Radiation Protection Dosimetry Advance Access published September 10, 2016

Radiation Protection Dosimetry (2016), pp. 1–8 doi:10.1093/rpd/ncw264

DEFINITION OF LOCAL DIAGNOSTIC REFERENCE LEVELS

IN A RADIOLOGY DEPARTMENT USING A DOSE TRACKING
SOFTWARE
C. Ghetti1, O. Ortenzia1,*, F. Palleri1 and M. Sireus2
1
Department of Medical Physics, University Hospital of Parma, Italy
2
Department of Physics, University of Cagliari, Italy

*Corresponding author: oortenzia@ao.pr.it

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Dose optimization in radiological examinations is a mandatory issue: in this study local Diagnostic Reference Levels
(lDRLs) for Clinical Mammography (MG), Computed Tomography (CT) and Interventional Cardiac Procedures (ICP)
performed in our Radiology Department were established. Using a dose tracking software, we have collected Average
Glandular Dose (AGD) for two clinical mammographic units; CTDIvol, Size-Specific Dose Estimate (SSDE), Dose Length
Product (DLP) and total DLP (DLPtot) for five CT scanners; Fluoro Time, Fluoro Dose Area Product (DAP) and total
DAP (DAPtot) for two angiographic systems. Data have been compared with Italian Regulation and with the recent litera-
ture. The 75th percentiles of the different dosimetric indices have been calculated. Automated methods of radiation dose
data collection allow a fast and detailed analysis of a great amount of data and an easy determination of lDRLs for differ-
ent radiological procedures.

INTRODUCTION MATERIALS AND METHODS

Diagnostic Reference Levels (DRLs) are dose levels in
medical radiodiagnostic practices for typical examina-
tions for groups of standard-sized patients or standard
phantoms for broadly defined types of equipment.
These levels are expected not to be exceeded for stand-
ard procedures when good and normal practice regard-
ing diagnostic and technical performance is applied(1).
DRL can be used as an optimization tool to
reduce radiation dose to patients and to identify
situations or facilities where patients can receive
unjustified high doses.
In order to define DRLs at local level (lDRLs), it
is necessary to collect patient data large enough to
be representative of the investigated radiological
practice in our department.
DRL for a certain examination is commonly cho-
sen as the 75th percentile (third-quartile) of dose
index distributions measured.
The recent introduction of dose tracking software
has the potential to facilitate the collection of data
and investigation of unusual high dose examinations.
Furthermore, dosimetric data of radiological exam-
ination must be recorded and reported to face the
request of the Euratom Directive 2013/59(2).
In this article we describe our experience with
one of this software that has been implemented to
define lDRL for selected radiological examinations
(Clinical Mammography, Computed Tomography,
Interventional Radiology) commonly considered
crucial in terms of dosimetric impact.
The study was approved by Ethics Committee of
University Hospital of Parma that accepted to
waive the requirement to obtain informed consent.
Before beginning the study we have worked with
radiologists and technologists to identify the main
procedures for each modality and to obtain homo-
geneous data.
Examination data was collected from two digital
mammography systems, five CT scanners and two
angiographic systems using Radimetrics version
2.5 b (Bayer HealthCare, Whippany, NY), a soft-
ware tool for monitoring and tracking radiation
dose.
Radimetrics was installed on a virtual server (OS
Linux Open Suse 11.3), on the existing RIS-PACS
(Esaote) infrastructure with two vCPU, 8 GB Ram,
20 GB allocated to database, 30 GB to OS and
100 GB to studies.
One study stored on the Radimetrics database
requires about 1 MB of disc space.
Using a web-based approach it is possible to use
each pc connected to the hospital Lan as client.
The software can extract data from the header
DICOM tags, from radiation dose structured report
(RDSR) or directly from the modality using modal-
ity performed procedure steps (MPPS).
Data were verified for completeness and
consistency.
Moreover, Radimetrics has been customized for
data anonymization.

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 C. GHETTI ET AL.
Clinical Mammography
Radimetrics was connected to GE Senographe
Essential and GE Senographe DS digital mammog-
raphy systems used for Clinical Mammography only.
Bilateral and monolateral mammographic exami-
nations performed from March to August 2015 on
adult female patients have been extracted from
DICOM header files.
We have examined the tube current, peak kilovol-
tage, breast thickness, anode/filter combination,
compression force and also the Entrance Surface
Dose (ESD) and Average Glandular Dose (AGD) to
the breast. Moreover, we investigated AGD in
magnifications.
Dosimetric parameters consistency has been veri-
fied with phantom measurements according to the
European guidelines 4th edition(3). The displayed
dose indices (AGD and ESD) and the measured
dose indices were in agreement with a discrepancy of
about 10%.
We report the results of this study in terms of
mean value (MV) and 75th percentile of AGD,
acquisition counts, compression force and breast
thickness.
Computed Tomography
Radimetrics was connected with five Siemens CT
scanners: a Somatom Definition Flash, an Emotion
16, a Sensation Cardiac 64 and two Emotion 6. All
scanners are equipped with mAs modulation systems.
The most common CT procedures performed on
adult patients (age > 15 years) with standard size have
been examined: standard head, sinuses, dental, chest,
abdomen, chest–abdomen, chest–abdomen–pelvis
(CAP), spine, pulmonary angiography and cardiac.
The clinical indications were trauma, hemorrhage,
neurologic deficits for head; sinus inflammation for
sinus; tooth extraction for dental; evaluation of thor-
acic malignancies, detection of metastatic disease,
infection and inflammations for chest; cancer diagno-
sis, infection and inflammatory for abdomen; cancer
staging for CAP; trauma and general indication for
spine; coronary disease for cardiac acquisitions.
Data of CT examinations performed between
March and August 2015 have been extracted from
the DICOM header and Dose Report files produced
by the scanners and stored in PACS.
The information collected include patient infor-
mation (ID, age, gender, accession number), examin-
ation data (protocol name, number of acquisitions,
name of the device), acquisition data (scan region,
series name and technical parameters of each scan)
and exposure data (CTDIvol, DLP, size-specific dose
estimates for body examinations). In dental CT we
2
also extracted the mean effective dose, that is the
metric used to compare dose from the different
imaging techniques (both planar and tridimensional)
used in clinical practice.
The Size-Specific Dose Estimate (SSDE) metric
has been introduced in AAPM report 204(4) to esti-
mate patient dose from CTDIvol by taking into con-
sideration patient size; it is recommended to
calculate SSDE on the basis of Water-Equivalent
Diameter (WED) to effectively account for patient
X-ray attenuation(5).
Radimetrics has been customized to estimate
WED from CT axial images: for each slice the area
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of the body is isolated from the background and it is
converted to a water-equivalent area on the basis of
pixel values(6).
SSDE is provided by the multiplication of
CTDIvol with a conversion factor depending on
WED and reported by AAPM TG 220.
The value of CTDIvol/SSDE given by Radimetrics
for protocols with multiple acquisitions is the sum of
the CTDIvol/SSDE of single series weighted for the
scan length.
For a sample of exams, CTDIvol values provided
by the CT scanners were verified by direct measure-
ments in 16 and 32 cm diameter dedicated poly-
methylmethacrylate (PMMA) phantoms with a
calibrated Victoreen NERO mAx 8000 equipment
and a pencil ionization chamber model 6000–100
(Victoreen Instrument Co., Cleveland, OH).
A good agreement, within 8%, between recorded
and measured values of CTDIvol was obtained, sug-
gesting that subsequent clinically calculated volume
doses were representative of actual doses.
The calculation of organ doses in Radimetrics is
obtained using pre-run simulations for different
types of CT scan protocols and 20 types of Cristy
phantoms. Organ doses are then used to calculate
effective dose according to the tissue weighting fac-
tors reported in ICRP103(7).
A CT study can include series referring to ana-
tomical areas different from that investigated. In
order to obtain homogeneous dosimetric indices for
each anatomical region, data have been extracted
both at examination and acquisition level; in this
way exams including scans of anatomical regions
different from that investigated have been removed
from statistics.
For each CT procedure we calculated the MV,
25th, 50th and 75th percentiles of CTDIvol (head or
body according to the anatomic area), SSDE (in
body region) and DLP for both single acquisition
and total examination.
In cardiac CT only Coronary Angiography has
been analyzed, for both electrocardiogram (ECG)-
gating prospective and retrospective technique.
 DOSE TRACKING FOR LOCAL DIAGNOSTIC REFERENCE LEVEL
Interventional Cardiac Procedures
In a period of 6 months (March–August 2015) the
most common Interventional Cardiology Procedures
performed in our hemodynamic department have
been analyzed: Coronary Angiography (CA),
Percutaneous Transluminal Coronary Angioplasty
(PTCA), CA + PTCA, Transcatheter Aortic Valve
Implantation (TAVI). Radiation dose data collec-
tion, such as Fluoro Time, Fluoro DAP and total
DAP, was performed using a direct MMPS connec-
tion between the dose tracking software and a GE
Innova 2000 and GE Innova 3100.
Preliminarily, the correctness of patient and dosi-
metric information transfer between the angiogra-
phies and the dose tracking software has been
verified.
We have also verified that the DAP values pro-
vided by the angiography systems were right with a
maximum discrepancy of 15%, performing a series
of independent measurements with an external DAP
meter (Diamentor PTW—Freiburg, Germany).
RESULTS
Clinical Mammography
We have processed about 16 000 radiograms from
3673 mammographic examinations (3025 bilateral
and 648 monolateral).
The 70% of exams were performed on GE
Senographe DS, the remaining on GE Senographe
Essential. The mean age of the patients was 57 years
and the mean compression force was 187 N.
The MV of AGD for each radiogram calculated
for GE Senographe DS and GE Senographe
Essential systems was 1.1 and 1.3 mGy, respectively.
The MV of total AGD calculated for GE
Senographe Essential and for GE Senographe DS
systems was 4.8 and 5.4 mGy, respectively.
Table 1. Results of significant parameters referring to single acquisition for both mammographic systems.
MG MV AGD SD AGD 75th AGD
(mGy) (mGy)
Senographe DS 1.1 0.4
Senographe Essential 1.3 0.2
Table 2. Results of significant parameters referring to complete exam for both mammographic systems.
MG MV AGD SD AGD 75th AGD
(mGy) (mGy)
Senographe DS 4.8 2.6
Senographe Essential 5.4 1.7
In Tables 1 and 2, we show the most significant
results for single acquisition and for complete
examination.
The EUREF guidelines 4th edition(3) advise not
to exceed 2.5 mGy for average glandular dose for a
standard breast in a single radiogram.
The ACR guidelines(8) also suggest that screen-
ing examination should be limited to technically
adequate craniocaudal (CC) and mediolateral
oblique (MLO) views of each breast. Additional
views may be required to visualize breast tissue
more effectively.
Diagnostic mammograms instead may include
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also supplemental views like spot compressions,
magnifications, tangential views or other special
views, to evaluate an area of clinical concern.
The third-quartile of acquisition counts for a com-
plete exam was five images for both mammography
systems.
In few cases we found a single examination with
more than 10 radiograms performed with a AGD
above 10 mGy.
To estimate the AGD in magnifications, data have
been downloaded at acquisition level in order to
analyze only the scans with source to patient dis-
tance equal to 366 mm and with focal spot equal to
0.1 mm.
We collected 167 magnifications that represent
about 1% of total acquisitions, and the 75th percent-
ile of AGD is 3.2 mGy (Figure 1). This value is
about 2.5 times the 75th percentile of AGD referring
to single radiogram.
Computed Tomography
Overall, 17 659 examinations and 40 326 acquisitions
have been extracted. The 27% of CT examinations
extracted have been removed from statistics because
they included series referring to anatomical areas
different from that studied.
MV breast MV compression
(mGy) thickness (mm) force (N)
1.2 41.4 174
1.4 56.5 181
MV /75th # MV compression
(mGy) acquisition count force (N)
5.7 4.6/5.0 185
6.2 4.3/5.0 191
3
 C. GHETTI ET AL.
The sample included 9737 patients (4811 men
and 4926 women). The mean age of the two groups
was 65 ± 18 and 68 ± 18 for men and women
respectively.
A total of 12 766 examinations and 21 744 acquisi-
tions have been analyzed: they correspond to the
71% of the total CT examinations performed in
adults in our Diagnostic Imaging Department.
The 10 examined regions were head (33%), chest
(11%), abdomen (9%), chest–abdomen (6%), CAP
(4%), CT pulmonary angiography (2%) spine (2%)
Figure 1. Distribution of AGD values in magnifications.
Figure 2. Distribution of examinations in the different CT scanners.
4
and sinuses (2%), dental (0.9%) and cardiac CT
(0.8%). The distribution of examinations in the dif-
ferent CT scanners is reported in Figure 2.
For head protocols we reported the MV, 25th,
50th and 75th percentiles of CTDIvol, DLP and total
DLP (Table 3). Results have been compared with
current Italian regulations(9) and with values
reported in the most recent studies(10–15) (Table 4).
In the same way, we reported dosimetric values
for body scan protocols (Table 5). For five anatomic
regions (chest, abdomen, chest–abdomen, CAP and
pulmonary angiography) we also calculated SSDE
distributions. The comparison of our results with
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values reported in law and in international litera-
ture(9–18) is shown in Table 6.
DRLs reported in D.Lgs. 187/2000 for CTDI are
expressed in terms of weighted CTDI (CTDIw).
Since our 75th percentiles values of CTDIvol and
CTDIw are the same for head, chest and abdomen,
we decided to add also this values in Tables 4 and 6,
marking them with a star.
We pointed out that cardiac CT examinations
result mainly performed with a prospective ECG-
gating technique: it enables an effective dose reduc-
tion compared to the retrospective way.
As regards the 75th values of SSDE in CT body
protocols, it is nearly 30% higher than the corre-
sponding values of CTDIvol.
Finally, almost all dental CT examinations are
performed with a Siemens Emotion 6 CT scanner
and the MV of effective dose is 343 µSv.
 DOSE TRACKING FOR LOCAL DIAGNOSTIC REFERENCE LEVEL
Table 3. Number of exams and acquisitions for CT head protocols; mean value, 25th, 50th, 75th percentiles of CTDIvol
(mGy) referenced to 16 cm PMMA phantom, DLP (mGy cm) and DLPtot (mGy cm).

CT protocol #Exams #Acq Parameter MV 25th 50th 75th

Head 5947 6848 CTDIvol 58 51 62 63

DLP 869 787 914 916
DLPtot 953 807 914 1005
Sinuses 199 199 CTDIvol 12 7 9 17
DLP 154 90 114 222
Dental 120 134 CTDIvol 12 12 12 12
DLP 106 87 100 119
DLPtot 122 92 106 139

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Table 4. Comparison between 75th percentiles of CTDIvol surgery: for this reason, TAVI dosimetric data are
(mGy), DLP (mGycm) and DLPtot (mGy cm) for CT head very rare.
protocols, recent International DRLs and Italian DRLs (the We have verified that our TAVI results are com-
values marked with * is expressed in terms of CTDIw). parable to those presented in a recent publication(20).
In this paper, for 31 patients subjected to a TAVI
Anatomic region and country 75th Percentile procedure, a median DAP value of 102.4 Gy cm2
and a median Fluoro Time of 23.9 min are reported.
CTDIvol DLP DLPtot These data are really similar to our TAVI results: the
median values of DAP and Fluoro Time provided by
Head Radimetrics in fact are 103.7 Gy cm2 and 23.4 min,
Present study 63 916 1005 respectively.
D.Lgs187/2000 60* 1050 —
Italy 2014(10) 69 1312 1382
California 2015(11) 62 — 1300 DISCUSSION
Canada 2015(12) 53 865 —
Ireland 2012(13) — 940 — Clinical Mammography
Germany 2010(14) 65 950 —
Sinuses We have evaluated the 75th percentile of AGD for
Present study 17 222 — each radiogram on both mammography systems and
California 2015(11) 29 530 610 the values are dosimetrically correct. The MV of
Switzerland 2010(15) 25 350 — these results was defined as our local LDR. For
Germany 2010(14) 9 100 — exams performed with more than five acquisitions
Ireland 2012(13) 16 210 — for breast, an alert message has been introduced in
the Radimetrics system.

Interventional Cardiac Procedures Computed Tomography

We have analyzed 1028 Interventional Cardiology
Procedures: 772 CA, 131 PTCA, 104 CA + PTCA,
21 TAVI. The patients were 358 women and 670
men with respectively a mean age of 73 and 68 years
and standard size.
All ICP procedures are performed in both angio-
graphic systems except for TAVI procedure that is
carried out exclusively on GE Innova 2000.
In Table 7, we show the values obtained in term of
MVs and 75th percentiles for CA, PTCA, CA +
PTCA and TAVI for Fluoro Time, Fluoro DAP and
total DAP.
As reported in Table 8 CA and PTCA dosimetric
data (Fluoro Time, total DAP) are similar to values
presented in the DIMOND study(19).
TAVI procedure has very recently become an
accepted treatment for aortic stenosis in patients
who are considered at high risk for conventional
Dosimetric data of the most common CT procedures
performed on adult patients in our department have
been analyzed.
In most cases our values result lower or compar-
able with values reported in recent scientific litera-
ture and in Italian law. However, for some
procedures we pointed out a deviation: in CAP and
chest–abdomen examinations the 75th percentile of
DLP is between 40 and 60% lower than published
value while total DLP result comparable(10, 11). The
reason is that in our department chest–abdomen and
CAP examinations are performed with an average of
three scans.
In prospectively triggered cardiac CTA the 75th
percentile of CTDIvol results nearly 85% lower than
values reported in literature(18): the use of a Dual
Source Somatom Definition Flash CT scanner and
high-pitch acquisitions enable the acquisition of the

5
 C. GHETTI ET AL.
Table 5. Number of exams and acquisitions for CT body protocols; mean value, 25th, 50th, 75th percentiles of CTDIvol
(mGy) referenced to 32 cm PMMA phantom, SSDE (mGy), DLP (mGy cm) and DLPtot (mGy cm).

CT protocol #Exams #Acq Parameter MV 25th 50th 75th

Chest 1976 2611 CTDIvol 9 7 8 10

SSDE 11 9 11 13
DLP 278 212 274 349
DLPtot 361 239 297 408
Abdomen 1794 4950 CTDIvol 8 5 7 9
SSDE 10 7 9 11
DLP 385 243 335 467
DLPtot 1080 610 951 1389

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Chest–abdomen 1119 3246 CTDIvol 11 7 9 14
SSDE 13 9 11 18
DLP 482 269 412 620
DLPtot 1409 846 1161 1749
CAP 765 2368 CTDIvol 12 10 12 14
SSDE 16 14 16 18
DLP 550 337 499 706
DLPtot 1735 1219 1615 2138
Spine 327 416 CTDIvol 20 13 18 25
DLP 326 162 261 430
DLPtot 419 228 355 520
Pulmonary angiography 416 869 CTDIvol 5 4 5 6
SSDE 7 5 6 8
DLP 169 98 133 199
DLPtot 395 243 305 426
Cardiac
Prosp. 66 66 CTDIvol 3 3 3 4
DLP 61 56 61 64
Retros. 37 37 CTDIvol 55 37 54 67
DLP 854 566 855 1078

entire volumetric information within one cardiac
cycle. As a consequence, the patient is exposed to a
low radiation dose.
The dose tracking software has also allowed us to
easily calculate the distribution of SSDE for body
protocols.
SSDE values for chest, abdomen and chest–abdo-
men found in this study result between 10 and 40%
lower than values reported in Smith–Bindman’s
study(11).
Even if the effect of body size on patient dose is a
matter of interest in the scientific community, there
are only few SSDE data published at the moment.
In our survey we also indicate SSDE values in pul-
monary angiography and CAP CT examinations.
In dental field, recent literature reports an effective
dose ranging between 199 and 1410 µSv for MSCT,
between 46 and 1073, 9 and 560 and 5 and 652 µSv,
respectively, for CBCTs with large, medium and
small field of views(21). Effective dose for panoramic
radiography instead ranges from 2.7 to 24.3 µSv(22)
and cefalometric radiography between 2 and
10 µSv.(23)
Our value of effective dose in dental CT examina-
tions were comparable to data reported for MSCT
and CBCT. However, to reduce effective dose we
decided to introduce a new optimized protocol with
a lower kVp value (110 instead of 130). Physicians
accepted the consequent change in image quality.
The mean effective dose of dental CT performed
with the new protocol is 190 µSv, a value closer to
dose resulting from 2D imaging methods.
Finally, since our values are generally inferior or
comparable to the recent data we decided to estab-
lish our lDRLs in terms of 75th percentiles of
CTDIvol/SSDE, DLP and DLPtot.
The introduction of new CT scan protocols is fre-
quent in our department. With Radimetrics we can
easily monitor dosimetric indices and if they exceed
our lLDRs we eventually optimize the protocol.
For example, we realized that both in a Head and
a Sinus CT protocols recently introduced the values
of CTDIvol were higher respect lDRLs (+30 and
+100% respectively). We decided with physicians to
low the exposure values of these new protocols by
reducing mA.
Interventional Cardiac Procedures
The hemodynamic interventional procedures exam-
ined were dosimetrically comparable with literature.

6
 DOSE TRACKING FOR LOCAL DIAGNOSTIC REFERENCE LEVEL
Table 6. Comparison between 75th percentiles of CTDIvol/ Table 7. Local DRLs in Interventional Cardiology
SSDE, DLP, DLPtot for CT body protocols, recent Procedures.
International DRLs and Italian DRLs (values marked with *
are expressed in terms of CTDIw). Exam type # Fluoro Fluoro DAPtot
Exams Time DAP (Gy cm2)
Anatomic region and 75th Percentile (min) (Gycm2)
country
CTDIvol/ DLP DLPtot MV 75th MV 75th MV 75th
SSDE
CA 772 7.7 10.5 27.4 35.0 43.5 55.5
Chest PTCA 131 12.2 15.8 42.8 56.9 56.7 76.6
Present study 10/13 349 408 CA + PTCA 104 11.2 14.1 42.5 50.7 62.7 84.4
D.Lgs187/2000 30* 650 — TAVI 21 24.4 26.8 93.0 96.9 124.9 129.5
Italy 2014(10) 15 569 754

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Germany 2010(14) 12 400 —
Ireland 2012(13) 9 390 —
Portugal 2014(16) 14 470 —
California 2015(11) 17/20 610 830 Table 8. Comparison between our dosimetric results in
Abdomen Interventional Cardiology Procedures and Dimond study
Present study 9/11 467 1389 data.(19)
D.Lgs 187/2000 35* 800 —
Italy 2014(10) 18 555 2157 Exam type #Exams 75th Fluoro 75th DAPtot
Ireland 2012(13) 13 — 1115 Time (min) (Gy cm2)
Portugal 2014(16) 18 800 —
California 2015(11) 17/19 860 1460 CA
Chest–abdomen Present 772 10.5 55.5
Present study 14/18 620 1749 study
California 2015(11) 17/20 1800 2020 Dimond(19) 672 6.5 45.0
CAP PTCA
Present study 14/18 706 2138 Present 131 15.8 76.6
Italy 2014(10) 17 1200 2115 study
Ireland 2012(13) 12 850 — Dimond(19) 662 15.5 85.0
Switzerland 2010(15) 15 1000 —
Spine
Present study 25 430 520
Italy 2014(10) 42 888 1060 CONCLUSIONS
Korea 2010(17) 40 1216 —
Angiography pulmonary
Before Radimetrics installation we have analyzed
Present study 6/8 199 426 some CT dosimetric data using a home-made soft-
Ireland 2012(13) 13 430 — ware that extracts information from the DICOM
Canada 2015(12) 16 — 579 fields of the images extracted from PACS one by
Cardiac one. This method is very time consuming and it is
Present study Prosp. = 4 Prosp. = 64 not possible to use it for an extensive evaluation but
Retrosp. = Retrosp. = only to analyze a sample of selected data.
67 1078 Automated methods of radiation dose data col-
France 2014(18) Prosp. = Prosp. = lection allow a fast and detailed analysis of a great
26 370
Retrosp. = Retrosp. =
amount of data and an easy determination of
44 870 lDRLs for different radiological procedures at
acquisition or examination level according to proto-
col and equipment. Furthermore the definition of
lDRLs enables to identify protocols that need an
optimization.
Furthermore, DRL for TAVI has been established Alert, productivity and benchmarking tools, avail-
at a local level and now it is a reference for the cardi- able in Radimetrics, enable to control the dosimetric
ologists involved in this procedure. trend of our radiological examinations and to per-
It is well known(24) that a DAP limit of 500 Gy cm2 form the necessary corrective actions in real time.
can be identified as the threshold for patient follow-
up in order to detect deterministic cutaneous
effects, so we have inserted an alert in Radimetrics
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