Radiation Physics and Chemistry 188 (2021) 109680

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Radiation Physics and Chemistry

journal homepage: www.elsevier.com/locate/radphyschem

Evaluation of patients radiation dose during mammography

imaging procedure
Nissren Tamam a, *, H. Salah b, c, Mohammad Rabbaa d, Mohammad Abuljoud d, A. Sulieman e,
M. Alkhorayef f, g, D.A. Bradley g, h
a
Department of Physics, College of Sciences, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
b
INAYA Medical Collage, Nuclear Medicine Department, Riyadh, Saudi Arabia
c
College of Medical Radiologic Science, Sudan University of Science and Technology, B.O.Box 1908, Khartoum, Sudan
d
Radiology Department, Riyadh Care Hospital, Riyadh, Saudi Arabia
e
Department of Radiology and Medical Imaging, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University, P.O.Box 422, Alkharj 11942, Saudi
Arabia
f
Department of Radiological Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
g
Centre for Nuclear and Radiation Physics, Department of Physics, University of Surrey, Guildford, Surrey GU2 7XH, UK
h
Centre for Applied Physics and Radiation Technologies, School of Engineering and Technology, Sunway University, 47500 Bandar Sunway, Selangor, Malaysia

A R T I C L E I N F O A B S T R A C T

Keywords: This study investigates patients’ dose levels during digital mammography procedures and proposes a local
Mammography diagnostic reference level (DRL). The patient sample is 1055 patients who have been examined at the Riyadh
Breast imaging Care Hospital, Riyadh, Saudi Arabia. All procedures were carried out for medically justified clinical conditions.
Cancer risk
All procedures were carried out using a direct digital mammography (DDR) radiology system. The mean and
Diagnostic radiology
range of ESAK (mGy) were 5.19 ± 3.18 (0.33–29.9), while the mean AGD (mGy) is 1.3±(1.0–7.2) per procedure.
The third quartile value for ESAK (mGy) and AGD (mGy) is 6 and 1.5, respectively. Measured ESAK (mGy) per
procedure and estimated AGD are comparable with previous studies. The interpatient and interdepartmental
variation is attributed mainly to the number of projections per procedure.

1. Introduction optical imaging, magnetic resonance imaging (MRI), and scintigraphy.

Breast malignancy is primary cancer in females with 30.7% mortal­
ity, corresponding to 11.6% of the total cancer death ((Hu et al., 2019;
Henderson et al., 2010). Typically, women have a 12% risk of breast
malignancy in their lifespan (Hendrick, 2010; ACS, 2019). Breast ma­
lignancy incidence is higher in developed countries up to 4 times
compared to developing countries (Ahmad, 2019). The occurrence of
breast malignancy depends on heritable and lifestyle related factors such
as obesity, smoking and alcohol intake, and exposure to carcinogenic
agents such exposure to X rays or other ionizing radiation. In Saudi
Arabia, the incidence of breast tumors consists of 28% of all cancers
(Bazarbashi et al., 2017; El-Bcheraoui et al., 2015). In contrast, the
global incidence is 25% of all cancers globally (Ahmad, 2019).
Currently, many imaging techniques are widely used in providing ac­
curate diagnoses for breast lesions. These imaging techniques include
mammography, contrast-enhanced mammography ultrasonography,
The selection of specific techniques, usually based on clinical re­
quirements, includes the benefits and risks of the procedures, the pur­
pose of the imaging (diagnosis or screening), and breast density
(Iranmakani et al., 2020). Radiation exposure from mammography from
the single or repetitive mammographic procedure could raise breast
malignancy risk (Sulieman et al., 2019; Miglioretti et al., 2016; Preston
et al., 2002; Brenner et al., 2001). However, mammographic imaging is
widely used for breast cancer diagnosis and screening purposes. The
main advantages are availability, cost-effectiveness, and the first step in
diagnosing breast malignancy (Ranger et al., 2010; Linton and Mettler,
2003). Mammographic procedures usually consisted of two bilateral
projections. These projections are mediolateral oblique (MLO), cranio­
caudal (CC) projections. Additional views may be requested including
lateral (mediolateral(ML) or lateromedial(LM) and lateromedial oblique
(LMO) projections. The reported average dose per projection and
average glandular doses (AGD) per procedures ranged from 1.1 to 2.2

* Corresponding author.
E-mail address: NMTamam@pnu.edu.sa (N. Tamam).

https://doi.org/10.1016/j.radphyschem.2021.109680
Received 20 April 2021; Received in revised form 23 June 2021; Accepted 24 June 2021
Available online 27 June 2021
0969-806X/© 2021 Elsevier Ltd. All rights reserved.
N. Tamam et al.
and 2.0 and 5.4 mGy per breast, respectively (Kabir et al., 2021; Koo and
Lee, 2020; Sulieman et al., 2019; Lekatou et al., 2019; Osteras et al.,
2018; Sa Dos Reis et al., 2018; Hauge et al., 2013; Borg et al., 2013).
However, the benefit from a justified diagnostic or screening mammo­
gram outweighs the projected radiation-induced malignancy linked with
the radiographic procedure. The benefit includes early detection of fatal
cancer, reducing the mortality risk due to breast malignancy up to 25%
of the screened females, and avoiding invasive procedures such as
mastectomy and chemotherapy by discovering malignant breast tumors
at an initial, treatable stage (Løberg et al., 2015). The breast is a
radiosensitive tissue with a weighting factor of 0.12, amongst the
highest, which represents 12% of overall radiation harm from cancer
effects from whole body uniform exposure (ICRP, 2007; Preston et al.,
2012). It was reported that young females with dense and huge breasts
have a higher radiogenic risk from radiation exposure induced breast
cancer. High-density breasts require higher exposure factors to provide
sufficient signal for image formation. It was reported that the use of the
Tungsten/Rhodium anode/filter combination would reduce the patient
dose by 9% compared to the Mo/Mo combination (Ranger et al., 2010;
Aşlar et al., 2020; Kim et al., 2019). Therefore, assessing patient doses
during mammography is crucial to evaluate the practice and ensure
compliance with national and international diagnostic reference levels.
Due to the continuous improvement of mammography imaging system
technology, sensitive detectors with less radiation exposure, high de­
tective efficiency, and a wide dynamic range are developed. In addition
to that, precise justification of the procedure is essential to prevent
unnecessary procedures. Implementation of optimization policy is rec­
ommended through proper adjustment of exposure factors, using the
least projections, and establishing the DRL to protect patients from
avoidable exposure and its related risk. This study investigates patients’
dose levels during digital mammography procedures and proposes a
local diagnostic reference level (DRL).
2. Material and method
The patient sample is 1055 patients who have been scanned at the
Department of Radiology, Riyadh Care Hospital. All procedures were
carried out for medically justified clinical conditions. The image
acquisition factors and (tube potential (kVp) and tube current (mA),
time (ms)), patients characteristic (breast thickness (mm), age (years)),
and machine setting (focal spot size, detector temperature, target/filter
combination), the geometry of image acquisition, image pixel spacing
and field of view and entrance surface air kerma (ESKA, mGy) were
registered.
2.1. X-ray unit
The mammographic X-ray examinations were conducted using direct
digital mammography (DDR) radiology system (Siemens AG Mammog­
raphy image, Wittelsbacherlatz 2, DE-80333 Muenchen, Germany). The
mammography unit is equipped with automatic exposure control (AEC).
The detector is manufactured from amorphous selenium (a-Se) with
direct conversion and 85 μm pixel spacing. The machine used Tungsten
(W)/Rhodium (Rh) anode/filter. The X-ray machine is calibrated regu­
larly according to the Saudi Food and Drug Authority guidelines.
2.2. Patients and procedure
Breast positioning is necessary in mammography in order to prevent
movement artefact and tissue overlap. The breast was anatomically
placed perpendicular to the thoracic cage and gently compressed with a
tissue equivalent paddle. As standard distance for all procedures, a sixty-
five cm skin distance source (SSD) was used. Breast thickness exposure
parameters have been selected.
2
Radiation Physics and Chemistry 188 (2021) 109680
2.3. Estimation of average glandular Dose(AGD, mGy)
Entrance surface air kerma (ESAK,mGy) is a helpful operational
quantity in dose measurement in diagnostic imaging. Thus, in
mammography procedure, it is the chosen quantity to compute the doses
during mammography image acquisition. ESAK (mGy) is the most
commonly used quantity for the patient dosimetric image in free in-air,
without backscattered radiation). In addition to the effective dose, this
allows a comparison of several previous studies. For each procedure,
ESAK (mGy) was measured by projection. The patient doses (ESAK
&AGD) were checked through precise calibration of the dosimetric unit
of the machine. AGD estimation details were previously reported by
Sulieman et al. (2019) using conversion elements provided by Dance
et al. (Dance et al., 2000& Dance et al., 2009).
3. Result and discussion
In total 1055, female investigated at the radiology department for
clinical investigation linked to breast malignancy. Table 1. The average
and range of patient age (yrs.) is 51.65 ± 9.3 (75–28) (Table 1). The
average tube potential (kVp) and the mAs are proportionate with pub­
lished literature (Tahiri et al., 2021; Sulieman et al., 2019; Lekatou et al.,
2019; Baek et al., 2017; and Tsapaki et al., 2008). Low tube voltage is
recommended in mammography tube voltage to obtain a high contrast
sensitivity image in the photoelectric effect range of interaction. The
mean and range of ESAK (mGy) were 5.19 ± 3.18 (0.33–29.9), while the
mean AGD (mGy) is 1.3±(1.0–7.2) per procedure. The third quartile
value for ESAK (mGy) and AGD (mGy) is 6 and 1.5, respectively. Ta­
bles 2 and 3 and Figs. 1 and 2 show kVp, mAs, and ESAK (mGy) per
procedure compared with the previous studies (Tahiri et al., 2021;
Sulieman et al., 2019; Lekatou et al., 2019; Baek et al., 2017; Maimani
et al., 2015; and Tsapaki et al., 2008). The attained results are within the
ranges reported in previous studies (Tables 2 and 3, Figs. 1 and 2). The
kVp and mAs were 29.1 and 115.7 respectively for the current study
comparing with other previous studies (Sulieman et al., 2019; Baek
et al., 2017; Tahiri et al., 2021; Lekatou et al., 2019; Tsapaki et al., 2008
respectively). The ESAK(mGy) was also 5.19 for this study compared
with other previous studies was 6.96, 8.98, 5 (Tahiri et al., 2021;
Lekatou et al., 2019; Tsapaki et al., 2008). Many factors influence the
radiation dose of the breast in mammograms. These include beam en­
ergy, tube current and time of exposure, breast thickness, dose decrease
pitch, and methods such as tube modulation. The effective dose of the
breast often approaches and exceeds cancer levels reported by (Tahiri
et al., 2021). Table 3 shows that the AGD per procedure is ranged from
1.1 mGy to 1.35 mGy per procedure, while the maximum value may
approach 13 mGy per procedure, depends on the number of projections
and breast thickness. Lekatou et al., 2019; Sulieman et al. (2019). The
AGD in this study is comparable with previously published studies
(Tahiri et al., 2021; Lekatou et al., 2019; 2019; Tsapaki et al., 2008).
Fig. 3 shows a comparison of AGD per single mammographic pro­
jection compared with previous studies(Oliveira et al., 2009; Tsapaki
et al., 2008; Lekatou et al., 2019; Yaffe and Mainprize, 2011; Preston
et al., 2002; Saggu et al., 2015). The dose among different previous
studies is small. However, the variation in AGD (mGy) and ESAK (mGy)
is high due to variation in the number of projections. For example, for
screening purposes, projections are usually used (mediolateral oblique
(MLO) craniocaudal (CC)). It was reported that 21% of screening
mammograms carried out utilizing more than four projections, with
wide dose variation from 0.15 mGy up to 13.0 mGy per procedure
(Miglioretti et al., 2016; Hendrick et al., 2010). For the diagnosis, up to
four projections may be used for a single breast (Iranmakani et al., 2020;
Sulieman et al., 2019). The variation in AGD could also be attributed to
the differences in the image receptors, imaging protocol, and patients’
related factors such as breast thickness and composition (percentage of
adipose and glandular tissues) (Lekatou et al., 2019; Ranger et al.,
2010). In the clinical environment, now DDR systems replaced in most
N. Tamam et al. Radiation Physics and Chemistry 188 (2021) 109680

Table 1
Radiographic factors during breast imaging.
Patient Age (year) Total number of Tube voltage Distance source to Distance source to Distance source to Exposure time X-ray tube
exposures (kVp) patient (mm) detector (mm) entrance (mm) (ms) current (mA)

1055 (51.65 ± (5.2 ± 1.17) (29.1 ± 1.4) (632.1 ± 14.88) 650 (577.01 ± 20.52) (782.8 ± (148.3 ± 21.9)
9.3) 376.8)
(28–75) (2–9) (26–35) (391–633) (328–614) (66–5569) (28–177)

Table 2
X ray machines characteristics.
Breast Relative x-ray ESAK (mGy) Series organ Focal spot Detector Field of view Image pixel Estimated radiographic
thickness (mm) exposure (mGy) dose temperature origin spacing magnification factor

(55.1 ± 13.9) 5.2 ± 3.2 5.19 ± 3.18 1.4 ± 0.57 0.3 ± (25.9 ± 3.2) 258.7 0.085 1.03 ± 0.039
0.012
(19–125) (0.33–29.9) (0.33–29.97) (0.039–5.48) (0.1–0.3) (19.1–33.5) (39–1262) (1.03–1.66)

documented that reported a high quality of images that reduce breast

Table 3
malignancy death by 30% (Lee et al., 2010). In literature, many attempts
Average ESAK(mGy) and AGD(mGy) image acquisition parameters during
were carried out to reduce the AGD, hence the radiation risk per pro­
mammographic procedure in comparison with previous studies.
cedure while keeping the quality of the mammogram. These approaches
Author This Sulieman Baek Lekatou Tsapaki
include the use of anode (target)/filter combinations, reduction in the
Study et al. et al. et al. et al.
number of projections, the use of DDR systems, and optimum use of
2019 2017 2019 2008 exposure parameters according to the patients’ thickness. However,
Tube voltage 29.1 29.6 28.1 29.6 28.1 alternative imaging techniques without ionizing radiation exposure are
(kVp) encouraged to provide the same diagnostic value.
Tube current 115.7 81.9 89.6 102 67
time product
(mAs) 4. Conclusions
ESAK (mGy) 5.19 4.4 6.85 5.1 5.0
AGD (mGy) 1.3 1.1 NA 1.25 1.35 Mammography procedures were performed for patients with specific
clinical indications or asymptomatic females for screening purposes.
Both procedures increase the radiogenic risk for the patients due to the
countries the conventional mammography imaging. Therefore, reducing
breast-high sensitivity. Measured ESAK (mGy) per procedure and esti­
patients’ dose with higher image quality is expected due to the wide
mated AGD are comparable with previous studies. The interpatient and
dynamic range of the DDR detectors compared to the films. The pub­
interdepartmental variation is attributed mainly to the number of pro­
lished studies in the literature are still limited compared to the frequency
jections per procedure. The attained results are within the ranges
of the procedures and their projected risk. Therefore, in many countries,
described in previous studies. The proposed DRL in this study (third
DRL is not established yet. Thus, the interpatient dose variation per
quartile value) is also comparable with previous studies. Establishing a
procedure could be high. The proposed DRL in this study (third quartile
national DRL with specific guidelines regarding patient’s age, breast
value) is comparable also with previous studies (Sulieman et al., 2019;
density, and compression is recommended to reduce the patients’ dose
Lekatou et al., 2019; Osteras et al., 2018; Sa Dos Reis et al., 2018; O’
per mammogram.
Leary and Rainford, 2013; Geeraert et al., 2012; Chevalier et al., 2004).
The radiogenic risk thus of concern to the breast. Adjustment of imaging
Author’s statement
factors and weighing the justification measures of exam depending on a
balance the achieved benefit to expected risk is recommended to reduce
This submission comply with ethical guidelines and all authors
unproductive exposure. It likewise aids the radiographers to reduce the
contributed in this manuscript.
least projection with minimum possible exposure to radiation. It was

Fig. 1. Image acquisition parameters in comparison with previous studies.

3
N. Tamam et al.
Fig. 2. Entrance surface air kerma compared with previous studies.
Fig. 3. AGD per single mammographic projection compared with previous studies.
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgement
This research was funded by the Deanship of Scientific Research at
Princess Nourah Bint Abdulrahman University through the Fast-track
Research Funding Program to support publication in the top journal
(Grant no. 42-FTTJ-68).
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