4.

Estimation of Effective
Dose Per Procedure

Estimation of effective dose is complicated by a number of

issues. These include determination of exposure factors, calcula-
tion of organ doses, use of various computational phantoms, and
changing values of wTs. As a result, estimates of effective dose for
a procedure that are reported in the literature may not be compa-
rable. This section of the Report elucidates these issues in detail
and provides information regarding the magnitude of effect that
they may have.
4.1 Definition and Use of Effective Dose in Medicine
The concept of the effective dose was developed by ICRP as a
dosimetric quantity loosely related to risk for managing the protec-
tion of stochastic radiation effects, principally cancer, in workers
and members of the general public exposed to occupational and
environmental radiation sources, respectively. Thus effective dose
enables comparison of planned or received doses with dose limits,
dose constraints, and reference levels, all of which are expressed in
the same quantity. Its use allows all radiation exposures from
external and internal sources to be considered together and
summed.
The quantity is based upon several assumptions including (1)
the linear nonthreshold dose-response relationship, (2) the equiva-
lence of acute and chronic exposures at low doses and low dose
rates to produce stochastic effects, and (3) the equivalence of exter-
nal and internal exposures to produce stochastic effects. While not
originally derived for applications in medical exposure of patients,
effective dose has been used extensively to (1) compare doses from
different diagnostic examinations and interventional procedures,
(2) compare the use of similar technologies and procedures in dif-
ferent hospitals and countries, and (3) compare different technolo-
gies for the same medical examination (ICRP 2007).
Effective dose as defined in ICRP Publication 60 (ICRP 1991)
and Publication 103 (ICRP 2007) is a radiation protection quantity
computed from (1) knowledge of the absorbed dose to individual
organs and tissues of the exposed patient, (2) wRs, and (3) wTs.
Effective dose is computed by multiplying the absorbed dose to a

39
40 / 4. ESTIMATION OF EFFECTIVE DOSE PER PROCEDURE

specific tissue by a wR for that specific type of radiation and then

multiplying that value by a wT for the same specific tissue and
finally summing the values for all tissues. In ICRP Publication 103
the effective dose is formally computed as follows:

M F
 D T,R + D T,R 
E =  w T  w R --------------------------------------------------- ,
2
(4.1)
T R

M F
where D T,R and D T,R are the mean absorbed dose to tissue T
(e.g., bone marrow, lungs, liver, etc.) delivered by radiation type R
(e.g., gamma rays, x rays, beta particles, alpha particles, etc.) to a
reference male (M) and reference female (F), respectively. Refer-
ence persons are idealized individuals nominally at “average”
heights or weights as defined in ICRP Publication 23 (ICRP 1975)
and later in ICRP Publication 89 (ICRP 2002). Radiation weighting
factors are defined as 1.0 for all photons and electrons/positrons
and 20 for alpha particles in both ICRP Publications 60 and 103.
The wR for protons has decreased from a value of five in ICRP Pub-
lication 60 to a value of two in ICRP Publication 103. The wR
accounts for different abilities of a unit absorbed dose of different
types of radiation to produce stochastic biological effects. Values of
the wT are addressed below in Subsection 4.5.
While effective dose is strictly defined for the ICRP reference
person at select reference ages (newborn, 1 y, 5 y, 10 y, and 15 y of
age and adult) (ICRP 2002), based upon sex averaging of the organ
doses in both reference male and reference female at each of these
defined ages, the quantity has been widely reported in medical
imaging for individual patients (male or female) and with body
morphometries that in many cases do not fully conform to the aver-
age heights and weights of the ICRP reference individuals. These
“detriment-weighted” whole-body doses are typically quoted as val-
ues of effective dose even though they are not computed as defined
in Equation 4.1 by ICRP.
While values of organ absorbed dose to patients undergoing
medical imaging have on occasion been assessed via physical
dosimetry within tissue-equivalent anthropomorphic phantoms,
the vast majority of patient organ doses in medical imaging are
assessed via Monte-Carlo radiation transport simulation using
computational anatomic models of the patient (Bolch et al. 2010;
ICRP 2016). Over the past five decades, computational patient
models have progressed in anatomic realism from stylized models,
to voxel models, to the most recent format based upon polygon-
mesh surface models. The effective dose per imaging procedure is
 4.2 EFFECTIVE DOSES IN NCRP REPORT NO. 160 / 41

typically determined via the use of organ DCs and a dose metric
unique to each imaging modality and discussed in Section 2.
The following text contains a review of values of effective dose
per imaging procedure as utilized in NCRP Report No. 160 (NCRP
2009). Issues related to changes in ICRP’s wTs and the selection of
the computational phantom representing the patient are briefly
reviewed. Final values of the effective dose per imaging procedure
used in this Report are included in the modality specific sections of
this Report. To facilitate comparisons between the collective effec-
tive doses given in this Report, and those previously reported in
Report No. 160, the default values of effective dose per procedure
were those used in the prior report. Only in cases where subse-
quent literature review produced strong evidence of the need for a
change were different values employed in the analyses of this
Report. A review of various uncertainties in the effective dose per
procedure, and in the final estimates of the collective effective dose
are contained in each modality section and then summarized in
Section 14 of the Report.

4.2 Effective Doses in NCRP Report No. 160

Data on the effective dose per imaging procedure that was uti-
lized in NCRP Report No. 160 (NCRP 2009) were obtained by in-
depth review of the peer-reviewed scientific literature on patient
radiation dosimetry in radiology and diagnostic nuclear medicine
published between the years of 1980 and 2007. Reported values
and ranges of effective dose were compiled for common procedures.
For some procedures (such as abdominal CT), there were more than
20 publications with the required information. In cases where
there were numerous sources with differing data, it was possible to
derive an arithmetic mean. This in itself was not very helpful, as it
was clear that some of the publications represented large interna-
tional surveys, some represented data from a single hospital, and
others reported measurements in physical phantoms. Some of the
articles included new data, but others presented data from prior
publications from other authors. The latter were thus not counted
twice. Only a few publications provided detailed data regarding
radiologic techniques or imaging protocols.
Additionally, for some procedures, the mean was not useful if it
was clear that the temporal trend in dose had been decreasing or
increasing. Finally, for some procedures, there were only a few ref-
erences. As a result, it was necessary to make an informed judg-
ment as to what would be a current representative value for
effective dose per imaging examination.
42 / 4. ESTIMATION OF EFFECTIVE DOSE PER PROCEDURE

4.3 European Commission Report No. 180: Parts 1 and 2

In 2014, the European Commission issued its Radiation Protec-
tion Report No. 180 (EC 2014a, 2014b). Part 1 of that report included
a comprehensive survey of 36 European countries regarding the
frequencies and radiation dose resulting from both diagnostic x-ray
imaging and nuclear medicine procedures. The survey was con-
ducted over the period 2007 to 2010. Final results were presented
as annual effective dose in the participating European countries
which was calculated to be 1.1 mSv for all medical imaging. The
report demonstrated that radiation dose from medical imaging var-
ied greatly among different countries in the survey, and that there
was an upward trend in many of countries of the study. The report
updates its earlier survey published in 2008 (EC 2008). Part 2 of
the document reports DRLs across each surveyed nation (Subsec-
tion 4.9). The study’s values of effective dose per radiology imaging
exam and nuclear medicine procedure, respectively, for adult
patients were found to not differ greatly from the values adopted
for use by NCRP (2009).

4.4 Peer-Reviewed Literature

For this Report, a literature review was conducted for new data
on effective dose. The pertinent results of the literature review are
included in each of the modality-specific sections of this Report.
Values of effective dose are carried forward from the previous
report with the exception of those examinations or interventions
for which a justified change in effective dose per procedure was
warranted.

4.5 Issues Related to Changing ICRP

Tissue Weighting Factors
An important parameter in the calculation of effective dose is
the tissue weighting factor (wT). This parameter represents the rel-
ative organ contribution to total detriment of an exposed reference
individual irradiated uniformly across the whole body. Detriment is
a complex quantity defined by ICRP which includes the stochastic
risk of cancer induction with subsequent adjustments for lethality
(probability of death following cancer incidence), quality of life
(subjective modification to account for suffering associated with
nonfatal cancers), and years of life lost (given higher weight to can-
cers induced at younger ages). Values of relative detriment are
determined based upon radiation epidemiology studies of the Jap-
anese atomic-bomb survivors (Life Span Study) as well as selected
additional studies of occupational, environmental, and medical
 4.5 ISSUES RELATED TO CHANGING ICRP wTs / 43

exposures of well characterized cohorts with associated dosimetry

at the organ level. Final reference values of the wTs are given as
values of relative detriment that have been rounded and binned
into four to five categories. ICRP has undertaken this analysis as
part of its past three recommendation documents: Publication 26
[defining the effective dose equivalent (HE)] (ICRP 1977), Publica-
tion 60 [defining the effective dose (E)] (ICRP 1991), and Publica-
tion 103 [redefining the effective dose (E)] (ICRP 2007). These
changes in values of wT are summarized below in Table 4.1.
Of interest to this Report are changes in wT from ICRP Publica-
tion 60 to Publication 103 (ICRP 1991, 2007), and in particular,
how these changes might impact values of effective dose per imag-
ing procedure, and in turn, estimates of collective effective dose to
exposed populations. Changes in values of wT from Publication 26
(ICRP 1977) to Publication 60 were mostly driven by a further

TABLE 4.1—Changes in wTs from ICRP (1977, 1991, 2007).

Publication 26 Publication 60 Publication 103

Tissue
(ICRP 1977) (ICRP 1991) (ICRP 2007)

Active marrow 0.12 0.12 0.12

Breast 0.15 0.05 0.12

Colon wall 0.12 0.12

Lungs 0.12 0.12 0.12

Stomach wall 0.12 0.12

Remainder tissues 0.30 0.05 0.12

Gonads 0.25 0.20 0.08

Thyroid 0.03 0.05 0.04

Esophageal wall 0.05 0.04

Liver 0.05 0.04

Urinary bladder wall 0.05 0.04

Skeletal endosteum 0.03 0.01 0.01

Brain 0.01

Salivary glands 0.01

Skin 0.01 0.01

Total 1.00 1.00 1.00

44 / 4. ESTIMATION OF EFFECTIVE DOSE PER PROCEDURE

decade plus medical follow-up in the survivors at Hiroshima and

Nagasaki. Table 4.1 shows that additional organs and tissues were
assigned unique values of wT in ICRP Publication 60 and again in
ICRP Publication 103. The additional wT values resulted in a
decrease in the remainder tissue wT of 0.30 to 0.05. Remainder tis-
sues have a limited number of observed cancer cases and it is diffi-
cult to assign risk values unique to those tissues. Only a collective
cancer risk (and thus detriment) could be assigned to the remain-
der tissues. In the revision of the ICRP wTs from Publication 60 to
Publication 103, three tissues in particular revealed substantial
changes. These included the breast (0.05 to 0.12), the gonads (0.20
to 0.08), and the remainder tissues (0.05 to 0.12).
There were several reasons for the increase in relative detri-
ment for breast cancer (ICRP 2007, Annex A). First, with the addi-
tional 15 y period of follow-up (1990 to 2005), those exposed as
juveniles in the Life Span Study Cohort made a larger contribution
to the overall breast cancer risk. Second, in the analysis of ICRP
Publication 103, the excess relative risk estimates for women
exposed over 40 y of age were shown to be higher than they were at
the time of the Publication 60 analysis. Studies of other exposed
populations confirmed this observation of a higher breast cancer
risk from radiation exposure. It was noted that, even though the
lethality fraction for breast cancer over this 15 y period had
decreased (most probably reflecting an increase in early detection
and improved treatment), this had little impact on estimate of rel-
ative detriment.
The wTs for the gonads (testes in the male and ovaries in the
female) were revised as well in ICRP Publication 103. The reduc-
tion in wT for the gonads (which is relevant to hereditary effects, not
cancer induction) stems in part in a change of methodology between
ICRP Publications 60 and 103. In Publication 60, all genetic dis-
eases were assumed to be lethal, and the genetic risks assigned
were given as their equilibrium values (over many generations fol-
lowing exposure of the parent). In Publication 103, the lethality
fraction for genetic diseases was revised downward to 80 %, and the
risk was considered to only two generations of offspring. It is also
noted that to date, no statistically significant increase in birth
defects has been observed in the Life Span Study Cohort, and thus
this component of total detriment is perhaps conservative and con-
tinues to be modeled based upon extrapolated animal data.
The further accumulation of Life Span Study data in the period
following Publication 60 substantially influenced the assignment
of wT to the remainder tissues [defined in Publication 103 as the
adrenal glands, extrathoracic airway tissues, gallbladder wall, heart
 4.5 ISSUES RELATED TO CHANGING ICRP wTs / 45

wall, kidneys, lymphatic nodes, skeletal muscle, oral mucosa, pan-

creas, prostate (male), small intestine wall, spleen, thymus, and
uterus/cervix (female)]. Evidence reviewed in ICRP Publication
103 indicated an excess radiation risk, in the aggregate, among a
variety of other tissues, although the degree of risk for a single tis-
sue in the remainder category was unclear. In the computation of
effective dose from Publication 103, the value of wT = 0.12 is applied
to the arithmetic mean (not a mass-weighted mean) of the absorbed
dose to each of these 13 tissues in either the reference male or ref-
erence female.
In 2010, Hart et al. (2010) reported the number and collective
doses to the U.K. population from medical and dental x-ray exam-
inations. In that report, values of effective dose per imaging proce-
dure, as well the collective effective dose from each major contrib-
uting imaging modality, were reported using both Publications 60
and 103 wTs. The overall impact of changes in wTs was shown to be
minimal, with the ratio of E103 to E60 of only 1.02 (Table 4.2). Note
that nuclear medicine procedures were not included in this assess-
ment. There are larger impacts of the changes in wT when specific
modalities and examinations are considered as discussed below.

4.5.1 Computed Tomography

The impact of changing values of the wT on the effective dose in

adult CT imaging was recently reviewed by Shrimpton et al. (2016)
for 14 different clinical CT exams. Organ doses were assessed via
Monte-Carlo radiation transport simulation using the ICRP refer-
ence adult male (ADAM) and reference adult female (EVA) voxel
phantoms. Organ absorbed doses were averaged and then either

TABLE 4.2—Value of S60 and S103 for the collective dose

(person-sievert) in the United Kingdom as of 2008 from medical
x-ray imaging procedures (Hart et al. 2010).

2008 U.K. Collective Dose (person-Sv)

Imaging Modality
S60 S103 S103 /S60

Conventional radiology 4,695 4,799 1.02

Computed tomography 16,302 16,723 1.03

Angiography (non-CT) 1,213 1,187 0.98

Interventional (non-CT) 2,037 1,985 0.97

Total 24,247 24,694 1.02

46 / 4. ESTIMATION OF EFFECTIVE DOSE PER PROCEDURE

ICRP Publication 60 or Publication 103 wTs were applied. These

simulations were performed for 12 different scanner makes and
models and 17 different combinations of filter and collimation set-
tings. Tube potentials were selected as average values, typically
110 or 120 kVp. All values of effective dose (either E60 or E103 ) were
normalized to the scan length for that particular exam, thus deriv-
ing DCs for effective dose (in millisievert) per DLP (in mGy cm). For
both E60 /DLP and E103 /DLP, the relative standard deviation of the
effective dose coefficients was small, and ranged from a low of 3.8 %
to a high of 5.5 % across the different scanners and technique fac-
tors. Ratios of E103 /E60 are shown to range from a high of 1.19 (CT
imaging of the cervical spine) to a low of 0.90 (CT imaging of kid-
neys and urinary bladder). Head scans yielded a ratio of 1.0, while
those of the neck and upper torso were in the range of 1.13 to 1.19,
driven primarily due to the increased value of wT for the breasts
between E60 and E103. Values of the effective dose ratio ranged from
1.14 to 0.90 in abdomen and pelvic regions. A whole-body CT scan,
as performed in conjunction with PET imaging, yielded a 3 %
decrease in E103 over E60. The relative standard deviation of these
mean values of the DC ranged from a low of 5.5 % (cervical spine)
to a high of 7.5 % (CT imaging of kidneys and urinary bladder).

4.5.2 Radiography and Dental Imaging

The E103 /E60 ratios used for radiography in this Report are those
from Hart et al. (2010) and are shown in Section 7. There are two
specific radiographic modalities (mammography and dental radiog-
raphy) in which the change of wTs had a very substantial effect in
increasing estimated effective dose. This was due to changing the
wT for the female breast from 0.05 to 0.12 and giving more weight
to brain tissue and for the first time, salivary glands, oral mucosa,
and the extrathoracic airway tissues were included in the weight-
ing scheme. As expected, there is a substantial reduction in esti-
mated effective dose for radiographs of the hip and pelvis due to
reduction in the wT for the gonads from 0.20 to 0.08.

4.5.3 Nuclear Medicine

The impact of changes in the wT on the value of the effective

dose in adult nuclear medicine studies was extensively reviewed by
Andersson et al. (2014, 2016; Andersson 2015). In their study, new
estimates of the effective dose coefficient (millisievert per megabec-
querel administered) were based upon reference biokinetic models
of ICRP given in ICRP Publications 53, 80, and 106 (ICRP 1987,
1998, 2008), values of specific absorbed fraction computed in the
 4.6 COMPUTATIONAL PHANTOM MODELS OF THE PATIENT / 47

adult male and female reference voxel phantoms of ICRP Publica-

tion 110 (ICRP 2009), and the revised human alimentary tract
model of ICRP Publication 100 (ICRP 2006). The resulting organ
doses in both the male and female phantoms were averaged, and
effective dose was computed using Publication 60 (ICRP 1991)
and Publication 103 (ICRP 2007) values of wT . Of interest to this
Report is the ratio of E103 to E60. For the 63 radiopharmaceuticals
and patient conditions considered, the average ratio E103 /E60 was
shown to be 0.97 ± 0.16. The maximum ratio was 1.83 (for 3H tri-
tium-labeled neutral fat and free fatty acids) and the minimum
ratio was found to be 0.78 (99mTc-technetium-labeled mercaptoace-
tyltriglycine (MAG3), normal renal function). There is little effect
on the myocardial perfusion cardiac imaging agents or 18F-fluoro-
deoxyglucose (FDG) which contribute ~60 % of the collective effec-
tive dose from nuclear medicine in the United States.

4.6 Computational Phantom Models of the Patient

For completeness this section includes a brief discussion of the
potential impact of computational phantoms on estimation of effec-
tive and collective effective doses from medical procedures. There
are uncertainties associated with converting the dose measured or
calculated in a phantom to patient dose. At present, there are no
comprehensive published assessments of the impact of using vari-
ous phantoms across even common medical procedures. It was not
within the scope of NCRP’s charge to perform such an assessment,
and as a result in this Report effective doses have not been modified
to include the advanced computational phantoms. The one excep-
tion to this is for nuclear medicine where the ICRP/ICRU phantom
data were utilized.
Monte-Carlo-based radiation transport simulation remains one
of the primary methods for establishing values of organ dose follow-
ing medical imaging of the patient. In these simulation studies, a
three-dimensional (3D) anatomic model of the patient must be
presented to the virtual radiation imaging field. These virtual
patient models (or computational phantoms) are presently avail-
able in one of three format types: stylized models (based upon 3D
mathematical equations of organ and body surfaces), voxel models
(based upon segmented CT or MR images of imaged patients) (Xu
et al. 2000), and hybrid models (based upon polygon or tetrahedral
mesh representations of organ and body surfaces). The majority of
studies to date report values of organ dose and effective dose per
imaging procedure which have employed stylized computational
phantoms based on either the age-dependent series of reference
phantoms from the Oak Ridge National Laboratory (Cristy 1980),
48 / 4. ESTIMATION OF EFFECTIVE DOSE PER PROCEDURE

or those of the ADAM and EVA from the former Gesellschaft für
Strahlenforschung Laboratory (Kramer 1982). More recently, voxel
phantoms have been employed for these purposes. While hybrid
phantoms have been available since the mid-2000s, for many years
these models had to be converted to a voxelized format for coupling
to radiation transport codes. Only within the past few years have
radiation transport codes advanced to the point where x-ray pho-
tons and their secondary electrons can be followed within body and
organs of a mesh-type phantom. As a result, there have been no
systematic compilations to date of organ and effective DCs for med-
ical imaging procedures using mesh-type phantoms. In studies
comparing external and internal DCs computed using both voxel-
and mesh-type phantoms of ADAM and EVA, small differences (few
percent) were observed, with the single exception of those coeffi-
cients pertaining to low-energy photons and electrons irradiating
skin and eye lens (Kim et al. 2016). These differences have been
attributed to the limited ability of the ICRP Publication 110 voxel
phantoms to model the very small target structures of the eye lens
and the skin basal-cell layer, which in contrast can be explicitly
represented within mesh-type phantoms.
Another feature of anatomic computational patient models
is their morphometric category. These included reference (nomi-
nally the 50th percentile height and weight as assigned by ICRP),
patient-dependent (represented by libraries of phantoms of varying
combinations of height/weight), patient-sculpted phantoms (those
altered to match the patient’s unique body contour with propor-
tional changes to internal anatomy), and finally, patient-specific
(those that are exact representations of the patient with respect to
both body contour and internal anatomy). The vast majority of
studies of effective dose per imaging procedure have employed the
use of reference phantoms and those values of organ dose and effec-
tive dose per imaging procedures are presented for male and
female patients as a function of subject age at fixed intervals (1 y,
5 y, 10, y 15 y of age, and adults). With the development of phantom
libraries, organ doses can now be presented in a more patient-spe-
cific manner in which portions of the phantom library cover under-
weight, normal weight, overweight, and even obese patients (Ding
et al. 2012; Segars et al. 2013; Geyer et al. 2014).

4.6.1 Computed Tomography

In 2017, Gao et al. published a comprehensive study comparing
adult and pediatric organ doses and effective dose from CT using
three different software codes (Gao et al. 2017). A general conclu-
sion is that when the entire torso is irradiated under CT imaging,
 4.6 COMPUTATIONAL PHANTOM MODELS OF THE PATIENT / 49

the phantom format type (stylized or voxel) has minimal impact on

effective dose. For head scans, it is clear that higher values of effec-
tive dose are reported with organ dosimetry from stylized phan-
toms. The primary organ of note in this discrepancy is the thyroid,
which lies fully within the small cylindrical neck of stylized phan-
toms. In the more realistic anatomy of the CT/MR-based voxel
phantoms, the thyroid is generally positioned in the neck at a level
laterally shielded in part by the shoulder musculature, clavicles,
and scapulae.

4.6.2 Radiography

Petoussi-Henss et al. (2002, 2005) introduced the Gesellschaft

für Strahlenforschung family of voxel computational phantoms. As
part of this study, organ DCs (organ equivalent dose in millisievert
per entrance absorbed dose in milligray) were reported for two
radiograph examinations using both the adult male voxel phantom
Golem and the ADAM stylized reference adult male phantom. The
two radiography examinations were (1) a PA thoracic exam and (2)
an anteroposterior (AP) lumbar spine exam. Effective doses were
not reported in this study, but they can be approximated using the
available values of organ dose given in that paper. In both examina-
tions, effective dose is shown to be 1.2 to 1.3 times higher in the
Golem voxel phantom than in the stylized ADAM phantom. The
authors note that although the Golem and ADAM phantoms have
similar external dimensions, the absorbed dose to the lungs, spleen,
and organs of the GI tract (colon, small intestine, and stomach
walls) differ substantially. These differences are attributed both to
different amounts of tissue shielding from external sources, and
organ shape and position which results in differing amounts of par-
tial organ irradiation in these two radiograph fields.

4.6.3 Diagnostic Fluoroscopy

Pazik et al. (2007) reported organ doses and effective doses

received by five newborn patients undergoing fluoroscopic and
radiographic imaging associated with voiding cystourethrogram
studies. Organ doses were reconstructed via detailed video-image
analysis and Monte-Carlo radiation transport using three different
computational models of the patient: (1) the Oak Ridge National
Laboratory stylized reference newborn, (2) the University of Flor-
ida newborn voxel phantom (Nipper et al. 2002) scaled to match the
reference newborn total body mass (Voxel1), and (3) the University
of Florida newborn voxel phantom scaled to match the actual
patient body mass (Voxel2 ratios of effective dose Voxel1 to stylized).
50 / 4. ESTIMATION OF EFFECTIVE DOSE PER PROCEDURE

Effective dose ratios ranged from 0.83 to 1.12 which is indicative of

differences in organ shape, depth and position between the two
phantom format types. A broader range of effective dose ratios
(Voxel2 to stylized) (0.68 to 1.31) are seen when the voxel phantoms
are rescaled to match the true size of each newborn patient.
4.6.4 Nuclear Medicine
In 2013, Hadid et al. (2013) computed effective DCs for 15 differ-
ent radiopharmaceuticals using newly computed photon and elec-
tron specific absorbed fractions in ICRP Publication 110 reference
adult voxel phantoms (ICRP 2009). These values of effective dose
were then compared to values previously published by ICRP based
on radiation transport in the Oak Ridge National Laboratory styl-
ized adult phantoms. The ratio of the effective DCs (voxel to stylized
phantoms) range from a low of 0.58 (99mTc-EC normal) to high of
1.60 [123I-metaiodobenzylguanidine (MIBG)]. The average ratio was
found to be 0.94 ± 0.32.
Andersson et al. (2014; Andersson 2015) performed an analysis
of 338 radiopharmaceuticals comparing the effect of using the Med-
ical Internal Radiation Dose Committee and ICRP/ICRU phantoms
with ICRP Publication 60 wTs and then the ICRP/ICRU phantom
with ICRP Publication 103 wTs. For 63 % of the 338 radiopharma-
ceuticals the effective dose was lower and as a mean for all radio-
pharmaceuticals they were 11 % lower. These changes were
predominantly due to use of the ICRP/ICRU phantom with much
less effect from use of ICRP Publication 103 wTs. These average val-
ues however cannot be applied to evaluation of collective effective
dose because the majority of these radiopharmaceuticals are rarely
used. The results for the most commonly used radiopharmaceuti-
cals in the United States are summarized in Table 4.3. For the
United States the impact of changing wTs and computational phan-
toms for cardiac studies using 99mTc-MIBI and tetrofosmin will pre-
dominate in estimations of collective effective dose.

4.7 Effective Dose from Medical Imaging of Children

The current Report includes Section 12 on effective dose from
medical imaging of children, a topic that was not addressed in
NCRP Report No. 160 (NCRP 2009). While it is common to report
values of effective dose to children undergoing medical imaging
examinations, and even fluoroscopically guided interventional car-
diology procedures, the limitations of effective dose as a measure of
patient stochastic risk must be understood. Data from the studies
of the atomic-bomb survivors, and other radiation epidemiological
investigations, have demonstrated a clear age and sex dependence
TABLE 4.3—Effective DCs (millisievert per megabecquerel) for radiopharmaceuticals commonly used in the United
States based upon organ doses computed using Medical Internal Radiation Dose Committee phantoms with ICRP

4.7 EFFECTIVE DOSE FROM MEDICAL IMAGING OF CHILDREN

Publication 60 wTs compared to using the ICRP/ICRU phantom with ICRP Publication 60 wTs and then using the
ICRP/ICRU phantom with ICRP Publication 103 wTsa (adapted from Andersson 2015).
Percent Change
MIRD ICRP/ICRU ICRP/ICRU
Radiopharmaceuticalb ICRP 60 to
ICRP 60 wT ICRP 60 wT ICRP 103 wT
ICRP 103 wT

13
N-ammonia 2.00E–03 2.35E–03 (+18) 2.32E–03 (+16) –1
18
F-FDG 1.9E–02 1.69E–02 (–11) 1.71E–02 (–10) 1
67Ga-citrate 1.00E–01 9.29E–02 (–7) 9.08E–02 (–9) –2
82
Rb 3.40–03 2.39E–03 (–30) 2.47E–03 (–27) 3
99m
Tc-colloids (large) normal 9.40E–03 1.24E–02 (+31) 1.12E–02 (+19) –10
liver function
99mTc-DTPA
4.90E–03 3.97E–03 (–19) 3.34E–03 (–32) –16
normal renal function
99mTc-ECD
7.7E–03 5.97E–03 (–23) 5.64E–03 (–27) –6
99mTc-HMPAO 9.30E–03 1.05E–02 (+13) 9.78E–03 (+5) –7
99mTc-MAG3
7.00E–03 5.12E–03 (–27) 4.00E–03 (–43) –22
normal renal function

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TABLE 4.3—(continued)

Percent Change
MIRD ICRP/ICRU ICRP/ICRU
Radiopharmaceuticalb ICRP 60 to
ICRP 60 wT ICRP 60 wT ICRP 103 wT
ICRP 103 wT

99mTc-IDA derivatives normal 1.70E–02 9.39E–03 (–45) 9.73E–03 (–43) 4

liver function
99m
Tc-MAA 1.1E–02 1.34E–02 (+22) 1.40E–02 (+27) 4
99mTc-MIBI resting 9.0E–03 6.81E–03 (–24) 6.61E–03 (–27) –3
99m
Tc-MIBI exercise 7.9E–03 6.55E–03 (–17) 6.29E–03 (–20) –4
99m
Tc-tetrofosmin 8.0E–03 5.92E–03 (–26) 6.15E–03 (–23) 3
resting
99m
Tc-tetrofosmin 6.9E–03 5.54E–03 (–20) 5.67E–03 (–18) 3
exercise
99mTc-erythrocytes
7.0E–03 1.06E–02 (+51) 1.11E–02 (+59) 5
99mTc-leukocytes 1.1E–02 1.28E–02 (+16) 1.02E–02 (–7) –20
99mTc-pertechnetate
1.3E–02 1.60E–02 (+23) 1.58E–02 (+22) –1
no blocking
99mTc-phosphates
5.7E–03 4.55E–03 (–20) 3.99E–03 (–30) –12
111In pentetreotide 5.4E–02 6.74E–02 (+25) 5.92E–02 (+10) –12

4.7 EFFECTIVE DOSE FROM MEDICAL IMAGING OF CHILDREN

111In leukocytes 3.60E–01 4.38E–01 (+22) 3.45E–01 (–4) –21
123
I-MIBG 1.30E–02 1.67E–02 (+28) 1.67E–02 (+28) 0
123
I-iodide 35 % uptake 2.2E–01 2.59E–01 (+18) 2.13E–01 (–3) –18
131
I-iodide 35 % uptake 2.4E+01 2.68E+01 (+11) 2.15E+01 (–10) –20
133Xe gas rebreathing 5 min 7.30E–04 1.28E–03 (+75) 1.30E–03 (+78) 2
201
Tl ion 1.40E–01 1.27E–01 (–10) 1.02E–01 (–27) –20
a
The difference between Column 2 and Columns 3 and 4 is shown as a percentage (in parentheses). The percentage impact due solely to
changing the wTs is shown in Column 5.
bDTPA = diethylenetriamine pentaacetic acid
ECD = ethyl cysteinate dimer
HMPAO= hexamethylpropyleneamine oxin
IDA = iminodiacetic acid
MAA = macroaggregated albumin
MAG3 = mercaptoacetyltriglycine
MIBG = metaiodobenzylguanidine
MIBI = sestamibi
MIRD = Medical Internal Radiation Dose Committee

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54 / 4. ESTIMATION OF EFFECTIVE DOSE PER PROCEDURE

of the probability of cancer incidence per unit absorbed dose to dif-

ferent organs and tissues. Estimates of cancer incidence to a broad
population of exposed children in given age intervals may be esti-
mated, with broad uncertainties, as the product of the mean tissue
absorbed dose and an age/sex/organ specific cancer risk coefficient,
as published by NA/NRC (2006), UNSCEAR (2008), and Eckerman
et al. (1999). In contrast, effective dose uses values of wTs (relative
values of total body detriment) which are averaged across all ages
and sex. Consequently, values of effective dose must be used with
caution in providing a measure of stochastic risk under the linear
nonthreshold dose-response relationship.