Medical Applications

of X-Rays

Prepared by:

Arunavo Dutta
Delhi Public School, Durgapur
 Contents
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Topic Page no
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 INTRODUCTION

X-rays are a form of electromagnetic radiation, just like light waves and radio waves. X-rays were
discovered in 1895 by Wilhelm Conrad Roentgen, a Professor at Wurzburg University in Germany.
Because X-rays are invisible and have higher energy than light waves, they can pass through the
body. Roentgen's discovery was a scientific bombshell, and was received with extraordinary interest
by both scientist and laymen. Public fancy was caught by this invisible ray with the ability to pass
through solid matter, and, in conjunction with a photographic plate, provide a picture of bones and
interior body parts. Today x-rays remain a valuable tool in diagnosis and treatment of many injuries
and diseases.

The famous radiograph made by Roentgen on December 22, 1895. This is

Traditionally known as the first X-ray picture and the radiograph of Mrs.
Roentgens hand.

X-rays are a form of electromagnetic radiation, just like light waves and radiowaves. Because X-
rays have higher energy than light waves, they can pass through the body. Just like other forms of
high-energy radiation, X-rays can cause damage to cells in the body, which in turn can increase the
risk of developing cancer. This increase in risk associated with each X-ray procedure is extremely
low but does slowly increase with the increasing number of X-rays tests one have. This is the same
principle as the way in which increased exposure to the sun increases skin cancer risk.
 A CENTURY OF RADIOLOGY: 18951995

The discovery of the X ray in 1895 was one of the most momentous events in science and medicine,
but it was only the beginning of what was to be accomplished in the next 100 years in radiology.
What follows are some highlights provided by American College of Radiology.
1895
German physics professor Wilhelm Conrad Roentgen discovers the X ray on November 8 in his
laboratory in Wrzburg.

1896

Roentgens discovery launches a flurry of experimentation round the world with the Crookes tubes.
Researchers study what the X rays will do and tinker with refining the design of the tubes. Although
the shapes and configurations of the tubes change, the basic concept will stay the same until1913.
Fluoroscopy is invented in January by Italian scientist Enrico Salvioni, while American inventor
Thomas Edison, an early and active X-ray enthusiast, works on a similar device. The fluoroscope is
a hand-held or mounted device consisting of an oblong box, one end of which fits tightly against the
eyes, the opposite end of which is a fluorescent screen. The basic concept is still used today. In
March, a Roentgen photograph is introduced as evidence in a Montreal courtroom by a man suing
a defendant who allegedly shot him. The X ray proves the presence of a bullet not detected by
exploratory surgery. Hospitals begin acquiring X-ray equipment to be used by people with and
without medical qualifications. One of the first physicians to specialize in X rays in 1896 is Dr.
Francis Henry Williams of Boston. He is also a graduate of the Massachusetts Institute of
Technology, making him one of the few physicians intimately conversant with the physics that
create X rays. He is instrumental in early uses
of X rays for medical diagnosis, including the use
of fluoroscopy to study the blood vessels. Later this
will be known as angiography.
 .
Angiographic work began in January, 1896, with this post-mortem
injection of mercury compounds. This image was made by E.
Haschek and O. Lindenthal of Vienna.
1898
In December, Marie and Pierre Curie, working in Paris, discover radium, a new element that emits
200 million times more radiation than uranium. In 1903, the Curies and Antoine-Henri Becquerel
share the Nobel Prize in Physics for their work on radioactivity. Like the discovery of X rays, the
discovery of radium captured the worlds imagination, says Nancy Knight, Ph.D., historian and
director of the Center for the American History of Radiology. Scientists knew that the radiation
from X rays and radium was similar, but radium was considered the natural version of X rays.
Around the world people believe radium to have marvellous medicinal properties. It is said to lessen
constipation, lower blood pressure, cure insomnia by soothing the nerves, and increase sexual
activity, and is put in skin creams and toothpastes. People flock to radium springs, where the water
is mildly radioactive, a craze that lasts into the 1930s, and use radium drinkers, ceramic vessels
made of irradiated earth, at radium cocktail parties, where inside everyones drink is a vial of
radium emanationradon gasto make the drinks glow in the dark. Also popular is radium
roulette, in which the roulette balls and table are painted with radioactive paint.
1900
German scientists Friedrich Giesel and Friedrich Walkhoff discover that radium rays are dangerous
to the skin; Pierre Curie purposely leaves a radium sample on his arm for ten hours and produces a
sunburn-like rash. En route to a conference, Henri Becquerel unthinkingly carries a sample in his
lower vest pocket and suffers a burn on his abdomen. Radiology begins to emerge as a medical
specialty. It becomes increasingly clear that producing an X-ray image requires skill and technical
know-how, and interpreting the image requires a knowledge of anatomy.
1904
Clarence Dally, Thomas Edisons assistant in X-ray research, dies of extreme and repeated X-ray
exposure. X rays had already caused severe burns on his face, hands, and arms, resulting in several
amputations. From this point on, the risks posed by radium and X rays become more clear. X-ray
use begins to be confined largely to doctors offices and hospitals.
1919
Dr. Carlos Heuser, an Argentine radiologist, is the first to use a contrast medium in a living human
circulatory system. The compound, potassium iodide diluted with water, is acceptable because it is
excreted by the body and causes the blood vessels to appear opaque on the X-ray image. Dr. Heuser
successfully injects the compound into a vein of a patients hand and simultaneously takes an X ray
to visualize the veins in the forearm and arm. His discovery, however, is lost on the scientific world
because it is published only in Spanish, in an Argentine medical journal.

19201929

Chest X rays are used to screen for tuberculosisa scourge of even greater concern to the public
than cancer. Exposures of up to 1 minute, with 10 to 20 rads (units of absorbed radiation dose) are
used. Roentgen dies February 10, 1923.The first practices of modern angiography are developed in
1927 by a Portuguese physician, Dr. Egaz Moniz, who is the first to create images of the circulatory
system in the living brain. He develops a carotid angiography technique, which involves making a
surgical incision into the neck, identifying the carotid artery and injecting contrast into the artery,
which transports it to the brain. Drs. Evarts Graham and Warren H. Cole of Washington University,
St. Louis, discover in 1923 how to visualize the gall bladder with X rays by using contrast media, a
discovery significant in the diagnosis of gall bladder disease. This discovery demonstrates the role
of chance in science, in that the doctors tried for four and one half months to visualize gall bladders
in dogs by injecting contrast medium into the dogs in the morning, then taking X rays in the
evening, to no avail. One day they finally produced a picture of a gall bladder in one particular dog,
but for several days thereafter were unable to recreate the results. In their hunt for an explanation
for this anomaly, they confronted the kennel attendanthad he done anything different to that one
dog? The attendant confessed that due to a severe hangover he had not gotten around to feeding that
particular dog on the morning of the test. If he had, the dogs gall bladder would have emptied when
the dogs food was digested. Thus the discovery was made..
19301939
In 1934, the American Board of Radiology is officially formed and recognized by the American
Medical Association. In 1936, the first Tomographan X-ray slice of the body is presented
at a radiology meeting. This revolutionary concept, in which the X-ray tube is moved by pulley
around the patient in order to take pictures on various planes, can focus on certain internal
structures that cannot otherwise be seen clearly. This technique, also called laminagraphy,
foreshadows the development in the 1970s of CT, or computed tomography. While higher voltages
X rays are being developed, their actual clinical benefit remains untested. Beginning in March
1932, clinical trials are initiated. Results of the studies, comparing 70,000-volt X rays to 200,000-
volt X rays used on cancers of the larynx and tonsils, among others, are reported by scientists this
way: The same results [cures] can be obtained using a [higher] dosage which causes considerably
less discomfort to the patient. These results encourage further research into super-voltage
equipment, although the equipment has some limitations; patient discomfort is not well measured
and the tumors evaluated are not the deep body lesions that physicians still want to treat.

19501959
Dr. W. Goodwin introduces the concept of X-ray guided percutaneous nephrostomy, in which a
needle and then a catheter are inserted directly into a kidney to create a drainage tract above an
obstruction (kidney stone, cancer), allowing urine to escape from the kidneys. This procedure
allows some patients to be treated without surgery. Radioisotopes are introduced as sources of
gamma-ray beams for radiation therapy. The process works, for example, by changing harmless
cobalt 59 into cobalt 60, a highly unstable nucleus that decays. As that happens, it releases two
gamma rays. The gamma-ray beams adequately reach deep cancers without damage to the skin.
Cobalt units are easy to make and quickly become a cheaper, safer alternative to the Betatron,
though later they will become virtually unused. Ultrasoundimages created from the echoes of
sound waves bounced off tissuewhich has its roots in World War IIs sonar (sound navigation
and ranging), begins to show promise in medical diagnostic applications. A Swedish physician, Dr.
Sven Ivar Seldinger, refines Dr. Monizs and Dr. Forssmanns work in angiography from the 1920s
when he learns how to insert a catheter into a blood vessel without surgery. He uses a tiny
guidewire inserted with the help of a needle into a blood vessel. The catheter is placed over the
guidewire and into the vessel, after which the guide wire is removed. He then watches the location
of the catheter on fluoroscopy.
19601969
In 1960, Dr. Robert Egan of the University of Texas M.D. Anderson Tumor Institute, Houston, with
the support of the U.S. Public Health Service, publishes the results of an intensive, three-year study
of mammography. Although previous studies of X rays of the breast have been done, Egans study
conclusively proves mammographys effectiveness in early diagnosis. With neither physical exams
nor any knowledge about the womens medical histories, Dr. Egan examines patients ammograms
and diagnoses whether or not cancer is present. Egans accuracy in finding breast cancers is
remarkable9799 percentand his precisely controlled mammography techniques mean that
other radiology facilities can duplicate his results. Drs. Charles Dotter and Melvin Judkins of
Portland, Oregon, are the first to report performing a transluminal angioplasty, a non-surgical
technique to unblock a vessel clogged with plaque. They insert screw-tipped catheters into the
narrowed vessel, starting with small diameter catheters and sliding bigger and bigger catheters over
them, to push the plaque to the interior walls of the vessel sides. The technique is not well-accepted
except in Europe; bypass surgery is still the preferred treatment method in the United States
19701979
CT, or computed tomography, which takes X-ray slices of the body and images them on a
computer screen, is introduced. Like the first tomography units introduced in 1936, the X-ray tube
rotates around the patients body, taking X-ray pictures as it moves. With the addition of computer
technology, CT images can now be manipulated and the slices can even be put back together to
create more 3-dimensional images. Thrombolysis, which dissolves clots in blood vessels by
delivering thrombolytic (clot breaking) drugs to the site or into the vascular system, is introduced by
Dr. Charles Dotter. Using a thin catheter, a dose of a thrombolytic agent such as streptokinase is
injected into the clot, dissolving it. One drawback of streptokinase is that it can induce allergies
with repeated use over time. Later, synthetic thrombolytics that do not appear to induce allergic
reactions will be used. Swiss physician Dr. Andreas Gruntvig, later in the United States, invents
balloon angioplasty. A tiny deflated balloon is placed at the end of a catheter and threaded on a
guidewire into a plaque-clogged section of blood vessel. The balloon is inflated, and the plaque is
pushed to the sides of the vessel. Then the balloon is deflated and removed. The first applications of
balloon angioplasty are all in arteries in the arms or legs. Balloon angioplasty is an instant success,
in part because it can be used to open smaller, more fragile arteries.
1980 Till Today
Pulsed fluoroscopy reduces radiation exposure by using short bursts of high-intensity X-ray beams
(up to 12 seconds; anything longer would burn out the tube) alternated with lower intensity beams.
The high-intensity beams linger on the video screen, allowing the physician to view the anatomy
like slow-motion moving pictures. PET (positron emission tomography) begins to be used in
clinical applications. It watches the way cells eat substances such as sugar. The substance is
tagged with a short-lived radioisotope (unstable atoms that release stray particles that can be seen
with gamma cameras), then injected into the body. The PET scanner watches as the radioactive
material lights up in cells, identifying areas where cancer cells might be present. Cancer cells
have a higher metabolism than normal, healthy cells.
 How do medical x-rays work?
To create a radiograph, a patient is positioned so that the part of the body being imaged is located
between an x-ray source and an x-ray detector. When the machine is turned on, x-rays travel
through the body and are absorbed in different amounts by different tissues, depending on the
radiological density of the tissues they pass through. Radiological density is determined by both the
density and the atomic number of the materials being imaged. For example, structures such as bone
contain calcium, which has a higher atomic number than most tissues. Because of this property,
bones readily absorb x-rays and, thus, produce high contrast on the x-ray detector. As a result, bony
structures appear whiter than other tissues against the black background of a radiograph.
Conversely, x-rays travel more easily through less radiologically dense tissues such as fat and
muscle, as well as through air-filled cavities such as the lungs. These structures are displayed in
shades of gray on a radiograph.
 When are medical x-rays used?

Radiography

This is the familiar X-ray where a beam of x-rays produced by an x-ray machine is directed at the
part of our body that is being examined and on to a special film to make a picture. Most people have
had dental x-rays. These are extremely low-dose tests that pose almost no risk. Chest x-rays are
another common test. X-rays are often taken of broken bones. Mammography is a test
recommended for early detection of breast cancer. These tests use extremely short bursts of x-ray
beams and pose little risk.

Fluoroscopy
This technique uses x-rays to produce a moving image on a TV screen. Individual still pictures
can be chosen and saved or the entire video may be saved. This technique is used to examine the
intestine or to obtain images of flowing blood in blood vessels. For example, in a barium meal a
drink of barium is used to give moving pictures of the stomach and intestine. An iodine-based dye
can be injected into an artery to obtain images of the arteries of the heart or of the leg in a procedure
called an angiogram. This technique can also be used to guide treatment procedures such as
drainage of an obstructed kidney, a nephrostomy, or widening of narrowed arteries, an
angioplasty. Fluoroscopic examinations usually involve higher radiation doses than simple
radiography.

Computed tomography (CT) scan

This is a more sophisticated way of using x-rays. The patient lies on a narrow table which passes
through a circular hole in the middle of the scanner. Many tiny beams of x-rays pass through a slice
of the body on to banks of detectors. The X-ray sources and the detectors rotate around inside the
machine. An image of the slice is formed by a computer and displayed on a TV screen. The patient
moves slowly through the hole to take pictures of different slices of the body and sometimes to
produce 3D pictures. If many slices are imaged, the radiation dose can be as high as or higher than
that for fluoroscopy.

Nuclear medicine or isotope scan

This is another way of using radiation (though not actually X-Rays) to produce pictures. Instead of
using an X-ray machine, a small amount of radioactive material (isotope) is injected into a vein
(occasionally it is swallowed or inhaled). The radioactive material concentrates in a particular organ
or tissue, for example in the skeleton for a bone scans. It emits gamma rays, which are a type of
radiation that behaves like X-rays. A special camera detects the gamma rays coming out of the body
and builds up a picture of what is happening inside the body.
The radioactivity in the body falls to insignificant levels in a few days. The total radiation dose one
receives while it is there will be similar to or less than that from fluoroscopy.

PET scan and PET CT scan

A PET scan is a special type of nuclear medicine scan that detects radiation from the emission of
positrons. Positrons are tiny particles emitted from a radioactive substance administered to the
patient. This can give information about how the heart is working, about the brain or in the
detection of cancer in the body. Because the positrons are very short lived the radiation dose is low.
A PET CT scan is a new and very useful test that combines the advantages of the PET scan to
detect an abnormality, such as cancer, somewhere in the body with a CT scan to define exactly what
part of which organ is affected. While the information provided may be very helpful for patent
treatment planning, the radiation dose of PET CT may be considerably more than that of CT alone.
It is therefore critical to plan such a test with careful regard to tests already done and how it might
replace other tests and the likely benefit to the patient of the information it is likely to give.

Therapeutic
Radiation therapy in cancer treatment: X-rays and other types of high-energy radiation can be used
to destroy cancerous tumors and cells by damaging their DNA. The radiation dose used for treating
cancer is much higher than the radiation dose used for diagnostic imaging. Therapeutic radiation
can come from a machine outside of the body or from a radioactive material that is placed in the
body, inside or near tumor cells, or injected into the blood stream.

Radiotherapy

The use of X-rays as a treatment is known as radiation therapy and is largely used for the
management (including palliation) of cancer; it requires higher radiation doses than those received
for imaging alone. X-rays beams are used for treating skin cancers using lower energy x-ray beams
while higher energy beams are used for treating cancers within the body such as brain, lung,
prostate, and breast.
 Advances in Medical Radiation Imaging for
Cancer Diagnosis and Treatment

Cancer management requires reliable diagnosis in order to identify the primary tumour and assess
its dissemination to surrounding tissues, as well as to other organs and structures throughout the
body. This process, technically called staging, is of paramount importance in deciding the
therapeutic approach to be taken, since staging dictates prognosis and consequently therapy.
Imaging by means of radiation medicine techniques is usually the first step in clinical management
and diagnostic radiology and nuclear medicine studies play important roles in screening, staging,
monitoring of treatment, and in long term surveillance of cancer patients. Until a few decades ago,
medical imaging was dominated by planar (projection view) X-ray radiography aimed at detecting
changes in tissue density that may result from disturbances in cell function, possibly due to cancer.
More recently, as a result of improvements in computer technology applied to imaging, digital
techniques were introduced into medical radiation imaging. Powerful diagnostic tomographic cross-
section view) modalities were made available to clinicians, namely X-ray computed tomography
(CT), magnetic resonance imaging (MRI) and nuclear medicine techniques such as single photon
emission computed tomography (SPECT) and positron emission tomography (PET) (see Fig. 1).
Diagnostic radiology techniques such as CT and conventional MRI depend on structural or
anatomical abnormalities to detect disease whereas nuclear medicine techniques, in particular PET,
and to some extent advanced MRI techniques, have the ability to detect cancer based on molecular
and biochemical processes within the tumour tissue.
The capacity of X-ray, CT and MRI to detect
millimetre-sized abnormalities is greater than that of nuclear medicine techniques, but the ability of
nuclear medicine to highlight functional abnormalities complements the resolution of CT and MRI.
Owing to the inherent resolution limitations of nuclear medicine, its imaging applications, initially
unique for many diseases, have either been fully substituted or much less employed for some years,
particularly those modalities aimed at investigating anatomic structure in cancer management.
Instead, new applications appeared to be specifically aimed at in vivo detection of abnormalities in
processes that cannot be effectively investigated in other ways. Among these, some examples are
SPECT imaging of myocardial perfusion (blood supply to the heart muscular tissue) during physical
or pharmacologic stress, receptor expression and density at the cellular level and antigen expression
in cancer cells.
PET, one of the most powerful diagnostic techniques that has appeared in the
last 10 years, which after the appearance of hybrid machines (PETCT scanners) gave this technique
a very important role to play in cancer management. It will not replace CT as first-line
 investigation, because of its cost and resolution limitation, but it appears to be very helpful in
situations where CT does not provide all the information required by clinical oncologists. These
could be: differentiating tumoural masses from benign lesions; identifying lymph nodes already
invaded by cancerous cells; differentiating residual tumour or local tumour relapses from scarring
and necrosis and detecting unsuspected distant metastases (Figure 4) that would affect patient
prognosis and treatment. The ability of PET, and other upcoming techniques, to investigate diseases
at the molecular level will produce a molecular imaging revolution which will lead to a much
greater ability to characterize diseases, diagnose them at a very early stage, treat them effectively,
and monitor the clinical outcome of such treatment.

Figure 4. Breast cancer suspected of recurrence. CT identifies a possible metastasis in the right
lung (yellow arrows) that does not show any FDG uptake in PET imaging. PET, on the other
hand, identifies an unknown metastasis on the contra-lateral side (red arrows).

The Role of Medical Radiation Imaging in Cancer

Management
Cure rate in cancer patients is strongly dependent on the stage of the disease at the time of its
diagnosis, and early detection remains a key issue. In medical imaging, early detection depends on
many factors, including spatial resolution, i.e. the ability to discriminate cancer lesions from normal
tissue when their volumes are still very small. A considerable range of spatial resolutions can be
achieved within the spectrum of medical imaging. They range from fractions of a millimetre in MRI
and CT to a few millimetres in PET and several millimetres in SPECT. Although the distinction is
somewhat arbitrary, medical radiation imaging techniques can be divided into anatomical
(structural) and functional. Imaging can be called anatomical to the extent that it reports on
acroscopic pathology, guides decisions based on disease stage, has tissue biopsy as its reference
standard, and provides information regarding surgical decisions. In contrast, functional imaging has
the ability to detect cancer based on molecular and biochemical processes within the tumour tissue,
in some cases prior to any tissue alterations becoming detectable using anatomical imaging.
 Structural Imaging -X-ray Computed Tomography (CT)

The most important imaging technique in detecting and diagnosing cancer remains X-ray CT, which
is based on the principle that when X-rays pass through the body they are absorbed or attenuated at
differing levels, according to the density and atomic number of the different tissues, creating a
matrix or profile of X-ray beams of different strength. This X-ray profile is registered on a detector,
thus creating an image. Radiographic film has been the main medical radiation imaging detector for
many years, and is now being replaced by digital X-ray detector types. In the case of CT ,the film is
replaced by a detector which measures the X-ray profile. Inside the CT scanner is a rotating frame
that has an X-ray tube mounted on one side and the detector mounted on the opposite side. A fan
beam of X-rays is created as the rotating frame spins the X-ray tube and detector around the patient.
Each time the X-ray tube and detector make one complete rotation, an image or slice is acquired.
This slice is collimated (focused) to a thickness that ranges from less than 1 mm to 10 mm using
special diaphragms in front of the X-ray tube and X-ray detector. As the X-ray tube and detector
make this rotation, the detector takes numerous snapshots (called profiles) of the attenuated X-ray
beam. Typically, in one lap, about 1000 profiles are sampled. Each profile is then backwards
reconstructed (or back-projected) by a dedicated computer into a two-dimensional image of the
slice that was scanned. Since its development in the early 1970s, CT has become the standard for
the evaluation of patients with malignancies because of its excellent definition of anatomical details.
The slip ring technology and faster computer systems have laid the foundations for helical data
acquisition, allowing fast volumetric scanning and multiphase enhancement techniques. State-of-
the-art multi-slice helical CT permits fast acquisition of volumetric and CT angiographic images,
and spiral CT scanners can now image entire anatomic regions, such as the lungs, in 20 to 30
seconds. Instead of acquiring a stack of individual slices that may be misaligned due to slight
patient motion or breathing (and lung/abdomen motion) between each slice acquisition, spiral CT
acquires a volume of data with the patient anatomy all in one position. This volume data set can
then be computer-reconstructed to provide three- dimensional pictures of complex structures. The
resulting 3D CT images allow medical physicists and radiation oncologists to visualize tumour
masses in three dimensions, which help them plan the treatment. Recently, to overcome problems
imposed by respiratory movements, respiration correlated, or 4-dimensional CT (4dCT) has been
introduced. As regards CT scanning, this represents a breakthrough in imaging, because 4dCT
generates both spatial and temporal information on organ mobility. In this technique, the respiratory
waveform is synchronously recorded with CT acquisition, and multiple CT slices are acquired at
each table position for at least the duration of one full respiratory cycle. This yields CT datasets for
up to 20 phases of the respiratory cycle. Multi-slice CT scanners equipped with respiratory gating
hardware, and 4-dimensional imaging software are now commercially available. Preliminary studies
indicate that a single 4dCT scan is sufficient to replace the use of 6 rapid CT scans for generating
the internal tumour volume of mobile peripheral lung tumours.

Figure 5. Lung CT examination showing a solitary nodule in the right lung.

Functional Imaging
Anatomical imaging modalities such as CT and conventional MRI rely on structural changes or
anatomical abnormalities to detect cancer. In some instances, however, this is not sufficient and
false negative results may be found. A typical example is lymph node involvement in metastatic
disease. In these cases, nodal invasion by cancer cells may be suspected when CT or MRI is used,
only when nodes are found to be enlarged and therefore stand out as being abnormal. However, this
is not always the case, as cancer dissemination can be found even in normal sized lymph nodes. In
contrast, functional imaging techniques have the ability to detect cancerous involvement based on
molecular and biochemical processes within the tumour tissue. It includes visualizing variations in
the tissue levels of specific bio-molecules and their turnover, and this information is directly linked
to the tissues biochemistry. In recent years, the major advances in imaging and the combination of
molecular biology and the imaging sciences have merged into a new research field named
molecular imaging. It includes all imaging modalities used in cancer imaging, and new
applications continue being developed. Technologies which are being used include PET, SPECT,
MR spectroscopy, functional MRI, dynamic MRI, dynamic CT, etc. Although this review has its
focus on nuclear imaging techniques, the role played by magnetic resonance in the field of
molecular imaging cannot be disregarded. Recent advances in dynamic MR imaging (diffusion-
weighted imaging, perfusion imaging), and spectroscopic imaging all have in common the ability to
provide quantitative cellular, haemodynamic (blood dynamic) and metabolic information that may
enhance understanding of tumour biology, improve the assessment of treatment response, more
accurately determine tumour activity more accurately during therapy, and differentiate between
recurrent tumours and treatment-related complications. The two most widely used MR spectroscopy
techniques involve acquiring resonance signals from hydrogen-1 nuclei in molecules other than
water, or phosphorus-31 containing molecules. Functional MRI makes it possible to analyse the
response of the brain to different external stimuli, and thereby to study normal brain function and
different brain diseases. Nuclear medicine functional imaging techniques such as gamma camera
imaging, SPECT, and PET, have the ability to detect cancerous involvement based on molecular
and biochemical processes within the tumour tissue. SPECT and PET procedures involve the
injection of an appropriate radionuclide usually bound to a biologically active ligand (an
extracellular substance that binds to receptors). Imaging is performed after a suitable time for the
ligand to be incorporated into the target organ(s).
Lung Cancer
Until the advent of PET, a consistent percentage of patients undergoing surgery for non-smallcell
lung cancers (NSCLC) experienced a tumour relapse due to the presence of metastases undetectable
by available staging modalities (CT; US; mediastinoscopy). This was the first proven clinical
application of FDG-PET and it was found to be significantly more accurate than structural imaging
methods such as CT scanning for determining whether pulmonary nodules are benign or malignant,
and for investigating tumour dissemination (staging). High levels of uptake of 18F-2-deoxy-2-
fluoro-D-glucose (FDG) are very accurate in characterizing pulmonary mass lesions that are either
unsuitable for, or that have failed, histopathological (microscopic study of diseased tissue)
characterization. PET has also been shown to be more accurate than CT for staging mediastinum
(central compartment of the thoracic cavity) involvement. The best non-invasive results have been
obtained by correlating the results of both PET and CT images. They conclusively prove that when
PET is used in addition to CT to evaluate intrathoracic lymph nodes for malignancy, the accuracy of
the assessment is significantly greater than for CT alone. In addition, PET can detect unsuspected
distant metastasis in patients with potentially-resectable stage I-II disease.
Lymphoma
The incidence of non-Hodgkins lymphoma (NHL) has been increasing approximately 3%-4% per
year for the last three decades. Hodgkins disease is much less common than NHL. Both Hodgkins
disease and NHL are amenable to curative therapy and many of the affected patients are young with
otherwise good life expectancies. FDG PET imaging can play a significant role in the staging and
management of patients with lymphoma. Treatment for NHL is dependent on several factors,
including tumour grade, and for this purpose it is broadly grouped into low-, intermediate-, and
high-grade disease subgroups. There is a direct correlation between the degree of FDG uptake and
the histological grade of lymphoma. High-grade tumours demonstrate greater metabolic activity
(and greater FDG accumulation) than low grade tumours. For Hodgkin's disease, the stage at
presentation and tumour cell type determine the patients overall prognosis and optimal method for
treatment. Since the anatomical extent of disease is the single most important factor influencing the
relapse-free duration and overall survival in patients with Hodgkins disease, accurate staging prior
to the initiation of therapy is essential for proper patient management. The optimal staging method
for lymphoma should be able to identify all sites of disease non-invasively. Conventional imaging
with CT or MR has been the primary means to evaluate and stage patients with lymphoma. These
modalities can reveal anatomical abnormalities suggestive of tumour involvement. Conventional
imaging is primarily dependent on lymph node size for the determination of tumour involvement.
Generally, lymph nodes greater than 1 cm in size are considered suggestive of tumour involvement
(depending on anatomical location). Unfortunately, normal-sized lymph nodes can harbour
malignancy and enlarged nodes may be reactive. Furthermore, infiltrative involvement of the liver,
spleen, and bone marrow cannot be accurately detected by conventional imaging modalities. As a
result of these limitations, up to 36% of lesions seen on PET images may not be visible on CT or
MRI examinations and, overall, FDG PET examinations are more sensitive in the evaluation of
lymphoma patients.
Breast Cancer
Routine evaluation for recurrent or residual disease after breast cancer treatment includes physical
examination and imaging tests such as mammography, CT, MRI, sonography, and radionuclide
whole-body imaging. These tests are frequently performed as routine clinical follow-up or are
prompted by rising levels of tumour markers or, in some cases, by patient symptoms. Some
metastatic sites such as lymph nodes or bone marrow are not easily depicted by conventional
imaging modalities, resulting in delayed diagnosis and therapeutic interventions. Several authors
have provided evidence that PET is more sensitive for establishing the extent of metastatic breast
cancer involvement. A prospective survey showed PET to have a considerable impact on staging
and managing breast cancer patients. The use of PET altered the clinical stage in 36% of patients
and the clinical management in 60%. The results are in keeping with a previous report suggesting
that FDG PET added information on the extent of disease in 29% of patients studied, mainly
through detection of additional lymph node involvement. Importantly, PET can uncover unknown
lymph node metastases and unknown distant metastases in 20% of the entire population studied. It
is noteworthy that there was a consistent fraction of patients whose stage was not altered by PET
but whose treatment nevertheless was managed differently after PET. This suggests that PET
provided the referring physicians with additional pertinent staging information. For instance, in
patients with stage disease, additional nodal or distant metastatic disease detected by PET may not
result in a stage change but may result in different management plans.
Head-and-Neck Cancer
Clinical studies have demonstrated that FDG-PET scans provide additional information for the pre-
treatment detection of lymph node metastases, localization of unknown primary tumours in patients
with cervical lymph node metastases, and for the detection of tumour recurrence after radiotherapy.
FDG-PET proved to be more sensitive (78100% probability of a positive test among patients with
disease) than CT-MRI (5785%) in detecting primary tumours in the head and neck area. Some
false negative PET results were observed in micro-metastatic disease, while false positive findings
occurred in inflammatory lymph nodes. In addition, anatomical structures like tonsils and salivary
glands can take up considerable amounts of FDG leading to false positive results. Thus, sensitivity
and specificity (probability of a negative test among patients without disease) of FDG-PET in
lymph node staging is higher than for MRI or CT. However, FDG-PET cannot replace invasive
diagnostic procedures.
Cervical Cancer
PET scanning is increasingly used in the initial evaluation of patients with invasive cervical cancer
using FDG. Abnormal uptake can be anticipated in 91% of the primary tumours. Compared with
surgical staging, PET scanning has a sensitivity of 72% and a specificity of 92% in detecting para-
aortic metastasis. FDG-PET is useful in re-evaluating women with cervical cancer after therapy.
Whole-body FDG-PET is a sensitive and specific tool for the detection of recurrent cervical cancer
in patients who have clinical findings implying the presence of a recurrence. A larger prospective
trial would be needed to determine whether this modality should be used routinely in conjunction
with, or in lieu of, other imaging studies to detect recurrent disease in a broader population of
cervical cancer patients. However the impact of routine PET scanning in patient treatment and in
terms of tumour control and survival remains to be established. The cost-benefit of routine PET
scanning in cervical cancer patients is a matter that will require future research as well.
Prostate Cancer
This is an area where the ability of PET to utilize different biological substrates to investigate
cancer proves of great value. Indeed, although FDG imaging proved very effective in investigating
almost all types of cancer, diagnosis of primary prostate cancer is hampered by the low glucose
metabolic rates and low FDG tumour uptake. In addition, a significant number of metastatic lesions
from prostate cancer will also not accumulate FDG (probably due to a low glucose metabolic rate).
11C-choline is a PET tracer that can be used for prostate cancer imaging, since choline is one of the
essential elements of phospholipids in cell membranes. Malignant tumours show a high cell
proliferation rate and increased metabolism of cell membrane components, which will lead to an
increased uptake of choline. Another benefit of PET imaging is that it can identify lymph node
metastases that are outside the field of modified lymphadenectomy surgery. 18F-fluorocholine has
been developed in order to overcome difficulties associated with the short half-life of carbon-11
labelled compounds. The sensitivity, specificity and accuracy of 11C-choline-PET in the diagnosis
of lymph node metastasis of prostate cancer are superior to traditional radiological imaging using
CT and MRI.
Brain Tumours
In general, FDG PET is of little value in primary brain neoplasms (abnormal, disorganized growth
in tissue) because of the great glucose uptake in normal brain tissue. There are, however, some
fields where PET proved helpful such as assessing tumour extension and in detecting some
malignant transformations. The general approach to treatment of brain neoplasms is surgical
resection of solitary lesions or limited disease, followed by radiation therapy (with or without
chemotherapy). Solitary lesions may alternatively be treated with local field radiotherapy or
stereotactic radiosurgery, while multiple or metastatic lesions receive whole-brain radiation.
Anatomical alterations and scarring after therapy can impair proper identification of residual or
recurrent neoplasms in conventional imaging studies. PET studies with FDG have shown that
recurrent tumour exhibits hyper-metabolism of glucose, while non-necrotic irradiated brain shows
hypo-metabolism, and necrotic brain has no detectable metabolic activity.

Post-treatment Evaluation

The objective evaluation of the response to treatment (either chemo- or radiation therapy or both)
remains an elusive goal in clinical oncology. Conventional imaging with CT and MRI does not
always provide sufficient evidence of therapeutic results since volumetric changes, on which these
techniques rely, take place later on during therapy, or because tumour mass can be replaced with
fibrotic tissue with no significant volume reduction. These modalities are not sufficient to
discriminate between residual malignant and still-viable cancer tissue. Also, fibrotic/necrotic tissue
that often results from radiotherapy may not be distinguishable from cancer itself. This ability to
discriminate viable from non-viable tissue was extensively evaluated in lymphomas (both
Hodgkins disease and non-Hodgkins lymphomas) where PET is a strong predictor of progression-
free and overall survival. This proved to be particularly useful in selecting patients for resective
surgery which is associated with considerable morbidity. It was also found that PET is useful for
early treatment evaluation, following the completion of a few chemotherapy cycles whose
metabolic effects are detected before tumour shrinkage could be detected by CT. Early detection of
subclinical response could be used to adapt specific treatment options for individual patients.
 Risks associated with use of X-rays

Diagnostic X-rays (primarily from CT scans due to the large dose used) increase the risk of
developmental problems and cancer in those exposed. X-rays are classified as a carcinogen by both
the World Health Organization's International Agency for Research on Cancer and the U.S.
government.It is estimated that 0.4% of current cancers in the United States are due to computed
tomography (CT scans) performed in the past and that this may increase to as high as 1.5-2% with
2007 rates of CT usage.

Experimental and epidemiological data currently do not support the proposition that there is
a threshold dose of radiation below which there is no increased risk of cancer.[33] However, this is
under increasing doubt. It is estimated that the additional radiation will increase a person's
cumulative risk of getting cancer by age 75 by 0.61.8%. The amount of absorbed radiation
depends upon the type of X-ray test and the body part involved. CT and fluoroscopy entail higher
doses of radiation than do plain X-rays.

To place the increased risk in perspective, a plain chest X-ray will expose a person to the same
amount from background radiation that people are exposed to (depending upon location) every day
over 10 days, while exposure from a dental X-ray is approximately equivalent to 1 day of
environmental background radiation. Each such X-ray would add less than 1 per 1,000,000 to the
lifetime cancer risk. An abdominal or chest CT would be the equivalent to 23 years of background
radiation to the whole body, or 45 years to the abdomen or chest, increasing the lifetime cancer
risk between 1 per 1,000 to 1 per 10,000. This is compared to the roughly 40% chance of a US
citizen developing cancer during their lifetime. For instance, the effective dose to the torso from a
CT scan of the chest is about 5 mSv, and the absorbed dose is about 14 mGy. A head CT scan
(1.5mSv, 64mGy) that is performed once with and once without contrast agent, would be equivalent
to 40 years of background radiation to the head. Accurate estimation of effective doses due to CT is
difficult with the estimation uncertainty range of about 19% to 32% for adult head scans
depending upon the method used.

The risk of radiation is greater to a fetus, so in pregnant patients, the benefits of the investigation
(X-ray) should be balanced with the potential hazards to the fetus. In the US, there are an estimated
62 million CT scans performed annually, including more than 4 million on children.[36] Avoiding
unnecessary X-rays (especially CT scans) reduces radiation dose and any associated cancer risk.[44]

Medical X-rays are a significant source of man-made radiation exposure. In 1987, they accounted
for 58% of exposure from man-made sources in the United States. Since man-made sources
accounted for only 18% of the total radiation exposure, most of which came from natural sources
(82%), medical X-rays only accounted for 10% of total American radiation exposure; medical
procedures as a whole (including nuclear medicine) accounted for 14% of total radiation exposure.
By 2006, however, medical procedures in the United States were contributing much more ionizing
radiation than was the case in the early 1980s. In 2006, medical exposure constituted nearly half of
the total radiation exposure of the U.S. population from all sources. The increase is traceable to the
growth in the use of medical imaging procedures, in particular computed tomography (CT), and to
the growth in the use of nuclear medicine.

Dosage due to dental X-rays varies significantly depending on the procedure and the technology
(film or digital). Depending on the procedure and the technology, a single dental X-ray of a human
results in an exposure of 0.5 to 4 mrem. A full mouth series may therefore result in an exposure of
up to 6 (digital) to 18 (film) mrem, for a yearly average of up to 40 mrem

(Abdominal radiograph of a pregnant woman, a

procedure that should be performed only after proper
assessment of benefit versus risk)

Deformity of hand due to an X-ray burn. These burns

are accidents. X-rays were not shielded when they
were first discovered and used, and people received
radiation burns.
 No matter how important x-rays are medically, they have their side effects like any other form of
radiation. We often see people getting x-rays done for injuries like a simple twist of the ankle or
something similar. But what makes this risky is that they take these steps without consulting a
physician first and, even worse, without being aware of its adverse effects. According to Ener-Chi
Wellness Centre, people experience at least one exposure to these high-frequency waves when they
visit the doctor, and unless it is an absolute emergency, getting an x-ray done must be avoided as far
as possible.
Some of its harmful effects:

Due to their relatively smaller physical size, children are more sensitive to the radiation as it could
badly affect their genitals. Parents accompanying their children during x-ray check-ups should wear
x-ray prevention clothes as a precaution.
Exposure to radiation as a foetus ups the chances of cancer by 40%, of developing tumour(s) by
50% and of leukaemia by 70%.
Thyroid glands, which are the primary glands of metabolism and energy, are also known victims of
x-rays. They are particularly sensitive to radiation because of which, excessive exposure to
radiation can lead to various thyroid conditions. Asking for a thyroid collar when getting into the
head, neck or collarbone area x-rayed could be a preventive measure.
Reports say that when exposed to x-rays, especially in the lower abdominal region, a person is at
the risk of developing genetic damage that could turn hereditary. They also link diseases like
diabetes, high BP, coronary heart disease, strokes and cataracts with exposure to x-rays.
A possible way of bringing down exposure to these harmful radiations is replacing old x-ray
machines that have passed their prime with new ones, as the radiation emitted by old x-ray
equipment are at least 20-30 times higher. An easier way to prevent such exposure would be not
playing doctor and avoiding getting unnecessary x-rays done.