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Dosimetry methods used in contemporary mammography clinical practice

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Radiation
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November 2014 / Issue 3

IN THIS ISSUE

Уводна статия Медицинското облъчване – Medical exposure – contributions

Introductory Article принос и предизвикателства and challenges in contemporary
пред съвременното общество society – K. Velkova
К. Велкова

Тема на броя Приложение на йонизиращите Medical uses of ionising radiation:

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международни стандарти и
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на пациентите и медицинския
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Преглед на Директивата за
основните европейски стандарти
за радиационна безопасност и
пътят за укрепване на радиационна
защита в цяла Европа – Г. Симеонов
international standards and actions
for better protection of patients
and medical staff – J. Vassileva
The revised European basic safety
standards directive and the way
forward to strengthening radiation
protection across Europe
G. Simeonov

Интервю Нуклеарната медицина – настояще Nuclear medicine – present and

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 НАУЧНИ СТАТИИ / SCIENTIFIC ARTICLES

ДОЗИМЕТРИЧНИ МЕТОДИ,
ИЗПОЛЗВАНИ В СЪВРЕМЕННАТА МАМОГРАФСКА КЛИНИЧНА ПРАКТИКА

Симона Аврамова-Чолакова, д. м.
Секция „Радиационна защита при медицинско облъчване“
Национален център по радиобиология и радиационна защита
София 1606, ул. „Св. Георги Софийски“ № 3, s.avramova@ncrrp.org

DOSIMETRY METHODS
USED IN CONTEMPORARY MAMMOGRAPHY CLINICAL PRACTICE
Simona Avramova-Cholakova, PhD
Radiation Protection at Medical Exposure Section,
National Centre of Radiobiology and Radiation Protection
3 “Sv. Georgi Sofiyski” str., Sofia 1606, s.avramova@ncrrp.org

Резюме: Рентгеновата мамография е доказал се метод
в образната диагностика за ранното диагностициране
рака на млчената жлеза. Той е свързан с известен
радиационен риск. Дозиметрията в мамографията е
важно средство за оптимизация на мамографското
изследване и за оценка на риска. Методите за дозиметрия
се развиват с времето, паралелно с появата на нови
такива за образна диагностика. Представен е обзор на
методите за дозиметрия в мамографията, използвани
в наши дни, включително при най-новите технологии
за диагностика, които се появяват на пазара или са
още в експериментална фаза. Описани са моделите
на гърдата и фантомите, използвани за дозиметрични
цели. Представени са измеримите величини, както и
факторите, от които зависят техните стойности.
Кючови думи: мамография, дозиметрия;
Abstract: X-ray mammography is an imaging method
that proved to be important tool for early breast cancer
detection. It is related to some radiation risk. Dosimetry
in mammography is an important tool for optimization
of the examination and for risk estimation. Dosimetry
methods evolve with time and with imaging technologies
development. An overview is presented on the methods
for breast dosimetry used nowadays, including the newer
imaging systems that appear on the market or are still at
experimental stage. The breast models and phantoms used
for dosimetry are described. The measured quantities are
presented, as well as the factors on which they depend.
Key words: mammography, dosimetry

Introduction The first techniques for imaging of the breast use

Medical exposure represents the largest artificial source
of exposure to ionizing radiation [1]. Examination of
the breast with x-rays is performed since long time.
Patient dosimetry in mammography is a component
of quality control programmes implemented for
estimation of equipment performance. It is used
for the purpose of optimization, determination of
diagnostic reference levels, comparative estimations
of patient radiation risk and risk-benefit analysis when
introducing mammography screening programmes.
general radiography systems and industrial films [2,
3]. At these times some estimations show that average
breast dose is of the order of 150 mGy [4]. In late 1970s
the risk-benefit ratio of screening programmes becomes
a concern and dosimetry becomes a necessity. At that
time average skin exposure is about 5 R (of the order of
50 mGy) [5]. Later dedicated mammography systems
are constructed and much lower doses are estimated.
In 1969 the first dedicated mammography machine is
introduced in practice [3].

36
Quantities used
Some authors in the past suggest estimation of average
dose to the whole breast, skin or midplane breast dose
[6]. In 1979 Hammerstein et al. express the idea that
the glandular tissue in the breast should be considered
for estimation of risk related to mammography x-ray
examination since breast cancer develop in glandular
tissue [7]. The glandular tissue includes the acinar
and ductal epithelium and associated stroma and it is
assumed to have equal sensitivity in the entire volume
[8]. Consecutively in 1987 the International Commission
on Radiological Protection (ICRP) recommends
radiation risk in mammography to be determined with
the quantity mean glandular dose (MGD), representing
the mean absorbed dose to the glandular tissue [9].
Several publications for estimation of radiation induced
risk due to mammography examinations and based on
MGD are available [10, 11, 12, 13, 14].
MGD cannot be measured directly. All dosimetry
protocols used in clinical practice nowadays propose
calculation of MGD through conversion coefficients
applied to a measurable quantity, namely incident air
kerma (IAK) or entrance skin exposure (ESE). IAK
is the air kerma from the incident beam on the central
x-ray beam axis at the skin entrance plane [15]. Only the
primary radiation incident on the patient is included.
In some cases entrance-surface air kerma (ESAK)
is measured (e.g. with TLD chips). It represents the
air kerma on the central x-ray beam axis at the point
where the x-ray beam enters the patient or phantom.
The contribution of backscattered radiation is included
[15]. Sometimes in the literature IAK is incorrectly
named ESAK [16, 17, 18]. Both quantities should not
be confused. ESE, used in the American protocols,
is in fact the incident exposure on the skin surface,
without backscatter, as is seen from the measurement
procedure described there [19].
The conversion coefficients are determined
experimentally or with Monte Carlo techniques and
experimental verifications [6, 7]. They depend on
compressed breast thickness (CBT), percentage of
glandular tissue content, and beam quality usually
expressed as half value layer (HVL). The percentage of
glandular and adipose tissue depends on age and breast
size, but however it is individual for each woman. In
infancy the female breast contains mainly adipose
tissue. At puberty glandular tissue develops, which
is degrading into adipose with age, especially after
menopause [20]. The age is not a strict indicator for
breast content – women at the same age may have quite
different glandular content. Thicker breasts usually
contain more adipose tissue.
Breast models and dosimetry phantoms
For the purpose of calculation of conversion
coefficients the standard approach uses Monte Carlo
37
techniques applied on simplified mathematical
phantoms, simulating firmly compressed breast, as is
the clinical situation, the so called “standard breast”.
In 1977 White develops an analytical procedure for
the formulation of tissue substitute materials [21].
The same year he publishes data on BR12 – tissue
substitute material simulating the breast and widely
adopted afterwards. He assumes an average breast of
50% fat and 50% water by weight for the formulation
of this material because of the lack of reliable data on
the chemical composition of breast [22]. Hammerstein
and co-workers accept this idea and suggest a typical
breast of 50% adipose and 50% glandular tissue
content [7]. The tissue compositions according to
Hammerstein differ from the recommended later in
1989 by the International Commission on Radiological
Units and Measurements (ICRU) [23].
The proposed by Hammertsein et al. model is used in
two modifications in several works. The compressed
breast is represented as a cylinder of semicircular or
semielliptical cross-section with a central region,
consisting of uniform mixture of adipose and
glandular tissues. It is surrounded on all sides apart
from the chest wall with a layer of skin or adipose
tissue with 4 or 5 mm thickness respectively [24,
25]. According to Beckett and Kotre the assumption
of 50:50 adipose/glandular composition leads to
overestimation of MGD of up to 13% over the age
group included in breast screening programmes in the
UK [26]. If using CBT to estimate breast glandularity,
the overestimation is decreased to 8%, and if using
both CBT and age estimates, the associated error is
about 1%. Geise and Palchevski study what is the most
suitable composition of breast phantom for phototimer
testing of the mammography machine [27]. They
conclude that a phantom composed of 30% glandular
tissue and 70% adipose tissue better simulates the
phototimer response for the average breast than the
adopted 50:50 model. Similar conclusions are made
by Klein et al., who determine 35% glandularity for
55mm medium-sized breast [28]. Yaffe et al. show that
the fibroglandular tissue composition in group of 191
patients, undergoing experimental breast CT, varied
from 13.7% to 25.6% with an overall mean of 19.3%
[29]. These findings are confirmed by other studies
based on dedicated breast CT images [30, 31].
The European protocols on quality control and
on dosimetry in mammography, as well as the
International Atomic Energy Agency (IAEA) Code
of practice TRS 457, use identical model of standard
breast [16, 17, 18, 25]. It consists of central region with
40 mm thickness and 50:50 adipose/glandular content
surrounded by 5 mm adipose tissue. It has semicircular
cross-section of radius ≥ 80 mm and total thickness
50 mm. Similar model is used in the UK protocols.
The 1994 UK protocol on quality control adopts 45
mm thick standard breast, while in the last edition of
this document from 2005 the standard breast is 53 mm
thick and with 29 % glandular content in the central
region [20, 32]. It is established that the last model is
typical for women of the UK population aged 50-64
years. According to Dance and co-workers the typical
glandular content of 50 mm breast for this population
is 33% [33].
The determination of MGD is performed on phantoms
or patients. The most used phantom materials are
polymetilmetacrilate (PMMA) and epoxy resin-based
BR12 [34]. Other materials are wax, RF-1, simulating
adipose tissue, gels and others [22, 23, 34, 35, 36,
37]. McLean examines radiographic equivalence of
different materials and concludes that various breast
compositions can be successfully simulated by using
an appropriate thickness of PMMA [38]. Data on
equivalence of PMMA and breasts with different
thicknesses and compositions are published by other
authors as well [33, 39, 40, 41]. The standard breast is
simulated with PMMA 45 mm thick phantom in all
mentioned protocols [16, 17, 18, 20, 25]. Exceptions
are the older UK protocols in which the phantom is
40 mm thick [32]. The American College of Radiology
(ACR) defines standard breast with 50:50 adipose/
glandular content, 42 mm total thickness and external
skin layer [19]. It is simulated with the standard ACR
phantom used for accreditation of mammography
systems in the USA. Argo et al. manufacture tissue-
equivalent series of phantoms across the range of 20%
to 70% of glandularities and wide range of thicknesses
[42]. These phantoms agree with the ICRU Report 44
recommendations and consist of epoxy resin matrix
with additional components [23]. Other authors
propose realistic voxel breast phantoms based on
computed tomography (CT) scans of specimens of real
breasts or computer simulated phantoms with varying
distribution of glandular tissue within the breast [43,
44, 45, 46, 47]. Ma et al. develop computational model
of the breast with the great advantage to simulate
compressed breast, as is in mammography and digital
breast tomosynthesis, or non-compressed breast, as is
in positron emission mammography or breast CT [48].
It can be designed for both x-ray and γ-ray imaging.
In later work Ma and Alghamdi develop open source
software aimed to construct realistic computational
breast phantoms with features for dosimetric studies
[49]. Almeida et al. produce epoxy resin-based
phantoms that represent breast glandularities from
0 to 50% and suggest their use instead of PMMA
for dosimetry measurements and optimization of
mammography systems [50].
Conversion coefficients
Conversion coefficients are proposed in 1980 by Doi
and Chan, and Dance [51, 52]. They are calculated
38
with Monte Carlo methods for monoenergetic or
polyenergetic x-rays from tungsten or molybdenum
anodes and are used for determination of skin dose,
average depth dose or average integral dose. In 1984
Stanton and co-workers compare values of conversion
coefficients measured in BR12 phantom and based
on energy fluence calculations [6]. Their results are
presented as graphs, depending on HVL and breast
thickness and they conclude that the experimental
method is more precise. Rosenstein et al. propose
coefficients calculated with Monte Carlo technique
for estimation of MGD from entrance exposure free-
in-air for fi rmly and moderately compressed breasts
of different glandularities (5%, 25%, 50%, 75%,
100%) [53].
Two publications of Wu et al. present Monte Carlo
derived coefficients for molybdenum/molybdenum
(Mo/Mo), molybdenum/rhodium (Mo/Rh) and
rhodium/rhodium (Rh/Rh) anode/filter combinations
of the x-ray tube and different glandular content of
the breast [24, 54]. Not only HVL dependence, but
tube voltage and tube voltage waveform are taken
into account as well. Sobol and Wu resume data from
both publications mentioned and propose analytical
expressions that match tabulated input parameters
within predefined uncertainty [55]. These expressions
can be used for determination of conversion coefficients
for arbitrary breast composition, depending on breast
thickness, tube voltage and HVL.
Boone performs Monte Carlo calculations of conversion
coefficients for monoenergetic (1-120 keV) x-ray
beams, polyenergetic (40-120 kV, tungsten anode) and
mammographic (Mo/Mo, Mo/Rh, Rh/Rh, tungsten/
rhodium (W/Rh), tungsten/palladium (W/Pd) and
tungsten/silver (W/Ag)) x-ray spectra [56]. The main
advantage of this work is that it provides coefficients
for breast dose calculations for general diagnostic and
CT procedures or for dual-energy mammography.
Another publication of Boone proposes best fit
equations, applying interaction-specific correction, for
determination of coefficients for monoenergetic beams
with energies from 8 keV to 50 keV, for different breast
thicknesses and compositions [57].
In 1990 Dance publishes conversion coefficients
obtained with Monte Carlo technique for determination
of MGD from IAK for breasts with 50% glandular
content and thicknesses from 2 to 8 cm, for Mo/Mo, W/
Mo, W/Rh, W/Pd and W/Al anode/filter combinations
[40]. He calculates equivalent thicknesses of PMMA
and breast of equal parts adipose and glandular
tissue content and surrounded by 0.5 cm adipose
tissue. In later publication Dance et al. complete the
calculations for breasts of thicknesses up to 11 cm
and with different glandular content. They propose
supplementary coefficients, correcting for any
difference in breast composition from 50% glandular
tissue. The coefficients are HVL and breast thickness
dependent and are available for two age groups, typical
for screening programmes in the UK – 40-49 and 50-64
years. The coefficients in this publication are intended
for Mo/Mo spectra and spectral correction factors
are included for other used in practice anode-filter
combinations (Mo/Mo, Mo/Rh, Rh/Rh, Rh/Al, W/
Rh) [33]. In 2009 Dance et al. publish supplementary
values of the spectral correction factors for W/Ag
with different thicknesses of the filter, and W/Al
combinations, calculated with voxelized model of the
breast and different conditions of the simulation. The
spectral factors for the latter combination are breast
thickness dependent [41].
Klein et al. measure x-ray spectra for various
anode/filter combinations and calculate conversion
coefficients for CBT ranging from 2 to 9 cm and
breast compositions from 0 to 100% glandular tissue
content. They estimate MGD based on actual patient
breast compositions and report variations of the doses
of about 15%, compared to the standard 50/50 model
[28]. The calculated by Zankl et al. coefficients using
voxel phantoms, derived from CT scans of real breasts,
agree well with literature data when the glandular
tissue is predominantly concentrated in the upper part
of the model [58]. In the opposite case they have lower
values by up to 40%. These results are confirmed by
Dance et al, who calculate conversion coefficients
using quasi-realistic high-resolution voxel phantoms
and find differences from standard tabulations used
for breast dosimetry by up to 59%, due to the different
spatial distribution of glandular tissue within the
breast [46]. Zoetelief and Jansen explore the influence
of the different conditions underlying the Monte
Carlo simulations, performed by several authors, on
conversion coefficient values [59]. The differences
found are: up to 7% due to variations in photon spectra;
up to 10% using different cross sections data for
photon interactions; up to 19% because of differences
in composition and thickness of superficial layer of
the breast; up to 14% employing Hammerstein’s tissue
compositions compared to those from the ICRU.
Huang et al. investigate breast CT images and report
1.45 ± 0.3 mm mean breast skin thickness [60]. Taking
into account that the adopted breast models for Monte
Carlo calculations of conversion coefficients assume
4 or 5 mm external skin (adipose) layer, the effect on
conversion coefficients is an increase of the values
up to 18%. That leads to a slight underestimate in
glandular dose.
The European protocol on dosimetry in mammography
[18] and the 1994 edition of the UK protocol on quality
control in mammography [32] propose methods for
breast dose calculations based on Dance coefficients
from 1990 [40]. The last editions of the European and
UK protocols for quality control [17, 20] and the IAEA
39
TRS 457 [25] are based on the same coefficients,
supplemented with the later data from 2000 [33]. In
2013 Supplement to the European protocol [61] is
issued including the new data from 2009 [41]. These
documents require measurement of IAK for breast
dose estimations. The ACR protocol [19] is based on
conversion coefficients published by Stanton et al. and
Wu et al., depending on anode/filter combinations [6,
24, 54]. The measured quantity is ESE. The Australian
and Canadian protocols are based on the same models
used in the USA [62, 63, 64].
The challenge of new breast imaging methods
In recent years new imaging methods using x-rays are
developed, tested and some introduced in practice.
Such methods are digital breast tomosynthesis (DBT),
dedicated breast CT and contrast enhanced digital
mammography (CEDM) that prove to be promising
in breast imaging [65, 66, 67,68]. The question arises
how to perform patient dosimetry related to these new
technologies.
In dedicated flat-panel breast CT the patient is usually
lying prone on the couch and the x-ray tube-flat panel
system is rotating around the hanging breast. One
approach for dosimetry is proposed by Thacker and
Glick [69]. They provide expressions for calculation
of conversion coefficients with computer programme
available online, for uncompressed breasts (as is the
case in CT imaging) with diameters from 10 cm to 18
cm, and for any spectra. Boone et al. provide conversion
coefficients from air kerma at the isocentre of the
dedicated CT scanner to MGD for different scanning
geometries, beam qualities and breast diameters
[70]. The coefficients proposed are validated through
measurements with pencil type ionization chamber
and PMMA cylindrical phantoms.
In the late 1990s, with the introduction of flat-panel
radiographic detectors, the old idea of tomographic
imaging is revived and the first experimental
tomosynthesis systems appear [71]. They find their big
application in mammography. In DBT the x-ray tube
is rotating around the breast at limited angles with
number of discrete exposures. In 2007 Sechopoulos
and co-workers perform Monte Carlo calculations of
conversion coefficient for the zero degree projection
angle of the DBT system and relative glandular dose
(RGD) coefficient for nonzero projection angles.
RGD describes the ratio of the glandular dose for a
particular projection to the glandular dose for the zero
degree projection, for the same exposure parameters
(kVp and mAs) [72]. The conversion coefficient for
the zero projection depends on the view (medio-
lateral oblique or cranio-caudal), the x-ray spectrum
(anode/filter/kVp), the percentage glandularity and
breast thickness. The RGD results are presented as
mathematical equations as well. The calculations are
performed for Mo/Mo, Mo/Rh and Rh/Rh anode/
filter combinations and are intended to be applied
to ESE. In 2008 Sechopoulos and D’Orsi provide
more zero degree projection coefficients for W/Al
and W/Rh combinations, while RGD are found to be
the same as for the other combinations [73]. Ma and
Darambara publish conversion coefficients for W/Al
and W/Al+Ag anode/filter combinations, derived with
Monte Carlo technique, that are CBT, projection angle,
breast thickness, and chest wall-to-nipple distance
dependent, for three glandularities [74]. Dance et al.
use approach, similar to the one used by Sechopoulos.
They introduce t-factors for calculation of breast dose
from a single projection and T-factors for a complete
exposure series, by means of Monte Carlo calculations
that are simple extension of the previously published
coefficients. [75]. Mo/Mo, Mo/Rh, Rh/Rh, W/Rh,
W/Ag and W/Al are the anode/filter combinations
considered. Additional Ts-factors are also published
for the Sectra tomosynthesis system, employing
scanned narrow-beam geometry. Extensions to the
earlier calculated g- (conversion from IAK to MGD for
50% glandular content of the breast) and c- (correct
for any difference in breast composition from 50%
glandularity for two age gropus) factors are provided
for harder x-ray beams used in digital mammography
systems. Feng and Sechopoulos estimate conversion
coefficients for a specific tomosynthesis system in both
DBT and full-field digital mammography mode [76].
They depend on breast thickness and glandularity.
Li et al. use parameterization algorithms to fit
previously published conversion coefficients for DBT
and thus offer easy computations of MGD conversion
coefficients [77]. They also provide Microsoft Excel
spread sheets.
Draft of European protocol for quality control of
DBT is available online and it includes the Dance’s
formalism for MGD calculation [78]. The American
Association of Physicists in Medicine (AAPM)
recently published report on radiation dosimetry in
DBT, based on Sechopoulos’s formalism [79].
Another new breast imaging method is CEDM. CEDM
is performed with exposures using single high-energy
x-ray spectrum and taking breast images without and
with contrast iodine based agent, or with exposures at
lower and higher energies, introducing contrast agent
[68]. The low energy beam is below the k-edge of
iodine and is generated with Mo or Rh anode and filter.
The high energy beam, suitable for iodine contrasts,
is generated with Mo, Rh or W anode and added
copper (Cu) filter at higher tube voltages (40-49 kVp).
The newest publication of Dance and Young provides
conversion coefficients for the high energy spectra
used in CEDM, supplementing the current coefficients
[80]. These are provided for W, Mo and Rh anodes
with copper (Cu) added filtration.
40
Determination of incident air kerma
IAK may be estimated with thermoluminescent
dosimeters (TLD). With this method TLD are
positioned on patient/phantom surface and ESAK is
measured directly. IAK is calculated through published
in the literature HVL dependent backscatter factors
(ESAK is equal to IAK multiplied by the backscatter
factor) [18, 25]. This method is not recommended for
patient measurements in TRS 457 because of the risk
TLD to be seen on the radiograph and hence of image
quality degradation [25].
Indirect method for determination of IAK is to
multiply tube output for the anode/filter combination
and tube voltage, used for the exposure, by the tube-
current exposure-time product for that exposure, and
to recalculate the air kerma thus obtained for breast/
phantom surface, applying inverse square law.
The reference point
The measurement position when determining tube
output (IAK) is important. The fluence rate is lower
at the anode side of the x-ray field because of the heel
effect [15]. For that reason the anode is positioned on
the opposite to the chest wall side in mammography
systems, where the breast is thinner. Faulkner and
Cranley report that tube output variations at a number
of locations within the primary beam could lead to
11.5% decrease in MGD from that estimated using an
ionization chamber centrally placed in the beam, but
closer to the chest wall [81]. The measurement point,
defined in different dosimetry protocols, is called
“reference point”. The last editions of the European
protocols on dosimetry and quality control state that
this point is positioned at 6 cm from the chest wall,
laterally centered [16, 17,18]. The UK protocols, IAEA
TRS 457 and the ACR protocol define the reference
point at 4 cm from the chest wall [19, 20, 25, 32]. This
point is not laterally centered in the ACR protocol, but
is found beside the ACR phantom, with which ESE is
measured [19]. Ng et al. find that replacement of the
measurement point off-central axis may lead up to 8%
lower values of ESE, and the presence of the phantom
next to the ionization chamber may lead to about 1.3%
increase of the measured exposure [82]. According to
the Nordic protocol, the reference point is positioned at
3 cm from the chest wall [83].
The compression plate
Measurement of tube output for the purpose of breast
dosimetry is performed with compression plate in the
beam. In recent years discussion arose in the scientific
community on the precise position of the plate relative
to the dosimetry detector used. This position is not
stated in the 3rd and 4th editions of the European
protocol on quality control and the European protocol
on dosimetry in mammography, as well as in the
1994 edition of the UK protocol [16, 17, 18, 32]. The
last UK protocol from 2005 states the position of the
plate at least 5 cm above the detector, while IAEA
TRS 457 defines the place of the plate in contact with
the detector, but only for phantom, not for patient
measurements [20, 25]. All these documents are
based on David Dance’s conversion coefficients. The
ACR protocol requires the plate to be in contact with
the detector, but this document is based on Wu’s and
Stanton’s coefficients [19]. Avramova-Cholakova et al.
find that the proximity of the compression plate to an
ionization chamber whose active volume is enveloped
in a metal ring may lead to about 7% higher value of
IAK, the plate in contact with another type of chamber
without metal ring leads up to 2.5% higher value and
measurement with the plate in contact with solid-state
detector leads up to 2.5% lower values [84, 85, 86].
Hemdal et al. publish similar results – about 6% higher
value when measuring with the plate in contact with an
ionization chamber, about 10 times lesser contribution
of scattered radiation when the same type of solid
state detector is used, and 2-10х% forward scatter
contribution with an ionization chamber in a later
publication [87, 88, 89]. The original article of Dance
from 1990, defining the first group of conversion
coefficients, describes the place of the compression
plate in contact with the ionization chamber for the
Monte Carlo simulation i.e. the measured IAK should
include the forward scattered radiation from the plate
[40]. In the more recent publication Dance et al. calculate
by Monte Carlo method 7.6% contribution of scatter
[41]. Hemdal suggests the introduction of forward
scatter factors (FSF) (with for example a standard
value of 1.06) for measurements with well collimated
semiconductor detectors with almost no contribution
of scatter, and measurements with the plate on the
detector in the case of ionization chamber [89]. Toroi et
al. propose similar approach - to measure IAK with the
plate at the maximum distance from the detector and to
apply FSF for all dosimeters used, thus minimizing the
uncertainty of the measurement [90]. Supplement to
the 2006th edition of the European protocol on quality
control describes IAK measurement with the plate in
contact with the dosimeter [61].
Half Value Layer
Since the conversion coefficients are HVL dependent,
HVL measurement is necessary for the purpose of
breast dosimetry. Some studies show that the absence of
compression plate or its position relative to the dosimeter
during HVL measurement may lead up to 14-15% lower
value in the first case and up to 5% higher value if the
plate is on the detector compared to the plate away [84,
85, 91]. All contemporary protocols explicitly describe
HVL measurement with compression plate and with
scatter free conditions (plate away from the detector).
More crucial for the measurement result is the energy
dependence of the dosimetry detector used. It is found
41
that for detectors with higher energy dependence an
increase of measured HVL may be observed up to
17% for ionization chambers or solid-state detectors
[84, 85, 92].
The position of the detector during measurement leads
to 5% differences in the case of detector close to the
chest wall or in case that it is on the far side of the
breast support, away from the chest wall, according
to Wagner et al., and to 9% differences according to
Terry et al. for similar positions [91, 92].
Robson proposes a method for HVL calculation by
performing tube output and HVL measurement for
one tube voltage, for a given anode/filter combination,
and calculating HVL and tube output for all other tube
voltages, using parametric equations [93]. Cranley et
al. develop software for simulation of x-ray spectra and
calculation of tube output and HVL [94]. Both methods
are proven to be in good agreement with measured
values for standard Mo/Mo spectra [84, 85].
Some estimations show that the differences of HVL
values depending on the measurement conditions
may lead from 10% underestimation up to 20%
overestimation of MGD, for breast thicknesses
from 2 to 11 cm, because of the different conversion
coefficients that would be included in the calculations
as consequence of differences in HVL [85].
Determination of mean glandular dose
MGD is derived by calculation using
one of the following formulas:
MGD = IAK.g.c.s (1)
or
MGD = ESE.DgN (2)
The first formula applies the David Dance’s
conversion coefficients [33, 40, 41]. Different gropus
of coefficients are provided for measurements with
phantom or with patients. The coefficients g convert
IAK to MGD for a breast of glandularity 50%. They
are HVL and compressed breast thickness dependent.
The coefficients c correct for any difference in
breast composition from 50% glandularity. They are
given for the age groups 40-49 and 50-64 years for
measurements with patients and for the age group
50-64 for PMMA measurements. These coefficients
are determined for the UK population and may be
different for other populations. The coefficients c are
also HVL and compressed breast thickness dependent.
As already mentioned (see Conversion coefficients)
spectral correction factor s is introduced to take
into account the different types of spectra used in
the contemporary digital systems. It is anode/filter
combination dependent. Formula (1) is applied in
all European protocols, IAEA TRS 457, as well as
in both documents of IAEA on quality assurance in
mammography (screen film and digital), issued recent
years [17, 18, 20, 25, 61, 95, 96].
The second formula applies the conversion coefficients
DgN of Wu et al. and Stanton et al. [6, 24, 54]. They are
dependent on HVL, anode/filter combination, breast
thickness and composition (percent of glandular tissue
content). This formula is used in the USA, Canadian
and Australian protocols [19, 62, 63, 64, 97].
To our knowledge the other countries use one of both
formulas and groups of coefficients mentioned. For
example in Bulgaria we adopt the approach of IAK
measurement and the Dance’s coefficients.
The future
New digital imaging methods provide the opportunity
of personalized breast composition estimation
and hence more precise dosimetry [98, 99]. Based
on this Geeraert et al. propose a new quantity for
individualized evaluation of radiation risk named
“glandular imparted energy (GIE)” [100] and
following the original suggestion of Hammerstein [7]
to use the total energy absorbed in the glandular tissue
as better quantity for risk assessment. GIE represents
integration of the cellular dose over the total glandular
mass.
Conclusions
X-ray mammography is an imaging method that
proved to be important tool for early breast cancer
detection and is the method of choice for breast
cancer screening programmes. It is continuously
developing from the early detector systems as
industrial film, through xeromammography and
dedicated screen-film mammography systems, to
full-field digital mammography and the modern state
of the art digital breast tomosynthesis, dedicated
breast CT, contrast enhanced digital mammography
and others, some of them still in experimental stage.
As in imaging techniques, methods for dosimetry in
mammography develop as well, sometimes depending
on the advancements in imaging. The precision of dose
estimates is improving with time. New quantities for
risk assessment are considered.
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