating physical or clinical factors

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Radiation Risks

Deterministic Risks to Skin

Collagen vascular disease

Gironet et al, 1998, Ann Dermatol Venerol, 125, 598 - 600 Wagner et al, 1999, Radiology, 213,

773 - 776

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Figures withheld

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Transient erythema

Figure withheld

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Note: This is an example of depilation in the scalp. I have no images of depilation in other body locations that are validated as caused by radiation

Figures withheld

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Granel et al, Ann Dermatol Venereol 1998; 125; 405 - 407Vañó, Br J Radiol 1998; 71, 510 - 516.

From: Lichtenstein DA, Klapholz L, Vardy DA, et al. Chronic radiodermatitis following cardiac catheterization. Arch Dermatol 1996; 132: 663-667

Figures withheld

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TJC Sentinel Event

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4 mos after procedures





Three TIPS procedures in 1 week in type II diabetic. Total procedure time 13 - 16 hours. Three weeks later noticed 13-cm x 17-cm mottled oval discoloration on back. Initially diagnosed as strep infection, then as herpes I, then as allergic reaction to oral diabetic medications. Diagnosis of radiodermatitisobtained ten months after procedure!

Figures withheld

Several months after 3rd

angioplasty

5 months after third angioplasty

22 months after third angioplasty

From: Wolff D, Heinrich KW. Hautnah derm 1993; 5: 450-452.

Diagnostic study and PTCA with 51 minutes of fluoroscopy14 d afterward erythema on rt shoulder, turned into moist superficial ulcer with poor healing, degenerated into deep muscular ulcer, cutaneous skin graft required

At 5.5 mos At 14 mos

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Figures withheld

9.5 wks after 1st procedure

23 wks after 1st procedure; 3 wks after 2nd procedure

6 wks after 2nd procedure



17.5 wks after 2nd procedure




•no one knows...nor does anyone want to know...what do I do...please help me.•Happened during stent placement December 2008.@ well-known hospital, two lengthy procedures with-in 3 days. •No one advised me nor informed me that I was exposed to excessive radiation. I recently received my records,(Dec 2010). I had a long duration of radiation exposure and yet not one person told me so. •I went through months of infection and pain and to this day it still hurts and unbearable itching. •In January 2010 I had a quad by pass and the surgeon said,and I quote, "in my opinion,when they placed the stents on wednesday and there was a serious problem,they should not have replaced the stents on friday but rather done a bypass“•I understand that I may be looking at cancer down the road. I don't know,I'm not a doctor. What kind of test can be made to keep a eye on this? Who should be responsible for any damage?•I had a endoscopy in February 2010 and the doctor said he thinks the radiation has thinned the wall of my esophagus and must watch it closely. Attached are photos I had taken through different stages and the wound appears to be getting red once again. Please if you can be of any help,please call me or Email me.

Recent communications on radiation injury

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• As you know, radiation is the gift that keeps on giving.

• After several weeks of having a different kind of pain on top of his usual ongoing pain, K had an MRI, showing rib fractures, posterior T9, possible nonunion, and a fracture at posterior T8.

• With his debilitating ongoing pain, K does very little in the way of physical activity so it is baffling to try to figure a cause of two fractured ribs. The doctor who did the surgery for K's latissimus flap diagnosed it as osteoradionecrosis.

• Ribs T9 ad T8 are in direct line of what he figures to be the strongest blast of radiation from K's two heart ablation procedures

• It has been over four years since his first ablation procedure and over three years since the latissimus flap surgery.

• At this point K is not certain what his next step will be to fix the fractured ribs; there are a few options, none of which are attractive to him.

• In your studies have you come across a delay in radiation injury to the ribs? And if so, do you know how the injury was addressed? Or once the radiation starts its grip on the ribs, how long will it continue to cause damage? If you are aware of anyone who has gone through, or is going through, this particular injury, could you please ask that they contact us?

Recent communications on radiation injury

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Dose in bone at diagnostic energies is about 3-4 times

greater than that in soft tissue due to the photoelectric interaction in calcium

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Five weeks after procedure

9 ½ Months after procedure

i really don't know how much more of this i can stand!!!!..do you have any idea looking at the photos, what i might be up against? it is so amazing but it seems i know more about my condition than all the doctors i have been to HOW CAN THAT BE???? do you have any stats on how many people suffer thru this????

Former major league professional athlete

From Vlietstra et al., J Interventional Cardiology 2004

From Wong et al., New Eng J Med 2004

Wagner – Archer, Minimizing Risks from Fluoroscopic X Rays, 3rd ed, Houston, TX, R. M. Partnership, 2000

Vano et al, Brit J Radiol1998, 71, 510-516

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Figures withheld

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7th July (treatment was on the 15th June)

19th July

Radiation RisksInduced Cataract

Reference: Vañó E et al, BJR 1998; 71, 728-733

Threshold < 0.7 GyOnset depends on dose

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PA orientation delivers only exit doseShield eyes from lateral beam using collimation

Radiation-induced cataract in medical personnel

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Figures withheld

Cataracts among Chernobyl Clean-up Workers: Implications Regarding Permissible Eye Exposures

Worgul BV, Kundiyev YI, Sergiyenko NM, Chumak VV, Vitte PM, Medvedovsky C, Bakhanova EV, Junk AK, Kyrychenko OY, Musijachenko NV, Shylo SA, Vitte OP, Xu

S, Xue X, Shore RERadiation Research 167, 233-243, 2007

•Prospective study of 8607 Chernobyl clean-up workers assessed at 12 and 14 years after exposure•Cohort young and prevalence of cataracts prior to clean-up assumed similar to prevalence of age-dependent cataract in non-cleanup cohorts. •Baseline reference was individuals exposed to less than 100 mGy.•Dose response effect found•Threshold for induction of Stage 1 opacities ~350 mGy, perhaps less, and not in excess of 700 mGy.

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