AAPM Medical Physics Practice Guideline 12.a: Fluoroscopy dose management

• Published in: Journal of applied clinical medical physics Vol. 23; no. 3; pp. e13526 - n/a
• Main Authors: Fisher, Ryan F., Applegate, Kimberly E., Berkowitz, Lindsey K., Christianson, Olav, Dave, Jaydev K., DeWeese, Lindsay, Harris, Nichole, Jafari, Mary Ellen, Jones, A. Kyle, Kobistek, Robert J., Loughran, Brendan, Marous, Loren, Miller, Donald L., Schueler, Beth, Schwarz, Bryan C., Springer, Adam, Wunderle, Kevin A.
• Format: Journal Article
• Language: English
• Published: United States John Wiley & Sons, Inc 01.03.2022; John Wiley and Sons Inc
• Subjects: AAPM Reports & Documents; Atrophy; Cardiology; Dosimetry; Erythema; Fluoroscopy; Health Physics; Humans; MPPG; Patients; Physics; practice guideline; Radiation Oncology; Radiation therapy; Skin; United States > US; fluoroscopy; practice guideline; MPPG
• ISSN: 1526-9914; 1526-9914
• DOI: 10.1002/acm2.13526

Many organizations and societies have provided guidance and resources for managing patient dose, including the National Council on Radiation Protection and Measurements (NCRP), the Conference of Radiation Control Program Directors (CRCPD), the Department of Veterans Affairs, the Society of Interventional Radiology (SIR), and multiple cardiology societies under the umbrella of the American College of Cardiology Task Force on Expert Consensus Decision Pathways.1–5 This AAPM practice guideline aims to outline the role of the diagnostic qualified medical physicist (QMP), as defined by AAPM Policy Number PP 1-J “Definition of A Qualified Medical Physicist,” in practical patient dose management for FGI procedures. 6 This role includes helping facilities set up policies related to dose management, including pre-procedure patient consent, intra-procedure dose index level notification, and post-procedure follow-up for potential tissue reactions. Tissue reactions do not occur at doses below a threshold dose, which the International Commission on Radiological Protection (ICRP) defines as the dose estimated to result in a 1% incidence of the tissue reaction. 8 Tissue reactions in patients undergoing FGI procedures may involve skin, hair, subcutaneous fat, muscle, the lens of the eye, and sometimes bone. 9,10 The generally accepted minimum threshold dose for transient skin effects is an absorbed skin dose of approximately 2 Gy, and permanent effects are unlikely below an absorbed skin dose of 5 Gy. 1,11 Risks for tissue reaction can conservatively be assumed as cumulative when the same skin area has been irradiated for other procedures. Tissue reactions in the skin range in severity from erythema and transient epilation to dermal necrosis, which can require surgical intervention. 12 Because of individual variability in radiosensitivity, the radiation dose necessary to produce a specific effect and the time course of the tissue reaction are best thought of as ranges, rather than specific values, as shown in Table 1, reprinted from Balter et al. 11 Additionally, it should be noted that previously irradiated skin is at a higher risk for developing tissue reactions than areas that have had no prior exposure. TABLE 1 Tissue reactions from single-delivery radiation dose to skin of the neck, torse, pelvis, buttocks, or arms Single-site acute skin NCI skin dose range reaction Approximate time of onset of effects Band (Gy) a grade Prompt Early Midterm Long term A1 0–2 NA No observable effects expected No observable effects expected No observable effects expected No observable effects expected A2 2–5 1 Transient erythema Epilation Recovery from hair loss No observable results expected B 5–10 1–2 Transient erythema Erythema, epilation Recovery; at higher doses, prolonged erythema; permanent partial epilation Recovery; at higher doses, dermal atrophy or induration C 10–15 2–3 Transient erythema Erythema, epilation; possible dry or moist desquamation; recovery from desquamation Prolonged erythema; permanent epilation Telangiectasia b; or induration; skin likely to be weak D >15 3–4 Transient erythema; after very high doses, edema and acute ulceration; long-term surgical intervention likely to be required Erythema, epilation; moist desquamation Dermal atrophy; secondary ulceration due to failure of moist desquamation to heal; surgical intervention likely to be required; at higher doses, dermal necrosis, surgical intervention likely to be required Telangiectasia b; dermal atrophy or induration; possible late skin breakdown; wound might be persistent and progress into a deeper lesion; surgical intervention likely to be required Note: Applicable to normal range of patient radiosensitivities in absence of mitigating or aggravating physical or clinical factors.