Endovascular abdominal aortic aneurysm repair: methods of radiological risk reduction

AIM

The management of abdominal aortic aneurysm with endovascular repair (EVAR) requires extended exposure to ionizing radiation, before, during and after the intervention. The aim of this study was to quantify the radiological risks to patients and operating team, and to develop strategies to assess and reduce them.

METHODS

EVAR was carried out in 97 patients using either a low-power mobile or a high-power stationary fluoroscopic unit. Empirically determined relationships between the indicated dose area product (DAP) and peak skin dose, obtained by direct in vivo dosimetry in a subgroup of patients, were used to predict the peak skin dose. Individual worker monitoring was used to assess personnel radiological burden.

RESULTS

The probability for radiation induced biological effects due to the repair itself and the preoperative and life-long surveillance, as carried out, was about 2.4 10-3. The peak skin dose of repairs was linearly correlated with the DAP and did not exceed 1.2 Gy. The collective effective dose of the staff that carried out repairs using the mobile unit was 5.5 and 8 μSv per repair using an angiographic and a surgical table, respectively. The use of the high-power fluoroscopic unit resulted in a many fold higher radiation burden to both patient and personnel.

CONCLUSION

The optimum strategy, including equipment-related factors, procedure-conduct factors and follow-up procedures, has to be studied, justified and optimized in each medical facility.

A high-sensitivity multidetector whole-body counter

A prototype multidetector shadow-shield whole-body counter is presented to be used as a monitor of internal contamination and as a tool in clinical research. The counter is equipped with 16 NaI(Tl) detectors located in the central region of a shielded tunnel surrounding the subject to be measured. The accuracy of the counting efficacy predictions was tested in a group of adults with various body shapes and sizes using X-ray absorptiometry. The precision of the total body potassium measurements allows the use of the counter in clinical follow-up studies.

Thermoluminescence dosimetry for quality assurance in radiation therapy

A methodology based on thermoluminescence dosimetry was developed to check the output of teletherapy units and the given doses. It was applied in a hospital as a part of an extemal quality audit programme. Over a 7 year period the mean ratios of the output doses measured by TLDs calibrated free-in-air to the doses measured at the hospital in a 6 MV X ray and in a 60Co unit were 1.000 +/- 0.024 (n = 86) and 0.997 +/- 0.027 (n=61), respectively. TLDs in capsules were attached to the patient's body or to a phantom to assess entrance, exit and midline doses and transmission. Factors were determined experimentally to relate the doses measured with TLDs in capsules and inside the body. The accuracy in given doses with pelvic and tangential breast fields and assessed via 752 in vivo measurements, was considered to be adequately good, taking into account the limitations of the equipment available in the hospital.

Boron neutron capture therapy of a murine mammary carcinoma using a lipophilic carboranyltetraphenylporphyrin

The first control of a malignant tumor in vivo by porphyrin- mediated boron neutron capture therapy (BNCT) is described. In mice bearing implanted EMT-6 mammary carcinomas, boron uptake using a single injection of either p-boronophenylalanine (BPA) or mercaptoundecahydrododecaborane (BSH) was compared with either a single injection or multiple injections of the carboranylporphyrin CuTCPH. The BSH and BPA doses used were comparable to the highest doses of these compounds previously administered in a single injection to rodents. For BNCT, boron concentrations averaged 85 microg (10)B/g in the tumor and 4 microg (10)B/g in blood 2 days after the last of six injections (over 32 h) that delivered a total of 190 microg CuTCPH/g body weight. During a single 15, 20, 25 or 30 MW-min exposure to the thermalized neutron beam of the Brookhaven Medical Research Reactor, a tumor received average absorbed doses of approximately 39, 52, 66 or 79 Gy, respectively. A long-term (>200 days) tumor control rate of 71% was achieved at a dose of 66 Gy with minimal damage to the leg. Equivalent long-term tumor control by a single exposure to 42 Gy X rays was achieved, but with greater damage to the irradiated leg.

Electron density of tissues and breast cancer radiotherapy: a quantitative CT study

PURPOSE

To obtain more accurate data on the electron density of tissues to be used in the treatment planning of breast cancer patients.

METHODS AND MATERIALS

Single kVp quantitative computed tomography was applied in 70 women, 20 to 77 years old, to study the electron density of the breast, the thoracic wall close and parallel to the breast, and the lung parenchyma.

RESULTS

The electron density of the entire breast decreases with increasing age in premenopausal women and remains practically constant in postmenopausal women (8% less than that of water). No difference was found in the electron densities of the right and left breast. The electron density of the lung parenchyma in proximity to the breast is lower than the density in the entire lung parenchyma.

CONCLUSIONS

Whenever no accurate data is available on individual patients, the electron density values to be used in treatment planning for breast and thoracic wall have to take into account both age and menstrual status. The regional differences in electron density of the lung also have to be considered.

Software upgrading in a CT scanner. Influence on quantitative CT

PURPOSE

In an attempt to improve field uniformity and CT number stability, the software in a CT scanner was replaced with a new version. The purpose of the present study was to investigate the influence of the software upgrading on density measurements.

MATERIAL AND METHODS

The upgrading influence was investigated by means of a torso phantom (European spinal). The phantom simulates a torso which contains 3 vertebrae of different densities.

RESULTS

Despite the use of a reference standard under the phantom, the software change resulted in: a) improved short-term precision; b) increased density values at 80 and 100 kVp, decreased at 130 kVp; and c) increased influence of the kVp on the values.

CONCLUSION

The results of the present study suggest that conversion factors have to be used in density values for reference populations as well as in the values of patients undergoing follow-up studies.

Elemental composition of bone minerals in women with breast cancer treated with adjuvant tamoxifen

Oestrogen levels play a major role in conditioning the rates of bone changes in women. Tamoxifen is a synthetic oestrogen antagonist commonly used as an adjuvant therapy for breast cancer. The goal of the present study was to study the amount and the elemental composition of bone minerals in the appedicular skeleton of women with breast cancer treated with adjuvant tamoxifen, as well as to investigate the possibility of increased risk for osteoporosis. Forty-two patients, aged 41-65 years, without skeletal metastases were studied. The mean duration of tamoxifen administration on a daily dose of 20 mg was 21 months (range 1-59 months). It was found that neither the amount of phosphorus in hands (HBP) nor forearm bone mineral content (BMC) differ statistically from those of age-matched healthy subjects. This was confirmed by reassessing bone mineral status after 30 months in 17 postmenopausal patients treated with tamoxifen for a mean time of 52 months. In conclusion, our data support that long-term tamoxifen treatment has no adverse or protective effect on the amount and elemental composition of the appedicular skeleton.

Amount and composition of bone minerals in chronic liver disease

Alterations in bone mineral are a common complication of chronic liver disease. The aim of the current study was to assess bone mineral status in patients with chronic liver disease not treated with corticosteroids and to investigate any possible correlation with the histological stage of liver disease. Bone mineral status in 27 patient with chronic active hepatitis, and 17 with active cirrhosis was compared to that of matched controls. Partial body neutron activation analysis was applied for measuring hand bone phosphorus, single-photon absorptiometry for measuring forearm bone mineral content, and dual-energy x-ray absorptiometry for measuring spinal bone mineral density. These noninvasive measurements were supplemented with data obtained by high resolution radiography and biochemistry. Decreased metacarpal cortical thickness was found in five patients, all in the cirrhotic group. In addition, both mean intact parathyroid hormone and 25-hydroxyvitamin D levels were reduced in this group of patients. The mean values of the quantities assessed by the in vivo techniques in patients in the early stages of the hepatic disease did not differ statistically from those of matched normal controls. On the contrary, these quantities were reduced by 9% in the patients at the late stages relative to controls. In conclusion, only the late stages of liver disease are associated with an increased risk of fractures.

Quantitative computed tomography for spinal bone mineral measurements in chronic renal failure

The aim of this study was to assess non-invasively the status of spinal trabecular bone in patients with chronic renal failure and the influence of the disease stage. Single energy quantitative computed tomography (CT) was used in 89 patients with chronic renal failure to measure spinal trabecular bone equivalent density. 23 patients were independent of dialysis and 66 were receiving long-term haemodialysis. Spinal trabecular bone density of the patients was compared with locally determined normal ranges. Although trabecular bone mineral density (BMD) was lower (9% on average) in the patients who were not dependent on dialysis compared with the predicted mean normal values (BMDp) for age- and sex-matched normal subjects, the difference was not statistically significant. A statistically significant reduction was found in patients on dialysis (BMD/BMDp 0.75 +/- 0.16, Z-score -1.3). Osteosclerosis was found in 11 patients and they were excluded from the study. Longitudinal measurements in 42 patients on dialysis without osteosclerosis showed a 2.9% mean reduction in BMD/BMDp over a period of 8 months. All but one of the 16 haemodialysis patients with osteopenic spinal fractures had trabecular BMD values lower than the fracture threshold determined by our technique. In conclusion, end-stage chronic renal failure was associated with reduction in the spinal trabecular bone density.

Bone mineral status after renal transplantation. Assessment by noninvasive techniques

RATIONALE AND OBJECTIVES

Bone mineral status in recipients of renal grafts is related to preexisting renal osteodystrophy and immunosuppressive treatment. The authors assessed bone mineral status after renal transplantation.

METHODS

Bone mineral status of 20 male graft recipients was evaluated using the following noninvasive techniques: 1) neutron activation analysis, to measure hand bone phosphorus (HBP); 2) single photon absorptiometry, to measure forearm bone mineral content (BMC); and 3) single energy spectrum quantitative computed tomography, to measure spinal trabecular bone equivalent density (TBED).

RESULTS

The mean (+/- SD, P) HBP, BMC, and TBED were found to be respectively, 4.8% (+/- 8.3%, P = .02), 6.6% (+/- 14.6%, P = .07) and 52% (+/- 8.5%, P < .001) lower than that measured in matched normal controls. Renal graft recipients demonstrated mean HBP and BMC decrements that were similar to those observed in matched patients on extrarenal dialysis, although the decrement in TBED was significantly greater in the graft recipients (P < .001). Repeated measurements performed during a 3-year period showed no statistically significant changes.

CONCLUSIONS

Renal transplantation was associated with minor degree of osteopenia in the primarily cortical bone tissue. We speculate that the remarkably low TBED values in graft recipients does not reflect a mean 52% decrement of spinal bone minerals, but rather may be attributed in part to the deposition of adipose tissue in the spine as a result of corticosteroid treatment.

Sequential measurements of bone lead content by L X-ray fluorescence in CaNa2EDTA-treated lead-toxic children

With the development of L X-ray fluorescence (LXRF) to measure cortical bone lead directly, safely, rapidly, and noninvasively, the present study was undertaken to a) evaluate LXRF as a possible replacement for the CaNa2EDTA test; b) quantify lead in tibial cortical bones of mildly to moderately lead-toxic children before treatment; and c) quantify lead in tibial cortical bones of lead-toxic children sequentially following one to two courses of chelation therapy. The clinical research design was based upon a longitudinal assessment of 59 untreated lead-toxic children. At enrollment, if the blood lead (PbB) was 25 to 55 micrograms/dL and the erythrocyte protoporphyrin (EP) concentration was greater than or equal to 35 micrograms/dL, LXRF measurement of tibial bone lead was carried out. One day later, each child underwent a CaNa2EDTA provocative test. If this test was positive, lead-toxic children were admitted to the hospital for 5 days of CaNa2EDTA therapy. These tests were repeated 6 weeks and 6 months after enrollment. Abatement of lead paint hazards was achieved in most apartments by the time of initial hospital discharge. The LXRF instrument consists of a low energy X-ray generator with a silver anode, a lithium-doped silicon detector, a polarizer of incident photons, and a multichannel X-ray analyzer. Partially polarized photons are directed at the subcutaneous, medial mid-tibial cortical bone. The LXRF spectrum, measured 90 degrees from the incident beam, reveals a peak in the 10.5 KeV region, which represents the lead L alpha line.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative computed tomography for bone mineral measurement: technical aspects, dosimetry, normal data and clinical applications

A single KVp quantitative CT (QCT) technique was used for measuring the spinal trabecular bone density. The trabecular bone equivalent density (TBED) was expressed as the density of a K2HPO4 solution that exhibits a linear attenuation coefficient identical to that of trabecular bone. A field non-uniformity correcting factor was obtained from experiments on phantoms. The effective equivalent dose of the whole examination (four sections and a scout view) is 370 muSv. The in vivo short-term precision (reproducibility coefficient of variation) ranges from 1.4% to 4.1% depending on the TBED values of the normal subjects. The TBED was measured in 206 normal Greeks aged 30-69 years. Average TBED decreased with increasing age for both sexes. Analysis considering separately each vertebra showed a tendency to a caudal spinal TBED reduction. No correlation was found between the TBED values and the body habitus, milk consumption, smoking habits in men, and number of full-term pregnancies. A significant difference (p less than 0.01) was found between the TBED values of the normals and those of 50 women suffering from post-menopausal osteoporosis, 37 alcoholic men, and 12 gastrectomized men (Billroth II). Quantitative CT has been established as a method of measuring TBED in health and disease, and the results from this study confirm these applications.

Sequential measurements of bone lead content by L X-ray fluorescence in CaNa2EDTA-treated lead-toxic children

With the development of L X-ray fluorescence (LXRF) to measure cortical bone lead directly, safely, rapidly, and noninvasively, the present study was undertaken to a) evaluate LXRF as a possible replacement for the CaNa2EDTA test; b) quantify lead in tibial cortical bones of mildly to moderately lead-toxic children before treatment; and c) quantify lead in tibial cortical bones of lead-toxic children sequentially following one to two courses of chelation therapy. The clinical research design was based upon a longitudinal assessment of 59 untreated lead-toxic children. At enrollment, if the blood lead (PbB) was 25 to 55 micrograms/dL and the erythrocyte protoporphyrin (EP) concentration was greater than or equal to 35 micrograms/dL, LXRF measurement of tibial bone lead was carried out. One day later, each child underwent a CaNa2EDTA provocative test. If this test was positive, lead-toxic children were admitted to the hospital for 5 days of CaNa2EDTA therapy. These tests were repeated 6 weeks and 6 months after enrollment. Abatement of lead paint hazards was achieved in most apartments by the time of initial hospital discharge. The LXRF instrument consists of a low energy X-ray generator with a silver anode, a lithium-doped silicon detector, a polarizer of incident photons, and a multichannel X-ray analyzer. Partially polarized photons are directed at the subcutaneous, medial mid-tibial cortical bone. The LXRF spectrum, measured 90 degrees from the incident beam, reveals a peak in the 10.5 KeV region, which represents the lead L alpha line.(ABSTRACT TRUNCATED AT 250 WORDS)

Boron neutron capture therapy of intracerebral rat gliosarcomas

The efficacy of boron neutron capture therapy (BNCT) for the treatment of intracerebrally implanted rat gliosarcomas was tested. Preferential accumulation of 10B in tumors was achieved by continuous infusion of the sulfhydryl borane dimer, Na4(10)B24H22S2, at a rate of 45-50 micrograms of 10B per g of body weight per day from day 11 to day 14 after tumor initiation (day 0). This infusion schedule resulted in average blood 10B concentrations of 35 micrograms/ml in a group of 12 gliosarcoma-bearing rats and 45 micrograms/ml in a group of 10 similar gliosarcoma-bearing rats treated by BNCT. Estimated tumor 10B levels in these two groups were 26 and 34 micrograms/g, respectively. On day 14, boron-treated and non-boron-treated rats were exposed to 5.0 or 7.5 MW.min of radiation from the Brookhaven Medical Research Reactor that yielded thermal neutron fluences of approximately 2.0 x 10(12) or approximately 3.0 x 10(12) n/cm2, respectively, in the tumors. Untreated rats had a median postinitiation survival time of 21 days. Reactor radiation alone increased median postinitiation survival time to 26 (5.0 MW.min) or 28 (7.5 MW.min) days. The 12 rats that received 5 MW.min of BNCT had a median postinitiation survival time of 60 days. Two of these animals survived greater than 15 months. In the 7.5 MW.min group, the median survival time is not calculable since 6 of the 10 animals remain alive greater than 10 months after BNCT. The estimated radiation doses to tumors in the two BNCT groups were 14.2 and 25.6 Gy equivalents, respectively. Similar gliosarcoma-bearing rats treated with 15.0 or 22.5 Gy of 250-kilovolt peak x-rays had median survival times of only 26 or 31 days, respectively, after tumor initiation.

In vivo measurement of cortical bone lead using polarized x rays

An x-ray fluorescence system which utilizes polarized radiation to measure lead in vivo in human subjects is described. The minimum detection limit is approximately 6.4 ppm wet weight lead in the cortex of the tibia with 4 mm of overlying soft tissue. This appears to be adequate for assessing lead stores in lead-toxic preschool children. The measurement requires 16.5 min and is associated with an effective equivalent whole body dose to the subject of 2.5 muSv. The system, its calibration and its validation are described herein.

L-line x-ray fluorescence of cortical bone lead compared with the CaNa2EDTA test in lead-toxic children: public health implications

Mild to moderate lead toxicity (blood lead, 25-55 micrograms/dl) is a preventable pediatric illness affecting several million preschool children ("lead-toxic children") in the United States. In-hospital lead-chelation treatment is predicated upon a positive CaNa2EDTA test, which is difficult to perform and impractical in large populations. After the development of an L-line x-ray fluorescence technique (LXRF) that measures cortical bone lead content safely, rapidly, and noninvasively, this study was initiated in lead-toxic children to compare LXRF with the CaNa2EDTA test. Moreover, LXRF provided the opportunity to quantify bone lead content. From blood lead and LXRF alone, 90% of lead-toxic children were correctly classified as being CaNa2EDTA-positive or -negative. In 76% of 59 lead-toxic children, bone lead values measured by LXRF were equal to or greater than those measured in normal and industrially exposed adults. These results indicate that LXRF may be capable of replacing the CaNa2EDTA test. When considered with the known neurotoxic effects on children of "low levels" of exposure to lead, these results also suggest that either an excessively narrow margin of safety or insufficient safety is provided by present U.S. guidelines, which classify an elevated blood lead concentration as 25 micrograms/dl or greater.

Boron neutron capture therapy of a murine melanoma

Boron neutron capture therapy has been carried out on BALB/c mice carrying the Harding-Passey melanoma s.c. on the thigh. p-Boronophenylalanine (BPA), a boronated analogue of natural melanin precursors, was used to target boron selectively to melanoma. BPA was administered to the mice either via i.p. injection or p.o. by intubation. 10B concentrations in tumor ranged from 15 to 40 ppm depending on the route and timing of administration. Irradiations with a predominantly thermal neutron beam were performed at the Brookhaven Medical Research Reactor. In the absence of BPA, only transient tumor growth delays were observed at low neutron fluences. At 5 x 10(16) n/m2, 4 of 22 tumors irradiated in the absence of BPA underwent long-term tumor growth control; after p.o. administration of BPA (40 ppm 10B in the tumor), the fraction of tumors controlled increased to 11 of 19. The average dose to the tumor in the latter group was 17.8 Gy, of which 14.8 Gy were due to the 10B neutron capture reaction. The biological effectiveness of the absorbed dose from the neutron capture reaction, at the 50% tumor control level, was found to be twice that of 100 kVp X-rays.

Central nervous system radiation syndrome in mice from preferential 10B(n, alpha)7Li irradiation of brain vasculature

Ionizing radiations were directed at the heads of anesthetized mice in doses that evoked the acute central nervous system (CNS) radiation syndrome. Irradiations were done using either a predominantly thermal neutron field at a nuclear reactor after intraperitoneal injection of 10B-enriched boric acid or 250-kilovolt-peak x-rays with and without previous intraperitoneal injection of equivalent unenriched boric acid. Since 10B concentrations were approximately equal to 3-fold higher in blood than in cerebral parenchyma during the reactor irradiations, more radiation from alpha and 7Li particles was absorbed by brain endothelial cells than by brain parenchymal cells. Comparison of the LD50 dose for CNS radiation lethality from the reactor experiments with the LD50 dose from the x-ray experiments gives results compatible with morphologic evidence that endothelial cell damage is a major determinant of acute lethality from the CNS radiation syndrome. It was also observed that boric acid is a low linear energy transfer radiation-enhancement agent in vivo.