Radiation dose and cataract surgery incidence in atomic bomb survivors, 1986-2005

Radiation dose response estimation with emphasis on low dose range using restricted cubic splines: application to all solid cancer mortality data, 1950-2003, in atomic bomb survivors

Using the all solid cancer mortality data set of the Life Span Study (LSS) cohort from 1950 to 2003 (LSS Report 14) data among atomic bomb survivors, excess relative risk (ERR) statistical analyses were performed using the second degree polynomial and the threshold and restricted cubic spline (RCS) dose response models. For the RCS models with 3 to 7 knots of equally spaced percentiles with margins in the dose range greater than 50 mGy, the dose response was assumed to be linear at less than 70 to 90 mGy. Due to the skewed dose distribution of atomic bomb survivors, the current knot system for the RCS analysis results in a detailed depiction of the dose response as less than approximately 0.5 Gy. The 6 knot RCS models for the all-solid cancer mortality dose response of the whole dose or less than 2 Gy were selected with the AIC model selection criterion and fit significantly better (p < 0.05) than the linear (L) model. The usual RCS includes the L-global model but not the quadratic (Q) nor linear-quadratic (LQ) global models. The authors extended the RCS to include L or LQ global models by putting L or LQ constraints on the cubic spline in the lower and upper tails, and the best RCS model selected with AIC criterion was the usual RCS with L-constraints in both the lower and upper tails. The selected RCS had a linear dose-response model in the lower dose range (i.e., < 0.2-0.3 Gy) and was compatible with the linear no-threshold (LNT) model in this dose range. The proposed method is also useful in describing the dose response of a specific cancer or non-cancer disease incidence/mortality.

Current discussions of DDREF, cataracts, circulatory diseases and dose limits

Although more than a century of radiation research has provided a lot of insight into radiation risk, there are still fields that need clarification. This is particularly true for the low dose range, meaning doses up to ∼100 mSv. One can detect biological effects in that dose range, but it is unclear whether these biological effects like mutations or chromosomal aberrations translate into health effects like cancer, cataracts or circulatory diseases. Thus, for radiation protection purposes, assumptions have to made that must be reappraised on the basis of new findings from time to time. Affected by new insights are currently the DDREF (dose and dose-rate effectiveness factor), cataracts and circulatory diseases. If the new findings are very convincing, dose limits have to be changed at short notice. If there are only weak indications, stability of the radiation protection system is more important than changing limits all the time.

[Radiation dose evaluation in 3D rotation angiography and cone-beam computed tomography with a flat panel detector]

The aim of this study was to evaluate radiation dose in patients undergoing three-dimensional rotation angiography (3DRA) and cone-beam computed tomography (CBCT) using a flat panel detector (FPD). Radiation doses were measured for angiography equipment using small silicon-photodiode dosimeters that were implanted in various positions in tissues and organs within an anthropomorphic phantom of a standard Japanese adult male. Output signals from the dosimeters were read out on a computer, from which organ and effective doses were calculated according to guidelines published in International Commission on Radiological Protection Publication 103. Lens doses and effective doses obtained in this study were 1.6 mGy and 0.13 mSv for 3DRA, 20 mGy and 1.7 mSv for CBCT (normal mode). 3DRA provided substantial lens doses and effective dose reduction, which were 8% of the doses in CBCT (normal mode).

Ionizing irradiation not only inactivates clonogenic potential in primary normal human diploid lens epithelial cells but also stimulates cell proliferation in a subset of this population

Over the past century, ionizing radiation has been known to induce cataracts in the crystalline lens of the eye, but its mechanistic underpinnings remain incompletely understood. This study is the first to report the clonogenic survival of irradiated primary normal human lens epithelial cells and stimulation of its proliferation. Here we used two primary normal human cell strains: HLEC1 lens epithelial cells and WI-38 lung fibroblasts. Both strains were diploid, and a replicative lifespan was shorter in HLEC1 cells. The colony formation assay demonstrated that the clonogenic survival of both strains decreases similarly with increasing doses of X-rays. A difference in the survival between two strains was actually insignificant, although HLEC1 cells had the lower plating efficiency. This indicates that the same dose inactivates the same fraction of clonogenic cells in both strains. Intriguingly, irradiation enlarged the size of clonogenic colonies arising from HLEC1 cells in marked contrast to those from WI-38 cells. Such enhanced proliferation of clonogenic HLEC1 cells was significant at ≥2 Gy, and manifested as increments of ≤2.6 population doublings besides sham-irradiated controls. These results suggest that irradiation of HLEC1 cells not only inactivates clonogenic potential but also stimulates proliferation of surviving uniactivated clonogenic cells. Given that the lens is a closed system, the stimulated proliferation of lens epithelial cells may not be a homeostatic mechanism to compensate for their cell loss, but rather should be regarded as abnormal. This is because these findings are consistent with the early in vivo evidence documenting that irradiation induces excessive proliferation of rabbit lens epithelial cells and that suppression of lens epithelial cell divisions inhibits radiation cataractogenesis in frogs and rats. Thus, our in vitro model will be useful to evaluate the excessive proliferation of primary normal human lens epithelial cells that may underlie radiation cataractogenesis, warranting further investigations.

Impact on the Japanese atomic bomb survivors of radiation received from the bombs

The Radiation Effects Research Foundation (RERF) studies various cohorts of Japanese atomic bomb survivors, the largest being the Life Span Study (LSS), which includes 93,741 persons who were in Hiroshima or Nagasaki at the times of the bombings; there are also cohorts of persons who were exposed in utero and survivors' children. This presentation attempts to summarize the total impact of the radiation from the bombs on the survivors from both an individual perspective (both age-specific and integrated lifetime risk, along with a measure of life expectancy that describes how the risk affects the individual given age at exposure) and a group perspective (estimated numbers of excess occurrences in the cohort), including both early and late effects. As survivors' doses ranged well into the acutely lethal range at closer distances, some of them experienced acute signs and symptoms of radiation exposure in addition to being at risk of late effects. Although cancer has always been a primary concern among late effects, estimated numbers of excess cancers and hematopoietic malignancies in the LSS are a small fraction of the total due to the highly skewed dose distribution, with most survivors receiving small doses. For example, in the latest report on cancer incidence, 853 of 17,448 incident solid cancers were estimated to be attributable to radiation from the bombs. RERF research indicates that risk of radiation-associated cancer varies among sites and that some benign tumors such as uterine myoma are also associated with radiation. Noncancer late effects appear to be in excess in proportion to radiation dose but with an excess relative risk about one-third that of solid cancer and a correspondingly small overall fraction of cases attributable to radiation. Specific risks were found for some subcategories, particularly circulatory disease, including stroke and precedent conditions such as hypertension. Radiation-related cataract in the atomic bomb survivors is well known, with evidence in recent years of risk at lower dose levels than previously appreciated. In addition to somatic effects, survivors experienced psychosocial effects such as uncertainty, social stigma, or rejection, and other social pressures. Developmental deficits associated with in utero exposure, notably cognitive impairment, have also been described. Interaction of radiation with other risk factors has been demonstrated in relation to both cancer and noncancer diseases. Current research interests include whether radiation increases risk of diabetes or conditions of the eye apart from cataract, and there continues to be keen interest as to whether there are heritable effects in survivors' children, despite negative findings to date. Introduction of Impact on the Japanese Atomic- Bomb Survivors (Video 1:52, http://links.lww.com/HP/A29).

Radiation impacts on human health: certain, fuzzy, and unknown

The atomic bomb and other studies have established with certainty that moderate-to-high doses of radiation cause many types of solid cancer and leukemia. Moving down the dose range to the vicinity of 100-200 mSv, the risks become fuzzy and then unknown at low doses on the order of 10-20 mSv. Nor have low-dose experimental studies provided definitive answers: some have suggested there may be adverse biological effects in the range of 5-50 mSv, while others support a "no risk" interpretation. Epidemiologic data contain intrinsic "noise" (variation by known and unknown factors related to genetics, lifestyle, other environmental exposures, sociodemographics, diagnostic accuracy, etc.) so are generally too insensitive to provide compelling answers in the low-dose range. However, there have been recent provocative reports regarding risk from relatively low-dose occupational and medical radiation exposures that warrant careful consideration. Summaries of the largest studies with low-dose or low dose-rate radiation exposure provide suggestive evidence of risk for solid cancer and stronger evidence for leukemia risk. Recently, interest in health endpoints other than cancer also has risen sharply, in particular the degree of cardiovascular and cataract risk following doses under 1 Sv. Data regarding cardiovascular disease are limited and fuzzy, with suggestions of inconsistencies, and the risk at low doses is essentially unknown. The evidence of cataract risk after low dose-rate exposures among those conducting interventional medical radiological procedures is becoming strong. The magnitude of radiation impacts on human health requires fuller documentation, especially for low-dose or low dose-rate exposures. From the epidemiologic vantage point, this will require longer observation of existing irradiated cohorts and development of new informative cohorts, improved accuracy in dose assessments, more attention to confounding variables, and more biosamples from irradiated groups to enable translational radiobiological studies. Introduction of Radiation Impacts on Human Health (Video 2:02, http://links.lww.com/HP/A35).

Ninth Annual Warren K. Sinclair Keynote Address: effects of childhood radiation exposure: an issue from computed tomography scans to Fukushima

The acute and chronic effects of radiation on children have been and will continue to be of great social, public health, scientific, and clinical importance. The focus of interest on ionizing radiation and children has been clear for over half a century and ranges from the effects of fallout from nuclear weapons testing to exposures from accidents, natural radiation, and medical procedures. There is a loosely stated notion that "children are three to five times more sensitive to radiation than adults." Is this really true? In fact, children are at greater risk for some health effects, but not all. For a few sequelae, children may be more resistant than adults. Which are those effects? How and why do they occur? While there are clear instances of increased risk of some radiation-induced tumors in children compared to adults, there are other tumor types in which there appears to be little or no difference in risk by age at exposure and some in which published models that assume the same relative increase in risks for child compared to adult exposures apply to nearly all tumor types are not supported by the scientific data. The United Nations Scientific Committee on Effects of Atomic Radiation (UNSCEAR) has a task group producing a comprehensive report on the subject. The factors to be considered include relevant radiation sources; developmental anatomy and physiology; dosimetry; and stochastic, deterministic, and hereditary effects.

A review of non-cancer effects, especially circulatory and ocular diseases

There is a well-established association between high doses (>5 Gy) of ionizing radiation exposure and damage to the heart and coronary arteries, although only recently have studies with high-quality individual dosimetry been conducted that would enable quantification of this risk adjusting for concomitant chemotherapy. The association between lower dose exposures and late occurring circulatory disease has only recently begun to emerge in the Japanese atomic bomb survivors and in various occupationally exposed cohorts and is still controversial. Excess relative risks per unit dose in moderate- and low-dose epidemiological studies are somewhat variable, possibly a result of confounding and effect modification by well-known (but unobserved) risk factors. Radiation doses of 1 Gy or more are associated with increased risk of posterior subcapsular cataract. Accumulating evidence from the Japanese atomic bomb survivors, Chernobyl liquidators, US astronauts, and various other exposed groups suggests that cortical cataracts may also be associated with ionizing radiation, although there is little evidence that nuclear cataracts are radiogenic. The dose-response appears to be linear, although modest thresholds (of no more than about 0.6 Gy) cannot be ruled out. A variety of other non-malignant effects have been observed after moderate/low-dose exposure in various groups, in particular respiratory and digestive disease and central nervous system (and in particular neuro-cognitive) damage. However, because these are generally only observed in isolated groups, or because the evidence is excessively heterogeneous, these associations must be treated with caution.

Estimation of radiation exposure for brain perfusion CT: standard protocol compared with deviations in protocol

OBJECTIVE

The purpose of this study was to measure the organ doses and estimate the effective dose for the standard brain perfusion CT protocol and erroneous protocols.

MATERIALS AND METHODS

An anthropomorphic phantom with metal oxide semiconductor field effect transistor (MOSFET) detectors was scanned on a 64-MDCT scanner. Protocol 1 used a standard brain perfusion protocol with 80 kVp and fixed tube current of 200 mA. Protocol 2 used 120 kVp and fixed tube current of 200 mA. Protocol 3 used 120 kVp with automatic tube current modulation (noise index, 2.4; minimum, 100 mA; maximum, 520 mA).

RESULTS

Compared with protocol 1, the effective dose was 2.8 times higher with protocol 2 and 7.8 times higher with protocol 3. For all protocols, the peak dose was highest in the skin, followed by the brain and calvarial marrow. Compared with protocol 1, the peak skin dose was 2.6 times higher with protocol 2 and 6.7 times higher with protocol 3. The peak skin dose for protocol 3 exceeded 3 Gy. The ocular lens received significant scatter radiation: 177 mGy for protocol 2 and 435 mGy for protocol 3, which were 4.6 and 11.3 times the dose for protocol 1, respectively.

CONCLUSION

Compared with the standard protocol, erroneous protocols of increasing the tube potential from 80 kVp to 120 kVp will lead to a three- to fivefold increase in organ doses, and concurrent use of high peak kilovoltage with incorrectly programmed tube current modulation can increase dose to organs by 7- to 11-fold. Tube current modulation with a low noise index can lead to doses to the skin and ocular lens that are close to thresholds for tissue reactions.

Uncertainties in estimating health risks associated with exposure to ionising radiation

The information for the present discussion on the uncertainties associated with estimation of radiation risks and probability of disease causation was assembled for the recently published NCRP Report No. 171 on this topic. This memorandum provides a timely overview of the topic, given that quantitative uncertainty analysis is the state of the art in health risk assessment and given its potential importance to developments in radiation protection. Over the past decade the increasing volume of epidemiology data and the supporting radiobiology findings have aided in the reduction of uncertainty in the risk estimates derived. However, it is equally apparent that there remain significant uncertainties related to dose assessment, low dose and low dose-rate extrapolation approaches (e.g. the selection of an appropriate dose and dose-rate effectiveness factor), the biological effectiveness where considerations of the health effects of high-LET and lower-energy low-LET radiations are required and the transfer of risks from a population for which health effects data are available to one for which such data are not available. The impact of radiation on human health has focused in recent years on cancer, although there has been a decided increase in the data for noncancer effects together with more reliable estimates of the risk following radiation exposure, even at relatively low doses (notably for cataracts and cardiovascular disease). New approaches for the estimation of hereditary risk have been developed with the use of human data whenever feasible, although the current estimates of heritable radiation effects still are based on mouse data because of an absence of effects in human studies. Uncertainties associated with estimation of these different types of health effects are discussed in a qualitative and semi-quantitative manner as appropriate. The way forward would seem to require additional epidemiological studies, especially studies of low dose and low dose-rate occupational and perhaps environmental exposures and for exposures to x rays and high-LET radiations used in medicine. The development of models for more reliably combining the epidemiology data with experimental laboratory animal and cellular data can enhance the overall risk assessment approach by providing biologically refined data to strengthen the estimation of effects at low doses as opposed to the sole use of mathematical models of epidemiological data that are primarily driven by medium/high doses. NASA's approach to radiation protection for astronauts, although a unique occupational group, indicates the possible applicability of estimates of risk and their uncertainty in a broader context for developing recommendations on: (1) dose limits for occupational exposure and exposure of members of the public; (2) criteria to limit exposures of workers and members of the public to radon and its short-lived decay products; and (3) the dosimetric quantity (effective dose) used in radiation protection.

Radiation Dose Responses, Thresholds, and False Negative Rates in a Series of Cataract Surgery Prevalence Studies among Atomic Bomb Survivors

In order to find imperfect sensitivity or the false-negative rate of cataract surgery due to latent clinically significant or severe cataract and a dose-response threshold, cataract surgery prevalence data analysis was made for each of the two-year periods from 1986 through 2005 among atomic bomb survivors. Using the latent variable regression model published earlier, cataract prevalence studies allowing for false-negative and/or false-positive rates were conducted in each of the 10 two-year periods during 1986 to 2005. As the best statistical model for prevalence data, a logistic model with a non-negligible false negative rate was selected for analysis. The commonly used naïve logistic analysis resulted in an average odds ratio (OR) at 1 Gy of 1.33 (95%CI: 1.28, 1.38) for cataract surgery with no linear time trend (p = 0.334), and the OR at 1 Gy with the model allowing for sensitivity was 1.48 (95%CI: 1.40, 1.56) for clinically significant or severe cataract with no linear time trend (p = 0.263). Cataract surgery is an imperfect surrogate for clinically significant cataract, and the sensitivity increased from 0.15 to 0.50 during the 20 y with increasing rate of sensitivity per 2-y period of approximately 22%. The dose-response threshold based on a naïve logistic model for cataract surgery ranged from 0.04-1.03 Gy (simple average of 0.41 Gy) with no linear time trend (p = 0.620) in the 10 2-y periods compatible with the no dose response threshold model in all periods.

Radiation-induced noncancer risks in interventional cardiology: optimisation of procedures and staff and patient dose reduction

Concerns about ionizing radiation during interventional cardiology have been increased in recent years as a result of rapid growth in interventional procedure volumes and the high radiation doses associated with some procedures. Noncancer radiation risks to cardiologists and medical staff in terms of radiation-induced cataracts and skin injuries for patients appear clear potential consequences of interventional cardiology procedures, while radiation-induced potential risk of developing cardiovascular effects remains less clear. This paper provides an overview of the evidence-based reviews of concerns about noncancer risks of radiation exposure in interventional cardiology. Strategies commonly undertaken to reduce radiation doses to both medical staff and patients during interventional cardiology procedures are discussed; optimisation of interventional cardiology procedures is highlighted.

Reduced radiation exposure for face transplant surgical planning computed tomography angiography

Objective

To test the hypothesis that wide area detector face transplant surgical planning CT angiograms with simulated lower radiation dose and iterative reconstruction (AIDR3D) are comparable in image quality to those with standard tube current and filtered back projection (FBP) reconstruction.

Materials and Methods

The sinograms from 320-detector row CT angiography of four clinical candidates for face transplantation were processed utilizing standard FBP, FBP with simulated 75, 62, and 50% tube current, and AIDR3D with corresponding dose reduction. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were measured at muscle, fat, artery, and vein. Image quality for each reconstruction strategy was assessed by two independent readers using a 4-point scale.

Results

Compared to FBP, the median SNR and CNR for AIDR3D images were higher at all sites for all 4 different tube currents. The AIDR3D with simulated 50% tube current achieved comparable SNR and CNR to FBP with standard dose (median muscle SNR: 5.77 vs. 6.23; fat SNR: 6.40 vs. 5.75; artery SNR: 43.8 vs. 45.0; vein SNR: 54.9 vs. 55.7; artery CNR: 38.1 vs. 38.6; vein CNR: 49.0 vs. 48.7; all p-values >0.19). The interobserver agreement in the image quality score was good (weighted κ = 0.7). The overall score and the scores for smaller arteries were significantly lower when FBP with 50% dose reduction was used. The AIDR3D reconstruction images with 4 different simulated doses achieved a mean score ranging from 3.68 to 3.82 that were comparable to the scores from images reconstructed using FBP with original dose (3.68–3.77).

Conclusions

Simulated radiation dose reduction applied to clinical CT angiography for face transplant planning suggests that AIDR3D allows for a 50% reduction in radiation dose, as compared to FBP, while preserving image quality.

Non-targeted effects of ionising radiation--implications for low dose risk

Non-DNA targeted effects of ionising radiation, which include genomic instability, and a variety of bystander effects including abscopal effects and bystander mediated adaptive response, have raised concerns about the magnitude of low-dose radiation risk. Genomic instability, bystander effects and adaptive responses are powered by fundamental, but not clearly understood systems that maintain tissue homeostasis. Despite excellent research in this field by various groups, there are still gaps in our understanding of the likely mechanisms associated with non-DNA targeted effects, particularly with respect to systemic (human health) consequences at low and intermediate doses of ionising radiation. Other outstanding questions include links between the different non-targeted responses and the variations in response observed between individuals and cell lines, possibly a function of genetic background. Furthermore, it is still not known what the initial target and early interactions in cells are that give rise to non-targeted responses in neighbouring or descendant cells. This paper provides a commentary on the current state of the field as a result of the non-targeted effects of ionising radiation (NOTE) Integrated Project funded by the European Union. Here we critically examine the evidence for non-targeted effects, discuss apparently contradictory results and consider implications for low-dose radiation health effects.