Administration of lower doses of radium-224 to ankylosing spondylitis patients results in no evidence of significant overall detriment

The use of low doses of radium-224 (224Ra) chloride for the treatment of ankylosing spondylitis was stopped following the discovery that patients treated with it had a higher than control incidence of leukaemia and other cancers. This was so even though the treatment resulted in decreased pain and increased mobility-both of which are associated with decreased mortality. It was decided to re-analyze the epidemiological data looking at all causes of death. The risk of leukaemia, solid cancer, death from non-cancer causes and from all causes in a study populations of men that received either the typical dose of 5.6 to 11.1 MBq of 224Ra, any dose of 224Ra or no radium were compared using the Cox proportional hazard model. For patients that received the typical dose of 224Ra agreed with the excess cancer was similar to that reported in previous studies. In contrast, these patients were less likely to die from non-cancer diseases and from all causes of death than the control patients. No excess mortality was also found in the population of all males that received the radionuclide. It is concluded that 224Ra treatment administered at low doses to patients with ankylosing spondylitis did not impact mortality from all causes. The study demonstrates the need to consider all causes of death and longevity when assessing health impacts following irradiation.

Incidence of leukaemia and other malignant diseases following injections of the short-lived alpha-emitter 224Ra into man

We performed an epidemiological study on 1,471 ankylosing spondylitis patients treated with repeated intravenous injections of the short lived alpha-emitter (224)Ra (excluding radiation therapy with X-rays) between 1948 and 1975. These patients have been followed together with a control group of 1,324 ankylosing spondylitis patients treated neither with radioactive drugs nor with X-rays. The mean follow-up time was 26.3 years in the exposed and 24.6 years in the control group. To date, causes of death have been ascertained for 1,006 exposed patients and 1,072 controls. Special emphasis was placed on the reporting of malignant diseases. Expected numbers of cases were computed for the age, sex and calendar year distribution of both groups using cancer registry incidence rates. In the exposed group 18 cases of kidney cancer (vs. 9.1 cases expected, P < 0.01) and 4 malignant thyroid tumours (vs. 1.2 cases expected, P = 0.03) were observed. In the control group the observed cases for these tumours were not significantly elevated. The most striking observation, however, were the 21 cases of leukaemia in the exposed group (vs. 6.8 cases expected, P < 0.001) compared to 12 cases of leukaemia in the control group (vs. 7.5 cases expected). Further sub-classification of the leukaemias demonstrated a high increase of myeloid leukaemia in the exposed group (12 cases observed vs. 2.9 cases expected, P < 0.001), and out of these, especially a high excess of acute myeloid leukaemias (7 cases observed vs. 1.8 expected, P = 0.003). In the controls the observed cases are within the expected range (4 myeloid leukaemias vs. 3.1 cases). This increase in total leukaemias as well as particularly in myeloid leukaemias is significant in direct comparison between the exposed and control groups too (P < 0.05). The enhanced leukaemia incidence in the exposed group is in line with the observation of increased leukaemia incidence in mice injected with (224)Ra.

Influence of the bystander phenomenon on the chromosome aberration pattern in human lymphocytes induced by in vitro alpha-particle exposure

A recent publication on both chromosome-type and chromatid-type aberrations in lymphocytes of patients during treatment with radium-224 for ankylosing spondilitis has revived the question of whether the chromatid-type aberrations may be the consequence of factors released by irradiated cells. Therefore, the aim of the present study was to investigate the influence of such a bystander phenomenon on the chromosome aberration pattern of lymphocytes. Monolayers of human lymphocytes were irradiated with 1 Gy of alpha-particles from an americium-241 source in the absence or presence of whole blood, autologous plasma or culture medium. In the presence of any liquid covering the monolayer during irradiation, the chromatid-type aberrations were, contrary to expectation, elevated. Whereas the intercellular distribution of dicentrics was significantly overdispersed, the chromatid-type aberrations showed a regular dispersion. It can be concluded that the enhanced frequency of chromatid aberrations is the result of a damage signal or a bystander phenomenon released by irradiated cells.

Leukaemia and aplastic anaemia in patients irradiated for ankylosing spondylitis. 1957

Reported here is a seminal study of leukaemia among patients who had been treated with x-rays for ankylosing spondylitis. The findings were first published in a Medical Research Council (MRC) report in 1957. The report is now published in a scientific journal for the first time, 50 years after it first appeared.

The 1957 MRC report on leukaemia and aplastic anaemia in patients irradiated for ankylosing spondylitis

The estimation of the carcinogenic effects of exposure to low doses of ionizing radiation has depended primarily on extrapolation from effects seen in two populations exposed to relatively high doses--the survivors of the atomic bomb explosions in Japan and patients treated in the UK with x-rays for the arthritic condition ankylosing spondylitis. The study of the leukaemia risk in over 14000 irradiated spondylitis patients was completed in an astonishingly short period of time in the mid-1950s. The full report of the original study has been difficult to access because it was not published in a journal but only as a Special Report of the UK Medical Research Council. To mark 50 years since this publication this full report is reproduced in this issue of the Journal. This accompanying review describes the background to the study, the principal findings and the further follow-up of the population that documented the risks of cancers in addition to leukaemia associated with the x-ray treatment. The architects of the study were a radiobiologist, Michael Court-Brown, and an epidemiologist, Richard Doll. Their very productive study of the leukaemia risk among spondylitics spawned a lifelong collaboration including further seminal studies of the carcinogenic effects of radiation exposure, which are also summarised in the review.

[Cost-benefit analysis of [224Ra] radium chloride therapy for ankylosing spondylitis (Bekhterev's disease)]

BACKGROUND AND PURPOSE

Cost-benefit analyses are helpful in setting priorities for funding health-care programs. The authors studied the cost/benefit of treatment with radium-224 compared to the treatment without radium-224 in patients with ankylosing spondylitis (AS).

MATERIAL AND METHODS

The data of a 2-year retrospective observational study were used to estimate cost/benefit of [224Ra] therapy. Twelve patients treated with [224Ra], complete recruit in AOK Saxony, matched (age, gender, employment status) with twelve patients receiving conservative treatment without [224Ra], were compared for lost productivity and direct medical costs, such as doctor visits, medication and hospitalization, 1 year before and after treatment.

RESULTS

1 year after the first i.v. injection of [224Ra], all cost factors in the case group were reduced compared to 1 year before treatment with [224Ra] (hospitalization 29.4%, doctor visits 23.5%, medication 9.4%, and lost productivity even 82.3%). The total costs decreased by an average of 3,870 Euros. Because of the small sample the differences showed a trend but were not significant.

CONCLUSION

The use of [224Ra] in patients with AS seems to reduce lost productivity and direct medical costs, but additional studies based on more patients and long-term data are needed.

[Effectiveness and safety of radium chloride in the treatment of ankylosing spondylitis. Results of an observational study]

After radium chloride was approved for the therapy of ankylosing spondylitis (AS) in Germany on October 23, 2000, an open, non-comparative prospective observational study was planed. The assessment involved 308 patients with the diagnosis of AS and radiological evidence of spinal involvement who were treated with at least one injection of radium chloride. 278 of these patients received the full cycle of 10 injections (a total of 10 MBq radium-224) one injection one per week for a period of 10 successive weeks. Validated outcomes were measured before therapy and six months after therapy according to the recommendations of the "assessment in ankylosing spondylitis working group"(ASAS). The primary endpoint was disease activity assessed using the BASDAI ("Bath Ankylosing Spondylitis Disease Activity Index"). Secondary endpoints included the BASFI ("Bath Ankylosing Spondylitis Functional Index"), as well as self-reported pain and global patient ratings. Patients showed significant improvement in all of the parameters assessed (BASDAI, BASFI, pain, global patient rating) at 6-months post-treatment. At this time, the mean BASDAI and BASFI scores improved from 5.5 to 3.5 and from 5.6 to 3.7, respectively. Pain decreased from a mean of 7.3 to 4.1, and disease activity (as rated by patients) also decreased from 7.2 to 4.1 (p < 0.001 for all of them). Drug tolerance was good. Six adverse events were documented, none of which was serious and none led to discontinuation of treatment. According to the data provided here medical treatment with radium chloride seems to be effective and safe during an observation period of 6 months. Nevertheless, a randomized placebo-controlled study should be performed in the near future in order to safeguard the level of evidence.

Estimation of cancer risks from radiotherapy of benign diseases

BACKGROUND

The effective-dose method which was proposed by the ICRP (International Commission of Radiation Protection) for the estimation of risk to the general population from occupational or environmental, low-dose radiation exposure is not adequate for estimating the risk of cancer induction by radiotherapy of malignant or nonmalignant diseases.

METHODS

The risk of cancer induction by radiotherapy of benign diseases should be based on epidemiologic data directly derived from follow-up studies of patients who had been given radiotherapy for nonmalignant diseases in the past.

RESULTS

Risk factors were derived from epidemiologic studies of patients treated with irradiation for nonmalignant diseases to be used for selecting treatment options and optimizing treatment procedures.

CONCLUSION

In most cases, cancer risks estimated by the effective-dose method may overestimate the true risks by one order of magnitude, yet in other cases even may underestimate it. The proposed method using organ-specific risk factors may be more suitable for treatment planning.

Chromosomal aberrations in peripheral lymphocytes of patients treated with radium-224 for ankylosing spondylitis

The aim of this study was to investigate the in vivo frequency of chromosomal aberrations (primarily dicentric chromosomes and chromatid breaks) potentially induced by (224)Ra alpha-radiation in peripheral lymphocytes. The study was designed to serve as a cytogenetic analysis along with the therapeutic procedure of ankylosing spondylitis patients who were undergoing a treatment with (224)Ra-chloride. The total administered activity was 10 MBq, and the treatment followed a schedule of 10 i.v. injections per week, each with a dose of 1 MBq of (224)Ra. The calculation of absorbed doses delivered to the blood used the models suggested by the ICRP and yielded a value of 4.7 mGy/MBq. The frequency of chromosomal aberrations observed during the course of therapy was related to the blood dose. The frequency of dicentric chromosomes induced in vivo was found to agree well with the corresponding value of dicentrics induced in vitro. However--given that peripheral lymphocytes are in the cell cycle's G(0) stage--an unexpected increase with dose in the yield of chromatid breaks was observed, with about 95% of them occurring in cells without any other chromosome-type aberrations. Reasons for the production of chromatid breaks are discussed.

Radon therapy for the treatment of rheumatic diseases--review and meta-analysis of controlled clinical trials

OBJECTIVE

The aim of this study was to analyze the effect of radon therapy on pain in rheumatic diseases.

METHODS

MEDLINE and MedKur databases were searched for the terms radon plus therapy, rheum, arthritis, and osteo. Radon therapy centers and experts in the field were contacted, proceedings hand-searched, and bibliographies checked for references of potential importance. Included were all prospective randomized controlled clinical trials that compared clinical effects of radon therapy with other interventions in patients with rheumatic diseases and studied pain intensity. Information concerning patients, interventions, results, and methodology were extracted in a standardized manner by all authors independently and summarized descriptively. Reports on pain reduction were pooled for meta-analysis.

RESULTS

Five clinical trials with a total of 338 patients and comparing the effect on pain of radon baths (three trials) or radon speleotherapy (two trials) with control intervention in degenerative spinal disease (two trials), rheumatoid arthritis (one trial) and ankylosing spondylitis (two trials) met the inclusion criteria. In meta-analysis, the pooled data showed no difference immediately after treatment (P=0.13) but significantly better pain reduction in the radon group than the control group at 3 months (P=0.02) and 6 months (P=0.002) after treatment.

CONCLUSIONS

The existing trials suggest a positive effect of radon therapy on pain in rheumatic diseases. With respect to the potential clinical effect and given the increasing public interest in radon therapy, there is an urgent need for further randomized controlled clinical investigations with long-term follow-up.

Evaluation of a freeze-dried kit for EDTMP-based bone-seeking radiopharmaceuticals

A freeze-dried kit developed for formulation of ethylenediamine-tetramethylenephosphonic acid (EDTMP) chelates with "pain-palliation" radiolanthanides (e.g., 153Sm and 177Lu) or "diagnostic" 99mTc has been evaluated, meeting quality and safety criteria required for medicinal use. The EDTMP kit enables an instant one-step preparation of a radiopharmaceutical of high radiochemical purity (>99%) and has a sufficiently long shelf life. Comparative biodistribution studies of 177Lu-EDTMP and 99mTc-EDTMP prepared from the kit revealed similar tissue uptake and clearance to those obtained for pre-formulated 153Sm-EDTMP. The most significant difference was observed for 99mTc-EDTMP, which shows a high retention in kidney, reaching ca. 2% ID after 90min p.i.v.Although preliminary clinical evaluations suggest that 99mTc-EDTMP possesses limited value for bone scintigraphy, application of the radiopharmaceutical for specific diagnostic purposes may still be considered, e.g., investigation of bone metastases or ossification processes in inflammatory spondyloarthropathy.

Mortality, course of disease and prognosis of patients with ankylosing spondylitis

Patients with ankylosing spondylitis (AS) have about a 50% increased risk of mortality on the basis of the limited amount of data available. There is some evidence that the progression of disease is strongest in the first 10 years of disease but it is also clear that the disease keeps on being active for further decades. The overall burden of disease is similar to rheumatoid arthritis but the overall disease duration of AS is longer. Prognostic factors have also not been studied extensively in AS but it seems clear that early hip involvement indicates a worse outcome. The same is true for early limitation of spinal mobility, laboratory evidence of ongoing disease activity (ESR, hypergammaglobulinemia), peripheral arthritis and dactylitis. The significance of organ involvement for the prognosis, especially in the kidney in the form of amyloidosis, and in the heart and lungs, is less clear. Radiation therapy of the spine, which had been performed quite extensively in former decades, has been associated with a mean radiation dose of about double that of atomic bomb survivors and an increased risk of leukemia and mortality. This therapy has been largely abandoned nowadays. Elder rheumatologists report however that the clinical improvement of irradiated patients has been partly impressive.

Ankylosing spondylitis--the history of medical therapies

This is a concise overview of the history of medical therapies for patients suffering from ankylosing spondylitis. Recent therapeutic advances are also summarised.

Therapy of ankylosing spondylitis with 224Ra-radium chloride: dosimetry and risk considerations

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease which reduces the quality of life and leads to disability in approximately one-third of the patients. The spectrum of therapeutic modalities is limited. The renaissance of the use of (224)Ra-radium chloride for AS treatment, however, gives rise to concern which should result in the reconsideration of (224)Ra dosimetry and in the discussion of the risks associated with this treatment. The present study introduces new dosimetric calculations for alpha and beta/gamma rays performed according to the model proposed by the International Commission on Radiological Protection (ICRP). After a treatment schedule of 10 intravenous injections, each with 1 MBq of (224)Ra, the absorbed doses were calculated to be highest on the bone surface of the patient (4.4 Gy) with a resulting effective dose of 2.5 Sv.

Peteosthor - a medical disaster due to Radium-224A personal recollection

Up to the end of World War II, there was no effective therapy against bone tuberculosis, and even today there is no treatment for ankylosing spondylitis. However, in the 1940s up to about 1956, radiotherapy with "Peteosthor" - a drug containing Thorium X ((224)Ra) as an effective compound - was introduced in Germany as a presumed cure and it maintained a central place in the treatment of these diseases. In 1948, I was entrusted to assess the new treatment. Animal studies and the clinical evaluation of the patients made me soon realise a number of severe adverse health effects which induced me to pronounce and subsequently repeat warnings against the intravenous administration of high doses of (224)Ra, especially because it was then administered predominantly to children and juveniles. As a consequence, this type of treatment was finally abandoned in 1956. But there remained a need to observe and document the resulting late health effects. Already in 1967, our initial follow-up study provided data for about 800 patients with exact information on the (224)Ra dose levels administered, administration schemes, and the resulting detrimental effects. A large number of bone sarcomas was the most severe consequence, but even today there is a broad spectrum of other grave health effects. A summary of the major scientific insights which have been achieved in the course of the still on-going epidemiological studies is part of this report.

Renaissance of 224 Ra for the treatment of ankylosing spondylitis: clinical experiences

Radium (224Ra) is commercially available again for the treatment of ankylosing spondylitis. Twenty patients suffering from ankylosing spondylitis were treated with weekly intravenous (i.v.) injections of 1 MBq 224Ra for 10 weeks. Therapeutic effect was measured by C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and full blood count, as well as a completion of the Bath ankylosing spondylitis functional index (BASFI) questionnaire. Follow-up was done after three and six months. At the end of the treatment course pain and movement restrictions had improved subjectively in 12 out of 20 patients. These patients were also able to discontinue or reduce their analgesic or anti-inflammatory medications. Subjective improvement was well correlated with a reduction of CRP by 45% and BASFI by 73%. At the six-month follow-up, ten patients reported a lasting improvement, whereas two had suffered a relapse. A late therapeutic response after three months was seen in a single patient only. Patients who did not respond to radium had lower initial levels of acute-phase reactants and peripheral joint involvement. Only mild side-effects, e.g. temporary worsening of pain, were observed. Leukocytes and platelets reversibly decreased by 25%, respectively. It is concluded that 224Ra is an effective and safe treatment for ankylosing spondylitis.

[Radiotherapy for pain in chronic, degenerative low back pain syndrome--results of a prospective randomized study]

AIM OF STUDY

A low-dose radiotherapy with 5 Gy on the lumbar spine in patients with chronic low back pain was investigated.

METHOD

31 patients with non-radicular low back pain since three years at the age of at least 50 years (64.3 years on average) were treated. A psychosomatic etiology of pain was excluded. 5 Gy or 0.5 Gy (placebo dose) were applied in five fractions to the lumbar spine including the facet joints. The pain was evaluated by means of the Oswestry-Disability-Score before, six weeks after therapy, and every three months during the follow-up (22.4 months on average). Drug therapy, physiotherapy, and physical treatment were continued.

RESULTS

According to the randomised distribution, 18 patients were treated with 5 Gy and 13 patients with 0.5 Gy. The Friedman-Test did not reveal any significant difference (p > 0.05) of the Oswestry-Disability-Index before and after therapy for both single questions and the sum of questions in both groups.

CONCLUSION

No significant decrease of the Disability Index after radiotherapy on the lumbar spine with 5 Gy could be demonstrated in the verum and placebo group. The authors do not recommend radiotherapy in cases of chronic low back pain. Individual successes have to be attributed to conservative treatment or placebo effects.

Cancer risk from low-level ionizing radiation: the role of age at exposure

This article examines methodological issues related to epidemiologic investigations of the influence of age at exposure on radiation risk estimates; the epidemiologic literature on the role of age at exposure in radiation-cancer associations; and biological mechanisms that may account for associations observed in these studies. There is substantial evidence that young children, and especially the fetus, are highly vulnerable to ionizing radiation. Investigations also suggest that sensitivity may increase at the oldest ages of exposure. Further attention to modifying factors in radiation-cancer associations, such as age at exposure, may help to protect workers and the public by improving our understanding of sensitivity variation within populations.

Multiple basal cell carcinomas and malignant melanoma following radiotherapy for ankylosing spondylitis

We present the case of a 53-year-old Caucasian woman with seven basal cell carcinomas and one malignant melanoma in situ along her back overlying her spine, which was irradiated in 1968 for ankylosing spondylitis. These lesions developed between 1997 and 1999. She has no other known risk factors for cutaneous malignancy, in particular no history of excessive sun exposure. She has skin type 2. Molecular studies of glutathione S-transferase and cytochrome P450 status showed her genotype not to constitute an overall increased inherited susceptibility. We therefore postulate that all her skin cancers have arisen as a consequence of her radiotherapy. To our knowledge this is the first case of multiple basal cell carcinoma in addition to a malignant melanoma following radiotherapy for benign disease.

Late effects in ankylosing spondylitis patients treated with 224Ra

This study is comprised of 1577 ankylosing spondylitis patients from 9 German hospitals who have been treated with multiple injections of (224)Ra. The majority of the patients, most of them treated in the years 1948-1975, received one series of 10 weekly intravenous injections of about 1 MBq of (224)Ra each. This dose leads to a mean absorbed dose due to alpha-particle radiation of 0.56 Gy to the marrow-free skeleton of a 70- kg man (mean bone surface dose of about 5 Gy). To provide comparative information on causes of death and on health effects possibly related to the basic disease itself, a control group of 1462 ankylosing spondylitis patients with roughly the same age distribution has been established. By the end of 1998, 649 patients in the exposed group and 762 control patients had died. Among other observations, it is of particular interest that 13 cases of leukemia in the exposed group have been observed. This is a highly significant excess (P < 0.001) compared to a standard population, but only a marginally significant excess in comparison to the seven cases observed in the control group. Subclassification of the leukemias shows a clear preponderance of the myeloid leukemias in the exposed group (8 cases observed compared to 1.7 cases expected, P < 0.001), whereas in the control group the observed cases are within the expected range for myeloid leukemia (3 cases observed compared to 2.2 cases expected, P = 0.3). The (224)Ra cohort of the earlier study (higher-dose group) has provided a risk coefficient that predicts about 8 excess malignant bone tumors for the irradiated cohort in this study. In actuality, 4 cases of malignant tumors in the skeleton have been observed so far. However, excess of breast cancer has not been observed in either the irradiated or the control group, which is in contrast to the findings in the earlier (224)Ra cohort of Study I.

Malignancies in patients treated with high doses of radium-224

Predominantly from 1945 to 1955, a group of patients in Germany was treated with multiple injections of the short-lived alpha-particle emitter (224)Ra. The patients suffered from ankylosing spondylitis, tuberculosis and in a few cases from other diseases. The "Spiess study" (study I) follows up the health of 899 of these patients; it includes most of the patients who were treated with high doses (mean bone surface dose: 30 Gy, mean specific activity: 0.66 MBq/kg), and nearly all of those treated under the age of 21 years. The most striking consequence of the (224)Ra injections was the occurrence of 56 malignant bone tumors. They appeared in a temporal wave that peaked around 8 years after exposure. A new analysis was recently performed, because a reassessment of the dosimetry resulted in changed bone surface doses, especially for the patients treated at younger ages. Averaged over all ages at exposure, the estimated risk coefficient is in general agreement with earlier analyses. However, there is now an increase in bone tumor risk that is significantly greater for younger ages at exposure. The earlier finding of an inverse protraction factor is confirmed. During the most recent years of follow-up, a significant excess of nonskeletal solid malignancies has become manifest. In 1998, a significant increase of breast cancer incidence, of soft tissue malignancies, of thyroid carcinomas, and of liver, kidney and bladder cancer was found. An eightfold increased risk of mammary cancers in those treated at a young age is particularly striking. Equally notable are two cases of breast cancer in male patients. To identify potential confounders, a control group of tuberculosis patients not treated with (224)Ra was established. The comparison confirms that the (224)Ra treatment is responsible for most of the excess of mammary cancer.

Risks of leukemia in Japanese atomic bomb survivors, in women treated for cervical cancer, and in patients treated for ankylosing spondylitis

The dose-response relationship for radiation-induced leukemia was examined in a pooled analysis of three exposed populations: Japanese atomic bomb survivors, women treated for cervical cancer, and patients irradiated for ankylosing spondylitis. A total of 383 leukemias were observed among 283,139 study subjects. Considering all leukemias apart from chronic lymphocytic leukemia, the optimal relative risk model had a dose response with a purely quadratic term representing induction and an exponential term consistent with cell sterilization at high doses; the addition of a linear induction term did not improve the fit of the model. The relative risk decreased with increasing time since exposure and increasing attained age, and there were significant (P < 0.00001) differences in the parameters of the model between datasets. These differences were related in part to the significant differences (P = 0.003) between the models fitted to the three main radiogenic leukemia subtypes (acute myeloid leukemia, acute lymphocytic leukemia, chronic myeloid leukemia). When the three datasets were considered together but the analysis was repeated separately for the three leukemia subtypes, for each subtype the optimal model included quadratic and exponential terms in dose. For acute myeloid leukemia and chronic myeloid leukemia, there were reductions of relative risk with increasing time after exposure, whereas for acute lymphocytic leukemia the relative risk decreased with increasing attained age. For each leukemia subtype considered separately, there was no indication of a difference between the studies in the relative risk and its distribution as a function of dose, age and time (P > 0.10 for all three subtypes). The nonsignificant indications of differences between the three datasets when leukemia subtypes were considered separately may be explained by random variation, although a contribution from differences in exposure dose-rate regimens, inhomogeneous dose distribution within the bone marrow, inadequate adjustment forcell sterilization effects, or errors in dosimetry could have played a role.

[Radiosynoviorthesis in the treatment plan of chronic inflammatory joint diseases]

The effectiveness of radiosynovirothesis in the local treatment of chronically inflammatory joint diseases, especially rheumatoid arthritis, was evaluated.

SUBJECTS AND METHODS

Follow-up examinations of 415 joints in 115 patients up to 4.5 years after intraarticular application of beta-emitting yttrium-90, rhenium-186, and erbium-169 were evaluated. The examination protocol included estimation of joint circumference, range of active joint moving capability, fist-bending power, and radiological assessment of joint destruction. Subjective assessment of pain, swelling, and joint function by the patients was evaluated by means of a score with three levels.

RESULTS

The mean range of active joint moving capability increased in all joint subgroups, compared with the initial examination, with exception of ankle joints examined more than 30 months after therapy. The mean joint circumference decreased in all joint subgroups. Good to excellent results were achieved in up to 66% of joints, satisfying results in up to 21%, and no improvement or further deterioration was noted in 13% according to subjective assessment by patients themselves. Treatment proved most effective in joints with poor or no alteration in X-ray examinations.

CONCLUSIONS

In the local treatment of chronically inflammatory joint diseases--especially beyond systemic drug therapy and local corticoid therapy--, radiosynoviorthesis is a low-invasive method, which may provide long-term relief of pain and swelling as well as improvement of joint function.

Samarium-153-EDTMP for palliation of ankylosing spondylitis, Paget's disease and rheumatoid arthritis

Samarium-153-EDTMP is an effective agent for palliation of widespread skeletal metastases because it concentrates in bone metastases which have an osteoblastic component. Similar concentration in areas of osteoblastic activity in ankylosing spondylitis, Paget's disease and rheumatoid arthritis suggests a possible new treatment approach. Three patients with ankylosing spondylitis, one patient with Paget's disease and one patient with rheumatoid arthritis were treated with 153Sm-EDTMP. Objective and subjective improvement was noted, especially in ankylosing spondylitis patients. Samarium-153-EDTMP has disease-modifying potential in ankylosing spondylitis and Paget's disease and has palliative value in resistant rheumatoid arthritis. Further trials to determine optimal dose, treatment scheduling, long-term disease-modifying potential and toxicity are needed.

Leukemia mortality after X-ray treatment for ankylosing spondylitis

Leukemia mortality has been studied in 14,767 adult ankylosing spondylitis patients diagnosed between 1935 and 1957 in the United Kingdom, of whom 13,914 patients received X-ray treatment. By 1 January 1992, there were 60 leukemia deaths among the irradiated patients, almost treble that expected from national rates. Leukemia mortality was not increased among unirradiated patients. Among those irradiated, the ratio of observed to expected deaths for leukemia other than chronic lymphocytic leukemia was greatest in the period 1-5 years after the first treatment (ratio = 11.01, 95% confidence interval 5.26-20.98) and decreased to 1.87 (95% confidence interval 0.94-3.36) in the 25+ year period. There was no significant variation in this ratio with sex or age at first treatment. The ratio for chronic lymphocytic leukemia was slightly but not significantly raised (ratio = 1.44, 95% confidence interval 0.62-2.79). Most irradiated patients received all their exposure within a year. Based on a 1 in 15 random sample, the mean total marrow dose was 4.38 Gy. Doses were nonuniform, with heaviest doses to the lower spine. The risk for nonchronic lymphocytic leukemia was adequately described by a linear-exponential model that allowed for cell sterilization in heavily exposed parts of the marrow and time since exposure. Ten years after first exposure, the linear component of excess relative risk was 12.37 per Gy (95% confidence interval 2.25-52.07), and it was estimated that cell sterilization reduced the excess relative risk by 47% at 1 Gy (95% confidence interval 17%-79%). The average predicted relative risk in the period 1-25 years after exposure to a uniform dose of 1 Gy was 7.00.

Management of refractory ankylosing spondylitis and related spondyloarthropathies

Ankylosing spondylitis is the prototype of an interrelated group of disorders termed spondyloarthropathies, which include reactive arthritis, psoriatic arthritis, and rheumatic disorders associated with inflammatory bowel disease. It can be difficult to differentiate between these disorders because they may occur simultaneously or sequentially. In addition, some of the clinical characteristics of these diseases, such as enthesiopathy and eye involvement, are similar no matter what the diagnosis. The monitoring, diagnosis, and treatment of these diseases are related more to their clinical presentation than to the precise diagnosis.

Chronic myelogenous leukemia and exposure to ionizing radiation--a retrospective study of 443 patients

Exposure to ionizing radiations (Rx) has been implicated as a causative factor of chronic myelogenous leukemia (CML). We performed a retrospective study of 443 consecutive CML patients, looking for a history of significant exposure to Rx, and evaluated the clinical and hematological characteristics in order to find any difference between radiation-related CML patients and those with de novo CML. We identified 406 patients without known exposure to mutagens (group I) and 37 patients with prior significant exposure to Rx (group II). In comparison to patients of group I, those of group II showed particular clinical and hematological features: significantly lower incidence of bulky splenomegaly (p < 0.05) and hyperleukocytosis (WBC > 100 x 10(9)/l; p < 0.05); significantly higher incidence of anemia (Hb < 10 g/dl; p < 0.01). Patients with radiation-related CML had a significantly better survival than those with de novo CML (median survival 61 months vs 42 months; p < 0.05). In conclusion, this study of a large cohort of CML patients indicates that the subgroup of patients with a history of significant exposure to ionizing radiation has particular clinical and hematological features at onset (lower tumor burden, higher frequency of anemia) and a better survival.

Cancer mortality following X-ray treatment for ankylosing spondylitis

Mortality has been studied in 15,577 ankylosing spondylitis (AS) patients diagnosed between 1935 and 1957 in the UK, of whom 14,556 received X-ray treatment. By January 1, 1992 over half of the cohort had died. Among the irradiated patients, cancer mortality was significantly greater than expected from the national rates for England and Wales, with a ratio of observed deaths to expected (relative risk, RR) of 1.30, and significant increases individually for leukaemia, non-Hodgkin's lymphoma, multiple myeloma and cancers of the oesophagus, colon, pancreas, lung, bones, connective and soft tissue, prostate, bladder and kidney. Among the unirradiated patients, cancer mortality was lower than expected from national rates (RR = 0.79). Among irradiated patients, the RRs for leukaemia, lung cancer, and all other neoplasms all decreased significantly with increasing time since first treatment following an initial increase. By 35 years after first treatment, the radiation-related excess for lung cancer had completely disappeared, while for other neoplasms the RR remained significantly raised, although at a lower level than in earlier periods. Most irradiated patients received several courses of treatment within a 5-year period. Based on a 1 in 15 random sample, the mean total body dose received in this period was 2.64 Gy, with the heaviest dose to the vertebrae. A linear dose-response model for all neoplasms except leukaemia gave an excess RR of 0.18 Gy-1 in the period 5-24.9 years after first treatment, which decreased significantly to 0.11 Gy-1 in the period more than 25 years after first treatment. There was no evidence that a linear-quadratic model fitted the data better than a linear model. There were significant dose-response relationships individually for cancers of the lung, oesophagus, colon, pancreas, prostate, bladder and kidney.

[Hepatocellular carcinoma following intravenous thorium X therapy]

Twelve years after receiving radiation therapy with thorium X (280 microCi) for long-standing Bechterew's disease (ankylosing spondylitis) a 52-year-old man was found, by ultrasonography and computed tomography, to have a round mass, 11 x 12 cm, in the left lobe of the liver. Laparoscopy discovered coarse, discoloured nodes on the surface of the right and left lobes of the liver which histologically showed hepatocellular carcinoma. There were no known risk factor for liver carcinoma (like cirrhosis, positive hepatitis B serology, alcohol abuse, haemochromatosis or alpha 1-antitrypsin deficiency). As exploratory laparotomy found the tumour to be inoperable, 15 chemotherapeutic embolizations were performed. An abdominal wall metastasis was resected after 17 months. At the time of this report, 20 months after the diagnosis was first made, the patient is in a poor general condition. Internal radiotherapy with thorium X was used, all else having failed, in the treatment of severe ankylosing spondylitis. Although it is not possible to prove a direct causal relationship between the thorium X radiation and development of a liver carcinoma, the coincidence is remarkable.

Chronic myelogenous leukemia following repeated radiation therapy for histiocytosis X

Low dose radiotherapy has been used to treat a variety of benign disorders including Histiocytosis X. Ionizing radiation may be leukemogenic with leukemia developing between 3.5 to 11 years after exposure. Twenty to 30% of these leukemias are chronic myelogenous leukemia (CML). In this report the rare development of PH1 + CML 11 years after radiation therapy for Histiocytosis X is recorded.

[Radiation-induced tumors of the nervous system in man]

The risk of developing a tumor of the nervous system in humans is analysed in several studies of populations, exposed to ionising radiation for medical reasons, or exposed to military or occupational radiation. The main data come from series of patients who underwent radiotherapy during childhood: a high incidence of tumors of the nervous system is found after irradiation of one to a few grays as treatment of a benign disease (especially tinea capitis), as well as after irradiation at higher doses of a few tens of grays for the treatment of cancer (in particular cerebral irradiation in acute lymphoblastic leukaemia). The type of radiation-induced tumors is variable, but meningioma is more frequent after low doses and glioma and sarcoma after higher doses used in the treatment of neoplastic diseases. A dose-effect relationship appeared between the risk of tumor of the nervous system and the radiation dose. The risk was higher when radiation was delivered at a younger age. Much less data are available after radiotherapy in the adulthood, but an increased risk of cerebral tumor appears in the series of ankylosing spondylitis patients. As for the exposures to radiodiagnosis exams, the main problem is the risk of cerebral tumor in children whose mother has undergone abdominal or pelvic X-rays during pregnancy. No risk of neurologic tumor was found in the A-bomb survivors irradiated at Hiroshima and Nagasaki. Occupational exposure to ionising radiation has been incriminated in the first radiologists exposed to high doses. In nuclear industry workers, the results of epidemiological studies are contradictory and at the present time it is not possible to link their radiologic exposure with a risk of tumor of the nervous system. In populations living near nuclear plants, mortality due to tumors of the nervous system was not increased.

Comparison of two yttrium-90 regimens in inflammatory and osteoarthropathies

Two yttrium-90 (90Y) radiosynovectomy procedures were compared. One procedure, performed at the Royal Perth Rehabilitation Hospital (RPRH) required a shorter immobilisation time than that performed at the Sir Charles Gardiner Hospital (SCGH). There were no significant differences in outcome between the two procedures for the groups with inflammatory and osteoarthropathy. Thirty two patients (45 joints) with inflammatory arthropathy were treated (25 with rheumatoid arthritis, three with psoriatic arthritis, two with ankylosing spondylitis, and two with unspecified inflammatory arthropathy) and 40 patients (58 joints) with osteoarthropathy. A separate assessment of local lymph node spread in patients treated by the RPRH showed a minor spread of 90Y in one of 37 joints assessed. A marked improvement in the patient evaluation scores in the inflammatory arthropathy group at three months persisted at 12 months. Good lasting responses were more common in patients with inflammatory arthropathy with a normal joint or early radiological disease. A marked improvement in the pain and evaluation scores occurred at three months in the group with osteoarthropathy but had disappeared by six months after treatment.

The reverse protraction factor in the induction of bone sarcomas in radium-224 patients

More than 50 bone sarcomas have occurred among a collective of about 800 patients who had been injected in Germany after World War II with large activities of radium-224 for the intended treatment of bone tuberculosis and ankylosing spondylitis. In an earlier analysis [H. Spiess and C. W. Mays, in Radiation Carcinogenesis. (C. L. Sanders et al., Eds.) pp. 437-450. USAEC Symposium Series 29, CONF-720505, 1973] it was concluded that, at equal mean absorbed doses in the skeleton, patients with longer exposure time had a higher incidence of bone sarcomas. The previous analysis was based on approximations; in particular, it did not account for the varying times at risk of the individual patients. In view of the implications of a reverse protraction factor for basic considerations in radiation protection, the need was therefore felt to reevaluate the data from the continued follow-up by more rigorous statistical methods. A first step of the analysis demonstrates the existence of the reverse dose-rate effect in terms of a suitably constructed rank-order test. In a second step of the analysis it is concluded that the data are consistent with a linear no-threshold dose dependence under the condition of constant exposure time, while there is a steeper than linear dependence on dose when the exposure times increase proportionally to dose. A maximum likelihood fit of the data is then performed in terms of a proportional hazards model that includes the individual parameters, dose, treatment duration, and age at treatment. The fit indicates proportionality of the tumor rates to mean skeletal dose with an added factor (1 + 0.18.tau), where tau is the treatment time in months. This indicates that a protraction of the injections over 15 months instead of 5 months doubles the risk of bone sarcoma.

Retrospective analysis of 376 irradiated patients with ankylosing spondylitis and nonirradiated controls

Controlled, prospective studies of deep X-ray therapy (DXT) in ankylosing spondylitis (AS) are lacking. We studied a self-help group of 1702 consecutive individuals with AS. Of these, most of whom were men, 376 (22%) had undergone DXT. An attempt was made to select a control for each. Because of the difference in ages at onset, 100 treatment recipients were matched with 100 controls (mean ages 44.5 years and 44.7 years, respectively). The mean Ankylosing Spondylitis Assessment Questionnaire disability score (range 0-8) was worse for the DXT group (5.5 vs 4.8 for controls: p less than 0.0001) and most components of the Arthritis Impact Measurement Scales showed a poorer outcome for those irradiated. Thus, 22% of nationwide AS sufferers had irradiation. This group could also have had more severe disease at the outset. At review, somewhat fewer of the irradiated group were taking NSAID. Although irradiation may have favorably affected the course of these patients our data do not support the use of irradiation except in exceptional cases.