Effective dose rate coefficients for exposure to contaminated soil

The Oak Ridge National Laboratory Center for Radiation Protection Knowledge has undertaken calculations related to various environmental exposure scenarios. A previous paper reported the results for submersion in radioactive air and immersion in water using age-specific mathematical phantoms. This paper presents age-specific effective dose rate coefficients derived using stylized mathematical phantoms for exposure to contaminated soils. Dose rate coefficients for photon, electron, and positrons of discrete energies were calculated and folded with emissions of 1252 radionuclides addressed in ICRP Publication 107 to determine equivalent and effective dose rate coefficients. The MCNP6 radiation transport code was used for organ dose rate calculations for photons and the contribution of electrons to skin dose rate was derived using point-kernels. Bremsstrahlung and annihilation photons of positron emission were evaluated as discrete photons. The coefficients calculated in this work compare favorably to those reported in the US Federal Guidance Report 12 as well as by other authors who employed voxel phantoms for similar exposure scenarios.     

An EGS4 based Monte Carlo code for the calculation of organ equivalent dose to a modified Yale voxel phantom.

Organ or tissue equivalent dose, the most important quantity in radiation protection, cannot be measured directly. Therefore it became common practice to calculate the quantity of interest with Monte Carlo methods applied to so-called human phantoms, which are virtual representations of the human body. The Monte Carlo computer code determines conversion coefficients, which are ratios between organ or tissue equivalent dose and measurable quantities. Conversion coefficients have been published by the ICRP (Report No. 74) for various types of radiation, energies and fields, which have been calculated, among others, with the mathematical phantoms ADAM and EVA. Since then progress of image processing, and of clock speed and memory capacity of computers made it possible to create so-called voxel phantoms, which are a far more realistic representation of the human body. Voxel (Volume pixel) phantoms are built from segmented CT and/or MRI images of real persons. A complete set of such images can be joined to a 3-dimensional representation of the human body, which can be linked to a Monte Carlo code allowing for particle transport calculations. A modified version of the VOX_TISS8 human voxel phantom (Yale University) has been connected to the EGS4 Monte Carlo code. The paper explains the modifications, which have been made, the method of coupling the voxel phantom with the code, and presents results as conversion coefficients between organ equivalent dose and kerma in air for external photon radiation. A comparison of the results with published data shows good agreement.     

A method for calculating the dose absorbed by terrestrial animals to assess the environmental impact of radioactive contamination

A method for calculating the exposures of terrestrial animals in areas contaminated with radionuclides using a point source dose function is presented. To take into account scattered γ-radiation, the Berger formula for dose buildup factor in an infinite air medium has been parameterized. In the dosimetric model proposed, an animal phantom is presented as a parallelepiped to estimate external exposures and as a tissue-quivalent sphere to estimate internal doses. Using analytical expressions, dose rate conversion coefficients for external and internal exposures of animals have been estimated for individual radionuclides. For energies of γ-rays above 50 keV, the results are in good agreement with those estimated by the Monte Carlo method for ellipsoidal phantoms of animals.     

Effective dose conversion coefficients for radionuclides exponentially distributed in the ground

In order to provide fundamental data required for dose evaluation due to environmental exposures, effective dose conversion coefficients, that is, the effective dose rate per unit activity per unit area, were calculated for a number of potentially important radionuclides, assuming an exponential distribution in ground, over a wide range of relaxation depths. The conversion coefficients were calculated for adults and a new-born baby on the basis of dosimetric methods that the authors and related researchers have previously developed, using Monte Carlo simulations and anthropomorphic computational phantoms. The differences in effective dose conversion coefficients due to body size between the adult and baby phantoms were found to lie within 50?%, for most cases; however, for some low energies, differences could amount to a factor of 3. The effective dose per unit source intensity per area was found to decrease by a factor of 2–5, for increasing relaxation depths from 0 to 5?g/cm², above a source energy of 50?keV. It is also shown that implementation of the calculated coefficients into the computation of the tissue weighting factors and the adult reference computational phantoms of ICRP Publication 103 does not significantly influence the effective dose conversion coefficients of the environment. Consequently, the coefficients shown in this paper could be applied for the evaluation of effective doses, as defined according to both recommendations of ICRP Publications 103 and 60.     

Feasibility of reducing differences in estimated doses in nuclear medicine between a patient-specific and a reference phantom

The feasibility of reducing the differences between patient-specific internal doses and doses estimated using reference phantoms was evaluated. Relatively simple adjustments to a polygon-surface ICRP adult male reference phantom were applied to fit selected individual dimensions using the software Rhinoceros®4.0. We tested this approach on two patient-specific phantoms: the biggest and the smallest phantoms from the Helmholtz Zentrum München library. These phantoms have unrelated anatomy and large differences in body-mass-index. Three models approximating each patient’s anatomy were considered: the voxel and the polygon-surface ICRP adult male reference phantoms and the adjusted polygon-surface reference phantom. The Specific Absorbed Fractions (SAFs) for internal photon and electron sources were calculated with the Monte Carlo code EGSnrc. Employing the time-integrated activity coefficients of a radiopharmaceutical (S)-4-(3-¹⁸F-fluoropropyl)-l-glutamic acid and the calculated SAFs, organ absorbed-dose coefficients were computed following the formalism promulgated by the Committee on Medical Internal Radiation Dose. We compared the absorbed-dose coefficients between each patient-specific phantom and other models considered with emphasis on the cross-fire component. The corresponding differences for most organs were notably lower for the adjusted reference models compared to the case when reference models were employed. Overall, the proposed approach provided reliable dose estimates for both tested patient-specific models despite the pronounced differences in their anatomy. To capture the full range of inter-individual anatomic variability more patient-specific phantoms are required. The results of this test study suggest a feasibility of estimating patient-specific doses within a relative uncertainty of 25% or less using adjusted reference models, when only simple phantom scaling is applied.     

Comparison of neutron organ and effective dose coefficients for PIMAL stylized phantom in bent postures in standard irradiation geometries

Neutron dose coefficients for standard irradiation geometries have been reported in International Commission on Radiological Protection (ICRP) Publication 116 for the ICRP Publication 110 adult reference phantoms. In the present work, organ and effective dose coefficients have been calculated for a receptor in both upright and articulated (bent) postures representing more realistic working postures exposed to a mono-energetic neutron radiation field. This work builds upon prior work by Dewji and co-workers comparing upright and bent postures for exposure to mono-energetic photon fields. Simulations were conducted using the Oak Ridge National Laboratory’s articulated stylized adult phantom, “Phantom wIth Moving Arms and Legs” (PIMAL) software package, and the Monte Carlo N-Particle (MCNP) version 6.1.1 radiation transport code. Organ doses were compared for the upright and bent (45° and 90°) phantom postures for neutron energies ranging from 1 × 10^??9 to 20 MeV for the ICRP Publication 116 external exposure geometries—antero-posterior (AP), postero-anterior (PA), and left and right lateral (LLAT, RLAT). Using both male and female phantoms, effective dose coefficients were computed using ICRP Publication 103 methodology. The resulting coefficients for articulated phantoms were compared to those of the upright phantom. Computed organ and effective dose coefficients are discussed as a function of neutron energy, phantom posture, and source irradiation geometry. For example, it is shown here that for the AP and PA irradiation geometries, the differences in the organ coefficients between the upright and bent posture become more pronounced with increasing bending angle. In the AP geometry, the brain dose coefficients are expectedly higher in the bent postures than in the upright posture, while all other organs have lower dose coefficients, with the thyroid showing the greatest difference. Overall, the effective dose estimated for the upright phantom is more conservative than that for the articulated phantom, which may have ramifications in the estimation or reconstruction of radiation doses.     

Dose coefficients of percentile-specific computational phantoms for photon external exposures

The use of dose coefficients (DCs) based on the reference phantoms recommended by the International Commission on Radiological Protection (ICRP) with a fixed body size may produce errors to the estimated organ/tissue doses to be used, for example, for epidemiologic studies depending on the body size of cohort members. A set of percentile-specific computational phantoms that represent 10th, 50th, and 90th percentile standing heights and body masses in adult male and female Caucasian populations were recently developed by modifying the mesh-type ICRP reference computational phantoms (MRCPs). In the present study, these percentile-specific phantoms were used to calculate a comprehensive dataset of body-size-dependent DCs for photon external exposures by performing Monte Carlo dose calculations with the Geant4 code. The dataset includes the DCs of absorbed doses for 29 individual organs/tissues from 0.01 to 104 MeV photon energy, in the antero-posterior, postero-anterior, right lateral, left lateral, rotational, and isotropic geometries. The body-size-dependent DCs were compared with the DCs of the MRCPs in the reference body size, showing that the DCs of the MRCPs are generally similar to those of the 50th percentile standing height and body mass phantoms over the entire photon energy region except for low energies (≤ 0.03 MeV); the differences are mostly less than 10%. In contrast, there are significant differences in the DCs between the MRCPs and the 10th and 90th percentile standing height and body mass phantoms (i.e., H10M10 and H90M90). At energies of less than about 10 MeV, the MRCPs tended to under- and over-estimate the organ/tissue doses of the H10M10 and H90M90 phantoms, respectively. This tendency was revised at higher energies. The DCs of the percentile-specific phantoms were also compared with the previously published values of another phantom sets with similar body sizes, showing significant differences particularly at energies below about 0.1 MeV, which is mainly due to the different locations and depths of organs/tissues between the different phantom libraries. The DCs established in the present study should be useful to improve the dosimetric accuracy in the reconstructions of organ/tissue doses for individuals in risk assessment for epidemiologic investigations taking body sizes into account.     

Evaluation of conversion coefficients from measurable to risk quantities for external exposure over contaminated soil by use of physical human phantoms

Conversion coefficients from measurable quantities such as air kerma free-in-air or personal dose equivalent to effective dose were determined by phantom experiments. Heterogenic anthropomorphic phantoms representing children of one and five years age, and a Rando phantom representing an adult were exposed in the open field contaminated by different levels of radiocesium in the upper soil layer, in a forest site and inside a wooden house. LiF thermoluminescent (TL) detectors were used inside the phantoms for the estimation of organ doses and effective dose. Personal dosimeters similar to those used in radiation protection for individual dose measurements were placed onto the phantom surface (chest area). The ratios of dose values in separate organs to air kerma free-in-air varied from 0.69 to 1.15 for the children phantoms, and from 0.55 to 0.94 for the adult phantom, respectively, when irradiated in the open field. Body size (weight) was found to be the most important factor influencing the values of the conversion coefficients. The differences observed can reach approximately 40% when comparing conversion factors from air kerma free-in-air to effective dose for adults and newborns. For conversion coefficients from personal dose to effective dose, these differences can reach approximately 15%. The dependences of the various conversion coefficients on body mass were quantified by regression analysis. The results were compared with those calculated for a plane mono-energetic photon source having an energy of 700 keV and being located in the ground at a depth of 0.5 g cm⁻². Calculated and measured conversion coefficients from air kerma free-in-air to effective dose agreed within 12%.     

Monte Carlo simulation of the dose distribution of ICRP adult reference computational phantoms for acquisitions with a 320 detector-row cone-beam CT scanner

PurposeThe purpose of this study was to develop and validate a Monte Carlo (MC) simulation tool for patient dose assessment for a 320 detector-row CT scanner, based on the recommendations of International Commission on Radiological Protection (ICRP). Additionally, the simulation was applied on four clinical acquisition protocols, with and without automatic tube current modulation (TCM).MethodsThe MC simulation was based on EGS4 code and was developed specifically for a 320 detector-row cone-beam CT scanner. The ICRP adult reference phantoms were used as patient models. Dose measurements were performed free-in-air and also in four CTDI phantoms: 150 mm and 350 mm long CT head and CT body phantoms. The MC program was validated by comparing simulations results with these actual measurements acquired under the same conditions. The measurements agreed with the simulations across all conditions within 5%. Patient dose assessment was performed for four clinical axial acquisitions using the ICRP adult reference phantoms, one of them using TCM.ResultsThe results were nearly always lower than those obtained from other dose calculator tools or published in other studies, which were obtained using mathematical phantoms in different CT systems. For the protocol with TCM organ doses were reduced by between 28 and 36%, compared to the results obtained using a fixed mA value.ConclusionsThe developed simulation program provides a useful tool for assessing doses in a 320 detector-row cone-beam CT scanner using ICRP adult reference computational phantoms and is ready to be applied to more complex protocols.     

Validation of irtGPUMCD,a GPU-based Monte Carlo internal dosimetry framework for radionuclide therapy

PurposeMonte Carlo (MC) simulations are highly desirable for dose treatment planning and evaluation in radiation oncology. This is true also in emerging nuclear medicine applications such as internal radiotherapy with radionuclides. The purpose of this study is the validation of irtGPUMCD, a GPU-based MC code for dose calculations in internal radiotherapy.MethodsThe female and male phantoms of the International Commission on Radiological Protection (ICRP 110) were used as benchmarking geometries for this study focused on ¹⁷⁷Lu and including ^99mTc and ¹³¹I. Dose calculations were also conducted for a real patient. For phantoms, twelve anatomical structures were considered as target/source organs. The S-values were evaluated with irtGPUMCD simulations (10⁸ photons), with gamma branching ratios of ICRP 107 publication. The ¹⁷⁷Lu electrons S-values were calculated for source organs only, based on local deposition of dose in irtGPUMCD. The S-value relative difference between irtGPUMCD and IDAC-DOSE were evaluated for all targets/sources considered. A DVHs comparison with GATE was conducted. An exponential track length estimator was introduced in irtGPUMCD to increase computational efficiency.ResultsThe relative S-value differences between irtGPUMCD and IDAC-DOSE were <5% while this comparison with GATE was <1%. The DVHs dosimetric indices comparison between GATE and irtGPUMCD for the patient led to an excellent agreement (<2%). The time required for the simulation of 10⁸ photons was 1.5 min for the female phantom, and one minute for the real patient (<1% uncertainty). These results are promising and let envision the use of irtGPUMCD for internal dosimetry in clinical applications.     

Dose estimation for astronauts using dose conversion coefficients calculated with the PHITS code and the ICRP/ICRU adult reference computational phantoms

Absorbed-dose and dose-equivalent rates for astronauts were estimated by multiplying fluence-to-dose conversion coefficients in the units of Gy.cm² and Sv.cm², respectively, and cosmic-ray fluxes around spacecrafts in the unit of cm⁻² s⁻¹. The dose conversion coefficients employed in the calculation were evaluated using the general-purpose particle and heavy ion transport code system PHITS coupled to the male and female adult reference computational phantoms, which were released as a common ICRP/ICRU publication. The cosmic-ray fluxes inside and near to spacecrafts were also calculated by PHITS, using simplified geometries. The accuracy of the obtained absorbed-dose and dose-equivalent rates was verified by various experimental data measured both inside and outside spacecrafts. The calculations quantitatively show that the effective doses for astronauts are significantly greater than their corresponding effective dose equivalents, because of the numerical incompatibility between the radiation quality factors and the radiation weighting factors. These results demonstrate the usefulness of dose conversion coefficients in space dosimetry.     

Dosimetric effect of tissue heterogeneity for 125I prostate implants

AimTo use Monte Carlo (MC) together with voxel phantoms to analyze the tissue heterogeneity effect in the dose distributions and equivalent uniform dose (EUD) for ¹²⁵I prostate implants.BackgroundDose distribution calculations in low dose-rate brachytherapy are based on the dose deposition around a single source in a water phantom. This formalism does not take into account tissue heterogeneities, interseed attenuation, or finite patient dimensions effects. Tissue composition is especially important due to the photoelectric effect.Materials and methodsThe computed tomographies (CT) of two patients with prostate cancer were used to create voxel phantoms for the MC simulations. An elemental composition and density were assigned to each structure. Densities of the prostate, vesicles, rectum and bladder were determined through the CT electronic densities of 100 patients. The same simulations were performed considering the same phantom as pure water. Results were compared via dose–volume histograms and EUD for the prostate and rectum.ResultsThe mean absorbed doses presented deviations of 3.3–4.0% for the prostate and of 2.3–4.9% for the rectum, when comparing calculations in water with calculations in the heterogeneous phantom. In the calculations in water, the prostate D₉₀ was overestimated by 2.8–3.9% and the rectum D_0.1cc resulted in dose differences of 6–8%. The EUD resulted in an overestimation of 3.5–3.7% for the prostate and of 7.7–8.3% for the rectum.ConclusionsThe deposited dose was consistently overestimated for the simulation in water. In order to increase the accuracy in the determination of dose distributions, especially around the rectum, the introduction of the model-based algorithms is recommended.     

External radiation doses from <Superscript>137</Superscript>Cs to frog phantoms in a wetland area: in situ measurements and dose model calculations

For assessment of external radiation doses to frogs in a wetland area contaminated with ¹³⁷Cs, frog phantoms were constructed from polymethyl methacrylate (PMMA). The frog phantoms contained thermoluminescence (TL) chips and were used in situ at two study sites to measure doses. To test if higher doses are received by the sensitive skin of frogs, extra-thin TL chips were applied close to the surface of the frog phantoms. In addition, the measured doses were compared with those calculated on the basis of soil sample data from the wetland multiplied with dose-conversion coefficients from the US Department of Energy’s RESRAD-BIOTA code and from the ERICA assessment tool. Measured doses were generally lower than those calculated to ellipsoids used to model frogs. Higher doses were measured at the frog phantoms’ surfaces in comparison to inner parts at one of the two sites indicating that the frogs’ thin skin could receive a higher radiation dose than expected. In the efforts to assure protection of non-human biota, in situ measurements with phantoms provide valuable dose information and input to dose models in site-specific risk assessments of areas contaminated with radionuclides.     

Tables of dose conversion coefficients for estimating internal and external radiation exposures to terrestrial and aquatic biota

Dose conversion coefficients (DCCs) for assessment of internal and external radiation exposures to terrestrial and aquatic biota are compiled for 75 radionuclides, for 14 terrestrial and 22 aquatic reference organisms. DCC values for internal exposure are calculated based on a homogeneous distribution of the radionuclides in both types of organisms. DCC values for external exposure of aquatic organisms are calculated for complete immersion in water. For external exposure of terrestrial organisms the soil is considered as a planar and homogenously contaminated volume source with a surface roughness of 3 mm and a thickness of 10 cm, respectively. For in-soil-organisms, DCC values for external exposure are given assuming that these organisms live in the middle of a uniformly contaminated 50 cm-thick soil layer. The tables can be used for assessment of exposures of animals and plants living in various habitats. The list of considered organisms covers the Reference Animals and Plants as adopted by the ICRP.     

A Monte Carlo study on dose distribution evaluation of Flexisource 192Ir brachytherapy source

Aim

The aim of this study is to evaluate the dose distribution of the Flexisource ¹⁹²Ir source.

Background

Dosimetric evaluation of brachytherapy sources is recommended by task group number 43 (TG. 43) of American Association of Physicists in Medicine (AAPM).

Materials and methods

MCNPX code was used to simulate Flexisource ¹⁹²Ir source. Dose rate constant and radial dose function were obtained for water and soft tissue phantoms and compared with previous data on this source. Furthermore, dose rate along the transverse axis was obtained by simulation of the Flexisource and a point source and the obtained data were compared with those from Flexiplan treatment planning system (TPS).

Results

The values of dose rate constant obtained for water and soft tissue phantoms were equal to 1.108 and 1.106, respectively. The values of the radial dose function are listed in the form of tabulated data. The values of dose rate (cGy/s) obtained are shown in the form of tabulated data and figures. The maximum difference between TPS and Monte Carlo (MC) dose rate values was 11% in a water phantom at 6.0 cm from the source.

Conclusion

Based on dosimetric parameter comparisons with values previously published, the accuracy of our simulation of Flexisource ¹⁹²Ir was verified. The results of dose rate constant and radial dose function in water and soft tissue phantoms were the same for Flexisource and point sources. For Flexisource ¹⁹²Ir source, the results of TPS calculations in a water phantom were in agreement with the simulations within the calculation uncertainties. Furthermore, the results from the TPS calculation for Flexisource and MC calculation for a point source were practically equal within the calculation uncertainties.     

Measuring the dose in bone for spine stereotactic body radiotherapy

PurposeCurrent quality assurance of radiotherapy involving bony regions generally utilises homogeneous phantoms and dose calculations, ignoring the challenges of heterogeneities with dosimetry problems likely occurring around bone. Anthropomorphic phantoms with synthetic bony materials enable realistic end-to-end testing in clinical scenarios. This work reports on measurements and calculated corrections required to directly report dose in bony materials in the context of comprehensive end-to-end dosimetry audit measurements (63 plans, 6 planning systems).Materials and methodsRadiochromic film and microDiamond measurements were performed in an anthropomorphic spine phantom containing bone equivalent materials. Medium dependent correction factors, k_med, were established using 6 MV and 10 MV Linear Accelerator Monte Carlo simulations to account for the detectors being calibrated in water, but measuring in regions of bony material. Both cortical and trabecular bony material were investigated for verification of dose calculations in dose-to-medium (D_m,m) and dose-to-water (D_w,w) scenarios.ResultsFor D_m,m calculations, modelled correction factors for cortical and trabecular bone in film measurements, and for trabecular bone in microDiamond measurements were 0.875(±0.1%), 0.953(±0.3%) and 0.962(±0.4%), respectively. For D_w,w calculations, the corrections were 0.920(±0.1%), 0.982(±0.3%) and 0.993(±0.4%), respectively. In the audit, application of the correction factors improves the mean agreement between treatment plans and measured microDiamond dose from −2.4%(±3.9%) to 0.4%(±3.7%).ConclusionMonte Carlo simulations provide a method for correcting the dose measured in bony materials allowing more accurate comparison with treatment planning system doses. In verification measurements, algorithm specific correction factors should be applied to account for variations in bony material for calculations based on D_m,m and D_w,w.     

A Monte Carlo simulation for the estimation of patient dose in rest and stress cardiac computed tomography with a 320-detector row CT scanner

PurposeTo estimate organ dose and effective dose for patients for cardiac CT as applied in an international multicenter study (CORE320) with a 320-Detector row CT scanner using Monte Carlo (MC) simulations and voxelized phantoms. The effect of positioning of the arms, off-centering the patient and heart rate on patient dose was analyzed.MethodsA MC code was tailored to simulate the geometry and characteristics of the CT scanner. The phantoms representing the adult reference male and female were implemented according to ICRP 110. Effective dose and organ doses were obtained for CT acquisition protocols for calcium scoring, coronary angiography and myocardial perfusion.ResultsFor low heart rate, the normalized effective dose (E) for cardiac CT was higher for female (5.6 mSv/100 mAs) compared to male (2.2 mSv/100 mAs) due to the contribution of female breast tissue. Averaged E for female and male was 11.3 mSv for the comprehensive cardiac protocol consisting of calcium scoring (1.9 mSv); coronary angiography including rest cardiac perfusion (5.1 mSv) and stress cardiac perfusion (4.3 mSv). These values almost doubled at higher heart rates (20.1 mSv). Excluding the arms increased effective dose by 6–8%, centering the patient showed no significant effect. The k-factor (0.028 mSv/mGy.cm) derived from this study leads to effective doses up to 2–3 times higher than the values obtained using now outdated methodologies.ConclusionMC modeling of cardiac CT examinations on realistic voxelized phantoms allowed us to assess patient doses accurately and we derived k-factors that are well above those published previously.     

Finding sensitive parameters in internal dose calculations for radiopharmaceuticals commonly used in clinical nuclear medicine

Internal dosimetry after incorporation of radionuclides requires standardized biokinetic and dosimetric models. The aim of the present work was to identify the parameters and the components of the models which contribute most to dosimetric uncertainty. For this a method was developed allowing for the calculation of the uncertainties of the absorbed dose coefficients. More specifically, the sampling-based regression method and the variance-based method were used to develop and apply a global method of sensitivity analysis. This method was then used to quantify the impact of various biokinetic and dosimetric parameters on the uncertainty of internal doses associated with the incorporation of seven common radiopharmaceuticals. It turned out that the correlation between biokinetic parameters and time-integrated activity or calculated absorbed dose is strongest when the source and target organ are identical, in accordance with the ICRP and the MIRD approach. According to the ICRP approach, the parameter F_s which describes the fractional distribution of any incorporated radioactivity to organ S, has the greatest correlation with the time-integrated activity in the corresponding source organ or with the calculated dose in the corresponding target organ. In contrast, the MIRD approach suggested several biokinetic parameters with similar correlation. The dosimetric parameters usually contribute more to uncertainty in the calculated dose coefficients than the biokinetic parameters, in both approaches. The results obtained are helpful for the revision of biokinetic models for radiopharmaceuticals, because the most important parameters in clinical applications can now be identified and investigated in future studies.     

Effective dose from radiation exposure in medicine: Past,present, and future

Effective dose (E) has been developed by the International Commission on Radiological Protection (ICRP) as a dose quantity with a link to risks of health detriment, mainly cancer. It is based on reference phantoms representing average individuals, but this is often forgotten in its application to medical exposures, for which its use sometimes goes beyond the intended purpose. There has been much debate about issues involved in the use of E in medicine and ICRP is preparing a publication with more information on this application. This article aims to describe the development of E and explain how it should be used in medicine. It discusses some of the issues that arise when E is applied to medical exposures and provides information on how its use might evolve in the future. The article concludes with responses to some frequently asked questions about uses of E that are in line with the forthcoming ICRP publication. The main use of E in medicine is in meaningful comparison of doses from different types of procedure not possible with measurable dose quantities. However, it can be used, with appropriate care, as a measure of possible cancer risks. When considering E to individual patients, it is important to note that the dose received will differ from that assessed for reference phantoms, and the risk per Sv is likely to be greater on average in children and less in older adults. Newer techniques allow the calculation of patient-specific E which should be distinguished from the reference quantity.